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Criteria (Symptoms) of DMDD

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DMDD: A New Controversy in Diagnosing Childhood Bipolar Disorder

DMDD or Disruptive Mood Dysregulation Disorder - A new controversy in diagnosing childhood bipolar disorder.

In May 2013, the DSM-5 was released. There are many changes, but the one that could have the most impact on children who have either already been diagnosed with or are in the process of being diagnosed with childhood bipolar disorder is Disruptive Mood Dysregulation Disorder (DMDD). DMDD was originally called Temper (or Tantrum) Dysregulation Disorder with Dysphoria (TDD), but the name was changed as it was felt that it might carry too much negativity in relation to "typical" temper tantrums. It should be noted that a diagnosis of DMDD should have onset of symptoms that began before the age of 10, and that a child cannot be diagnosed until they are at least 6 years old.

The DSM-5’s new diagnosis of DMDD was created to address the "over-diagnosis" of bipolar disorder in children who experience explosive rages. DMDD will be a new diagnostic home for children who have frequent, severe temper tantrums that interfere with their ability to function in school, at home, or with their friends. The American Academy of Child & Adolescent Psychology (AACAP) states that some children were previously diagnosed with childhood bipolar disorder, even though they did not have all of the signs and symptoms. The AACAP further elaborates that while occasional temper tantrums are a normal part of growing up, if children are usually angry or irritable or temper tantrums are frequent, intense, and ongoing, it may be signs of the mood disorder DMDD.

What the AACAP and others fail to mention, is that the criteria and symptoms for bipolar disorder in the DSM-IV and the DSM-V are geared towards adults, especially in respect to duration of episodes. The DSM does provide a category for Bipolar Disorder – Not Otherwise Specified (NOS) for individuals who do not fit the duration requirements for manic, depressive, and/or mixed episodes, but again, this is still primarily geared towards adults.

Many feel that the diagnosis of DMDD may be misdiagnosed and/or abused, as well as putting children at greater risk. The Juvenile Bipolar Research Foundation (JBRF) and the National Alliance for the Mentally Ill (NAMI) are two groups that have concerns over this diagnosis ranging from the lack of new and compelling evidence to the proposed treatment guidelines that begin with psychotherapy and psychoeducation. The JBRF has expressed serious concerns to both the direct and indirect consequences of this new diagnosis and believes that the proposed treatment regimen is inadvisable and may in fact hasten onset and/or increase suicidal behavior.

OUR OPINIONS/THOUGHTS

While we would like to see the inclusion of a diagnostic home of childhood bipolar disorder in the DSM, we believe the authors of the DSM are going about things the wrong way. Instead of looking at a category such as DMDD as a diagnosis for children with bipolar disorder who they feel do not meet all the criteria of bipolar disorder (currently geared towards adults), they should consider a category of bipolar disorder for children with criteria geared towards children.

It should not be difficult to understand that children will not meet all of the criteria for adult bipolar disorder as there are certain behaviors and/or symptoms that children would have no way of fulfilling. When considering criteria for mania, would we see children (who have no access to credit cards and bank accounts) going on wild spending sprees, or taking part in sexual indiscretions? When we consider the criteria for depression, is a child going to communicate openly and honestly about feelings they might not understand such as recurrent thoughts of death, feelings of worthlessness and guilt, feeling fatigued, or an inability to concentrate?

It is quite clear to us that the nature of children and their normal development should be taken into consideration when looking at a proper diagnostic home for children who may have childhood bipolar disorder. DMDD is not the answer. Many of the criteria or symptoms of DMDD are not adequately defined and can be open to interpretation. Who is to say that a "temper outburst" is severely out of proportion in duration or intensity for the situation and how is it determined that a child's reaction is bigger than expected? Often children do have reactions bigger than expected - this could be because they are trying to provoke a response from someone or maybe it could be a learned behavior that if they have a bigger than expected reaction they get what they want.

One of our concerns is that children who do have bipolar disorder and do not meet the adult criteria for bipolar disorder will be incorrectly diagnosed with DMDD. This could have severe consequences as the current treatment regimen is to begin with therapy and education. If a child truly has bipolar disorder, a misdiagnosis could have severe and detrimental effects on their mental and emotional well-being, as well as affect their parents and/or caregivers. Is it worth the risks of self-harm, suicide, worsening mental health, and/or increasing instability just to appease those groups or individuals who believe that bipolar disorder is being over-diagnosed in children?

We are also concerned that DMDD will follow in the footsteps of ADHD and be the first and sometimes, only, diagnosis a doctor will consider for a child who may in reality have bipolar disorder. This could have risks of its own, as children who do have bipolar disorder could go misdiagnosed, receive incorrect and/or inadequate treatment, or even receive no treatment for years. What effects might there be on a child misdiagnosed with DMDD? How might a child's life have been different if they had received a proper diagnosis and the correct treatment?

It is our hope that parents who believe their child may have bipolar disorder will educate themselves when going through the process of receiving a diagnosis for their child. Parents should ask specific questions of the doctor as to why the doctor feels a certain diagnosis fits and what recommendations the doctor is making for treatment.

We also hope that one day the DSM will include a category for childhood bipolar disorder with criteria that are geared towards children. With the efforts of organizations to educate and inform people on childhood bipolar disorder, as well as the research studies conducted by the Juvenile Bipolar Research Foundation and others, we hope that a diagnostic category of childhood bipolar disorder will appear within the DSM in the near future.

 

CRITERIA (SYMPTOMS) FOR DMDD

  • The diagnosis should not be made for the first time before the child is 6 years old or after the child is 18 years old
  • Symptoms must have begun before age 10
  • Symptoms must be present for at least 1 year
  • Severe, recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation, and occur at least 3 or more times a week
  • The temper outbursts are manifest in the form of verbal rages or physical aggression towards people or property
  • The temper outbursts are inconsistent with the child’s developmental level
  • Sad, irritable, or angry mood almost every day
  • Reaction is bigger than expected
  • The child has trouble functioning in more than one place (i.e., home, school, in the community, with friends)
  • There has never been a distinct period lasting for more than 1 day during which an abnormally elevated and/or expansive mood was accompanied by the onset or worsening, of 3 of the criteria for mania (i.e., decreased need for sleep, grandiosity, pressured speech, flight of ideas, inflated self-esteem, distractibility, increase in goal-directed activity, excessive involvement in activities with a high potential for painful consequences)
  • The behaviors do not occur exclusively during an episode of Major Depressive Disorder (MDD) and are not better accounted for by another mental disorder; the symptoms are not due to the effects of a drug, neurological condition, or general medical condition

 

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