CNS 762-DG Carter

J'Nae Broadnax
February 13, 2016

Disruptive
Mood
Dysregulati
on
Disorder in
the Young
Child

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Introduction Disruptive Mood Dysregulation Disorder

All individuals within our society can reflect on times witnessing a young child
4-5 years of age, exhibiting tantrums in a public setting. Judgements are often made
as to whether the behavior is disregarded considering it to developmentally
appropriate to the child, (i.e. an extended phase of the terrible twos), to questions
regarding the effectiveness of parenting styles with being able to control the childs
behavior. Considering the many changes in our society today with increased stress
levels, heightened arousal states that in turn affect behavior& mood, it sparks
curiosity about the trajectory of young children as it relates to mental health and
well-being and their ability to cope in a chaotic world. The purpose of this paper is
to identify one of the latest childhood diagnoses relative to mood/depressive
disorders, Disruptive Mood Dysregulation Disorder.
Disruptive Mood Dysregulation Disorder is considered a new classification
phenomenon identified within the DSM-V to alleviate the over diagnosing of
pediatric bipolar disorder, (APA, 2013). Increases in pediatric bipolar disorder has
precipitated trends within the field of psychiatry, psychology/counseling relative to
how to effectively diagnose and treat it. Several years of working with young
children from an early intervention approach, addressing childhood
behavioral/emotional disorders, has prompted desire to study this topic further.
Future work with this particular diagnostic group is contingent on the current
literature for Disruptive Mood Dysregulation Disorder and new developments in
treatment. Descriptions of the DSM-V classification DMDD, provides information on
this topic in conjunction with the incorporation of a case study as illustration of the

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disorder are presented. Advocacy, legal approaches and ethics surrounding issues
with DMDD are also addressed.

Existing literature on Disruptive Mood Dysregulation Disorder

Diagnostic criteria according to the DSM-V for Disruptive Mood Dysregulation
Disorder describes, severe recurrent temper outbursts characterized by either
verbal rages and or behaviorally acting out through physical aggression toward
people or property that is grossly out of proportion in intensity and duration to the
situation or provocation, (APA, 2013). Another critical factor in diagnosing DMDD is
that the temper outburst is inconsistent with the individuals developmental level,
occurring on average 3 or more times per week, (APA 2013). The American
Psychological Association (2013) also describes the range of the individuals mood
from persistent irritability or anger present most of the day, daily and is able to be
observed by others that provide care or support to the child. Duration of the
disorder must be evident for more than 12 or more months, and observable in 2 or
more settings. During this time frame the individual must not have a period of more
than a three consecutive month absence of the symptoms described above. It is
important to note that the typical, age for diagnosing DMDD is around 6 years of
age and before 10 years old (APA, 2013). DMDD has a prevalence through age 18,
(APA, 2013). Considerations for diagnosis are that DMDD cannot co-exist with other
psychiatric diagnoses such as Oppositional Defiant Disorder, Intermittent Explosive
Disorder or the diagnosis DMDD is often mistaken for as the episodic Bi-Polar
Disorder, (APA, 2013). The diagnosis of DMDD must be in the absence of manic or

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hypomanic episodes, substance abuse and are not allocated as any other
neurological conditions, (APA, 2013).
Features of the disorder according to the DMS-V (2013) include symptoms of
chronic, persistent irritability characterized by frequent temper outbursts which are
in response to frustrations experienced by the child or individual (APA, 2013).
Symptoms manifest intensely in the form of either verbal or physical aggression
directed toward self, others or property, (APA, 2013). Another manifestation can be
perceived in severe irritability with a chronic and persistent angry mood that as a
characteristic of the child daily, (APA, 2013). The irritable/angry mood is more
apparent between temper outburst, (APA, 2013). Frequency of DMDD symptoms are
on average of 3 or more events within a given week span and with a duration of
occurrence over a year in at minimum of 2 settings, (APA, 2013).
Prevalence of DMDD is estimated at 2-5% of school age children with higher
occurrences in males than females for both school age and adolescents according to
the DMS-V, (2013). In terms of the cause of DMDD, speculations remain due to the
limited research and literature on this new diagnosis. Studies promote exploration of
causes in attempts to make correlations between similar diagnoses such as SMD
(Severe Mood Dysregulation) and areas in the brain with impaired functioning with
DMDD. Ryan, 2013s article discussing DMDD and Associated Brain circuit changes
stated in regards to SMD, In the whole-brain analyses, youths with severe mood
dysregulation exhibited less activation in parietal, parahippocampal, and
thalamic/cingulate/striatal regions than healthy youths on negative feedback trials
but not on positive feedback trials. Until more research is conducted in regards to
the potential causes of DMDD relative to the brain and external negative stimuli
causes of DMDD will remain a mystery.

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Available Treatments
Most of the literature reviewed on DMDD indicated two methods of treatment
which are pharmacological management and psychosocial interventions. Roy, A.,
Lopes, V., & Klein, R., (2014) conveys initial implications for treatment in regards to
pharmacological management, stating, Since DMDD is a new diagnosis, there are
no informative clinical trials from which to establish judicious practice. However,
rational clinical guidelines may be distilled from treatment studies of disorders that
share the main inclusion criteria with DMDD. This indicates that based on
diagnoses that are similar in symptom presentation to DMDD and medications that
are used to treat symptoms (irritability, aggression) in other diagnoses are being
prescribed to address symptoms in DMDD. Most of the literature supports the use
of medications such as Atypical antipsychotics (Risperidone), stimulants
(methylphenidate), and antidepressants (fluoxetine) to name a few in the treatment
of aggressive behavior in DMDD. It is important to point out the high comorbidity of
DMDD with ADHD, Major Depressive Disorder or Anxiety Disorder. Tourian, L.,
LeBoeuf, A., Breton, J.-J., Cohen, D., Gignac, M., Labelle, R., Renaud, J. (2015)
article describes comorbidity and treatment approaches relaying that, DMDD is
highly comorbid with disruptive behavior disorders such as ADHD, ODD, and CD. It
seems legitimate to recall that psychosocial and behavioral approaches are highly
effective in many cases of chronic irritability and/ or aggression. Behavior
modification (Waxmonsky 2008; Frazier, 2010), multisystemic family therapy
(Kazdin, 2002), or inpatient stay (Dickstein, 2009) have proved to be beneficial in
well-designed studies.
This premise of what works for similar diagnoses may work for DMDD is also
true for other treatment methods such as psychosocial and psychotherapeutic

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interventions. Literature on the topic of DMDD confirms the use of interventions

such as positive parenting/parent training, and individual or group therapy utilizing
approaches such as cognitive behavioral therapy, mindfulness (DBT) or behavior
modification. Psychotherapy in conjunction with pharmacotherapy are suggested as
the best course of treatment. Family therapy is also a consideration due to the
significant impact DMDD has on family dynamics which Roy et.al., (2014) confirms
in his closing statements, Given the complex clinical picture of children with DMDD
and the negative ramifications the disorder has on family function and parent-child
relationships, a combination of therapeutic approaches will likely be needed to
achieve meaningful improvement. Although the literature suggests these
treatments for DMDD further research is needed to determine the efficacy of their
use to treat DMDD.

Case Study
A means to assist readers in grasping a true illustration of DMDD a discussion
surrounding the case of a six-year-old client who in order to maintain anonymity is
referred to as Megan, is presented. A brief description of the client, background,
symptomology, along with conceptualization and treatment plan are constructed.
Megan, a 6-year old petite Caucasian female, presented to the office with her
parents to receive treatment services due to severe recurrent outbursts that
escalate to physical aggression towards peers in school and has resulted in

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significant property damage. Client has continued to have behavioral issues

within the academic setting over the course of 2 years which has resulted in
being expelled from 1 private childcare setting and a private educational
setting. Prior treatments during the course of 2 years has been, outpatient
therapy for the duration of 1 year, intensive in-home services for 8 months,
occupational therapy for 1 year to address sensory needs and address mood
instability. Previous diagnosis includes ADHD (impulsivity/distractibility traits).
Parents have pursued pharmacological management with stimulants within
this last year. Although Megans progress has been limited in all treatment
aspects she has refrained from any prior hospitalizations. She consistently
presents pervasive irritability (mood instability) during most of the day and
has difficulty participating or even being motivated to participate in
academic tasks or even physical task during PE without verbal or physical
altercations occurring on average 3-5 times a week. Parents express
concerns for Megans escalating aggressive behavior causing physical injury
to 2 other peers while at school when on one occasion a peer cut in line in
front of her and on another occasion a peer was acknowledged by a teacher
instead of her during class time.
Megan resides in the natural home with two loving parents and a
younger sibling. She has no history of trauma, medical or health
contraindications to note. Parents report observations of social challenges
getting along with same age peers and sibling due to her behavior. Temper
outburst occur in the home environment as well to the point that parents
have used physical restraint of Megan 2 x in the course of the last 8 weeks
due to rage when asked to share with her sister. Parents describe Megans

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case in the office and both become tearful expressing the uncertainties of
how to proceed considering her previous interventions have not been
successful.

Conceptualization & Treatment Formulation:

Megan presents definite symptomology consisting of recurrent temper
outburst that manifest through aggressive behaviors that have been exhibited in
multiple settings (school & home). These aggressive behaviors cause parents to be
concerned about Megans safety as well as the safety of others that she comes in
contact with. She has had prior interventions with noted increasing levels of care to
more restrictive settings. Limited effectiveness of treatment has been acquired
through lower level interventions (OPT/ Intensive In-home). Observations of her
during the intake process revealed moderate distractibility, impulsivity and verbal
resistance when prompted to engage in a drawing task with the therapist as she
initiated statements, I dont want to. Mild anxiety and irritability was noted during
transition to the playroom for the Mental Status Exam and comprehensive clinical
assessment.

No reports of previous diagnoses or symptoms other than ADHD for

which she currently receives stimulant medication (methylphenidate 5 mg BID). She

continues to have ongoing behavioral outburst which have occurred over a 2 year,
period on average for 3-5 x weekly. Information gathered is indicative of a diagnosis
of Disruptive Mood Dysregulation Disorder 296.99 (F34.8) and continuing diagnosis
of ADHD 314.01 (F90.2) Combined Presentation.
Highlighting Megans strengths are integral pieces that can be of resource in
treatment planning. Megan is highly intelligent and desires social engagement with
peers however lacks appropriate social skills and due to impulsivity, and mood

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instability she is unable to apply skills that she may have acquired during prior
interventions to cope and navigate socially. She gravitates towards activities that
evoke use of creativity, dramatic play. She also has a supportive family with a two
parent home and stability. Factors impacting family dynamics are Megans mother a
geriatric nurse has been diagnosed with Generalized Anxiety Disorder, which is key
to consider in relation to parenting styles. Bearing in mind the family history, Megan
is possibly genetically pre-disposed to development of anxiety/depression as she
matures. Megans father is less engaged in treatment aspects due to his high
intense job as a detective with the local police department which leaves Megans
mother to bear the weight managing behavior. This highlights the emotional impact
Megans behavior has on the family collectively and is another area to consider with
treatment recommendations. Culturally there are no observable or indicated factors
that play into Megans diagnosis and family dynamics. Overall perceptions are that
Megan has not been adequately diagnosed and symptoms of ADHD have been the
primary focus with treatment interventions versus addressing persistent irritable
mood /dysregulation which continues to manifest.
The overall objectives in working with Megan, conceptualizing the key pieces
of this case, is to use evidence based methodology of combining ongoing
pharmacological management with psychotherapy interventions. Emphasis is on
reducing aggressive behavior, stabilizing mood and improving interpersonal
(friendship) skills. Therapeutic strategies would be initially following discussing the
diagnostic review with parents at the next visit, to initiate a referral for medication
management to possibly pursue addressing Megans pervasive irritability with the
addition of medication trials. Comorbidity is evident in this case, of ADHD and
DMDD. Psychotherapeutic approaches would consist of a combination approach

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during day treatment services with both individual and group therapy centered on
CBT and DBT/Mindfulness/Interpersonal Skills specifically tailored for children.
Megan will begin psychotherapy with individual sessions and will transition into
groups (that allow for application of skills) in efforts to note improvement in social
skills, mood stability and coping skills. Sessions will also incorporate the use of
favored activities (drama, and other high interest activities) to motivate Megan to
participate. Ongoing assessment of Megans progress will be noted.
Megan will participate in a comprehensive partial hospitalization program
services, with an anticipated duration for up to 6 months at Triad Child Treatment
Center. During Megans course of treatment, she will be assigned to a clinician
(LPC) who will provide individual therapy 3 x during the week for 50 minutes, to
work on coping skill development using DBT & CBT models. Group therapy
interventions will be scheduled on alternating days 2 x week (50 minutes) to work
on application of skill development in a group setting. Group sizes will be limited to
3-4 same age peers that also will be working on specific skill development. Ongoing
collaboration with Megans referred psychiatrist during medication trials (potentially
atypical antipsychotic) will be initiated providing reports of progress or regression
on medication.
Assessments instruments such as CBCL-DP (Child Behavior Checklist
Dysregulation Profile; CBQ Child Behavior Questionnaire; Childrens Behaviors scale
& CGAS are used during the course of Megans treatment to measure mood
dysregulation, aggression and pro-social behaviors. Parent training sessions are
scheduled with a LMFT on site 1 x weekly (50 minutes) and evolve to application of
skills with Megan in direct observation training using parent management skills.
Behavior modification using incentive based programs while engaging in therapy

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are incorporated (token economy). Adjunct services will be ongoing continuation of

Occupational Therapy for sensory integration and consultation with a Licensed
Recreational Therapist to assist with Leisure supports and counseling for Megan to
be successfully engaged in community activities to promote wellness.
Megans prognosis for improved mood stability, concentration, and pro-social
engagement is very good considering the level of supports that will be provided
during participation in the intensive partial hospitalization program. Not only is
Megan receiving the concentrated care needed with accuracy of a diagnosis but her
parents are also receiving support and are actively engaged.
Advocacy, multicultural, and legal/ethical considerations
Advocacy strategies will be imperative for Megan and her family especially
during treatment and when she transitions from the IPHP Program. Community reentry with determining appropriate placement in a school setting that will provide
adequate supports will be needed. Referral information for parents to consult with
school personnel regarding Megans needs are critical to her ongoing success.
Advocacy will be an ongoing process for Megan throughout her life considering her
diagnosis. Parents will initially be the primary source to advocate for Megans needs
until she matures into young adulthood an is able to advocate for herself.
Although little information is known about Megan and her familys cultural
views it would be advantageous to explore this area for example assessing their
views on medication use, religion/spirituality and how this may impact treatment.
Family values and the upbringing of Megans parents may have significant effects
on how they parent her and their beliefs surrounding parenting. As mentioned at
the beginning of this paper, society has differing views on parenting where some

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cultures believe in spanking children where as others may not. This is just one
example of how belief systems and values may come into play with working with
children and families.
Legal issues that potentially may arise considering this clinical issue first and
foremost is related to the use of atypical antipsychotic medications (and other
psychotropic meds) with young children. The risks to side effects due to use of
medication could be detrimental to the development of a young child impacting
them on into adulthood. This is one of the key elements that psychiatrist and
mental health professionals are constantly cognizant of working in early
intervention. Continuing the advancement of research in the field and specific to
the diagnosis of DMDD will hopefully improve care for the clients we serve as we
walk alongside them supporting, educating, guiding and most of all instilling hope!
References
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Vidal-Ribas, P.,
Towbin, K., Brotman, M. A. and Leibenluft, E. (2015), A PROSPECTIVE STUDY
OF SEVERE
IRRITABILITY IN YOUTHS: 2- AND 4-YEAR FOLLOW-UP. Depress. Anxiety,
32: 364372. doi: 10.1002/da.22336

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