In Part Three of our new blog series…Dissecting the DSM-5…What it Means for Kids and Families we’ll look at one of the most controversial  diagnoses in the new diagnostic manual for mental disorders: Disruptive Mood Dysregulation Disorder (DMDD).

One of the most common reasons parents bring their kids to a practice like ours is for help in managing severe anger outbursts. We do very thorough assessments when kids have problems with irritability and anger because there are so many potential conditions that can predispose them to or precipitate meltdowns associated with aggressive or potentially self-injurious behavior. It’s not uncommon for us to see kids who have two or more conditions contributing to aggressive outbursts…in many instances, the treatment used to address aggression associated with one condition can precipitate aggression associated with a comorbid condition.

Over the last 15-20 years, kids with irritability as their predominant mood state along with protracted aggressive outbursts/meltdowns began receiving diagnoses of bipolar disorder at rates that alarmed many (myself included) in the mental health community…a 4,000% increase in prevalence of bipolar disorder over a ten year period!

Most kids receiving the bipolar disorder diagnosis didn’t fit the traditional diagnostic criteria in terms of duration of mood episodes (a distinct period of elevated, expansive or irritable mood lasting at least a week).

Medications shown or thought to be effective for bipolar disorder in children and teens have been associated with the potential for very serious side effects…significant weight gain, elevation in lipid and cholesterol levels, diabetes or prediabetic conditions, elevated prolactin levels and tardive dyskinesia in the case of second-generation antipsychotics, renal and thyroid toxicity with lithium, and polycystic ovary disease and weight gain with sodium valproate. For more information, see this post on safety issues with antipsychotic medication.

Why was there such an uptick in the frequency with which the bipolar diagnosis was applied to children from the mid-1990s on?

• For some time, there was a lack of consensus among researchers in the field as to the appropriate diagnostic criteria for bipolar disorder in children and teens, or whether bipolar disorder presented differently in kids as opposed to adults.

• Many clinicians were prone to misinterpret the research that was being published on pediatric bipolar disorder at the time from several very prestigious academic medical centers.

• Lots of parents of kids with chronic irritability and aggression latched onto the diagnosis of bipolar disorder following the publication of a very influential book, The Bipolar Child.

• In a reimbursement-driven mental health system in which treatment for most conditions is limited to brief psychiatric visits for medication management and weekly outpatient psychotherapy with clinicians of  wildly inconsistent training backgrounds and experience, the bipolar diagnosis provided a rationalization for the use of medication that occasionally provided temporary relief from crisis situations for families of kids with serious mental illnesses in the absence of a better continuum of services for kids with chronic irritability and aggressive behavior.

A number of researchers, most notably Dr. Ellen Leibenluft and her team at the National Institute of Mental Health began to do longitudinal studies with kids who presented with irritability as their predominant mood state and severe difficulties with emotional and behavioral self-regulation. What they found laid the foundation for the new diagnostic classification in the DSM-5 of DMDD (listed below)…

Compared to kids who fit the traditional diagnosis of bipolar disorder…

1. The kids with DMDD had serious mental illness…their functional impairment was typically as severe (if not more severe) than kids who met criteria for bipolar disorder in the DSM-IV.
2. Kids with DMDD exhibited measurable differences in neuroimaging studies and computer tasks measuring attention deployment in response to emotional stimuli frustration tolerance and cognitive flexibility.
3. Kids with DMDD were at greater risk for developing depressive disorders and anxiety disorders as they grew older…kids with bipolar disorder become adults with bipolar disorder.

An obvious question comes to mind…Why would so many kids start turning up in mental health clinics and physician offices with severe anger outbursts and chronic irritability around the turn of the current century? The answer to that question may provide hints as to how kids who meet the criteria for DMDD will be most safely and effectively treated. Allow me to share a hypothesis…

We know that kids with the condition described as DMDD struggle with anxiety and depression as they grow older, and that most meet the diagnostic criteria for ADHD. They have difficulties with emotional self-regulation and impulse control, and they think too much…I’d use the terms “obsess,” “perseverate” and “ruminate” to describe this quality of their thinking. The parents give affirmative answers to the following  questions…

• Does your child have a hard time making up their mind when they need to choose between two or three things?
• When somebody says or does something that bothers your child, do they have a hard time letting it go?  
• Does your child have a hard time transitioning from activities they like to do to activities they have to do?  

What else happened that had a big impact on mental health care for kids in the mid to late 1990s? From the Centers for Disease Control…

The first national survey that asked parents about ADHD was completed in 1997. Since that time, there has been a clear upward trend in national estimates of parent-reported ADHD diagnoses. It is not possible to tell whether this increase represents a change in the number of children who have ADHD, or a change in the number of children who were diagnosed. Perhaps relatedly, the number of FDA-approved ADHD medications increased noticeably since the 1990s, after the introduction of long-acting formulations.

The late 1990s were the time when we began to see a big increase in the use of ADHD medication, especially longer-acting ADHD medications with effects extending beyond the bounds of the school day. The trend accelerated following FDA approval of Concerta in 2000, Adderall XR in 2001 and Strattera in 2002. One problem frequently seen with ADHD medication is that kids prone to obsessive, ruminative thinking and perseveration often become angry, moody, irritable and emotional in response to commonly used ADHD medications, especially at home where they don’t have the same intensity of cognitive stimulation serving as a distraction from bothersome thoughts. I’d suggest that many of these kids are mislabeled with bipolar disorder when clinicians fail to recognize that their ADHD medication is exacerbating other traits…traits that contribute to anger outbursts and aggressive behavior in the short run and predispose kids to anxiety or depression as they get older.

As a result, the way I’ve been approaching kids who meet the criteria for DMDD is to become significantly more conservative in the use of medications for ADHD and anxiety in the absence of research that informs how we might most effectively treat them. I’ll encourage parents to pursue cognitive-behavioral therapy to help with the rigid, obsessive thinking that frequently leads to protracted meltdowns. I’ll suggest more environmental or educational accommodations to try to decrease the need for ADHD medication that often exacerbates irritability. In my experience, I’ve found that many kids who meet the criteria for DMDD are very sensitive to behavioral activation from the serotonin-specific antidepressants that are approved to treat anxiety, depression and obsessive thinking in children and teens, resulting in the need to start with very low doses and monitor carefully for increases in restlessness, agitation or aggression.

Critics of the DSM-5, including the eminent psychiatrist Allen Francis, have raised concerns that inclusion of DMDD increases the risk of excessive use of medication, when the intent of the APA was to call attention to the practice of inappropriate diagnosis of pediatric bipolar disorder. Quoting from the DSM-5…

“In fact, disruptive mood dysregulation disorder was added to DSM-5 to address the considerable concern about the appropriate classification and treatment of children who present with chronic, persistent irritability relative to children who present with classic (i.e., episodic) bipolar disorder.

Other critics, including Dr. David Axelson have valid points in suggesting we lack sufficient scientific data to support a new diagnosis, and observing the criteria for DMDD lack good inter-rater reliability.

On the whole, I think we have more than enough data to recognize that there is a very large subset of kids who are inappropriately being diagnosed with bipolar disorder and unnecessarily exposed to medication treatments associated with substantial health risk. Because of biases introduced through differences in training and experience, the consistency with which clinicians would accurately apply any new criteria involving irritability and mood in children would be low, regardless of the breadth and depth of the scientific data supporting the new condition. Adding diagnostic criteria to the DSM-5 for DMDD is a significant plus for kids if the new guidelines help clinicians to be more thoughtful in  evaluating and treating kids with moodiness and irritability.

Here’s a download from the American Psychiatric Association on DMDD.

Updated June 28, 2014

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Key Ministry has assembled resources to help churches more effectively minister to children and adults with ADHD, anxiety disorders, Asperger’s Disorder, Bipolar Disorder, depression and trauma. Please share our resources with any pastors, church staff, volunteers or families looking to learn more about the influence these conditions can exert upon spiritual development in kids, and what churches can do to help!