Disruptive Mood Dysregulation Disorder (DMDD)

1. Disruptive Mood Dysregulation Disorder (DMDD) Josie Boehlert and Rachel Spenia

2. Fact or Myth: Children with disruptive mood dysregulation disorder usually go on to have bipolar disorder in adulthood.

3. MYTH!!!

4. The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) is updated once a year

5. MYTH!!!!

6. A child under the age of 6 cannot be diagnosed with DMDD.

7. FACT!!!!

8.    Medication is a proposed treatment for DMDD.

9. FACT!!!

10. DSM-V Diagnostic Criteria • Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation. • The temper outbursts are inconsistent with developmental level. • The temper outbursts occur, on average, three or more times per week. • The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers). • Criteria A–D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A–D. • Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these. • The diagnosis should not be made for the first time before age 6 years or after age 18 years. • By history or observation, the age at onset of Criteria A–E is before 10 years. • There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. • Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania. • The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]). • Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned. • The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.

11. Prevalence • Around 2%–5% • Higher in males and • Higher in school-age children (American Psychiatric Association, 2013)

12. Effects • Extremely low frustration tolerance • Difficulty succeeding in school • Often unable to participate in the activities typically enjoyed by healthy children • Family life is severely disrupted by their outbursts and irritability • Trouble initiating or sustaining friendships • Dangerous behavior, suicidal ideation or suicide attempts, severe aggression, and psychiatric hospitalization are common

13. How is DMDD Different from ODD? • DMDD: • Severe, recurrent, frequent outbursts • Disrupted mood between outbursts • Irritability is the result of depression • ODD: • Outburst and irritability stem from a disruptive disorder • Children who meet criteria for both disorders should be given only the diagnosis of DMDD (American Psychiatric Association, 2013)

14. How is DMDD Different from Bipolar? • DMDD: • Persistent • Long-term • Bipolar: • Distinct episodes • Presence of elevated mood (American Psychiatric Association, 2013)

15. http://www.mentalhealthday.org/show/tag/disruptive-mood-dysregulation-disorder/http://www.mentalhealthday.org/show/tag/disruptive-mood-dysregulation-disorder/ (Finnerty, 2013)

16. Evidence Based Practices

17. Mindfulness-based Cognitive Therapy (MBCT) • Used with individuals with depression • Has also been effective in treating irritability • Increase awareness of negative thinking • Reduces anxiety, depression, anger and aggression (Leigh, Smith, Milavic & Stingaris, 2012)

18. Behavioral Activation (BA) • Aims to reduce repetitive thinking (RT) • Effective in treating depression and irritability • May practice monitoring thoughts through diary • Analyze possible triggers in the environment • Behavioral experiments • Provide alternatives to RT (Leigh et al., 2012)

19. First Steps to Success • school-based program with home components for kindergarten children who display early signs of aggression, oppositional behavior, and severe temper tantrums • Comprises three interconnected components and is implemented in 3 to 4 months. • Designed for children with challenging behaviors, aggression, and acting out • Coaches trained to work with 2 or 3 students in school and home intervention • Contingency reward system – consultant works with the student closely in the classroom, offering direct feedback using color cards to identify behavior • Children work toward a reward by demonstrating positive behavior. (U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2011)

20. Early Risers: Skills for Success • Multi-component, competency skill-based intervention • Designed for children ages 6-12 who display, or are at risk of displaying, conduct-related problems • Provides comprehensive mental health promotion services to early elementary school-age children displaying early onset aggressive, disruptive, and socially withdrawn behaviors • Grounded in social learning, social cognition, and social bonding theoretical perspectives • Offers child-focused and family-focused components • Skill-building and support services delivered in unison over time • Interventions are summer day camps, school year friendship groups, monitoring and mentoring school support, and family nights (U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2011)

21. The Incredible Years • Goal is to reduce child aggression by teaching parents and teachers how to manage children’s misbehavior • Promotes children’s problem-solving strategies, emotional regulation, and social competence • Parent-training component called BASIC, • Teacher training component • Child treatment program titled “Dinosaur Curriculum.” Conducted in small groups. (U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2011)

22. Resources American Psychiatric Association. (2013). In Diagnostic and statistical manual of mental disorders (5th ed.). Doi:10.1176/appi.books.9780890425596.807874 Finnerty, T. (Producer) (2013, April 24). Mental health day pod cast Leigh, E., Smith, P., Milavic, G., & Stingaris, A. (2012). Mood regulation in youth: Research findings and clinical approaches to irritability and short-lived episodes of mania like symptoms. CurrOpin Psychiatry, 4, 271-276. doi: 10.1097/YCO.0b013e3283534982. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. July, 2011. Evidence-based and promising practices: Interventions for disruptive behavior disorders. Retrieved from http://store.samhsa.gov/shin/content//SMA11-4634CD-DVD/EBPsPromisingPractices-IDBD.pdf.