Editorial: Irritable Mood and Emotional Outbursts Beyond Typical ADHD
We all see kids with attention-deficit/hyperactivity disorder, and some of these children seem to have a very irritable mood and out-of-the-ordinary behavioral outbursts.
Some respond well to comprehensive treatment for ADHD and get better. Others, however, continue to erupt with emotional outbursts that are different in character and intensity than what we’ve come to expect from treatment-responsive kids with ADHD. The mood state seems disproportionate to the ADHD, and is not a side effect of stimulant medication.
While tantrums are a typical part of early childhood, these outbursts may appear more random, more frequent, more intense and long lasting, and out of proportion to whatever may have stimulated them.
Child and adolescent psychiatrists initially began to wonder: Why are these kids not responding to treatment? Why is their mood so difficult to manage? Why these outbursts and constant irritability? Could this be something other than ADHD?
This is a very controversial topic that is generating a great deal of active discussion and research. Child and adolescent psychiatrists are essentially divided into three camps. Some believe this may be part of a clinical picture consistent with a childhood form of manic-depressive disorder, now commonly called bipolar disorder; others propose a new diagnosis called Disruptive Mood Dysregulation Disorder; and others, like me, believe we simply do not know enough about these children, especially the very young ones, to make the call at this point.
The one thing we do know is that these families are desperate. They are on constant high alert, waiting for two to three unexpected, unexplained, potentially violent outbursts per day. Their irritable, disruptive, even sometimes violent 3-year-old, 4-year-old, 5-year-old, or 6-year-old child greatly alters the family dynamic and causes everyone much distress.
No matter which classification perspective you take, these children and families require our maximum effort. For the child, make adjustments at school and at home, offer support, and treat the child using therapy, family work, behavioral training, and/or medication in a thoughtful way. The psychopharmacology will likely be beyond the scope of a primary care pediatrician and will require expert consultation or management. The parents will need your support – they typically try to do everything logical to make the children feel good, to boost their self-esteem, and to improve their mood state; and almost nothing works well. In particular, the usual parenting approach of reward and consequence is often ineffective or even seems to make matters worse.
You’ve seen a 2-year-old with a temper tantrum. Now imagine a 4-year-old who has temper tantrums almost without cause. A parent may say, "Come in for dinner now!" and the kid erupts. Dinner gets cold on the table while the parent deals with a screaming, unhappy child who has now escalated by attacking his brother or destroying the kitchen area. Finally, everyone sits down, they are in tears, and everyone feels badly about themselves. The parent says, "That behavior is unacceptable. No dessert for you!" and another outburst might erupt.
Children and Manic-Depressive Disorder
Proponents of a manic-depressive diagnosis point to a family history of manic-depressive disorder in some children. Several family studies using rigorous direct interviewing techniques have found high rates of bipolar disorder in relatives of children meeting diagnostic criteria for mania, even when the children have predominately irritable rather than euphoric moods. Three longitudinal studies have documented persistence of course, and one study by Geller et al. followed 54 children for 8 years beyond age 18 years and found an evolution to the adult disorder (Arch. Gen. Psychiatry 2008;65:1125-33).
Much more, however, needs to be done and redone to confirm these findings in different samples. In addition, some outbursts are so out of control that they look like mania or co-occur with the full diagnostic picture of mania with grandiosity, decreased need for sleep, pressured speech (rapid talk where they can’t get the words out quickly enough), and distractibility, even to a greater extent than in typical ADHD.
Consideration of manic-depressive disorder in this population allows the use of medications to stabilize mood and reduce irritability. Currently, five medications are Food and Drug Administration–approved for the treatment of mania in children: risperidone, aripiprazole, and quetiapine (approved down to age 10 years); olanzapine (down to age 13 years); and lithium, which has been "grandfathered" in by the FDA for mania in youth. Nonetheless, a trial-and-error approach is still necessary to find the medication or combination of medications most useful for not only the mood symptoms of mania and depression, but also the many co-occurring symptoms of ADHD and anxiety.
