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

Abstract

Background: 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. 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 body: In 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. Conclusions: Psychiatric 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.

<p>The Impact of Childhood Trauma on Developing Bipolar Disorder: Current Understanding and Ensuring Continued Progress</p>

“…[53][54][55][56][57][58] The mechanistic processes leading from CT to the development of mental health problems remain unclear, although some genetic and psychological risk factors have been identified. 48,59,60 Most studies examined the relationship between the occurrence of CT and clinical characteristics of BD, including illness onset and chronicity in adulthood, with the majority using cross-sectional designs. 11 To better understand the role of CT as a risk factor for the development of BD, both cross-sectional and longitudinal studies have included young people who have experienced CT and show BD symptoms or who are at an increased risk of developing BD.…”

“…It will be crucial to support these particularly vulnerable children and youths over the course of years based on the known chronicity of early-onset outcomes. 48,62 Youths and Young Adults at High Risk of Developing BD: Two recent studies included youths and young adults at high risk of developing BD or followed up a student sample 89,90 (Table 2). Emotional maltreatment was associated with an earlier age at illness onset in young people at high familial risk.…”

“…At the same time, postnatal treatment to improve mothers' depressive episodes, psychoeducational programs for parents with mood disorders and early interventions for improving cognitive problems in children are highly recommended. 48,62,156,157 Novel evidence from studies in young people at high risk of developing BD proposes to focus on the developmental perspective when ensuring and optimizing ongoing efforts. It is known that the prenatal and first seven postnatal years of life are highly critical for brain development, which lay the foundations for affective and cognitive development 49,158 as well as HPA axis function.…”

Prepubertal bipolar disorder: a diagnostic quandary?

“…Duffy and colleagues (Duffy et al 2020) (this issue) detail how differing perspectives that created controversy concerning the diagnosis of pre-pubertal bipolar disorder (PPBD), have in more recent times fostered a desire to find common ground. At the crux of this diagnostic dispute, lie a number of diagnostic requirements that build on the supposition that adult bipolar disorder begins early in life and therefore must manifest in childhood.…”

Reflections on: "The diagnosis of bipolar disorder in pre-pubertal children—what was the controversy about and what did we learn as a result?"

“…The review of the diagnosis of bipolar disorder in prepubertal children (Duffy et al 2020) was sparked by a very real controversy over an unexpected and dramatic rise in the reported prevalence of prepubertal bipolar disorder (PBD) in the US. One means of exploring scientific disputes such as this, is cross country comparisons.…”