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Disruptive Mood Dysregulation Disorder

Disruptive Mood Dysregulation Disorder is a new disorder intended to address the over-diagnosis of Bipolar Disorder in children. Since the early 1990’s, the rate of Bipolar Disorder in kids has multiplied by five, and mood stabilizing medication prescriptions (which can carry unpleasant side effects) have risen as well. Before the introduction of this new diagnosis, children who had a baseline irritable mood and regular anger outbursts were frequently diagnosed with Bipolar Disorder even though they may not have had manic or hypomanic episodes.

A new diagnosis is more fitting for this group of kids because they do not grow into adults with Bipolar Disorder. Instead, these children usually have depressive and anxiety disorders as adults, which is why this new disorder is grouped with depressive disorders.

These children have a persistently irritable mood and significant difficulty regulating their emotions in frustrating situations. Minor annoyances can easily set off sudden instances of uncontrolled verbal and physical violence, and this happens four times a week on average. This leaves parents, siblings, and peers exhausted and on edge, nervous about what might trigger the next one.

But what’s the difference between these anger outbursts and standard, childhood temper tantrums? Temper tantrums last a few minutes, have a gradual rise and fall of anger and frustration, and are expected in all children up to age 4. In contrast, the anger outbursts characteristic of this disorder last longer (up to 30 minutes) and are much more intense. The onset of the child’s rage is much more sudden and slowly declines afterward.

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Causes and Risk Factors

Population rates

Because this disorder is new, population rates have not been studied much, but early research shows this disorder may appear in about 2-5% of children. Additionally, it seems to be much more common in boys than in girls. This disorder starts early, too. More than 80% of children who have the diagnosis at age 9 were diagnosed at age 6.

Parent’s mental health

At least 75% of children with this disorder have parents who also suffer from mental health issues. The most common mental disorders in these parents are depressive disorders, attention problems, substance use disorders, and anxiety disorders.

Family environment

This disorder is more common in children who did not enjoy a nurturing home life. These parents are more likely to have been critical of their children and not emotionally supportive in times of need. Furthermore, trauma in general, be it emotional, physical, or sexual, is associated with difficulty regulating emotions, but this has not been studied specifically with Disruptive Mood Dysregulation Disorder.

Emotional processing

Children who have difficulty regulating their emotions also tend to focus their attention differently when reading others’ emotions, especially facial expressions. Irritable children hone in on negative (sad or angry) facial expressions automatically faster than happy or neutral faces. Additionally, the severity of the irritability correlates increased attention on the negative expressions.

Co-occurring disorders

This disorder very rarely occurs alone. The most common accompanying disorders are Oppositional Defiant Disorder, depressive disorders, and anxiety disorders. In fact, 55% of children with this disorder also have Oppositional Defiant Disorder. Additionally, symptoms of depressive disorders, Attention Deficit/Hyperactivity Disorder, and Oppositional Defiant Disorder in children as young as 3 years old predict the later development of Disruptive Mood Dysregulation Disorder.

Diagnosing Disruptive Mood Dysregulation Disorder

Making the diagnosis

These children have a consistently irritable or angry mood for most of the time on most days that is noticeable to family, friends, and teachers. This mood is punctuated by multiple, serious, angry outbursts usually in response to frustrating situations. They can be verbally or physically aggressive and are much more intense than expected for the situation. These happen at least three times a week and are not appropriate for the child’s age.

To qualify, these symptoms must have lasted at least a year and not had a break longer than three months. They occur and cause problems in at least two of the following situations: at school, at home, or with friends. This disorder is only diagnosed in children aged 6 to 17, and it usually starts before age 10.

This disorder cannot coexist with Oppositional Defiant Disorder or Intermittent Explosive Disorder. If the child seems to have one of these and Disruptive Mood Dysregulation Disorder, they only get diagnosed with the latter.

Distinguishing from Bipolar Disorder

Previous to the creation of Disruptive Mood Dysregulation Disorder, this is a population of children who may have been diagnosed with Bipolar Disorder but did not have definite mania or hypomania. These two symptoms are the hallmark characteristics of Bipolar Disorders I and II. If a child has a true episode of mania or hypomania, that excludes the diagnosis of Disruptive Mood Dysregulation Disorder.

In contrast, Disruptive Mood Dysregulation Disorder denotes kids who have persistent irritability and anger outbursts. Though irritability is a symptom of mania and hypomania, in this disorder, the irritability is a near constant aspect of the child’s mood instead of existing only in distinct episodes like mania. Furthermore, these children do not display the grandiosity, flight of ideas, or elevated, euphoric mood of mania and hypomania.

Treating Disruptive Mood Dysregulation Disorder

Because this disorder is so new, there have been very few studies on it specifically. Presently, treatment decisions are based on current treatments for Bipolar Disorder, Oppositional Defiant Disorder, Conduct Disorder, and Attention Deficit/Hyperactivity Disorder.

Therapy

Cognitive Behavioral Therapy (CBT) is the starting point for most therapies used to treat different forms of mood disorders in children, including Disruptive Mood Dysregulation Disorder. Tested treatments for this disorder focus on teaching children to observe and identify their emotions and understand that their emotions are separate from their personality. They grade how powerful they are, and learn how they can lead to problematic behaviors. Children hone skills and techniques to navigate triggering situations in non-destructive ways. This is an important step in maturity that these children need assistance with, learning to regulate negative emotions peacefully.

Parents play a crucial role in a child’s treatment because they need to create an environment that supports what the child learns in therapy. The first step is educating parents about the disorder and separating disorder signs and symptoms from normal child behaviors. Parents learn to recognize their child’s anger triggers, how their emotions and behaviors affect their child’s, and how to manage their own emotional responses to the child’s issues. They need to ignore and not reinforce unwanted behavior and to reward the child’s use of appropriate coping mechanisms. Additionally, parents learn the importance of a structured environment: a regular routine for eating, sleeping, play, and school.

Medications

There are no medications approved for this disorder by the Food and Drug Administration currently. Most available research points to medications like Risperdal (risperidone) and Depakote (divalproex) because of their utility in treating mood instability in Bipolar Disorder. Stimulants like Ritalin (methylphenidate) have been shown to reduce aggression in children with coexisting Attention Deficit/Hyperactivity Disorder. Unfortunately, these medications have not been studied enough yet for this disorder to make them go-to choices for treatment.

Managing Disruptive Mood Dysregulation Disorder

Outcomes in adolescence and adulthood

Children with Disruptive Mood Dysregulation Disorder have major issues with their peer group as adolescents. They are frequently bullied and excluded from groups. They also have a tendency to be aggressive in peer relationships.

These children and adolescents grow into adults who tend to have multiple areas of difficulty functioning. They are more likely to develop depressive and anxiety disorders in adulthood. They have more health issues like smoking and sexually transmitted diseases. These adults also have behavioral problems, such as fighting, legal issues, and frequent police contact. Trouble with finances, job instability, and failure to complete high school or higher education also plague these adults.

Educating caretakers

Although part of treatment includes educating parents about the disorder, teachers, who spend a significant amount of time with these children, also need to understand it. Schools need to have plans in place for managing anger outbursts during the day. They also need to be aware of potential side effects if any medications are being used in treatment.

Different from Oppositional Defiant Disorder

Both of these disorders involve anger outbursts, frequently occur together, and are often confused. A key difference is that kids with Oppositional Defiant Disorder have trouble specifically with authority figures, be they parents, teachers, or police. Those children are driven to defy authority and show little (or no) regret for doing so. Children with Disruptive Mood Dysregulation Disorder get angry in the presence of anyone, authorities and peers, and feel bad afterward.

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References
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