Editorial: Irritable Mood and Emotional Outbursts Beyond Typical ADHD
Under the best circumstances, an accurate diagnosis can lead to use of a medication or combination of medicines that can make the patient, and, therefore the family, able to function better. Trial and error sounds negative, but these child and adolescent psychiatrists employ a step-by-step, risk-benefit approach to each medication. Children begin to feel better, begin to tolerate life at home with siblings, have some friends, and go to school in a regular classroom. The benefits include a less restrictive environment, improved sense of self/self-esteem, and enhanced family and peer relationships.
Other Stances on Disruptive Children
Other researchers believe that using the adult diagnostic label of manic-depressive disorder is inappropriate. They say that calling symptoms in a 4- or 7-year-old manic grandiosity is too much of a stretch, and argue that we do not know if these children will become adults with a formal diagnosis of manic-depressive disorder. Although these kids grow up with many difficulties, it’s premature to label them as "manic-depressive" if they eventually have some other disorder as adults, they say.
The clinicians with these latter concerns are part of an effort to rewrite the Diagnostic and Statistical Manual of Mental Disorders. They propose a new diagnostic category called Disruptive Mood Dysregulation Disorder (DMDD) for the DSM-V. This is a descriptive term that, like all the DSM diagnoses, avoids etiology. This condition is not manic-depression, but it has something to do with mood that is dysregulated and disruptive.
Although these children have irritable mood and appear "down," they often do not meet the classic criteria for depression. Clinicians with this perspective will say the children don’t get manic by adult standards and they don’t get depression by adult standards, and yet we’re calling them manic-depressive or bipolar. That, again, they say, supports DMDD.
I belong to the third group, those who say we do not sufficiently understand this behavior in children whether we call it bipolar disorder or DMDD. Neither of these diagnoses really gets to the cause, and without an etiology, it’s going to be very difficult to determine the differential diagnosis. Until our ability to identify biomarkers improves, additional descriptive categories may not bring clarity. I suspect there will be some overlap and extensive debate as various individuals and groups defend their perspective and research. We need longitudinal studies, including family history and genetic studies, as well as brain imaging studies such as functional magnetic resonance imaging, that could reveal activity in different regions of the brain that relate to observed behaviors.
I do believe this work has to be done to root these different perspectives in science and to optimize the care of these children. In the meantime, my approach is more cautious and pragmatic. Look at every aspect of these kids’ lives. Work with parents to try to head off outbursts at a very early point. Once the outbursts start, generally you cannot stop them. Sometimes there is almost a prodrome indicating that the child is getting ready for an outburst. Help the family figure out what they can do if they spot the signs 1 minute or even 10-15 seconds ahead of time. Work to set reasonable expectations, look for activities and structure to build self-esteem, and work with a team that includes an expert in psychopharmacology, as this will likely be a challenging effort.
Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital. He said he has no relevant financial disclosures. E-mail him at pdnews@elsevier.com.
This column, "Behavioral Consult," appears regularly in Pediatric News, a publication of Elsevier.
