CHILDHOOD DYSREGULATION: Diagnostic Considerations and Treatment

Abstract

It is quite common to see children described as “chronically irritable,” “explosive,” or “dysregulated” in both inpatient and outpatient psychiatric settings. These children are often highly impaired, have difficult to characterize symptoms and multiple diagnoses, and can be especially challenging to treat. The characteristic affective instability led clinicians to conceptualize this presentation as a juvenile form of bipolar disorder.1 In recent years, however, there have been three lines of research that have argued against classification of these children as having bipolar disorder: 1) children with chronic irritability or broad dysregulation rarely grow up to exhibit symptoms supportive of adult bipolar disorder;2-4 2) neurobiological differences are found between chronically irritable youth and those who meet criteria for Bipolar Disorder; 5-6 and 3) pharmacologic agents thought to be effective in bipolar disorder are less effective for symptom management in dysregulated youth.7 Several potential solutions have been proposed to better characterize these children, including the concepts of Severe Mood Dysregulation (SMD)/Disruptive Mood Dysregulation Disorder (DMDD) and the Child Behavior Checklist–Dysregulation Profile (CBCL-DP). Here, we delineate similarities and differences among SMD, DMDD, and CBCL-DP and describe how they came to be defined. We then describe what is currently known about prevalence, longitudinal course, and treatment. Finally, we explore the relationship between DMDD and CBCL-DP with an eye towards issues of comorbidity and how diagnosis affects treatment.