Will disruptive mood dysregulation disorder reduce false diagnosis of bipolar disorder in children?

Stimulant Medication Shortens the Duration of Impairing Emotional Outbursts

Objective

Emotional dysregulation, often presenting as severe emotional outbursts, is being increasingly recognized as a source of considerable impairment for individuals with attention-deficit/hyperactivity disorder (ADHD). The aim of this study was to conduct a secondary analysis of data examining the impact of standing stimulant medication on the duration of emotional outbursts.

Method

The as needed (PRN)-medicated outbursts of psychiatrically hospitalized children, 5 to 12 years of age, were tracked by psychiatric nurses using the Behavioral Activity Rating Scale from the time of PRN administration until the child became calm. The impact of extended-release (ER), immediate-release (IR) stimulant and dose, type and reason for outburst/PRN (aggression, agitation, distress), standing concomitant psychotropic medications and time of day, and days since admission were examined.

Results

Forty-seven children had a total of 405 outbursts, 96 of which occurred when no stimulant was prescribed and 309 with stimulant medication. Controlling for time of day and standing neuroleptic dose, outbursts that occurred on an ER stimulant medication were statistically significantly shorter than those that occurred on no stimulant by about 20 minutes (52.7 vs 72.4 minutes), or 30 minutes for aggressive outbursts. Results were unchanged when further controlling for stimulant type and dose, α-agonist, days since admission, PRN medication type, or reason for PRN/outburst. Immediate-release stimulants and short-acting stimulants did not shorten outburst duration.

Conclusion

In children with ADHD with severe outbursts, ER stimulants were associated with shorter outburst duration than IR stimulants.

Irritability and Temperament: Concurrent and Prospective Relationships in Childhood and Adolescence

OBJECTIVE

Irritability symptoms are closely associated with, and may reflect, temperament traits, particularly negative affectivity (NA). However, there are few empirical data on the relationships between child temperament and irritability symptoms.

METHOD

We investigated cross-sectional and longitudinal relationships between irritability symptoms and temperament traits from age 3-15 in a community sample of 609 children and their parents. Irritability symptoms were assessed through structured interviews with parents at ages 3/6, and inventories completed by parents and youth at ages 12/15. Temperament traits were assessed using parent reports at ages 3/6, and parent and child reports at ages 12/15. Path analysis and structural equation modeling were used to explore longitudinal associations from ages 3-6 and 12-15, respectively.

RESULTS

Higher levels of irritability symptoms at ages 3/6 were concurrently associated with higher levels of NA and lower levels of effortful control (EC). In adolescence, higher irritability symptoms were concurrently associated with higher negative temperament and disinhibition. In longitudinal analyses from age 3-6 and 12-15, irritability symptoms showed modest but significant stability after adjusting for the stability of temperament traits. However, there were significant differences in the stability paths at age 3-6, reflecting lower stability of irritability symptoms. Finally, EC at age 3 predicted increased irritability symptoms at age 6, while irritability symptoms at age 3 predicted increased NA at age 6.

CONCLUSION

Irritability symptoms are robustly associated with both temperamental NA and difficulty regulating attention and behavior. These findings help situate irritability symptoms within widely accepted temperament/personality taxonomies.

ICD-11 Guidelines for Mental and Behavioral Disorders of Children and Adolescents: Reliability and Clinical Utility

OBJECTIVE

ICD-11 clinical guidelines for mental and behavioral disorders must be tested in clinical settings to guarantee their usefulness worldwide. The purpose of this study was to evaluate interrater reliability and clinical utility of the ICD-11 guidelines for children and adolescents in assessing and diagnosing mood, anxiety, and fear-related disorders; attention-deficit hyperactivity disorder (ADHD); and disruptive behavioral disorder (DBD).

METHODS

Children and adolescents ages 6-17 from two specialized settings in Mexico City were interviewed. Each was interviewed by a pair of psychiatrists (interviewer and observer), who independently codified established diagnoses and evaluated the clinical utility of the guidelines with each participant. Kappa values were calculated to determine the level of general diagnostic correlation between the two clinicians.

RESULTS

A total of 25 psychiatrists evaluated 52 children and adolescents. Kappa values between clinicians ranged from 0.46 to 0.53 for mood, anxiety, and fear-related disorders and for ADHD; the kappa value was 0.81 for DBD guidelines. Over 80% of psychiatrists reported that the guidelines, qualifiers, and descriptions of developmental presentations were quite useful.

CONCLUSIONS

ICD-11 guidelines for mental and behavioral disorders of children and adolescents demonstrated mostly moderate interrater reliability and strong interrater reliability in the case of DBD. A large proportion of clinicians regarded the guidelines as quite useful clinical tools.

Development and Initial Validation of the Disruptive Mood Dysregulation Disorder Questionnaire Among Adolescents From Clinic Settings

OBJECTIVES

Disruptive mood dysregulation disorder (DMDD) is a new DSM-5 diagnosis. It is observed in youths and is characterized by chronic irritability and temper outbursts. This study aimed (i) to develop a brief questionnaire administered during a semi-structured interview and (ii) to assess its psychometric properties with adolescents 12-15 years old by estimating its internal consistency and its concurrent association with measures of depressive symptoms and borderline personality traits.

METHODS

A 10-item questionnaire was developed based on the DSM-5 criteria and input from mental health professionals. The questionnaire was administered to 192 adolescents from youth centres, inpatient units and specialized outpatient clinics in Montreal, as were the Schedule for Affective Disorders and Schizophrenia for School-Aged Children (K-SADS-PL), the Abbreviated version of the Diagnostic Interview for Borderlines revised (Ab-DIB), and the Dominic Interactive for Adolescents-Revised (DIA-R).

RESULTS

A DMDD Questionnaire among adolescents from clinic settings is obtained. The content of the instrument's items was initially developed based on DSM-5 criteria and expert judgment to ensure that this new instrument covered the theoretical concepts of DMDD in English and French. Twelve participants (6.3%) met nine or more criteria and 11 youths (5.7%) met the three main criteria of DMDD (A, C, and D), which suggested the likely presence of DMDD. The total Cronbach's alpha was 0.90. In addition, the DMDD Questionnaire was significantly associated with depressive symptoms and borderline personality traits.

CONCLUSION

The reliability and concurrent validity indices suggest that the questionnaire as a decision-support tool may be used with adolescents in clinical settings. It highlights that the DSM-5 DMDD criteria seem associated with depressive symptoms and borderline personality traits. Finally, future studies will be necessary to establish more robust calculations in relation to the validity and reliability of this questionnaire.

Irritability in developmental age: A narrative review of a dimension crossing paediatric psychopathology

OBJECTIVE

Irritability is an important theme in paediatric psychiatry considering its high frequency in developmental age, its association with negative outcomes and consequently significant public health impact. Present as main or associated feature of several psychiatric diagnoses, irritability represents a challenge for clinicians who try to understand its origin and role in developmental psychopathology. In this review we try to: (1) get an overview of this dimension and its relationship with each of the main neuropsychiatric disorders in paediatric population and (2) provide a summary of currently available instruments to assess irritability in children and adolescents.

METHOD

In this narrative review, an overview of irritability in children and adolescents is proposed focusing on selected literature.

RESULTS

Irritability as feature of many paediatric psychiatric conditions has been evaluated by many authors and included in classifications of paediatric psychiatric diseases. Framework of irritability evolved over time and dimension of irritability has been investigated using different tools and methodologies, both qualitative and quantitative. Metrics of irritability as clinical dimension are important in the diagnostic process of paediatric diseases.

CONCLUSION

Investigating the presence of irritability in all children with related disorders is mandatory if we consider the risk for functional impairment and affective and behavioural disorders associated with high levels of irritability. Using rigid threshold in developmental age to differentiate physiological from pathological irritability could lead many children having subthreshold levels of irritability to receive no diagnosis and, consequently, no treatment where instead a dimensional approach to irritability could allow to identify prodromal phase and prevent the evolution towards clinical pathological expressions.

Missing the forest for the trees? A high rate of motor and language impairments in Disruptive Mood Dysregulation Disorder in a chart review of inpatient adolescents

Youths with severe and persistent irritability have a particularly high rate of school failures and learning difficulties. The aim of this study was to determine whether inpatient adolescents with Disruptive Mood Dysregulation Disorder (DMDD) have more motor and/or language impairments compared to patients with other psychiatric disorders. A retrospective chart review of all consecutive cases admitted in two adolescent inpatient units between January 2017 and December 2018 was conducted (N = 191). All patients received multi-disciplinary clinical and developmental assessments. For a subtest of subjects, additional standardized tests were used to document motor and language impairments. In this clinical chart 53 adolescents with a DMDD (mean age 13.6 ± 1.5, min 12, max 16, 70% males) were compared to patients with a major depressive disorder (MDD, n = 64, mean age 15.3 ± 1.6, 52% males) and patients with a non-mood disorder (NMD, n = 61, mean age 14.4 ± 1.55, 59% males). Among inpatients with DMDD, 71% had an associated motor and/or language disorder, with combined forms in around two-thirds of cases. Compared to youths with MDD, participants with DMDD were more likely to have an associated developmental coordination disorder (67% vs. 22%, OR = 4.7) and a written language disorder (35% vs. 10%, OR = 4.6). While 31% of inpatients with DMDD had an associated communication/oral language disorder, this rate was not statistically different from those observed in the MDD group (11%, OR = 3.2). The frequencies of motor and language impairments were not statistically different between participants in the DMDD group and in the NMD group. The high rate of motor and written language disorders found in DMDD patients may partly account for their academic difficulties. Such finding, if confirmed, supports systematic screening of motor and written language impairments in youths with chronic irritability and suggests remediation potential.

Editorial: Do we need inpatient units?

There is probably a consensus that psychiatric hospitalization for children and adolescents should be part of a continuum of care, but that given its expense and unnatural nature (children should be with families in a community), as noted by Kyriakopoulos in this issue, it should be used sparingly. Child psychiatrists in both the United States (McClellan) and the United Kingdom (Cotgrove and Northover) rue the fact that resources spent on inpatient units would be better spent on preventing hospitalization or providing better aftercare. It is certainly easy to see that the significant financial cost of a child's inpatient stay might well pay for his or her psychiatric treatment in the community for a year - assuming there were enough well-trained clinicians and resources to provide it. As we describe below, that is the rate-limiting step to providing alternatives and may account for why treatment is centralized rather than kept in communities. Hamdani et al eloquently describe the situation in low- and middle-income countries where there is a dearth of both inpatient and community resources; requiring urgent attention to the provision of holistic care for young people with mental health problems from preventive services upwards. The approach they describe is what our other authors are calling for, due to an historical over-reliance on inpatient beds in higher income countries.

The Phenomenology of Outbursts

Outbursts (severe temper loss) in children are a common reason for treatment referral. However, the diagnostic system has not classified them in a way that expands knowledge. Outbursts are nested in the concept of irritability, which consists of a feeling and a behavioral dimension. Both need to be identified but kept separate. This review summarizes the phenomenology of outbursts normatively and clinically. Severe temper loss needs a consistent label, an operationalized way of classification and measurement, and an assessment approach independent of diagnosis until other data are gathered to more accurately determine what condition provides the most accurate diagnostic home.

Across-subjects multiple baseline trial of exposure-based cognitive-behavioral therapy for severe irritability: a study protocol

INTRODUCTION

Irritability is defined as a tendency towards anger in response to frustration. Clinically, impairing irritability is a significant public health problem. There is a need for mechanism-based psychotherapies targeting severe irritability as it manifests in the context of disruptive mood dysregulation disorder (DMDD). This study protocol describes a randomised multiple baseline design testing the preliminary efficacy of a new treatment, exposure-based cognitive-behavioral therapy for severe irritability in youth, which also integrates components of parent management training. We will investigate associations of this intervention with primary clinical measures, as well as ecological momentary assessment measures.

METHODS AND ANALYSIS

Forty youth will be enrolled. Participants, aged 8-17 years, must present at least one of two core symptoms of DMDD: abnormal mood or increased reactivity to negative emotional stimuli, with severe impairment in one domain (home, school, peers) and moderate in another, or moderate impairment in at least two domains. Each participant is randomised to a 2-week, 4-week or 6-week baseline observation period, followed by 12 active treatment sessions. Clinical ratings are conducted at baseline, biweekly (clinician), weekly (parent/child) throughout treatment, post-treatment, and 3-month and 6-month follow-up (clinician). Clinician ratings on the Affective Reactivity Index and Clinical Global Impressions-Improvement scale for DMDD are our primary outcome measures. Secondary outcome measures include parent and child reports of irritability. Post hoc additional symptom measures include clinician, parent and self-ratings of depression, anxiety and overall functional impairment. Prospective, digitally based event sampling of symptoms is acquired for a week pre-treatment, mid-treatment and post-treatment. Based on our pathophysiological model of irritability implicating frustrative non-reward, aberrant threat processing and instrumental learning, we probe these three brain-based targets using functional MRI paradigms to assess target engagement.

ETHICS AND DISSEMINATION

The research project and all related materials were submitted and approved by the appropriate Institutional Review Board (IRB) of the National Institute of Mental Health (NIMH).

TRIAL REGISTRATION NUMBERS

NCT02531893 and NCT00025935.

An organization- and category-level comparison of diagnostic requirements for mental disorders in ICD-11 and DSM-5

In 2013, the American Psychiatric Association (APA) published the 5th edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In 2019, the World Health Assembly approved the 11th revision of the International Classification of Diseases (ICD-11). It has often been suggested that the field would benefit from a single, unified classification of mental disorders, although the priorities and constituencies of the two sponsoring organizations are quite different. During the development of the ICD-11 and DSM-5, the World Health Organization (WHO) and the APA made efforts toward harmonizing the two systems, including the appointment of an ICD-DSM Harmonization Group. This paper evaluates the success of these harmonization efforts and provides a guide for practitioners, researchers and policy makers describing the differences between the two systems at both the organizational and the disorder level. The organization of the two classifications of mental disorders is substantially similar. There are nineteen ICD-11 disorder categories that do not appear in DSM-5, and seven DSM-5 disorder categories that do not appear in the ICD-11. We compared the Essential Features section of the ICD-11 Clinical Descriptions and Diagnostic Guidelines (CDDG) with the DSM-5 criteria sets for 103 diagnostic entities that appear in both systems. We rated 20 disorders (19.4%) as having major differences, 42 disorders (40.8%) as having minor definitional differences, 10 disorders (9.7%) as having minor differences due to greater degree of specification in DSM-5, and 31 disorders (30.1%) as essentially identical. Detailed descriptions of the major differences and some of the most important minor differences, with their rationale and related evidence, are provided. The ICD and DSM are now closer than at any time since the ICD-8 and DSM-II. Differences are largely based on the differing priorities and uses of the two diagnostic systems and on differing interpretations of the evidence. Substantively divergent approaches allow for empirical comparisons of validity and utility and can contribute to advances in the field.

Disruptive Mood Dysregulation Disorder and its Impact on Rates of Bipolar Disorder among Children and Adolescents

Background:

In 2013, Disruptive Mood Dysregulation Disorder (DMDD) was introduced in the DSM-5 in part to curb the rapid rise in the rates of bipolar diagnosis among children and adolescents during the decade before the DSM-5 publication. DMDD proved to be a controversial diagnosis for many reasons.

Objective:

This brief review aims to provide an overview of the DMDD diagnosis and its origins and summarize available data on the impact of the introduction of the DMDD diagnosis on the rates of bipolar disorder among children and adolescents.

Methods:

Multiple scientific databases were searched using the related terms “DMDD”, “Disruptive Mood Dysregulation”, and “pediatric bipolar disorder” in combination with the terms “diagnosis” and “impact”. The retrieved articles were reviewed carefully.

Results:

The DMDD diagnosis rates have steadily increased since its introduction. Furthermore, available data show a decrease in the rates of bipolar disorder diagnosis among children and adolescents over the past few years.

Conclusion:

The very limited available data since 2013 show a decline in the diagnosis of bipolar disorder among children and adolescents. More time and further research are needed to more accurately determine the impact of the DMDD diagnosis on the rates of bipolar disorder in this population.

The Diagnostic Infant Preschool Assessment-Likert Version: Preparation, Concurrent Construct Validation, and Test-Retest Reliability

Objective: The Diagnostic Infant and Preschool Assessment was revised to include Likert ratings (DIPA-L) to give a broader range of severity ratings that may have greater utility for clinical and research purposes. In addition, the instrument was updated for Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), and two types of Likert ratings-frequency versus problem intensity-were explored for posttraumatic stress disorder (PTSD) symptoms. Concurrent construct validation and test-retest reliability were examined for the five most common disorders seen in very young children in outpatient clinics: PTSD, attention-deficit/hyperactivity disorder, oppositional defiant disorder, separation anxiety disorder, and generalized anxiety disorder (GAD). A sixth disorder, disruptive mood dysregulation disorder (DMDD), which was created in DSM-5, was tested for the first time. Functional impairment was also examined. Methods: The caregivers of 58 two- through six-year-old children (57 mothers and 1 father) were recruited from an outpatient clinic. They were interviewed at Time 1, and 52 were reinterviewed at Time 2 by research assistants (children's age M 4.7 years, standard deviation 1.2). Results: Few differences were found between the ratings of frequency versus problem intensity for PTSD symptoms. Tests of concurrent criterion validation were acceptable for all disorders when compared against disorder-specific questionnaires; the range of Pearson correlation coefficients was 0.56-0.94. A trend for attenuation of diagnoses from Time 1 to Time 2 was evident, but not statistically significant. Test-retest reliabilities were strong when examined with continuous Likert scores, except for GAD (the range of intraclass correlation coefficients values was 0.29-0.91, but were less consistent for categorical disorder-level status [the range of Cohen's κs was 0.35-0.79]). The range of internal consistencies was 0.78-0.95, excluding DMDD, which could not be calculated. Conclusions: The updated and revised DIPA-L demonstrated many acceptable features of a valid and reliable instrument for the assessment of very young children. While the findings are tentative given the small sample size, the DIPA-L is the only diagnostic instrument for young children with a replication, tested in clinic populations, updated for DSM-5, with psychometrics for functional impairment, and has Likert ratings.

Behavior Modification Is Associated With Reduced Psychotropic Medication Use in Children With Aggression in Inpatient Treatment: A Retrospective Cohort Study

OBJECTIVE

There are few data to guide management of agitated and aggressive psychiatrically hospitalized children. Available studies do not account for setting, age, sex, diagnosis, admission reason, or clinical intervention. Seclusion, restraint, and physical holds (S/R/H) are usually the only outcome measure. In this study, we examine changes in PRN (pro re nata, or "as needed") psychotropic medication use to manage severe aggression on a children's psychiatric inpatient unit, comparing rates before and after a behavior modification program (BMP) was discontinued.

METHOD

We compare 661 children (aged 5-12 years) in 5 cohorts over 10 years, 510 (77%) of whom were admitted for aggressive behavior. PRN use per 1,000 patient-days was the primary outcome measure, but S/R/H was also examined. We use the following as predictors: BMP status, full- or half-time child and adolescent psychiatrist (CAP) oversight, diagnosis, age, length of stay, and neuroleptic use.

RESULTS

Children admitted for aggression had high rates of externalizing disorders (79%), low rates of mood (27%) and anxiety (21%) disorders, and significantly higher rates of PRN and S/R/H (p < .001) use. Rate of PRN use was significantly lower (p < .001) when the BMP was present (mean [SD], 163 [319] per 1,000 patient-days) than when it was absent (483 [569]; p < .001). Higher PRN use was predicted by BMP absence, neuroleptic treatment, and young patient age (p < .001), and by half-time CAP oversight (p = .002).

CONCLUSION

In this sample of young children with primarily externalizing disorders, data support the effectiveness of a BMP in lowering rates of PRN and S/R/H use.

Assessment of irritability in school-aged children by pediatric, family practice, and psychiatric providers

BACKGROUND

Irritability, a common behavioral problem for school-aged children, is often first assessed by primary care providers, who manage about a third of mental health conditions in children. Until recent changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM), irritability was often associated with mood disorders, which may have led to increases in bipolar disorder diagnosis and prescription of mood stabilizing medication.

OBJECTIVE

Our aim was to explore differences between the approaches psychiatric and primary care providers use to assess irritability.

METHODS

A single trained interviewer conducted detailed interviews and collected demographic data from a homogeneous group of physicians that saturated with a sample size of 17 pediatric, family medicine, and psychiatric providers who evaluate and treat school-aged children. Qualitative and quantitative data were collected and analyzed.

RESULTS

In general, primary care providers chose to refer children with irritability to mental health specialists when medication management became complex, while the psychiatric providers chose behavior modification and parent education strategies rather than medications. The psychiatric group had a significantly higher caseload mix, prior experience with irritability, and more confidence in their assessment capabilities. There was lack of continuing medical education about irritability in all groups.

CONCLUSION

This preliminary study highlights the importance of collaboration between primary care and subspecialties to promote accurate assessment and subsequent treatment of school-aged children with irritability, who can represent a safety concern for self and others. More research is needed to establish an efficient method of assessing and managing irritability in primary care and better utilization of specialists.

Are youths with disruptive mood dysregulation disorder different from youths with major depressive disorder or persistent depressive disorder?

BACKGROUND

Although the disruptive mood dysregulation disorder (DMDD) was included in the depressive disorders (DD) section of the DSM-5, common and distinctive features between DMDD and the pre-existing DD (i.e., major depressive disorder, MDD, and persistent depressive disorder, PDD) received little scrutiny.

METHODS

Youths consecutively assessed as outpatients at two Canadian mood clinics over four years were included in the study (n = 163; mean age:13.4 ± 0.3; range:7-17). After controlling for inter-rater agreement, data were extracted from medical charts, using previously validated chart-review instruments.

RESULTS

Twenty-two percent of youths were diagnosed with DMDD (compared to 36% for MDD and 25% for PDD), with substantial overlap between the three disorders. Youths with DMDD were more likely to have a comorbid non-depressive psychiatric disorder - particularly attention deficit hyperactivity disorder, odds ratio (OR=3.9), disruptive, impulse-control and conduct disorder (OR=3.0) or trauma- and stressor-related disorder (OR=2.5). Youths with DMDD did not differ with regard to the level of global functioning, but reported more school and peer-relationship difficulties compared to MDD and/or PDD. The vulnerability factors associated with mood disorders (i.e., history of parental depression and adverse life events) were found at a comparable frequency across the three groups.

LIMITATIONS

The retrospective design and the selection bias for mood disordered patients restricted the generalizability of the results.

CONCLUSIONS

Youths with DMDD share several clinical features with youths with MDD and PDD. Further studies are required to determine the developmental trajectories and the benefits of expanding pharmacotherapy for DD to DMDD.

A Double-Blind Randomized Placebo-Controlled Trial of Citalopram Adjunctive to Stimulant Medication in Youth With Chronic Severe Irritability

OBJECTIVE

Despite the clinical importance of chronic and severe irritability, there is a paucity of controlled trials for its pharmacological treatment. Here, we examine the effects of adding citalopram (CTP) to methylphenidate (MPH) in the treatment of chronic severe irritability in youth using a double-blind randomized placebo-controlled design.

METHOD

After a lead-in phase of open treatment with stimulant, 53 youth meeting criteria for severe mood dysregulation (SMD) were randomly assigned to receive CTP or placebo (PBO) for 8 weeks. A total of 49 participants, 48 of them (98%) meeting disruptive mood dysregulation disorder (DMDD) criteria, were included in the intent-to-treat analysis. The primary outcome measure was the proportion of response based on improvements of irritability at the week 8 of the trial.

RESULTS

At the end of the trial, a significantly higher proportion of response was seen in those participants randomly assigned to CTP+MPH compared to PBO+MPH (35% CTP+MPH versus 6% PBO+MPH; odds ratio = 11.70, 95% CI = 2.00-68.16, p = 0.006). However, there were no differences in functional impairment between groups at the end of the trial. No differences were found in any adverse effect between treatment groups, and no trial participant exhibited hypomanic or manic symptoms.

CONCLUSION

Adjunctive CTP might be efficacious in the treatment of chronic severe irritability in youth resistant to stimulant treatment alone.

CLINICAL TRIAL REGISTRATION INFORMATION

A Controlled Trial of Serotonin Reuptake Inhibitors Added to Stimulant Medication in Youth With Severe Mood Dysregulation; https://clinicaltrials.gov; NCT00794040.

Editorial: Antidepressants to the Rescue in Severe Mood Dysregulation and Disruptive Mood Dysregulation Disorder?

Children with irritability and outbursts pose a serous therapeutic problem. Many of them have attention-deficit/hyperactivity disorder (ADHD) with emotion dysregulation, which is sometimes captured in the diagnosis of disruptive mood dysregulation disorder (DMDD). Some follow-up data find a connection between DMDD and depression and anxiety in adults. This prompted Towbin and colleagues¹ to launch a trial where children (ages 7-17) with DMDD were treated first with methylphenidate (MPH) and then randomized to citalopram (CTP) or placebo over 8 weeks. The response to CTP was complicated by lack of specific measures of both irritable mood and severity of outbursts. Future studies should include standardized and normed parent and teacher measures of both externalizing and internalizing behavior as well as irritability specific measures rating how the child feels. Studies also need better measures of the actual outbursts-not just their frequency but how agitated or aggressive the child gets during an outburst (ie, what the child does) and how long the outbursts last. Measuring DMDD on inpatient units is especially complicated because of the therapeutic nature of the setting. Further work is needed with much larger samples to identify who improves with the treatment, exactly which domains of psychopathology improve and by how much. Finally, It is also critical to conduct longer-term trials to determine the stability of the response beyond 8 weeks.

The Clinician Affective Reactivity Index: Validity and Reliability of a Clinician-Rated Assessment of Irritability

Irritability is impairing in youth and is the core feature of disruptive mood dysregulation disorder (DMDD). Currently, there are no established clinician-rated instruments to assess irritability in pediatric research and clinical settings. Clinician-rated measures ensure consistency of assessment across patients and are important specifically for treatment research. Here, we present data on the psychometric properties of the Clinician Affective Reactivity Index (CL-ARI), the first semistructured interview focused on pediatric irritability. The CL-ARI was administered to a transdiagnostic sample of 98 youth (M age = 12.66, SD = 2.47; 41% female). With respect to convergent validity, CL-ARI scores were (a) significantly higher for youth with DMDD than for any other diagnostic group, and (b) showed uniquely strong associations with other clinician-, parent-, and youth-report measures of irritability compared to measures of related constructs, such as anxiety. The three subscales of the CL-ARI (temper outbursts, irritable mood, impairment) showed excellent internal consistency. Test-retest reliability of the CL-ARI was adequate. These data support that irritability can be feasibly, validly, and reliably assessed by clinicians using the CL-ARI. A validated, gold-standard assessment of pediatric irritability is critical in advancing research and treatment efforts.

Heritability, stability, and prevalence of tonic and phasic irritability as indicators of disruptive mood dysregulation disorder

BACKGROUND

Little is known about genetic and environmental influences on the components of disruptive mood dysregulation disorder (DMDD), tonic irritability (i.e., irritable mood) and phasic irritability (i.e., temper outbursts). This study examined prevalence, stability, and heritability of tonic irritability, phasic irritability, and a DMDD proxy (pDMDD) based on DSM-5 criteria.

METHODS

pDMDD was derived using data from clinical interviews of parents and their twins (N = 1,431 twin pairs), ages 8-17, participating in Waves 1 and 2 of the Virginia Twin Study of Adolescent Behavioral Development. Biometrical modeling was used to compare a common pathway model (CPM) and an independent pathway model (IPM), and heritability estimates were obtained for pDMDD using the symptoms of irritable mood (tonic irritability; DMDD Criterion D), intense temper outbursts (phasic irritability; DMDD Criterion A), and frequent temper outbursts (phasic irritability; DMDD Criterion C).

RESULTS

Lifetime prevalence of pDMDD was 7.46%. The stability of DMDD symptoms and the pDMDD phenotype across approximately one year were moderate (.30-.69). A CPM was a better fit to the data than an IPM. Phasic irritability loaded strongly onto the pDMDD latent factor (.89-.96) whereas tonic irritability did not (.28). Genetic influences accounted for approximately 59% of the variance in the latent pDMDD phenotype, with the remaining 41% of the variance due to unique environmental effects. The heritability of tonic irritability (54%) was slightly lower than that of frequent and intense temper (components of phasic irritability; 61% and 63%, respectively).

CONCLUSIONS

Compared to tonic irritability, phasic irritability appears to be slightly more stable and heritable, as well as a stronger indicator of the latent factor. Furthermore, environmental experiences appear to play a substantial role in the development of irritability and DMDD, and researchers should seek to elucidate these mechanisms in future work.

Pediatric Bipolar Disorder: Onset, Risk Factors, and Protective Factors

The current article discusses the diagnosis of bipolar disorder in children throughout the years as it has evolved, focusing on very early-onset and early-onset bipolar disorder. Proper care of children with bipolar disorder requires a thorough understanding of the subtleties in symptoms at different developmental ages, as well as a shift in diagnostic thinking, which grew to include disruptive mood dysregulation disorder (DMDD). DMDD was added to address potential overdiagnosis of an already unusual diagnosis in young children. Critical discussion of risk factors, protective factors, and lack of data to support protective factors in the literature follows. Implications for advanced practice RNs are included, as these children transition from pediatric practice to adult practice. [Journal of Psychosocial Nursing and Mental Health Services, 57(9), 32-37.].

The morbidity of subthreshold pediatric bipolar disorder: A systematic literature review and meta-analysis

OBJECTIVE

The objective of this study was to evaluate the morbidity of subthreshold pediatric bipolar (BP) disorder.

METHODS

We performed a systematic literature search in November 2017 and included studies examining the morbidity of pediatric subthreshold BP. Extracted outcomes included functional impairment, severity of mood symptoms, psychiatric comorbidities, suicidal ideation and behaviors, and mental health treatment. We used meta-analysis to compute the pooled standardized mean difference (SMD) for continuous measures and the pooled risk ratio (RR) for binary measures between two paired groups: subthreshold pediatric BP vs controls and subthreshold pediatric BP vs pediatric BP-I.

RESULTS

Eleven papers, consisting of seven datasets, were included. We compared subthreshold pediatric BP (N = 244) to non-BP controls (N = 1125) and subthreshold pediatric BP (N = 643) to pediatric BP-I (N = 942). Subthreshold pediatric BP was associated with greater functional impairment (SMD = 0.61, CI 0.25-0.97), greater severity of mood symptomatology (mania: SMD = 1.88, CI 1.38-2.38; depression: SMD = 0.66, CI 0.52-0.80), higher rates of disruptive behavior (RR = 1.75, CI 1.17-2.62), mood (RR = 1.78, CI 1.29-2.79) and substance use (RR = 2.27, CI 1.23-4.21) disorders, and higher rates of suicidal ideation and attempts (RR = 7.66, CI 1.71-34.33) compared to controls. Pediatric BP-I was associated with greater functional impairment, greater severity of manic symptoms, higher rates of suicidal ideation and attempts, and higher rates of mental health treatment compared to subthreshold pediatric BP. There were no differences between full and subthreshold cases in the severity of depressive symptoms or rates of comorbid disorders.

CONCLUSIONS

Subthreshold pediatric BP disorder is an identifiable morbid condition associated with significant functional impairment including psychiatric comorbidities and high rates of suicidality.

What do we really know about PRN use in agitated children with mental health conditions: a clinical review

What is the evidence that 'pro re nata' (PRN) medication is effective for ending agitated outbursts in children and adolescents in psychiatric emergency rooms or inpatient units? Literature search was performed for studies of PRN medication use in children and adolescents that included an outcome measure. One randomised controlled trial, three prospective studies and six retrospective studies that included some outcome measure were identified. Outcome measures were heterogeneous, and frequently did not use standardised metrics assessing agitation level to measure effectiveness. The single small Randomized Controlled Trial (RTC) does not find a difference between placebo and medication, and outcomes of other studies do not control for potential placebo effect of the intervention itself as opposed to the medication. There is insufficient evidence to support the common practice of PRN medications for the management of acute agitation, and no data with which to inform clinical practice, such as which medicines and doses are helpful for specific populations or situations. Psychiatrists have no evidence-based medication interventions for acutely managing agitated outbursts in children and adolescents.

Commentary: Frying pan to fire? Commentary on Stringaris et al. (2018)

The bipolar disorder diagnosis in prepubertal children became popular because it answered a clinical need to treat the explosive behavior component of irritability and the hope that antimanic strategies would be helpful. Poor definition of episodes resulted in mixing chronic and episodic irritability in samples of children with bipolar disorder. The subsequent dramatic increase in neuroleptic use is a testimony to the importance of the problem of irritability and our need to better understand it. Insofar as our use of the term irritability conflates proneness to anger with the subsequent aggressive response, it will again not be clear who is being studied. We need to uncouple the mood and behavior aspects of irritability for further study or we will have traded the imprecision of "bipolar" for the imprecision of irritability.

Distinguishing disruptive mood dysregulation disorder from pediatric bipolar disorder

This article outlines diagnostic criteria and features of the newly established diagnosis disruptive mood dysregulation disorder (DMDD), and discusses how this disorder differs from bipolar disorder in childhood. The chronic, severe, nonepisodic irritability seen in patients with DMDD contrasts with the characteristic episodic mood swing symptoms of bipolar disorder. Differentiating between the two diagnoses is important in regard to prognostic and treatment considerations, as children with DMDD are more likely to develop a mood disorder later in life rather than to develop classic bipolar disorder. Research is needed to establish clear treatment guidelines for DMDD.

Disruptive mood dysregulation disorder, severe mood dysregulation and chronic irritability in youth at high familial risk of bipolar disorder

OBJECTIVE

Disruptive mood dysregulation disorder is a newly proposed childhood disorder included in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition to describe children ⩽18 years of age with chronic irritability/temper outbursts. This study aimed to examine the prevalence of disruptive mood dysregulation disorder, severe mood dysregulation and chronic irritability in an Australian study of young people at increased familial risk of developing bipolar disorder ('HR' group) and controls ('CON' group).

METHODS

A total of 242 12- to 30-year-old HR or CON subjects were administered the severe mood dysregulation module. Of these, 42 were aged ⩽18 years at the time of assessment, with 29 subjects in the HR group and 13 in the CON group.

RESULTS

No subjects ⩽18 years - in either group - fulfilled current or lifetime criteria for disruptive mood dysregulation disorder or severe mood dysregulation, the precursor to disruptive mood dysregulation disorder. Similarly, no subjects in either group endorsed the severe mood dysregulation/disruptive mood dysregulation disorder criteria for irritable mood or marked excessive reactivity. One HR participant endorsed three severe mood dysregulation criteria (distractibility, physical restlessness and intrusiveness), while none of the comparison subjects endorsed any criteria. Exploratory studies of the broader 12- to 30-year-old sample similarly found no subjects with severe mood dysregulation/disruptive mood dysregulation disorder in either the HR or CON group and no increased rates of chronic irritability, although significantly more HR subjects reported at least one severe mood dysregulation/disruptive mood dysregulation disorder criterion (likelihood ratio = 6.17; p = 0.013); most of the reported criteria were severe mood dysregulation 'chronic hyper-arousal' symptoms.

CONCLUSION

This study comprises one of the few non-US reports on the prevalence of disruptive mood dysregulation disorder and severe mood dysregulation and is the first non-US study of the prevalence of these conditions in a high-risk bipolar disorder sample. The failure to replicate the finding of higher rates of disruptive mood dysregulation disorder and chronic irritability in high-risk offspring suggests that these are not robust precursors of bipolar disorder.

Temper Loss and Persistent Irritability in Preschoolers: Implications for Diagnosing Disruptive Mood Dysregulation Disorder in Early Childhood

Disruptive Mood Dysregulation Disorder (DMDD) is a new and controversial child psychiatric disorder characterized by persistent irritability and frequent temper loss. Among the controversies surrounding DMDD is whether the age of onset criterion-that DMDD may not be diagnosed before age 6 years-is justified. This study examined DMDD symptoms and associated patterns of psychiatric comorbidity, behavioral, and family functioning in a sample of 139 preschoolers (ages 4-0 to 5-11 years) admitted to an early childhood psychiatric day treatment program. DMDD symptoms were common in this acute clinical sample, with 63 children (45.3 %) presenting with frequent temper outbursts and chronic irritability. As compared to children who did not present with DMDD symptoms, these children demonstrated more aggression and emotional reactivity and lower receptive language skills, with high rates of comorbidity with the disruptive behavior disorders. Findings contribute to an emerging literature on preschool DMDD, with implications for early childhood psychiatric assessment and clinical interventions.

Predictors of Later Psychopathology in Young Children with Disruptive Mood Dysregulation Disorder

OBJECTIVE

This study aimed to identify childhood factors that predict later psychiatric problems in children with disruptive mood dysregulation disorder (DMDD).

METHODS

The sample consisted of 36 6-year-old children who met criteria for DMDD who were followed up at 9 years of age. Child psychopathology was assessed at age 6 using the Preschool Age Psychiatric Assessment (PAPA) and at age 9 using the Kiddie-Schedule for Affective Disorders and Schizophrenia. We compared children with DMDD at age 6 who continued to have a psychiatric diagnosis at age 9 (n = 17) to children with DMDD at age 6 with no psychiatric diagnosis at age 9 (n = 19) across several age 6 predictors: child psychopathology, irritability and temperament, parenting, and maternal psychopathology. In addition, we examined whether children with DMDD at age 6 and no psychiatric diagnosis at age 9 continued to experience elevated psychiatric symptoms and impairment at age 9 compared to children with a non-DMDD diagnosis at age 6 and no psychiatric diagnosis at age 9 (n = 44) and children with no psychiatric diagnosis at age 6 or 9 (n = 266).

RESULTS

The following variables predicted which children with DMDD at age 6 would have a psychiatric diagnosis at age 9: higher levels of externalizing symptoms, anger/frustration, headstrong/hurtful behaviors, functional impairment, and temperamental surgency and negative affect; lower levels of effortful control/executive functioning; and maternal depression. However, children with DMDD at age 6 and no psychiatric diagnosis at age 9 continued to demonstrate greater disruptive behavior disorder symptoms and impairment at age 9 compared to children with no psychiatric diagnosis at age 6 or 9.

CONCLUSIONS

These findings identify factors predicting later psychopathology in children with DMDD. In addition, we found that the subgroup of children with DMDD at age 6 but no psychiatric diagnosis at age 9 continued to evidence symptomatology and impairment 3 years later.

Irritability in child and adolescent psychopathology: An integrative review for ICD-11

In preparation for the World Health Organization's development of the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11) chapter on Mental and Behavioral Disorders, this article reviews the literature pertaining to severe irritability in child and adolescent psychopathology. First, research on severe mood dysregulation suggests that youth with irritability and temper outbursts, among other features of hyperactivity and arousal, demonstrate cross-sectional correlates and developmental outcomes that distinguish them from youth with bipolar disorder. Second, other evidence points to an irritable dimension of Oppositional Defiant Disorder symptomatology, which is uniquely associated with concurrent and subsequent internalizing problems. In contrast to the Diagnostic and Statistical Manual of Mental Disorders' (5th ed.) Disruptive Mood Dysregulation Disorder, our review of the literature supports a different solution: a subtype, Oppositional Defiant Disorder with chronic irritability/anger (proposal included in Appendix). This solution is more consistent with the available evidence and is a better fit with global public health considerations such as harm/benefit potential, clinical utility, and cross-cultural applicability. Implications for assessment, treatment, and research are discussed.

Evidence-based treatments for youths with severely dysregulated mood: a qualitative systematic review of trials for SMD and DMDD

The aim of this literature review was to examine the evidence for psychotherapeutic and pharmacological treatments in subjects with severely dysregulated mood and to identify potential areas for improvements in research designs. A literature search was conducted using several databases for published (PubMed, PsycINFO) and ongoing (clinical trial registries) studies conducted in youths who met NIMH's criteria for Severe Mood Dysregulation (SMD) or the DSM-5 diagnosis of Disruptive Mood Dysregulation Disorder (DMDD). Eight completed studies were identified: three randomized trials, four open pilot studies and one case report. Seven ongoing studies were found in trial registries. The available evidence suggests potential efficacy of psychotherapies which have previously been developed for internalizing and externalizing disorders. The two main pharmacological strategies tested are, first, a monotherapy of psychostimulant or atypical antipsychotic such as risperidone, already used in the treatment of severe irritability in youths with developmental disorders; and second, the use of a serotonergic antidepressant as an add-on therapy in youths treated with psychostimulant. Ongoing studies will further clarify the effectiveness of psychotherapeutic interventions for DMDD individuals and whether they should be given alone or in conjunction with other treatments. The short duration of the trials for a chronic disorder, the low number of studies, the lack of placebo or active comparator arm, and restrictive inclusion criteria in most of the controlled trials dramatically limit the interpretation of the results. Finally, future research should be conducted across multiple sites, with standardized procedures to measure DMDD symptoms reduction, and include a run-in period to limit placebo effect.

The History, Diagnosis and Treatment of Disruptive Mood Dysregulation Disorder

Disruptive mood dysregulation disorder was newly included as a diagnostic category in Diagnostic and statistical manual of mental disorders fifth edition (DSM-5), but the knowledge about it in the clinical practice field is still limited. Therefore, the aim of the present article is to introduce this diagnostic category's history, key points of diagnosis, treatment and its impact on clinical practice for clinical reference.

Functional consequences of attention-deficit hyperactivity disorder on children and their families

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder with core symptoms that include hyperactivity, impulsiveness, and inattention, and it is the most common psychiatric disorder among children and adolescents. These core symptoms are continuously recognized throughout the day from childhood to adulthood. Furthermore, children with ADHD from childhood to adulthood might also have various comorbid psychiatric disorders. Recently, bipolar disorder and disruptive mood dysregulation disorder, a new clinical issue, have been discussed as comorbid disorders or differential disorders associated with ADHD. Furthermore, comorbid disorders of ADHD are related to quality of life and family burden. Children with ADHD have poorer long-term outcomes than controls with respect to: academic achievement and attainment, occupational rank and job performance, risky sexual practices and early unwanted pregnancies, substance use, relationship difficulties, marital problems, traffic violations, and car accidents. Irritability of children with ADHD has been a key symptom that clinicians and researchers have used to evaluate the developmental condition of children with ADHD. ADHD is sometimes a chronic disorder that occurs over a long period, increasing the family burden of these children (including health-care costs), which will increase with aging for unremitted children with ADHD. Therefore, clinicians should evaluate not only the mental condition of the child but also the family burden. Children with ADHD should be treated during childhood to reduce their clinical symptoms and family burden.

Disruptive mood dysregulation disorder at the age of 6 years and clinical and functional outcomes 3 years later

BACKGROUND

Little is known about the predictive validity of disruptive mood dysregulation disorder (DMDD). This longitudinal, community-based study examined associations of DMDD at the age of 6 years with psychiatric disorders, functional impairment, peer functioning and service use at the age of 9 years.

METHOD

A total of 473 children were assessed at the ages of 6 and 9 years. Child psychopathology and functional impairment were assessed at the age of 6 years with the Preschool Age Psychiatric Assessment with parents and at the age of 9 years with the Kiddie-Schedule of Affective Disorders and Schizophrenia (K-SADS) with parents and children. At the age of 9 years, mothers, fathers and youth completed the Child Depression Inventory (CDI) and the Screen for Child Anxiety Related Disorders, and teachers and K-SADS interviewers completed measures of peer functioning. Significant demographic covariates were included in all models.

RESULTS

DMDD at the age of 6 years predicted a current diagnosis of DMDD at the age of 9 years. DMDD at the age of 6 years also predicted current and lifetime depressive disorder and attention-deficit/hyperactivity disorder (ADHD) at the age of 9 years, after controlling for all age 6 years psychiatric disorders. In addition, DMDD predicted depressive, ADHD and disruptive behavior disorder symptoms on the K-SADS, and maternal and paternal reports of depressive symptoms on the CDI, after controlling for the corresponding symptom scale at the age of 6 years. Last, DMDD at the age of 6 years predicted greater functional impairment, peer problems and educational support service use at the age of 9 years, after controlling for all psychiatric disorders at the age of 6 years.

CONCLUSIONS

Children with DMDD are at high risk for impaired functioning across childhood, and this risk is not accounted for by co-morbid conditions.

Irritability in Pediatric Patients: Normal or Not?

The goal of this article is to describe the concept of irritability in children and youth, which has been revisited in the DSM-5. Traditionally, this behavior has been more commonly associated with mood disorders, which may account for the rising incidence of bipolar disorder diagnosis and overuse of mood-stabilizing medications in pediatric patients. While not predictive of mania, persistent nonepisodic irritability, if undetected, may escalate to violent behavior with potentially serious outcomes. It is therefore important to educate clinicians about how to accurately assess irritability in pediatric patients.

Disruptive Mood Dysregulation Disorder and Bipolar Disorder Not Otherwise Specified: Fraternal or Identical Twins?

OBJECTIVE

The purpose of this study was to examine similarities and differences between disruptive mood dysregulation disorder (DMDD) and bipolar disorder not otherwise specified (BP-NOS) in baseline sociodemographic and clinical characteristics and 36 month course of irritability in children 6-12.9 years of age.

METHODS

A total of 140 children with DMDD and 77 children with BP-NOS from the Longitudinal Assessment of Manic Symptoms cohort were assessed at baseline, then reassessed every 6 months for 36 months.

RESULTS

Groups were similar on most sociodemographic and baseline clinical variables other than most unfiltered (i.e., interviewer-rated regardless of occurrence during a mood episode) Young Mania Rating Scale (YMRS) and parent-reported General Behavior Inventory-10 Item Mania (PGBI-10M) items. Children with DMDD received lower scores on every item (including irritability) except impaired insight; differences were significant except for sexual interest and disruptive-aggressive behavior. Children with DMDD received lower scores on eight of 10 PGBI-10M items, the other two items rated irritability. Youth with DMDD were significantly less likely to have a biological parent with a bipolar diagnosis than were youth with BP-NOS. Children with DMDD were more likely to be male and older than children with BP-NOS, both small effect sizes, but had nearly double the rate of disruptive behavior disorders (large effect). Caregiver ratings of irritability based on the Child and Adolescent Symptom Inventory-4R (CASI-4R) were comparable at baseline; the DMDD group had a small but significantly steeper decline in scores over 36 months relative to the BP-NOS group (b = -0.24, SE = 0.12, 95% CI -0.48 to -0.0004). Trajectories for both groups were fairly stable, in the midrange of possible scores.

CONCLUSIONS

In a sample selected for elevated symptoms of mania, twice as many children were diagnosed with DMDD than with BP-NOS. Children with DMDD and BP-NOS are similar on most characteristics other than manic symptoms, per se, and parental history of bipolar disorder. Chronic irritability is common in both groups. Comprehensive evaluations are needed to diagnose appropriately. Clinicians should not assume that chronic irritability leads exclusively to a DMDD diagnosis.

Loss of Temper and Irritability: The Relationship to Tantrums in a Community and Clinical Sample

BACKGROUND

This study explores the relationship of irritability to tantrums and loss of temper in a community and clinical sample.

METHODS

The community sample, recruited via commercial mailing lists, consisted of 462 6-year-olds whose parents completed the Child Behavior Checklist (CBCL), and Preschool Age Psychiatric Assessment (PAPA). Tantrums were assessed in the oppositional defiant disorder (ODD) section of the PAPA. Irritability was assessed in the depression section to identify persistently irritable and/or angry mood. The clinic sample, drawn from a child psychiatry clinic, included 229 consecutively referred 6-year-olds from 2005 through 2014 whose parents completed the CBCL and Child and Adolescent Symptom Inventory (CASI). Temper loss and irritability items came from the ODD and depression sections of the CASI, and tantrum description was taken from an irritability inventory. Children's Global Assessment Scale (CGAS) and the CBCL Dysregulation Profile were examined in both samples. Logistic and multiple regression were used to compare rates of diagnosis, CBCL subscales, CGAS, and tantrum quality between children with tantrums only and tantrums with irritability.

RESULTS

Almost half (45.9%) of clinic children had severe tantrums; only 23.8% of those were said to be irritable. In the community, 11% of children had tantrums, but 78.4% of those were called irritable. However, irritability in the clinic, although less common, was associated with aggressive tantrums and substantial impairment. In contrast, irritability was associated with only a relatively small increase in impairment in the community sample.

CONCLUSIONS

Irritability may have different implications in community versus clinic samples, and tantrums assessed in the community may be qualitatively different from those seen in clinics.

Prevalence and Correlates of Disruptive Mood Dysregulation Disorder Among Adolescents with Bipolar Disorder

OBJECTIVE

The purpose of this study was to examine the prevalence and correlates of disruptive mood dysregulation disorder phenotype (DMDDP) in a clinical population of adolescents with bipolar disorder (BD).

METHODS

DMDD criteria were modified and applied to a sample of 116 adolescents with BD-I (n = 30), BD-II (n = 46) or BD-not otherwise specified (NOS) (n = 40) from a tertiary teaching hospital. Diagnoses were determined via the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children, Present and Lifetime version (KSADS-PL). Diagnostic and Statistical Manual of Mental Disorders (DSM-5) DMDD Criteria A-G were derived from the KSADS oppositional defiant disorder (ODD) screening interview and supplement, as well as narrative summaries. Chi-square analyses or t tests (p < 0.05) were conducted as appropriate, followed by logistic regression. P values were adjusted using the false discovery rate (FDR) approach.

RESULTS

DMDDP criteria could not be determined for 8 adolescents because of missing data from the ODD supplement. Twenty-five percent of the remainder (27/108) met criteria for DMDDP. DMDDP was not associated with BD subtype or with family history of BD. In univariate analyses, after controlling for age, sex, and race, DMDDP was associated with lower functioning, increased family conflict, assault history, and attention deficit and/or hyperactivity disorder (ADHD) (FDR adjusted p values: <0.0001, < 0.0001, 0.007, and 0.007, respectively). Lifetime substance use disorder and medication use approached significance (adjusted p = 0.05). In logistic regression, DMDDP was independently associated with greater parent-reported family conflict (odds ratio [OR] 1.17; confidence interval [CI- 1.06-1.30; p = 0.001) and greater functional impairment (OR 0.89; CI 0.82-0.97; p = 0.006). DMDDP was also associated with a threefold increase in ADHD, although ADHD was only marginally significant (OR 3.3; CI 0.98-10.94; p = 0.05).

CONCLUSIONS

Despite the positioning of DMDD as phenotypically and biologically distinct from BD, these phenotypes commonly overlap in clinical settings. This overlap is not explained by BD-NOS or by nonfamilial BD. The association of ADHD with DMDDP in this sample draws into question whether arousal symptoms should have been retained as originally elaborated in the severe mood dysregulation phenotype. Strategies to mitigate the excessive functional impairment of this comorbidity are warranted.

Comorbidity and correlates of disruptive mood dysregulation disorder in 6-8-year-old children with ADHD

This study aimed to characterize the nature and impact of disruptive mood dysregulation disorder (DMDD) in children with attention-deficit/hyperactivity disorder (ADHD) including its co-occurrence with other comorbidities and its independent influence on daily functioning. Children with ADHD (6-8 years) were recruited through 43 Melbourne schools, using a 2-stage screening (parent and teacher Conners 3 ADHD index) and case-confirmation (Diagnostic Interview Schedule for Children, Version IV; [DISC-IV]) procedure. Proxy DMDD diagnosis was confirmed via items from the oppositional defiant disorder (ODD) and major depressive disorder modules of the DISC-IV. Outcome domains included comorbid mental health disorders, academic functioning, social functioning, child and family quality of life, parent mental health, and parenting behaviors. Unadjusted and adjusted linear and logistic regression were used to compare children with comorbid ADHD and DMDD and children with ADHD without DMDD. Thirty-nine out of 179 children (21.8 %) with ADHD had comorbid DMDD. Children with ADHD and DMDD had a high prevalence of ODD (89.7 %) and any anxiety disorder (41.0 %). Children with ADHD and DMDD had poorer self-control and elevated bullying behaviors than children with ADHD without DMDD. Children with ADHD and DMDD were similar to children with ADHD in the other domains measured when taking into account other comorbidities including ODD. One in five children with ADHD in their second year of formal schooling met criteria for DMDD. There was a very high diagnostic overlap with ODD; however, the use of a proxy DMDD diagnosis containing items from the ODD module of the DISC-IV may have artificially inflated the comorbidity rates. DMDD added to the burden of ADHD particularly in the area of social functioning.

Disruptive Mood Dysregulation Disorder in a Community Mental Health Clinic: Prevalence, Comorbidity and Correlates

OBJECTIVE

The revision of the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) added a new diagnosis of disruptive mood dysregulation disorder (DMDD) to depressive disorders. This study examines the prevalence, comorbidity, and correlates of the new disorder, with a particular focus on its overlap with oppositional defiant disorder (ODD), with which DMDD shares core symptoms.

METHODS

Data were obtained from 597 youth 6-18 years of age who participated in a systematic assessment of symptoms offered to all intakes at a community mental health center (sample accrued from July 2003 to March 2008). Assessment included diagnostic, symptomatic, and functional measures. DMDD was diagnosed using a post-hoc definition from item-level ratings on the Schedule for Affective Disorders and Schizophrenia for School-Age Children that closely matches the DSM-5 definition. Caregivers rated youth on the Child Behavior Checklist.

RESULTS

Approximately 31% of youth met the operational definition of DMDD, and 40% had Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) diagnoses of ODD. Youth with DMDD almost always had ODD (odds ratio [OR] = 53.84) and displayed higher rates of comorbidity with attention-deficit/hyperactivity disorder (ADHD) and conduct disorder than youth without DMDD. Caregivers of youth with DMDD reported more symptoms of aggressive behavior, rule-breaking, social problems, anxiety/depression, attention problems, and thought problems than all other youth without DMDD. Compared with youth with ODD, youth with DMDD were not significantly different in terms of categorical or dimensional approaches to comorbidity and impairment.

CONCLUSIONS

The new diagnosis of DMDD might be common in community mental health clinics. Youth with DMDD displayed more severe symptoms and poorer functioning than youth without DMDD. However, DMDD almost entirely overlaps with ODD and youth with DMDD were not significantly different than youth with ODD. These findings raise concerns about the potentially confusing effects of using DMDD in clinical settings, particularly given that DSM-5 groups DMDD with depressive disorders, but ODD remains a disruptive behavior disorder, potentially changing the decision-making framework that clinicians use to select treatments.

Ten-year updated meta-analysis of the clinical characteristics of pediatric mania and hypomania

OBJECTIVES

The phenomenology and diagnosis of pediatric bipolar disorder has been controversial. We aimed to update a 2005 meta analysis of the prevalence of manic symptoms in youth, in order to determine whether the picture of pediatric mania has changed as research on pediatric bipolar disorder has grown.

METHODS

We conducted literature reviews in PsycINFO and PubMed; studies with the prevalence of manic symptoms in youth were included. Two raters coded each study; kappa was 0.86-1.0.

RESULTS

Twenty studies were meta-analyzed (N = 2,226 youths). The most common symptoms across bipolar subtypes, using a random-effects model, were: increased energy 79%, irritability 77%, mood lability 76%, distractibility 74%, goal-directed activity 72%, euphoric/elated mood 64%, pressured speech 63%, hyperactive 62%, racing thoughts 61%, poor judgment 61%, grandiosity 57%, inappropriate laughter 57%, decreased need for sleep 56%, and flight of ideas 54%. Symptom rates were heterogeneous across samples; potential predictors were explored but no clear patterns were found.

CONCLUSIONS

Debate continues about the definitions of pediatric bipolar disorder; the results of this meta-analysis suggest that there is significant heterogeneity of symptom prevalence between studies, and that symptoms vary widely across individuals. Understanding the roots of this heterogeneity could broaden understanding of the complex clinical presentation of pediatric mania, and aid in diagnosis.

Disruptive Mood Dysregulation Disorder Among Children and Adolescents

Disruptive mood dysregulation disorder (DMDD) was introduced in the mood disorders section of DSM-5. Its primary symptoms are "severe, recurrent temper outbursts" (manifested verbally and/or physically) superimposed on and associated with chronic irritability. DMDD is a condition with an early age of onset (i.e., symptoms apparent by age 10, although the diagnosis cannot be made before age 6); however, nothing is known about the condition among adults in part because questions about temper outbursts (versus "often losing temper") are not consistently asked after 6 years of age. Other qualifiers are present so that better-known conditions are not overlooked. For instance, manic symptoms that are present for more than 1 day, symptoms that are not exclusively occurring during major depressive disorder, or symptoms that are better explained by autism, posttraumatic stress disorder, separation anxiety, and dysthymia are exclusionary. Although DMDD can co-occur with attention-deficit hyperactivity disorder (ADHD), conduct disorder, and substance use disorder, it preempts diagnoses of both oppositional defiant disorder and intermittent explosive disorder.

Disruptive mood dysregulation disorder: a new diagnostic approach to chronic irritability in youth

Disruptive mood dysregulation disorder (DMDD), a newcomer to psychiatric nosology, addresses the need for improved classification and treatment of children exhibiting chronic nonepisodic irritability and severe temper outbursts. In recent years, many of these children have been diagnosed with bipolar disorder, despite the lack of distinct mood episodes. This diagnostic practice has raised concerns, in part because of the escalating prescription of atypical antipsychotics. This article provides an overview of the limited literature on DMDD, including its history and relevant studies of assessment and treatment. A case study is included to illustrate key points, including diagnostic issues that clinicians may encounter when considering a diagnosis of DMDD.

DSM-5 disruptive mood dysregulation disorder: correlates and predictors in young children

BACKGROUND

Despite the inclusion of disruptive mood dysregulation disorder (DMDD) in DSM-5, little empirical data exist on the disorder. We estimated rates, co-morbidity, correlates and early childhood predictors of DMDD in a community sample of 6-year-olds.

METHOD

DMDD was assessed in 6-year-old children (n = 462) using a parent-reported structured clinical interview. Age 6 years correlates and age 3 years predictors were drawn from six domains: demographics; child psychopathology, functioning, and temperament; parental psychopathology; and the psychosocial environment.

RESULTS

The 3-month prevalence rate for DMDD was 8.2% (n = 38). DMDD occurred with an emotional or behavioral disorder in 60.5% of these children. At age 6 years, concurrent bivariate analyses revealed associations between DMDD and depression, oppositional defiant disorder, the Child Behavior Checklist - Dysregulation Profile, functional impairment, poorer peer functioning, child temperament (higher surgency and negative emotional intensity and lower effortful control), and lower parental support and marital satisfaction. The age 3 years predictors of DMDD at age 6 years included child attention deficit hyperactivity disorder, oppositional defiant disorder, the Child Behavior Checklist - Dysregulation Profile, poorer peer functioning, child temperament (higher child surgency and negative emotional intensity and lower effortful control), parental lifetime substance use disorder and higher parental hostility.

CONCLUSIONS

A number of children met DSM-5 criteria for DMDD, and the diagnosis was associated with numerous concurrent and predictive indicators of emotional and behavioral dysregulation and poor functioning.