The clinical presentation of bipolar-disorder (BD) in the pre-adolescent and early adolescent age groups is greatly debated, although mid- to late-adolescent–onset BD is considered similar to adult BD [2]. Apart from the classical descriptions of bipolar disorder, children presenting with ‘‘affective storms,’’ mood lability, severe irritability and temper outbursts, symptoms of depression, anxiety, hyperactivity, poor concentration, and impulsivity with or without clear episodicity, can attract the DSM IV diagnosis of bipolar disorder- not otherwise specified (BD-NOS) [3]. Over the past decade, there is a surge in the numbers of children and adolescents diagnosed with BD in USA. However, there is a considerable transatlantic debate and European skepticism over the high prevalence of pediatric BD in the US [2]. A large epidemiological study in the UK did not detect any cases of pre-adolescent mania. Studies in psychiatric hospitals found BD in 0.0006% of hospitalized patients in Finland, 1.2% in Denmark, and 2.5-4.2% in India [4].

Additionally, the treatment for pre-pubertal affective disorder is controversial due to the limited evidence of the efficacy and safety of mood-stabilizer and antipsychotic medications in this population [5]. Ethical challenges in conducting clinical trials of psychotropic medications in children [6] and Blackbox warnings against the use of certain anti-depressants in this group has guidelines focusing on the efficacy of psychotherapy in depression [1] and off label clinical use of psychotropics. The proponents of the debate claim that the early detection and treatment of affective disorder would prevent adult morbidity and site examples from adult psychiatry literature of retrospective studies claiming that a high percentage of affective disorders have roots in childhood and adolescence. The skeptics claim that affect-dysregulation can be a symptom of a broad range of clinical condition like ADHD, conduct disorder, developmental trauma and misdiagnosis and pharmacological treatment may be detrimental [5].

In the background of such global controversies, this study by Sagar, et al. [7] gives an interesting insight in the Indian clinical scenario. Although the study is retrospective, it shows bipolar disorder as being less common than depression, half with an onset in early childhood, presentation age being <13 years, lack of major psychosocial stressors in majority of the cases and male preponderance. The study doesn’t make clear distinctions in the clinical presentation between pre-pubertal and post- pubertal presentations. However, the SD of <3 in both the groups indicate that there were a substantial number of patients below the age of 10 years and a significant number of patients in the bipolar group presented with >1 episode, indicating an earlier onset of the illness. Although difficult to extend the findings to any epidemiological trends in the Indian population, it sheds some light on the clinical presentation of mood disorders in the clinic based population from an Indian context, adding to the emerging literature and greater understanding of the concept of mood disorders in childhood.

Funding: None; Competing interests: None stated

1. Harrington R. Affective disorders. In: Rutter M, Taylor E, editors. Child and Adolescent Psychiatry. Fourth edition. Massachusetts: Blackwell Publishing Ltd; 2002.p.463-85.

2. Soutullo CA, Chang KD, Dýez-Suaìrez A, Figueroa-Quintana A, Escamilla-Canales I, Rapado-Castro M, et al. Bipolar disorder in children and adolescents: international perspective on epidemiology and phenomenology. Bipolar Disord. 2005:7:497–506.

3. Biederman J, Faraone S, Mick E, Wozniak J, Chen L, Ouellette C, et al. Attention-deficit hyperactivity disorder and juvenile mania: an overlooked comorbidity? J Am Acad Child Adolesc Psychiatry.1996;35:997-1008.

4. Hoop JG. Ethical issues in psychiatric research on children and adolescents. Child Adolesc Psychiatr Clin N Am. 2008;17:127-48.

5. Parry P, Allison S. Pre-pubertal paediatric bipolar disorder: a controversy from America. Australas Psychiatry. 2008;16:80-4; discussion 85-6.

6. Rajeev J, Srinath S, Girimaji S, Seshadri SP, Songh P. A systematic review of the naturalistic course and treatment of early-onset bipolar disorder in a child and adolescent psychiatry center. Compr Psychiatry. 2004;45:148–54.