Mania and Attention Deficit Hyperactivity Disorder in a Prepubertal Child: Diagnostic and Treatment Challenges

IntroductionIn rare cases, the first beginnings can be traced back even to before the tenth year. Kraepelin, 1921 Early-onset bipolar illness is historically an understudied area. Increasing awareness that prepubertal mania may occur more frequently than has been previously recognized has led to greater attention to bipolar disorder in the young (1). However, while there is widespread agreement that bipolar disorder may have its onset during adolescence, the diagnosis in children—and to a lesser extent, preadolescents—remains controversial (2, p. 187). Manic and depressive symptoms resembling those seen in adolescents and adults have traditionally been considered rare in prepubertal youth. In a study of more than 900 subjects, Kraepelin (3) observed that 0.4% of his patients experienced onset of their illness before age 10. Utilizing criteria that emphasized classical clinical descriptions of mania in adults—which are now thought to be suboptimal for classifying childhood bipolar illness—Anthony and Scott (4) discounted 96% of the cases with prepubertal onset in their review of the psychiatric literature between 1884 and 1954. A contemporary shift away from the classical conceptualization of bipolar illness in children toward a more developmentally defined bipolar variant syndrome of childhood has since occurred (5). Key features of the prepubertal bipolar variant include a nonepisodic presentation of chronic mixed mania or continuous rapid cycling, marked irritability as the predominant mood abnormality, extreme, protracted temper tantrums or "affective storms," and near-ubiquitous comorbidity with attention deficit hyperactivity disorder (ADHD) (6–8). It is not surprising that this shift has generated considerable controversy as well....