Irritable mood, outbursts beyond typical ADHD.
Some respond well to comprehensive treatment for ADHD and get better. However, others 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.
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.
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.
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.
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). However, much more needs to be done and redone to confirm these findings in different samples. Also, some outbursts are so out of control that they look like mania or co-occur with the flail 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. Under the best circumstances, an accurate diagnosis can lead to use of a medication or combination of medicines that can make the patient, and, therefore the family, able to function better. Trial and error sounds negative, but these child and adolescent psychiatrists employ a step-by-step, risk-benefit approach to each medication. Children begin to feel better, begin to tolerate life at home with siblings, have some friends, and go to school in a regular classroom. The benefits include a less restrictive environment, improved sense of self/self-esteem, and enhanced family and peer relationships.
Other researchers believe that using the adult diagnostic label of manic-depressive disorder is inappropriate. They say that calling symptoms in a 4- or 7-year-old manic grandiosity is too much of a stretch, and argue that we do not know if these children will become adults with a formal diagnosis of manic-depressive disorder. Although these kids grow up with many difficulties, it's premature to label them as "manic-depressive" if they eventually have some other disorder as adults, they say.
The clinicians with these latter concerns are part of an effort to rewrite the Diagnostic and Statistical Manual of Mental Disorders. They propose a new diagnostic category called Disruptive Mood Dysregulation Disorder (DMDD) for the DSM-V. This is a descriptive term that like all the DSM diagnoses avoids etiology. This condition is not manic-depression, but it has something to do with mood that is dysregulated and disruptive.
Although these children have irritable mood and appear "down," they often do not meet the classic criteria for depression. Clinicians with this perspective will say the children don't get manic by adult standards and they don't get depression by adult standards, and yet we're calling them manic-depressive or bipolar. That, again, they say, supports DMDD.
I belong to the third group, those who say we do not sufficiently understand this behavior in children whether we call it bipolar disorder or DMDD. Neither of these diagnoses really gets to the cause, and without an etiology, it's going to be very difficult to determine the differential diagnosis. Until our ability to identify biomarkers improves, additional descriptive categories may not bring clarity I suspect there will be some overlap and extensive debate as various individuals and groups defend their perspective and research. We need longitudinal studies, including family history and genetic studies, as well as brain imaging studies such as functional magnetic resonance imaging, that could reveal activity in different regions of the brain that relate to observed behaviors.
I do believe this work has to be done to root these different perspectives in science and to optimize the care of these children. In the meantime, my approach is more cautious and pragmatic. Look at every aspect of these kids' lives. Work with parents to try to head off outbursts at a very early point. Once the outbursts start, generally you cannot stop them. Sometimes there is almost a prodrome indicating that the child is getting ready for an outburst. Help the family figure out what they can do if they spot the signs 1 minute or even 10-15 seconds ahead of time. Work to set reasonable expectations, look for activities and structure to build self-esteem, and work with a team that includes an expert in psychopharmacology, as this will likely be a challenging effort.
MICHAEL S. JELLINEK, M.D.
DR. JELLINEK is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital. He said he has no relevant financial disclosures. E-mail him at email@example.com.
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|Title Annotation:||BEHAVIORAL CONSULT|
|Author:||Jellinek, Michael S.|
|Date:||Jun 1, 2011|
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