Provisional Early-onset Bipolar Disorder with Phonological Reading Disorder and Attachment-related Difficulties in a Child Exposed to Severe Parental Conflict: A Case Report

Abstract

Background: Severe mood dysregulation in childhood requires careful differentiation among episodic bipolar-spectrum illness, chronic irritability, trauma-related responses, anxiety, neurodevelopmental conditions, sleep disturbance, and environmental stress. Diagnostic uncertainty increases when learning difficulties and disrupted caregiving relationships coexist. Case Presentation: An 8-year-old boy was admitted for inpatient psychiatric care with marked emotional lability, episodic behavioural activation, explosive irritability, insomnia, aggression, withdrawal, freeze-like episodes, and intense anxiety associated with a family-contact context. A neuropsychological evaluation identified a selective pattern of phonological decoding and phonological working-memory difficulty despite preserved general intellectual and visuospatial functioning. The family environment was characterised by prolonged parental conflict, disputed allegations of maltreatment, acute maternal psychiatric decompensation, and marked dependence on the mother for emotional regulation. The clinical team formulated a provisional early-onset bipolar-spectrum disorder with mixed and dysphoric features, a developmental learning disorder with impairment in reading, anxiety and trauma-related symptoms, and attachment-related difficulties. Management included sodium valproate, low-dose risperidone, adjunctive propranolol with cardiovascular monitoring, daily psychotherapy, multisensory phonological rehabilitation, parental guidance, school accommodations, and coordination with child-protection and legal services. During short-term follow-up, reduced fear, hypervigilance, crying, and autonomic arousal were observed after a temporary modification of family-contact arrangements, while pharmacological, psychological, educational, and environmental interventions continued concurrently. Conclusion: The case illustrates the difficulty of assigning a single diagnosis to severe childhood dysregulation occurring in the context of neurodevelopmental impairment and chronic family adversity. The temporal sequence of improvement is clinically informative but does not establish causality. A cautious, developmentally informed, multidisciplinary formulation and longer longitudinal observation are required.