Disruptive Mood Dysregulation Disorder: A Diagnosis for Tantrums?
The DSM-5 is generating a lot of controversy. I could write a lot of about my position on various aspects of DSM-5 - the changes to the autism spectrum, the callous-unemotional specifier, bereavement, and so forth. But in this post, I'll focus on Disruptive Mood Dysregulation Disorder (DMDD) and why I think this condition, despite the negative reaction it's gotten, is actually a good idea. (Though I still would like some changes to it.)
First, the criticism about this diagnosis seems to be predominantly about one thing - the perception of it as a 'tantrum diagnosis'. The fear is that this will be used to diagnose children with normal tantrums, giving a psychiatric diagnosis to something that doesn't really need one.
If you look at the proposed criteria, however, you can notice the following three things:
Age of Onset
A child under 6 is not allowed to get a DMDD diagnosis (nor is an adult over 18 - the idea is that DMDD normally turns into other things). In addition, first symptoms must be present before the age of 10. In other words, to meet criteria, the child has to be having tantrums at least three times a week between the ages of 6-10 years old. (Even if you were to diagnose a kid who is between 10 and 18 years old with DMDD, you have to prove they showed tantrums between 6-10 years.)
There are two main age periods where tantrums tend to be common in typically-developing children. The first age period is toddlerhood. Before about 3 or 4, many kids have tantrums on a daily basis, and even skilled parenting cannot prevent many tantrums. Specifically, one study found that 87% of 18-24 month olds and 91% of 30-36 month olds had tantrums, so there is definitely an age at which tantrums are normal. In fact, it's more likely that an 18-36 month old who never has tantrums would have a problem, although as far as I know no one has specifically examined those kids to find that out. However, by 42-48 months, this had dropped to 59%, and by the age of 6, tantrums are fairly uncommon.
The second age period at which tantrums are common is adolescence. Hostility between parent and child increases as children enter adolescence. Parent-child conflict tends to peak in early adolescence, although not as consistently as tantrums in toddlers. There is also evidence that this relates to physical pubertal development, with conflict tending to peak when the child is midway through puberty.
The age range delineated by the DMDD diagnosis, therefore, is an age where tantrums are less common in typical children. Most 6-10 year olds are between high-tantrum stages - they've outgrown toddlerhood and are not yet in puberty. A kid who tantrums frequently in that age range, therefore, is a lot more likely to be atypical in some way.
Developmentally Inappropriate
As an added safeguard against diagnosing normal tantrums, they include the sentence 'The temper outbursts are inconsistent with developmental level'. What this means is that diagnosticians need to take into account what would be expected in terms of tantrumming in that child.
There are two main groups who, at 6-10 years old, are likely to be having frequent developmentally appropriate tantrums - cognitively disabled kids and early developers.
In terms of cognitively disabled kids, a 6-10 year old who is at a 1-5 year old level cognitively and has frequent tantrums is not acting that unusual for his or her cognitive level. Given the research I already reviewed, even daily tantrums would be consistent with that child's cognitive level. Overall, it's probably going to be pretty tricky to diagnose DMDD in a child with significant cognitive impairment, although unusually severe tantrums (extremely long-lasting or associated with serious risk of physical harm) may be considered in excess of what their cognitive level would predict.
For early developers, if a child (especially a girl) has suddenly started having tantrums, and is towards the later end of that 6-10 year age range, it would make sense to consider puberty as an alternate explanation. The cutoff for clinical definition of precocious puberty is currently 8 years for girls and 9 for boys, although some research suggests we should be lowering the cutoff. Therefore, although most 6-10 year olds are prepubertal, there will be some who are not. Tantrums in child who is entering puberty are developmentally expected.
Irritability
Lastly and most importantly, although everyone has focused in on the tantrum-related criteria, a child who has frequent developmentally inappropriate tantrums without any other behavioral or mood issues will not actually meet criteria for DMDD, because DMDD is more than just tantrums. Take a look at this:
"C. Mood between temper outbursts:
1. Nearly every day, most of the day, the mood between temper outbursts is persistently irritable or
angry.
2. The irritable or angry mood is observable by others (e.g., parents, teachers, peers)."
So, a DMDD child is not just a kid who throws tantrums. Even when he or she is not pitching a fit, the child acts grumpy or angry most of the time. Even without the tantrums, this persistent irritability could be a cause for concern by itself.
Persistent irritability, by the way, is not typical for any developmental stage. Toddlers are not persistently irritable - instead, they tend to have rapidly changing moods, including both ups and downs. Teenagers are also not persistently irritable. Though the more rebellious teens may be irritable whenever interacting with adults, they don't act that way with their peers, or when doing an activity they enjoy. A persistently irritable kid won't find much to enjoy in life.
Incidentally, this criteria is the main reason this condition is considered a mood disorder. Tantrums, by themselves, are externalizing behavior, and developmentally abnormal tantrums are seen in most externalizing disorders (ADHD, ODD, CD, etc). But persistent irritability is a mood problem. In DSM-IV, irritable mood is listed as a characteristic of depression in children. (I couldn't find information on whether they are removing this criterion in DSM-5. Anyone know?)
And now, on to my criticisms of DMDD.
Unclear Criteria
Both tantrums and irritability are described in very sparse terms, leaving a lot to the clinician's judgment.
Apart from describing verbal and/or physical aggression, they say almost nothing about what defines a tantrum. How long does the behavior have to be ongoing to be considered a tantrum? If the tantrums is interrupted by some non-tantrumming behavior (such as going to the bathroom), is it one tantrum or two? If the kid has been throwing a fit on and off about one topic for several days, is that a 3-day long tantrum, or 6 different tantrums within a 3 day period? Does a single act of aggression within a bout of crying make it count as a tantrum, or does angry behavior have to be more prominent than distressed behavior in a tantrum episode?
Similarly, what is irritability? Is it a baseline unpleasant mood, or is it overreacting to minor triggers? What specific behaviors are signs of irritability? How do you distinguish a persistently irritable child from a persistently depressed or anxious child? How long does the kid need to have been irritable before it counts for diagnosis? If he started feeling irritable two weeks before he saw the doctor, does that count?
For most DSM diagnoses, they unpack this a lot more. Hopefully, they will start to do so with DMDD, otherwise I could see a lot of individual clinicians disagreeing about diagnosis.
Irritability Alone
What if you have a kid who is irritable most or all of the time, but who either doesn't have tantrums, or averages fewer than three tantrums a week? That kid is clearly in distress and needs help, but what condition does he or she have?
According to the suggested criteria, that kid doesn't have DMDD. Does he or she have depression or dysthymia? Possibly, but what if the kid's energy level is fine, he or she is eating and sleeping well, and instead of feeling guilty or worthless, he or she is feeling angry and resentful?
I could see these kids slipping through the cracks. There needs to be more research - maybe it so happens that kids who are persistently irritable always have tantrums at least three times a week, or maybe kids who are irritable without tantrums have very little in common with kids with both issues, but we just don't know. And if there are persistently irritable kids, who are not depressed and don't have regular tantrums, what do we diagnose them with?
Conclusion
On the balance of things, I think adding DMDD is a good idea. Well before DSM-5 was announced, I'd wondered why the DSM had diagnoses focused on problematic fear and sadness, but nothing directly related to problematic anger. (Just diagnoses about behavior that could result from anger, but might not.) And I'd read research suggesting that there was a category of kids whose main issue was irritability and anger.
It bothers me that most of the people who criticize changes in the DSM-5 have no idea of the research that goes behind those changes. For example, 'aspies' who insist that Asperger Syndrome is distinct from autism, ignoring all the research showing that the two cannot be reliably distinguished. (Best I can tell, most of them want to feel special by distancing themselves from the stigma of autism.) Or the people complaining about DSM-5 allowing depression diagnosis in recently bereaved individuals, who seem to have no knowledge of the research showing that recently bereaved people who meet depression criteria have the same sorts of problems and outcomes as people whose depression was triggered by other stressors or came out of the blue.
In the case of DMDD, the predominant criticism seems to be of a familiar tone. 'This psychiatric disorder vaguely resembles a pattern of normal behavior, so it must be the same as that normal behavior.' The reality is that virtually all psychiatric conditions have elements that, in much milder degrees, is present in most people. Everyone gets sad now and then, only some people get clinically depressed. Most people are shy at times, only a few have social anxiety disorder. Most people feel upbeat and energetic some of the time, but only a few actually become manic. Even some delusions have shadows in normal behavior - paranoia is an exaggeration of normal distrust of others, grandiosity is an exaggeration of normal self-enhancement, and so forth. Just because some people are dumb doesn't mean that someone with an IQ of 50 is normal. The degree to which you show a characteristic matters.
First, the criticism about this diagnosis seems to be predominantly about one thing - the perception of it as a 'tantrum diagnosis'. The fear is that this will be used to diagnose children with normal tantrums, giving a psychiatric diagnosis to something that doesn't really need one.
If you look at the proposed criteria, however, you can notice the following three things:
Age of Onset
A child under 6 is not allowed to get a DMDD diagnosis (nor is an adult over 18 - the idea is that DMDD normally turns into other things). In addition, first symptoms must be present before the age of 10. In other words, to meet criteria, the child has to be having tantrums at least three times a week between the ages of 6-10 years old. (Even if you were to diagnose a kid who is between 10 and 18 years old with DMDD, you have to prove they showed tantrums between 6-10 years.)
There are two main age periods where tantrums tend to be common in typically-developing children. The first age period is toddlerhood. Before about 3 or 4, many kids have tantrums on a daily basis, and even skilled parenting cannot prevent many tantrums. Specifically, one study found that 87% of 18-24 month olds and 91% of 30-36 month olds had tantrums, so there is definitely an age at which tantrums are normal. In fact, it's more likely that an 18-36 month old who never has tantrums would have a problem, although as far as I know no one has specifically examined those kids to find that out. However, by 42-48 months, this had dropped to 59%, and by the age of 6, tantrums are fairly uncommon.
The second age period at which tantrums are common is adolescence. Hostility between parent and child increases as children enter adolescence. Parent-child conflict tends to peak in early adolescence, although not as consistently as tantrums in toddlers. There is also evidence that this relates to physical pubertal development, with conflict tending to peak when the child is midway through puberty.
The age range delineated by the DMDD diagnosis, therefore, is an age where tantrums are less common in typical children. Most 6-10 year olds are between high-tantrum stages - they've outgrown toddlerhood and are not yet in puberty. A kid who tantrums frequently in that age range, therefore, is a lot more likely to be atypical in some way.
Developmentally Inappropriate
As an added safeguard against diagnosing normal tantrums, they include the sentence 'The temper outbursts are inconsistent with developmental level'. What this means is that diagnosticians need to take into account what would be expected in terms of tantrumming in that child.
There are two main groups who, at 6-10 years old, are likely to be having frequent developmentally appropriate tantrums - cognitively disabled kids and early developers.
In terms of cognitively disabled kids, a 6-10 year old who is at a 1-5 year old level cognitively and has frequent tantrums is not acting that unusual for his or her cognitive level. Given the research I already reviewed, even daily tantrums would be consistent with that child's cognitive level. Overall, it's probably going to be pretty tricky to diagnose DMDD in a child with significant cognitive impairment, although unusually severe tantrums (extremely long-lasting or associated with serious risk of physical harm) may be considered in excess of what their cognitive level would predict.
For early developers, if a child (especially a girl) has suddenly started having tantrums, and is towards the later end of that 6-10 year age range, it would make sense to consider puberty as an alternate explanation. The cutoff for clinical definition of precocious puberty is currently 8 years for girls and 9 for boys, although some research suggests we should be lowering the cutoff. Therefore, although most 6-10 year olds are prepubertal, there will be some who are not. Tantrums in child who is entering puberty are developmentally expected.
Irritability
Lastly and most importantly, although everyone has focused in on the tantrum-related criteria, a child who has frequent developmentally inappropriate tantrums without any other behavioral or mood issues will not actually meet criteria for DMDD, because DMDD is more than just tantrums. Take a look at this:
"C. Mood between temper outbursts:
1. Nearly every day, most of the day, the mood between temper outbursts is persistently irritable or
angry.
2. The irritable or angry mood is observable by others (e.g., parents, teachers, peers)."
So, a DMDD child is not just a kid who throws tantrums. Even when he or she is not pitching a fit, the child acts grumpy or angry most of the time. Even without the tantrums, this persistent irritability could be a cause for concern by itself.
Persistent irritability, by the way, is not typical for any developmental stage. Toddlers are not persistently irritable - instead, they tend to have rapidly changing moods, including both ups and downs. Teenagers are also not persistently irritable. Though the more rebellious teens may be irritable whenever interacting with adults, they don't act that way with their peers, or when doing an activity they enjoy. A persistently irritable kid won't find much to enjoy in life.
Incidentally, this criteria is the main reason this condition is considered a mood disorder. Tantrums, by themselves, are externalizing behavior, and developmentally abnormal tantrums are seen in most externalizing disorders (ADHD, ODD, CD, etc). But persistent irritability is a mood problem. In DSM-IV, irritable mood is listed as a characteristic of depression in children. (I couldn't find information on whether they are removing this criterion in DSM-5. Anyone know?)
And now, on to my criticisms of DMDD.
Unclear Criteria
Both tantrums and irritability are described in very sparse terms, leaving a lot to the clinician's judgment.
Apart from describing verbal and/or physical aggression, they say almost nothing about what defines a tantrum. How long does the behavior have to be ongoing to be considered a tantrum? If the tantrums is interrupted by some non-tantrumming behavior (such as going to the bathroom), is it one tantrum or two? If the kid has been throwing a fit on and off about one topic for several days, is that a 3-day long tantrum, or 6 different tantrums within a 3 day period? Does a single act of aggression within a bout of crying make it count as a tantrum, or does angry behavior have to be more prominent than distressed behavior in a tantrum episode?
Similarly, what is irritability? Is it a baseline unpleasant mood, or is it overreacting to minor triggers? What specific behaviors are signs of irritability? How do you distinguish a persistently irritable child from a persistently depressed or anxious child? How long does the kid need to have been irritable before it counts for diagnosis? If he started feeling irritable two weeks before he saw the doctor, does that count?
For most DSM diagnoses, they unpack this a lot more. Hopefully, they will start to do so with DMDD, otherwise I could see a lot of individual clinicians disagreeing about diagnosis.
Irritability Alone
What if you have a kid who is irritable most or all of the time, but who either doesn't have tantrums, or averages fewer than three tantrums a week? That kid is clearly in distress and needs help, but what condition does he or she have?
According to the suggested criteria, that kid doesn't have DMDD. Does he or she have depression or dysthymia? Possibly, but what if the kid's energy level is fine, he or she is eating and sleeping well, and instead of feeling guilty or worthless, he or she is feeling angry and resentful?
I could see these kids slipping through the cracks. There needs to be more research - maybe it so happens that kids who are persistently irritable always have tantrums at least three times a week, or maybe kids who are irritable without tantrums have very little in common with kids with both issues, but we just don't know. And if there are persistently irritable kids, who are not depressed and don't have regular tantrums, what do we diagnose them with?
Conclusion
On the balance of things, I think adding DMDD is a good idea. Well before DSM-5 was announced, I'd wondered why the DSM had diagnoses focused on problematic fear and sadness, but nothing directly related to problematic anger. (Just diagnoses about behavior that could result from anger, but might not.) And I'd read research suggesting that there was a category of kids whose main issue was irritability and anger.
It bothers me that most of the people who criticize changes in the DSM-5 have no idea of the research that goes behind those changes. For example, 'aspies' who insist that Asperger Syndrome is distinct from autism, ignoring all the research showing that the two cannot be reliably distinguished. (Best I can tell, most of them want to feel special by distancing themselves from the stigma of autism.) Or the people complaining about DSM-5 allowing depression diagnosis in recently bereaved individuals, who seem to have no knowledge of the research showing that recently bereaved people who meet depression criteria have the same sorts of problems and outcomes as people whose depression was triggered by other stressors or came out of the blue.
In the case of DMDD, the predominant criticism seems to be of a familiar tone. 'This psychiatric disorder vaguely resembles a pattern of normal behavior, so it must be the same as that normal behavior.' The reality is that virtually all psychiatric conditions have elements that, in much milder degrees, is present in most people. Everyone gets sad now and then, only some people get clinically depressed. Most people are shy at times, only a few have social anxiety disorder. Most people feel upbeat and energetic some of the time, but only a few actually become manic. Even some delusions have shadows in normal behavior - paranoia is an exaggeration of normal distrust of others, grandiosity is an exaggeration of normal self-enhancement, and so forth. Just because some people are dumb doesn't mean that someone with an IQ of 50 is normal. The degree to which you show a characteristic matters.
posted by Ettina at 10:09 AM
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