Abstract
BackgroundEvidence from epidemiological, clinical and high-risk studies has established that the peak period of risk for onset of bipolar disorder spans late adolescence and early adulthood. However, the proposal of the existence of a pre-pubertal form of bipolar disorder manifesting in early childhood created substantial debate. In this narrative review, the literature and contributing factors pertaining to the controversy surrounding the proposed pre-pubertal bipolar disorder subtype are discussed. The resolution of the debate and lessons learned are highlighted.Main bodyIn the mid 1990s US researchers proposed that chronic irritability and explosive temper in pre-pubertal children with pre-existing ADHD and/or other learning and developmental disorders might represent a variant of mania. A number of factors contributed to this proposal including severely ill children with no diagnostic home given changes in the ADHD DSM diagnostic criteria and over-reliance on symptoms and structured interviews rather than on a clinical assessment incorporating developmental history, social context and clinical course. Prospective studies of children at high familial risk did not support the proposed pre-pubertal bipolar phenotype; but rather provided convergent evidence that bipolar disorder onset in adolescence and early adulthood not uncommonly preceded by sleep and internalizing symptoms and most often debuting as depression in adolescence (after puberty). Epidemiological studies of population and hospital discharge data provided evidence that the pre-pubertal bipolar phenotype was largely a US driven phenomenon.ConclusionsPsychiatric diagnosis is particularly challenging given the current lack of objective biomarkers. However, validity and utility of clinical diagnoses can be strengthened if all available predictive information is used to formulate a diagnosis. As in other areas of medicine, critical information required to make a valid diagnosis includes developmental history, clinical course, family history and treatment response—weighed against the known trajectories of classical disorders. Moreover, given that psychiatric disorders are in evolution over childhood and adolescence and symptoms, in of themselves, are often non-specific, a thorough clinical assessment incorporating collateral history and psychosocial context is paramount. Such an approach might have avoided or at least brought a more timely resolution to the debate on pre-pubertal mania.
Highlights
Evidence from epidemiological, clinical and high-risk studies has established that the peak period of risk for onset of bipolar disorder spans late adolescence and early adulthood
Key findings in high-risk children include that (i) premorbid social and cognitive/academic functioning is comparable to the general population; (ii) childhood internalizing symptoms and disorders and sleep problems but not neurodevelopmental, cognitive or externalizing disorders predict for onset of mood disorder in adolescence and early adulthood; (iii); bipolar disorder typically debuts with depressive episodes with a recurrent illness course starting in adolescence; (iv) psychotic symptoms in depressive episodes predict for conversion to bipolar disorder; (v) clinically significant sub-threshold manic symptoms have a variable age of onset, and predict for subsequent onset of bipolar disorder in emergent adulthood
Several different forces have contributed to the proposal that chronic aggression and explosive temper in very young children with comorbid attention deficit hyperactivity disorder (ADHD) and associated problems in social and academic functioning represented a pre-pubertal form of bipolar disorder
Summary
Several different forces have contributed to the proposal that chronic aggression and explosive temper in very young children with comorbid ADHD and associated problems in social and academic functioning represented a pre-pubertal form of bipolar disorder. Longitudinal prospective studies of children at confirmed familial high-risk of developing bipolar disorder have not supported the validity of the pre-pubertal bipolar phenotype proposed by Geller et al (2004), Wozniak et al (1995) and others This is important because bipolar disorder is highly heritable (McGuffin et al 2003; Bienvenu et al 2011) and children of affected parents would be the most likely group expected to manifest an early-onset prepubertal form of bipolar disorder—if it existed. This debate profoundly matters because diagnoses have significant meaning and consequences for the individual and their family and for scientific advancement
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