Today’s guest blogger is R. Rao Gogineni,M.D., head of the division of child & adolescent psychiatry, at Cooper University Hospital and associate professor of psychiatry at Cooper Medical School of Rowan University.
Occasional temper tantrums and bad moods are a normal part of growing up. Many children are irritable, upset or moody from time to time. However, there may be a problem for children with severe and frequent temper tantrums that interfere with their ability to function at home, in school, or with their friends.
To address this condition, the American Psychiatric Association proposed a new diagnostic classification called Disruptive Mood Dysregulation Disorder in its new manual (DSM-5) released in May. A child must have rages that are "grossly out of proportion" three or more times per week on average to receive a DMDD diagnosis.
The symptoms of DMDD include:
- Severe verbal and/or behavioral temper outbursts, on an average three times a week. These temper outbursts are inconsistent with the child’s developmental level.
- Mood between outbursts is persistently irritable or angry almost every day.
- The child has trouble functioning in more than one setting (e.g., home, school and/or with friends).
- The child’s reaction is more magnified than expected.
- The child must be at least six years old and symptoms must begin before age ten.
- The symptoms are present for at least a year.
Exclusionary criteria include presence of mania, major depressive disorder, dysthymia, psychosis, post-traumatic stress disorder, pervasive developmental disorders, or separation anxiety.
Prevalence rates of DMDD are estimated to be 0.8 to 3.3 percent. Research demonstrated children with this disorder may later develop depression or anxiety, but not bipolar disorder.
The major reason the APA proposed this diagnosis was a finding that between 1994-1995 and 2002-2003, the diagnosis of bipolar disorder grew by 40-fold in children and that many of these children had behaviors that were not consistent with a bipolar diagnosis.
The new diagnosis isn’t without some controversy. Ellen Leibenluft, MD, of the National Institute of Mental Health, who is responsible for the research leading to the DMDD classification, and Gabrielle Carlson, MD, a leading authority on bipolar disorder from Stony Brook University, concurred with this finding. But some other leading authorities and some anti-psychiatry groups fear that the new DMDD diagnosis will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children.
What can be done?
The treatment for DMDD needs to be individualized and may include individual therapy, and working with the family and school. It may also include the use of medication to help address specific symptoms. Parents should learn about the disorder, the specific treatment options and feel free to get a second opinion. Having a child with DMDD can be a challenging experience. Appropriate treatment for the child is important.
Here’s a case example:
A 6 year-old boy, living with his mother, step father and younger sister was brought to the clinic with history of severe temper outbursts, both verbal and behavioral (throwing things, stomping, hitting self and others) “when things don’t go his way”. This would last 10 minutes to 2 hours, or until he became tired. This happened almost daily and sometimes several times a day. Often he was angry and irritable. Attention span for desired activities was not impaired. These tantrums started when he was 2 ½ yrs of age. There was no known family history of bipolar disorder.
The treatment prescribed included parent education, training, supportive child therapy and 1 mg of long acting Guanfacine (Intuniv) once a day with a plan to use for 3 to 6 months if needed. After three months, there was marked improvement in his behavior. If a child is symptom free for three months, we try to taper medication off and then stop. About a quarter of the time, a child may require medication longer term.
For more information about children with DMDD and other challenging behaviors:
The Balanced Mind Foundation
National Alliance on Mental Illness
Mental Health America
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