Disturbances of mood and behavior in pre-adolescent children are both ubiquitous and varied. They can defy simple diagnostic categorization and warrant a thorough individualized diagnostic assessment. The biopsychosocial model still offers the best guide to considering all the relevant factors that contribute to mood lability and behavior dysregulation in children. Further, a developmental psychological perspective adds another layer to more accurately guide elucidating the contributory etiological factors to a child’s presenting symptom complex.
Despite more classical psychiatric disorders such as schizophrenia, bipolar disorder, panic disorder, severe major depression generally not presenting prior to adolescence, childhood mood lability and behavioral dysregulation can be severe. In the 1990s some researchers, primarily in the USA, hypothesized that mania, and thus bipolar disorder, was presenting very early in young children, with irritable, mixed and ultra-rapid cycling of manic and depressive episodes to cause extreme mood lability and oppositional behavior. The ‘new’ disorder was described as “juvenile bipolar disorder” or “pediatric bipolar disorder” (PBD).
The PBD hypothesis had heuristic value in that the developmental precursors to bipolar disorder were at the time neglected. Diagnosis of mania in adolescence and young adulthood was often late. Today, earlier recognition of first episodes of mania remains an important task for mental health services. Also, since the 1990s, longitudinal high-risk offspring studies have been providing insights into the developmental precursors to bipolar disorder.
Unfortunately, the PBD hypothesis prematurely translated into widespread clinical practice and many children were misdiagnosed with bipolar disorder when other diagnostic formulations such as
responses to maltreatment and trauma, ADHD, autism spectrum and learning disorders, oppositional defiant and conduct disorders, family relationship and parenting issues, anxiety, and depressive syndromes were the likely etiological factors contributing to the mood lability and behavior dysregulation.
Given that the severity was felt to not always be well described by those diagnostic categories, a new diagnosis was coined for DSM-5: Disruptive Mood Dysregulation Disorder (DMDD). As stated, by the DSM-5 committee, the intention of DMDD was to reduce overdiagnosis of PBD as well as draw attention to a cluster of children with severe mood lability and disruptive behavior.
Yet DMDD is simply a descriptive label that restates the phenomenology. Research as to what it means has generally not yet fully explored the myriad of potential biopsychosocial predisposing, precipitating, perpetuating, or protective factors. The need to apply the classical biopsychosocial case formulation diagnostic approach is one lesson from the PBD era.
There have been iatrogenic consequences of the PBD era: missed alternative more accurate diagnoses; adverse effects of heavy psychotropic medication regimes; and warping of children’s self-identity through the medicalization of normal, albeit perhaps extreme, emotional states. The pharmaceutical industry encouraged a wide adoption of the PBD label by sponsoring research, continuing medical education, and consumer advocacy groups.
The lessons to draw from the PBD era are several and this Frontiers Research Topic is open to submissions on the following:
• Applying a biopsychosocial diagnostic formulation in a developmental context to children with internalizing and externalizing disorders, particularly severe mood lability and disruptive behavior
• Reviews of the PBD era and lessons to be learned from an overdiagnosis epidemic, including factors such as insurance-driven ‘diagnostic inflation’ and over-medicalization of emotional distress and context driven behavior
• Studies, reviews and debates on the prevalence and age of onset of bipolar disorder
• Studies, reviews and debates on the merits or otherwise of the DMDD diagnostic category
• Studies, reviews and debates on the developmental precursors of bipolar disorder as determined thus far in high-risk offspring studies
• Reviews and critiques of the role of the pharmaceutical industry in influencing psychiatric nosology
• Issues of iatrogenesis: from inappropriate psychotropic medication; diagnostic labelling; and missed alternative diagnostic formulations
• Biopsychosocial assessment and management strategies for childhood DMDD-like syndromes, with a focus on parent training programs, parent-child dyadic narrative therapies, and family therapy.
Disturbances of mood and behavior in pre-adolescent children are both ubiquitous and varied. They can defy simple diagnostic categorization and warrant a thorough individualized diagnostic assessment. The biopsychosocial model still offers the best guide to considering all the relevant factors that contribute to mood lability and behavior dysregulation in children. Further, a developmental psychological perspective adds another layer to more accurately guide elucidating the contributory etiological factors to a child’s presenting symptom complex.
Despite more classical psychiatric disorders such as schizophrenia, bipolar disorder, panic disorder, severe major depression generally not presenting prior to adolescence, childhood mood lability and behavioral dysregulation can be severe. In the 1990s some researchers, primarily in the USA, hypothesized that mania, and thus bipolar disorder, was presenting very early in young children, with irritable, mixed and ultra-rapid cycling of manic and depressive episodes to cause extreme mood lability and oppositional behavior. The ‘new’ disorder was described as “juvenile bipolar disorder” or “pediatric bipolar disorder” (PBD).
The PBD hypothesis had heuristic value in that the developmental precursors to bipolar disorder were at the time neglected. Diagnosis of mania in adolescence and young adulthood was often late. Today, earlier recognition of first episodes of mania remains an important task for mental health services. Also, since the 1990s, longitudinal high-risk offspring studies have been providing insights into the developmental precursors to bipolar disorder.
Unfortunately, the PBD hypothesis prematurely translated into widespread clinical practice and many children were misdiagnosed with bipolar disorder when other diagnostic formulations such as
responses to maltreatment and trauma, ADHD, autism spectrum and learning disorders, oppositional defiant and conduct disorders, family relationship and parenting issues, anxiety, and depressive syndromes were the likely etiological factors contributing to the mood lability and behavior dysregulation.
Given that the severity was felt to not always be well described by those diagnostic categories, a new diagnosis was coined for DSM-5: Disruptive Mood Dysregulation Disorder (DMDD). As stated, by the DSM-5 committee, the intention of DMDD was to reduce overdiagnosis of PBD as well as draw attention to a cluster of children with severe mood lability and disruptive behavior.
Yet DMDD is simply a descriptive label that restates the phenomenology. Research as to what it means has generally not yet fully explored the myriad of potential biopsychosocial predisposing, precipitating, perpetuating, or protective factors. The need to apply the classical biopsychosocial case formulation diagnostic approach is one lesson from the PBD era.
There have been iatrogenic consequences of the PBD era: missed alternative more accurate diagnoses; adverse effects of heavy psychotropic medication regimes; and warping of children’s self-identity through the medicalization of normal, albeit perhaps extreme, emotional states. The pharmaceutical industry encouraged a wide adoption of the PBD label by sponsoring research, continuing medical education, and consumer advocacy groups.
The lessons to draw from the PBD era are several and this Frontiers Research Topic is open to submissions on the following:
• Applying a biopsychosocial diagnostic formulation in a developmental context to children with internalizing and externalizing disorders, particularly severe mood lability and disruptive behavior
• Reviews of the PBD era and lessons to be learned from an overdiagnosis epidemic, including factors such as insurance-driven ‘diagnostic inflation’ and over-medicalization of emotional distress and context driven behavior
• Studies, reviews and debates on the prevalence and age of onset of bipolar disorder
• Studies, reviews and debates on the merits or otherwise of the DMDD diagnostic category
• Studies, reviews and debates on the developmental precursors of bipolar disorder as determined thus far in high-risk offspring studies
• Reviews and critiques of the role of the pharmaceutical industry in influencing psychiatric nosology
• Issues of iatrogenesis: from inappropriate psychotropic medication; diagnostic labelling; and missed alternative diagnostic formulations
• Biopsychosocial assessment and management strategies for childhood DMDD-like syndromes, with a focus on parent training programs, parent-child dyadic narrative therapies, and family therapy.