ADD or Bipolar? Why it’s hard to diagnose the difference.

image via Flickr, Matt Anderson

image via Flickr, Matt Anderson

Differentiating between Attention Deficit Disorder and Bipolar Disorder can be very challenging, particularly for the inexperienced clinician. In part, this is because these two syndromes share some common behaviors, but also because there is an overlap in the incidence of the two problems.

Research and clinical experience suggest that a many as 30% of individuals with Bipolar Disorder also have ADD and somewhere around 3.5% of people with ADD have Bipolar Disorder. Therefore, there are a number of individuals who have both ADD and Bipolar Disorder.

While there can be shared characteristics between the two syndromes, there are a few factors that can help differentiate them. ADD is a chronic problem that shows up early in childhood and manifests itself continuously throughout life. On the other hand, Bipolar Disorder is very difficult to recognize before the early teen years and when it does show up, is episodic in nature.

In my experience, more than 95% of people with ADD demonstrate markers of what I call “neuromaturational delay” such as gross or fine motor incoordination, excessive numbers of soft neurological signs, persistent articulation difficulties in childhood, or a history of bedwetting or febrile seizures. This is not the case with individuals with Bipolar Disorder.

Finally, since both problems tend to run in families, a positive family history can help point us toward the right diagnosis.


Concerned about getting the right diagnosis?  Dr. Liden‘s (free!) download ebook, ADD/ADHD Basics 101, will steer you in the direction of a clinician you can trust and give you the knowledge you need to KNOW you have the right diagnosis.  Download ADD/ADHD Basics 101 right away!

 

ADD is NOT the same as Hyperactivity

image via Flickr, Carolyn Tiry

image via Flickr, Carolyn Tiry

Hyperactivity is one of the many labels that have been used over the years to describe individuals who demonstrate the characteristics of ADD. Other labels that have been applied to this same grouping of individuals include hyperkinesis, Minimal Brain Dysfunction (MBD), dyslexia, and learning disability.

The use of so many diverse terms to describe the same or similar behaviors has contributed to much of the confusion that surrounds ADD.

In fact, today many use the term ADHD or Attention Deficit Hyperactivity Disorder to describe all ADD individuals. They go on to break ADHD into several subtypes: primarily hyperactive, primarily inattentive, and combined type. I don’t embrace these labels and distinctions for several important reasons.

Don’t Perpetuate the Hyperactive Myth

First, holding onto the ‘hyperactive’ label perpetuates the myth in the minds of many lay and professional people that one must be hyperactive in order to have ADD. Clearly, this is not the case, since the majority of individuals with ADD demonstrate either a normal or a low activity level!

Hyperactivity is NOT a Core Characteristic of Attention Deficit Disorder!

Secondly, I don’t believe that hyperactivity is a core characteristic of the ADD syndrome. My observations over the years are that individuals with ADD show “hyperactive” behavior for two reasons, both grounded in underlying attention difficulties.

image via Flickr, Dana

image via Flickr, Dana

Some individuals with ADD demonstrate fidgetiness and motoric overactivity because they have underlying problems with low arousal and need extra movement such as squirming in their chair, bouncing their leg, or tapping their fingers to keep them awake.  Interestingly, these unconscious attempts to maintain arousal frequently disappear quickly when these individuals take one of the ADD medications that wakes them up.

Other ADD individuals appear to be “hyperactive” because their attentional weaknesses preclude efficient self-control of a temperamentally-based high activity level.

I have seen this in my own family. My older son got his mother’s weak attention and my high activity level. His impulsivity, distractibility, and poor self-monitoring coupled with his high activity level lead to his bouncing off the wall, numerous careless accidents, and disturbing out of his seat behavior. On the other hand, my high activity level has never been as problem for me. When it is coupled with my strong attention, I have been able to “put a method to my madness” to accomplish many things.

Real World People Don’t Fit Into Neat Little Boxes

I appreciate that categorization systems like DSM (Diagnostic and Statistic Manual) that split ADD into various subtypes (e.g., Hyperactive) may serve a purpose in defining a pool of research subjects or to clarify communication between professional. However, my experience in the real world is that individuals don’t fit into such neat little boxes defined by narrow criteria.

When all is said and done, what matters most when it comes to ADD are the five key characteristics of inattention. After this, every individual with ADD is unique: some hyperactive, some underactive, some intense, some very sensitive, some gifted, some retarded. What we see on the outside is the result of how the core characteristics mix with other traits, abilities, and characteristics.


Craig B. Liden, MD  is an internationally recognized expert in the diagnosis and treatment of ADD/ADHD.  Since the 1980’s, Dr. Liden has been in private practice evaluating and treating behavior and developmental issues across the life span.   He has treated more than 10,000 patients with ADD/ADHD and related co-morbidities.  Dr. Liden  has written and lectured extensively about ADD/ADHD, education, individual differences and a variety of health problems, most recently publishingAccommodations for Success: A Guide and Workbook for Creating 504 Agreements and IEP’s for Children with ADD/ADHD and ADD/ADHD Basics 101: How to Be A Good Consumer of Diagnostic and Treatment Services for ADD/ADHD.   Dr. Liden is the Founder and Medical Director of The Being Well Center located in Pittsburgh, PA.  He is available for speaking engagements, workshops, and interviews.

Do ADD Medications Interfere with Growth?

image via Flickr, aussiegall

image via Flickr, aussiegall

At one time it was believed that stimulant medications, used for prolonged periods of time, could interfere with growth.

In fact, it was for this reason that some physicians began recommending “drug holidays” to allow for a period of catch up growth.

However, most scientific studies suggest that medications for ADD do not significantly impact on growth. In those that have shown some impact on growth, the magnitude of the change is actually miniscule.

I monitor height and weight every three months in all patients for whom I am prescribing medication. After treating thousands of patients over many years, I have yet to see the first patient where medication treatment for ADD could be blamed for an alteration in growth.

Actually, my observations of growth patterns in children and adolescents with ADD are in sync with recent research. Many children with ADD have a relative deceleration of their growth rate as they approach and enter into puberty and tend to experience their growth spurt at a later point in puberty compared to their non-ADD peers.

Depending upon the age when ADD medication is instituted, this “normal ADD growth pattern” should be taken into account when interpreting any changes in growth rate that might occur.


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7 Keys to Successful (and Safe) Medication Treatment for ADD

image via Flickr, Purple Sherbet Photography

image via Flickr, Purple Sherbet Photography

Medication is often needed to help individuals optimally manage their ADD.

Without the aide of medication, it is almost impossible for most individuals with ADD to function to the best of their abilities and take advantage of other intervention strategies.

Yet, fear of medication, much of it unfounded, stands as a major barrier for many people to even take the step to get evaluated for ADD, let alone begin treatment for it.  Based upon more than 30 years of experience with over 10,000 patients with ADD, I’ve found there are seven keys to a successful and safe experience with medication.

  1. Find the right physician.

    Successful management of ADD requires that prescribing physicians have had specific ADD training and lots of experience working with ADD and the medications used to treat it.  They should have strong communication skills, the willingness to listen to your concerns and address them in a timely manner and a commitment to providing regular long-term follow-up. Critically evaluate your physician and his/her approach before you commit to medication treatment.

  1. Get an accurate diagnosis.

    Most knowledgeable physicians follow systematic procedures to arrive at an accurate diagnosis.  This may include the use of checklists, questionnaires, structured interviews, and ideally, some objective testing of attention abilities.  It’s one thing to hear about symptoms from a patient or significant other, but actually observing the individual’s attention during testing raises the reliability and validity of a physician’s ability to diagnose ADD to a whole different level.  Objective testing helps sort out individuals who don’t really have ADD and weed out those who might be drug seeking.  It also provides a baseline that can be used to accurately judge responsiveness to medication treatment. Response to a trial of medication should never be used as a diagnostic test!

  1. Make sure someone looks at the whole you.

    Each individual with ADD has their own unique profile…different temperaments, skills, abilities, health status, life experiences, attitudes, and beliefs.  Understanding these individual differences and their potential impact on medication treatment are critical for a successful experience.  Incorporating them into the process can help you and your physician interpret and manage apparent side effects and comply with the appropriate medication regimen.  More than 70% of individuals with ADD have co-existing mental health and/or chronic medical problems, sometimes as a consequence of untreated ADD.  If these go unrecognized or untreated, they can sabotage a successful experience with medication.

  1. Participate in objective medication trial tests.

    image via Flickr, Purple Sherbet Photography

    image via Flickr, Purple Sherbet Photography

    Judging the effectiveness of a given dosage or regimen of medication by relying on informal, unstructured observations or simple checklist/behavior ratings forms is fraught with difficulties.  Some observers don’t really understand what they should be looking for or have preconceived ideas about what should or shouldn’t happen, while others may have attitudes or beliefs about medication that color their observations.  The context of where people are making their observations can also result in great variability…monitoring effectiveness in a structured classroom is very different from watching a child play with peers in the backyard or sit in front of the TV or computer.  Asking an adult with ADD “How’s it going?” is like asking the blind to lead the blind…what it takes to make accurate self-observations is good attention and that’s the very thing they don’t have!  It is far better to find the right starting dose for a particular medication by participating in serial objective tests of attention on various doses of medication beginning with the lowest one that could make a difference and advancing as needed until an optimal dose is found.  This process helps ensure that the initial starting dose that you or your child starts taking in the real world is in the right ball park.  Then, fine tuning can be done based upon targeted observations in multiple life arenas.  The right medication, dosage, and daily regimen varies greatly from individual to individual based upon their unique attentional profile, degree of their problem, and the genetically-based way they metabolize various medications.  It is not uncommon for an optimal medication regimen to exceed the drug manufacturer’s marketing guidelines.

  1. Request a regimen that provides you all day coverage.

    ADD is a neurologically-based problem that is present 24 hours per day, 7 days a week, 365 days a year.  It affects all aspects of life functioning.  As the day proceeds, the demands for efficient attention don’t decrease, they actually increase…it’s harder to pay attention during homework time, completing chores, maintaining healthy eating habits, driving a car, controlling emotional reactions, and communicating with others than it is to pay attention at school or work.  Therefore, individuals with ADD should have medication regimens that give them good attention from as close to the moment they wake up in the morning to the time they go to bed at night.  This might require using different combinations of medications: multiple doses of a short-acting medication, a long-acting combined with a short-acting, 2 doses of a long-acting or a stimulant in combination with a non-stimulant (e.g., Strattera).  It is safe to take multiple doses of these medications during the day because their effects are not additive.  More importantly, all day coverage helps reduce the serious risks that come with untreated ADD.  All day, all week coverage actually helps reduce the frequency of more common side effects such as appetite suppression and sleep disruption.

  1. Establish and maintain a Healthy Daily Routine (HDR).

    Having a balanced HDR is probably the most important thing you can do to have a positive experience with medication treatment for ADD.  Maintaining a predictable bedtime and wake time seven days a week, eating at least three meals a day, getting daily aerobic exercise, practicing some type of mind centering every day, and setting up a structure for staying on top of daily responsibilities provide an important foundation for success with medication.  Each of the elements of a balanced HDR in and of themselves helps improve aspects of your attention and your ability to regulate your behavior.  As a result, the medication doesn’t have to work so hard to get you to where you need to be, which could mean being able to use lower doses of the medications.  A balanced HDR will also help eliminate or reduce many of the more common side effects that occasionally occur with the medications used to treat ADD.  So, Get Balance!  It’s good for ADD, it minimizes side effects, makes the medication experience go more smoothly, and it’s the right thing to do for your overall health.

  1. Never use medication as the sole form of treatment.

    image via Flickr, Purple Sherbet Photography

    image via Flickr, Purple Sherbet Photography

    Relying on medication as the sole form of treatment is a setup for problems.  Dramatic things can happen when an individual with ADD starts using a proper medication regimen.  Many positive things will happen: you’ll be more alert during the day, less impulsive, less distractible, and better able to sustain your focus.  These changes may lead to increased performance at school and work, better follow through with responsibilities, greater behavior control and improved relationships with others.  However, the medication opens up a “new world”, not only the good but also a greater awareness of problem areas.  If you’re a sensitive, intense person, there may be more things to be sensitive and intense about, you may tune into areas where you have been dropping the ball, or behaviors that are problematic and irritating to others.  Therefore, having improved attention can be difficult, anxiety producing or even depressing.  Sometimes these consequences of improved self-awareness are misinterpreted as side effects of the medication.

Most individuals starting medication need support to understand and cope with this “new world” and develop new strategies to address problems with emotional regulation, independent functioning, and social/communication difficulties that they become more aware of.  Having an experienced counselor or coach to help lead you down a path to success is critical.  They can help you process your experiences, define the contributors to your problems, brainstorm new strategies to address problems, and support acceptance of who you really are.  In addition, they can help you establish and maintain the all important HDR.  Medication treatment for ADD goes much better when you walk down this new path with an experienced guide!


Dr. Craig B. Liden | The Being Well CenterCraig B. Liden, MD  is an internationally recognized expert in the diagnosis and treatment of ADD/ADHD.  Since the 1980’s, Dr. Liden has been in private practice evaluating and treating behavior and developmental issues across the life span.   He has treated more than 10,000 patients with ADD/ADHD and related co-morbidities.  Dr. Liden  has written and lectured extensively about ADD/ADHD, education, individual differences and a variety of health problems, most recently publishing Accommodations for Success: A Guide and Workbook for Creating 504 Agreements and IEP’s for Children with ADD/ADHD and ADD/ADHD Basics 101: How to Be A Good Consumer of Diagnostic and Treatment Services for ADD/ADHD.   Dr. Liden is the Founder and Medical Director of The Being Well Center located in Pittsburgh, PA.  He is available for speaking engagements, workshops, and interviews.

Why ADD/ADHD is Frequently Misdiagnosed

image via Flickr, Raul Hernandez Gonzalez

image via Flickr, Raul Hernandez Gonzalez

The ways that ADD shows itself are highly variable from person to person depending upon an individual’s age, unique personality characteristics, profile of strengths and weaknesses, and the stresses and demands place upon him.  Differences in any one of these areas combine with the characteristics of ADD to produce an unlimited variety of problem behaviors.

For example, the preschooler with ADD who is strong-willed, sensitive, and intense may be labeled as a behavior management problem; the school-age child with ADD, who has difficulty organizing his thoughts into words and following directions and has problems with phonetics may be diagnosed as language disordered; the adolescent with ADD who is defiant and unkempt and whose grades are suddenly slipping with the new academic demands may be suspected of abusing drugs and alcohol; and the adult with ADD who is shy, socially withdrawn, overweight, and has a low self-esteem may be seen as being depressed.

Because of our limitations as observers of human behavior, we tend to judge the book by its cover. Our snap judgments often interfere with responsibly looking below the surface to investigate the possible role of ADD in these problems.

Our suspicions regarding the cause of a problem naturally influence to whom we go for help. Commonly, this means we seek help from a single professional who has expertise in the area in which we think the problem lies. This increases the possibility of misdiagnoses in several ways.

Even good clinicians’ approaches to problems are colored by their disciplinary bias and training; that is, they generally find what they are looking for. The psychiatrist makes a psychiatric diagnosis; the neurologist makes a neurological diagnosis; and the school psychologist makes an educational diagnosis. Furthermore, depending upon their training and experience, many clinicians may not even consider the possibility of ADD.

All of this serves to reinforce the need for a comprehensive, systematic, team approach to evaluating all behavior, learning, social, life performance, and chronic health problems.

The fact that there is no definitive test for ADD further complicates diagnosis. While there is some general agreement, there are not universally accepted diagnostic criteria for ADD. This means that making the diagnosis of ADD requires qualitative data interpretation and decision-making. Unless it is highly systematic, such qualitative diagnostic techniques are susceptible to multiple sources of error. Pediatricians, family practitioners, and other health-related professionals who have received training in transdisciplinary approaches to diagnosis and treatment are uniquely qualified to conduct effective team evaluations.


How do you know if your chosen health care provider is qualified to diagnose ADD/ADHD accurately?  Dr. Liden gives you a series of criteria and key questions to ask when seeking an accurate diagnosis for ADD in ADD Basics 101.

Losing Sleep Over ADD?

How does ADD impact sleep?

image via Flickr, Vic

image via Flickr, Vic

In our practice, about 70% of people with ADD come to us with sleep problems—trouble getting to sleep, staying asleep, or waking up in the morning. This makes all the sense in the world—as a key feature of ADD is low arousal, it falls to reason that an event that involves arousal in the day will play a role in the sleep-wake cycle at night.

Some of my patients who have trouble falling asleep at night experience wakefulness, in part, because they are unable to turn off their minds; as they lay in bed, distractibility keeps their minds active, moving from one thought, worry, or plan to another never quieting sufficiently to shift into the sleep mode. Others seem to struggle with getting to sleep as a consequence of a second wind: they come home wiped out; they zone in front of the television until 10:00 PM; get a surge of energy, act on it and find it tough to come down to sleep when they try.

It is not uncommon for my patients with ADD to experience nighttime wake ups. For some of these individual’s this is actually related to sleep apnea—periods of cessation of breathing during sleep. Research suggests that sleep apnea occurs in the ADD population more frequently than in the general population; it is likely that this is a function of a higher incidence of obesity in people with ADD and obesity is a key contributor to sleep apnea. Many of my patients do not suffer from sleep apnea but still more often wake up during the night. My understanding of this is a function of a less than good sleep-wake cycle in ADD population.

Probably, one of the hallmarks of ADD is trouble waking up in the morning. While this is particularly difficult for those who get their second wind at night and don’t fall off to sleep until very late, it is also experience by ADD individuals who have had the benefit of eight hours of sleep. Again, it is likely that this is a result of the disorder arousal system in the ADD population.

Apart from its being a drag, sleep difficulties are a serious problem for the ADD individual; we know that sleep deprivation on top of an arousal problem only intensifies his impulsivity, distractibility, poor monitoring, and weak vigilance.


Don’t fight those sleepless nights alone!  A thoughtful doctor or therapist can help you tackle the challenges of ADD and restful sleep.  For help finding the right care provider, Dr. Liden offers a step-by-step guide to finding a diagnosis and treatment plan you can trust to succeed: ADD/ADHD Basics 101

Friends Should Tell Friends About ADD/ADHD

While scientific research has only begun to demonstrate it, my observation and experience suggest that ADD may be everywhere in contemporary society. My bet is that ADD is an important biological contributor that interacts with life circumstances to cause some of the more significant health, educational, social, and economic dilemmas that we face.

In fact, by putting ADD into the mix and addressing its role, we may find that some of these perplexing problems are far more solvable than we thought.

Friends Should Tell Friends

image via Flickr, coolio-claire

image via Flickr, coolio-claire

It is imperative in addressing these perplexing societal problems that we increase society’s awareness of this important, but hidden, biological difference. All of us need to be more aware of the critical role that paying attention plays. We need to recognize that difference of weakness in attention places an individual at risk for problems in almost every area of life — problems which, at first glance, hardly seem to be related to a difference in brain chemistry.

Responsibly written and produced articles, books, and media presentations can play a significant role in enhancing awareness about ADD. Too often, ADD is presented in a cursory, negative, and sensational way in the media. Such a simplistic approach to a complex problem like ADD only confuses the picture and heightens parents’ and teachers’ fears.

Professionals Need Informed Training

Another key step in increasing awareness of ADD involves improving and expanding the training that professionals who work with ADD receive.

Too often professionals who are in the position to work with ADD individuals have a poor understanding of ADD. In fact, many professionals continue to be unaware of the fact that ADD is not just a school problem. It is a life problem whose basis is biological. Effective assessment and treatment is impossible without a comprehensive team approach.

Professionals who lack appropriate training and experience with ADD have an obligation to make a concerted effort to match up the ADD individual and his family with the best resources available.

Schools Should Put Some Muscle Behind ADD/ADHD Support

image via Flickr, alamosbasement

image via Flickr, alamosbasement

We also need to break down the barriers that limit access to appropriate comprehensive services. Schools should do more than pay lip service to providing multidisciplinary services to ADD children. The team cannot consist solely of a school psychologist and teachers and other educational personnel.

Since ADD is a biologically-based problem, the team must include a physician who is knowledgeable in this area.

And, because the impact of ADD goes beyond the schoolyard, dedicated school personnel need to feel comfortable encouraging parents to seek appropriate help from other nonschool professionals for management of the problem in other life arenas.

ADD is NOT a “Mental” Problem

To make this possible, insurance companies and government health financing systems need to evaluate critically policies and reimbursement mechanisms that unfairly discriminate against individuals with ADD. At a most basic level, they need to accept that ADD is not a “mental problem,” but that its physical basis is as real as diabetes and coronary artery disease. These health care financiers would be wise to consider the cost efficiency of early intervention, health education, and comprehensive team treatment of ADD.

Give ADD the Middle Ground

Finally, as a society, we need to find the middle ground. We need to strike a balance between emphasis on skill acquisition and on learning how to live, between permissiveness and firm discipline, between reliance on technology and humanistic intuition, and between manipulation of the brain and counseling the mind.

It is in this middle ground that true quality of life is found.