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Pre-pubertal bipolar disorder: origins and current status of the controversy

Authors
  • Duffy, A.1, 2
  • Carlson, G.3
  • Dubicka, B.4
  • Hillegers, M. H. J.5
  • 1 Queen’s University, Kingston, Canada , Kingston (Canada)
  • 2 University Oxford, Oxford, UK , Oxford (United Kingdom)
  • 3 Stonybrook University, Stony Brook, NY, USA , Stony Brook (United States)
  • 4 University of Manchester, Manchester, UK , Manchester (United Kingdom)
  • 5 Erasmus Medical Center-Sophia Children’s Hospital, Rotterdam, The Netherlands , Rotterdam (Netherlands)
Type
Published Article
Journal
International Journal of Bipolar Disorders
Publisher
Springer (Biomed Central Ltd.)
Publication Date
Apr 20, 2020
Volume
8
Issue
1
Identifiers
DOI: 10.1186/s40345-020-00185-2
Source
Springer Nature
Keywords
License
Green

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.

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