Paediatric bipolar disorder and its controversy

Abstract

Objectives Paediatric bipolar disorder – bipolar disorder occurring in prepubertal children – is a diagnosis subject to considerable controversy. Whilst historically considered to be very rare, proponents since the 1990s have argued that mania can present differently in children and, as such, is much more common than previously thought. Such proposals raise questions about the validity of proposed phenotypes and potential risks of iatrogenic harm. Methods I critically examine the construct of paediatric bipolar disorder using Robins and Guze’s (1970) influential criteria for validity of a psychiatric diagnosis. I review, in turn, evidence relating to its clinical description, delimitation from other conditions, follow-up studies, family studies, laboratory studies, and treatment response. Results Across domains, existing research highlights significant challenges establishing the diagnosis. This includes significant heterogeneity in operationalising criteria for children; variable or poor inter-rater reliability; difficulty distinguishing paediatric bipolar disorder from other conditions; large differences in rates of diagnosis between the United States of America and other countries; limited evidence of continuity with adult forms; and a lack of evidence for proposed paediatric phenotypes in children at genetic high-risk of the condition. Laboratory and treatment studies are limited, but also do not provide support for the construct. Conclusions Evidence for the more widespread existence of paediatric bipolar disorder and its various proposed phenotypes remains weak. The ongoing popularity of the diagnosis, most evident in America, may reflect social pressures and broader limitations in psychiatric nosology. The uncertainty around the diagnosis highlights the need for careful longitudinal assessment of children potentially affected.

The diagnosis of bipolar disorder in children and adolescents: Past, present and future

“…22 A key problem is the transposition of adult diagnostic criteria to define the illness in children and adolescents. 16 This is an approximation, which in our view, is based predominantly on assumptions. 23 However, before considering why this is cause for concern, it is important to examine the deep-seated flaws within our current adult diagnostic criteria for bipolar disorder, which must be addressed simultaneously to ensure diagnosis is accurate and can be usefully applied to much younger people.…”

“…4 However, the extent of the discrepancy between clinical diagnostic rates of PBD in the US compared to other countries suggests that additional reasons are in play and that perhaps there is a divergence in the threshold applied to diagnosis that is likely dependent on geography. 16,17…”

“…Consequently, structured interviews employed in epidemiological research may lead to misdiagnosis and a potential failure to capture the prevalence of individuals that would otherwise be diagnosed in a clinical setting 4 . However, the extent of the discrepancy between clinical diagnostic rates of PBD in the US compared to other countries suggests that additional reasons are in play and that perhaps there is a divergence in the threshold applied to diagnosis that is likely dependent on geography 16,17 …”

“…At the core of controversies surrounding paediatric bipolar disorder (PBD) † is the complexity of making the diagnosis and the degree of confidence with which this can be achieved 22 . A key problem is the transposition of adult diagnostic criteria to define the illness in children and adolescents 16 . This is an approximation, which in our view, is based predominantly on assumptions 23 .…”

Missed conceptions about paediatric bipolar disorder: a reply and discussion of DMDD

“…We read with interest Dr Connors reply (Connors, 2023a) to our letter to the editor (Malhi et al, 2023b) in which we had questioned a number of aspects of his thoughtful examination of paediatric bipolar disorder (PBD) (Connors, 2023b).…”