Bipolar Disorders 2012  2012 John Wiley and Sons A/S

BIPOLAR DISORDERS

Original Article

Will disruptive mood dysregulation disorder

reduce false diagnosis of bipolar disorder in
children?
Margulies DM, Weintraub S, Basile J, Grover PJ, Carlson GA. Will David M Marguliesa, Sheldon
disruptive mood dysregulation disorder reduce false diagnosis of bipolar Weintrauba, Joann Basileb, Paul J
disorder in children? Groverb and Gabrielle A Carlsona
Bipolar Disord 2012: 00: 000–000.  2012 The Authors a
Department of Psychiatry and Behavioral Science,
Journal compilation  2012 John Wiley & Sons A ⁄ S.
School of Medicine, State University of New York at
Stony Brook, bUniversity Hospital, Stony Brook
Objectives: The frequency of diagnosis of bipolar disorder has risen
University Medical Center, New York, NY, USA
dramatically in children and adolescents. The DSM-V Work Group has
suggested a new diagnosis termed disruptive mood dysregulation
disorder (DMDD) (formerly temper dysregulation disorder with
dysphoria) to reduce the rate of false diagnosis of bipolar disorder in
young people. We sought to determine if the application of the proposed
diagnostic criteria for DMDD would reduce the rate of diagnosis of
bipolar disorder in children. doi: 10.1111/j.1399-5618.2012.01029.x

Keywords: aggressionchild – explosiveness –

Patients and methods: Eighty-two consecutively hospitalized children,
ages 5 to 12 years, on a childrenÕs inpatient unit were rigorously
diagnosed using admission interviews of the parents and the child, rating
scales, and observation over the course of hospitalization.
inpatient – irritability – mania – rages
Received 6 June 2011, revised and accepted for
publication 14 March 2012

Results: Overall, 30.5% of inpatient children met criteria for DMDD Corresponding author:
by parent report, and 15.9% by inpatient unit observation. Fifty-six Gabrielle A. Carlson, M.D.
percent of inpatient children had parent-reported manic symptoms. Department of Psychiatry and Behavioral Sciences
Of those, 45.7% met criteria for DMDD by parent-report, though only Stony Brook University School of Medicine
17.4% did when observed on the inpatient unit. Putnam Hall-South Campus
Stony Brook, NY 11794-8790
Conclusion: Although DMDD does decrease the rate of diagnosis of USA
bipolar disorder in children, how much depends on whether history or Fax: 631-632-8953
observation is used. E-mail: gabrielle.carlson@stonybrook.edu

though interestingly, the controversy is not a new

Introduction
Over the past 25 years, there has been an increased
interest in the phenomenology of bipolar disorder
in both adults and children. The question of
whether bipolar disorder should be narrowly or
broadly defined is an issue that has clinical and
research significance (1). Narrowly defined, clini-
cally impairing mania ⁄ bipolar I disorder occurs in
about 0.5% of the adult population (2, 3) whereas
rates of bipolar spectrum disorder may be at least
10 times that (4).
The narrow versus broad view of bipolar disor-
der in children has been especially contentious,
one (5, 6). The narrow view states that bipolar I
disorder is a condition described by clear episodes
of at least a weekÕs duration of manic symptoms
that represent a clear departure from the personÕs
prior function and is impairing. Criteria are strictly
defined and unmodified. The broad view is that
there is a spectrum which includes less discrete
episodes of severely irritable and explosive behav-
ior (7, 8), and symptom definitions may require
modification because elation and grandiosity as
defined in adults are difficult to apply to children
(9). Some researchers hypothesize that what is
called juvenile bipolar disorder may be better
1
Margulies et al.
described as problems in mood regulation (10). A
series of studies by Leibenluft and colleagues (11),
comparing children with narrow phenotype bipolar I
disorder and a condition defined as severe mood
dysregulation, have not demonstrated that the latter
condition is probably not on a bipolar spectrum.
Severe mood dysregulation is defined as perva-
sive anger ⁄ irritability, explosive behavior, and
hyperarousal symptoms (e.g., insomnia, agitation,
distractibility, racing thoughts or flight of ideas,
pressured speech, and intrusiveness) and cannot be
diagnosed if there are symptoms of elated mood,
grandiosity, or episodic decreased need for sleep,
are better explained by schizophrenia, pervasive
developmental disorder (PDD), post traumatic
stress disorder or substance use disorder (10). Over
80% of children with severe mood dysregulation in
fact meet criteria at least for combined attention-
deficit hyperactivity disorder (ADHD) and oppo-
sitional defiant disorder (ODD), and not infre-
quently, an anxiety disorder as well (12).
CliniciansÕ interpretation and application of
DSM bipolar mania criteria, and their under-
standing of the literature, appear to have trans-
lated into a dramatic increase in the diagnosis of
bipolar disorder in children (13, 14). This has
worried some clinicians because of the lifetime
nature of bipolar disorder and thus possible
exposure to lifetime medication. As a result, the
DSM-V committee has been debating returning
bipolar I disorder to the more narrow phenotype,
and, at least in children, relabeling and expanding
the definition of severe mood dysregulation into a
proposed condition initially called temper
dysregulation disorder with dysphoria (TDD) and
recently renamed disruptive mood dysregulation
disorder (DMDD) (15).
As of this writing (December 2011), DMDD is
defined as a disorder with combined recurrent,
severe temper outbursts in response to common
stressors, in the context of a chronic, irritable
mood. The latter is important as this condition is
not simply defining children who have bad tempers
with euthymic mood between outbursts. More
specifically, according to the DSM5.org website
(http: ⁄ ⁄ www.dsm5.org ⁄ ProposedRevision ⁄ Pages ⁄
proposedrevision.aspx?rid=397), the criteria in-
clude:
A. The disorder is characterized by severe recur-
rent temper outbursts in response to common
stressors.
1. The temper outbursts are manifest verbally
and ⁄ or behaviorally, such as in the form of
verbal rages, or physical aggression towards
people or property.
2
2. The reaction is grossly out of proportion in
intensity or duration to the situation or
provocation.
3. The responses are inconsistent with develop-
mental level.
B. Frequency: the temper outbursts occur, on
average, three or more times per week.
C. Mood between temper outbursts:
1. Nearly every day, the mood between temper
outbursts is persistently negative (irritable,
angry, and ⁄ or sad).
2. The negative mood is observable by others
(e.g., parents, teachers, and peers).
D. Duration: criteria A–C have been present for at
least 12 months. Throughout that time, the
person has never been without the symptoms of
criteria A–C for more than 3 months at a time.
E. The temper outbursts and ⁄ or negative mood
are present in at least two settings (at home, at
school, or with peers) and must be severe in at
least one setting.
F. Chronological age is at least 6 years (or equiv-
alent developmental level).
G. The onset is before age 10 years.
Exclusionary criteria are meant to insure that true
mania ⁄ bipolar disorder is not overlooked and
include manic symptoms (elation, grandiosity,
and decreased NEED for sleep) that have lasted
a day or longer. Other conditions that might
otherwise explain irritability are also excluded so
that the behaviors should not occur exclusively
during the course of a psychotic or mood disorder
(e.g., major depressive disorder, dysthymic disor-
der, or bipolar disorder) or are not better
accounted for by another mental disorder (e.g.,
PDD, ODD, posttraumatic stress disorder, or
separation anxiety disorder). [Note: This diagnosis
can co-exist with ADHD, conduct disorder, and
substance use disorders.] The symptoms are not
due to the direct physiological effects of a drug of
abuse, or to a general medical or neurological
condition.
The purpose of DMDD as we understand it is
basically to provide a diagnostic home for children
whose rages do not otherwise satisfactorily fit into
current concepts of ADHD or ODD and have thus
been called ÔbipolarÕ to signal the severity of the
problem and its mood-related nature.
This study poses four questions: (i) How often
do children with parent-reported irritability and
explosiveness meet criteria for DMDD? (ii) How
often do children under direct observation have
DMDD? (iii) How often would children who might
have been diagnosed with bipolar disorder be
rediagnosed with DMDD? In other words, how

successful would DMDD be in preventing children
from being misdiagnosed with bipolar disorder?
(iv) What current DSM disorders do explo-
sive ⁄ irritable children have?
Methods
Sample
The sample consists of children, aged 5 to 12 years,
consecutively admitted to a 10-bed university
hospital childrenÕs inpatient psychiatric unit. The
unit operates with a behavioral system similar to
that described by Dean and colleagues (16), with a
multidisciplinary treatment team and an inpatient
school operated by the Board of Cooperative
Educational Services (B.O.C.E.S.)
Assessment
The admissions assessment begins with parents
completing several rating scales including the Child
and Adolescent Symptom Inventory (CASI) (17,
18). The CASI is a DSM-IV-based rating scale that
uses a Likert format (never, sometimes, often, or
very often) for each symptom. It combines the
Child Symptom Inventory (19) and the Adolescent
Symptom Inventory (20). The former elicits symp-
toms of ADHD (inattentive, hyperactive, or
combined), ODD, conduct disorder, generalized
anxiety disorder, social phobia, separation anxiety
disorder, obsessive-compulsive disorder, specific
phobia, major depressive disorder, dysthymic dis-
order, schizophrenia, PDD, AspergerÕs disorder,
and motor and vocal tics. The adolescent version
additionally inquires about schizophrenia, schizoid
personality, panic attack, bipolar disorder, anor-
exia, bulimia, and drug use. Extensive research
documentation on the inventory, including
reliability and validity, is available at http: ⁄ ⁄ www
.checkmateplus.com ⁄ research ⁄ research_univ.htm.
After the parent ⁄ caregiver completes the form,
the clinician obtains a psychiatric history which
ascertains symptoms that led to hospitalization,
and uses the CASI as a guide to flesh out relevant
diagnostic criteria. At the end, the CASI is used as
a psychiatric review of systems to ensure all
symptom areas are covered. This approach differs
from the usual semi-structured interview that
follows the same format regardless of the present-
ing problem. It corresponds well to structured
interviews (19, 21) and has been used in the past to
study manic symptoms on this inpatient unit (22).
If bipolar disorder is suspected, either because of
information in the history or mental status or
because parents asked about bipolar disorder, the
Disruptive mood dysregulation disorder in children
parent and child are further interviewed with the
Schedule for Affective Disorders and Schizophre-
nia for School-Age Children–Present and Lifetime
Version (K-SADS-PL) (23) by the senior author.
Parents are also asked to complete the Child
Mania Rating Scale–Parent version (CMRS-P),
a questionnaire that solicits symptoms of mania
using a four-point Likert scale format (24). The
CMRS-P cut-off score of 20 has been found to
distinguish mania from ADHD with a sensitivity
of 0.81 and specificity of 0.94 at the site that
developed the instrument (24). For this study, we
use the CMRS-P as a way of labeling a population
at risk for being diagnosed as having bipolar
disorder by parent-described symptoms.
Finally, parents complete an inventory of rage
behaviors (available from authors) which ascer-
tains what precipitates a childÕs rage, what s ⁄ he
does during a rage, how often rages occur, how
long they last, whether the behaviors are chronic or
episodic and whether onset was in infancy, at age
3–6 years or at age 6–12 years. This is used to
quantify information from parents about the
explosive outbursts used for the diagnosis of
DMDD and was developed because standardized
aggression scales do not specifically address the
aforementioned information. The inventory also
elicits some of the information needed to make the
DMDD diagnosis.
Assessment additionally includes interview of
the child and close observation and re-interview
over the 3 to 5 weeks of hospitalization by clini-
cians, nurses, ancillary staff, and special education
teachers. The teachers complete a short version of
the CASI which covers ADHD, ODD, mood
disorder and PDD symptoms (25, 26). All staff
members participate in consensus ratings of behav-
iors at admission and discharge which include
items that address irritability and explosiveness as
well as the ChildrenÕs Global Assessment Scale
(CGAS) (27). Throughout hospitalization, a care-
ful record is kept of the frequency with which a
child is unable to Ôtime outÕ for the usual 10 min
and needs either more time to calm down or a less
stimulating environment (28). The latter was
defined as a rage outburst because the child was
so much more out of control. Time outs and rage
outbursts defined actual explosiveness. For this
study, we also computed the mean number of time
outs and rage outbursts for each childÕs length of
stay.
During the school year, each child receives a
psychoeducational evaluation by the school psy-
chologist and special education teacher which
includes intelligence quotient (IQ) testing using
the Wechsler Intelligence Scale for Children-IV
3
Margulies et al.
(WISC-IV) (29) and achievement testing (Kaufman
Test of Educational Achievement (KTEA-II) (30).
For this study, consensus ratings were made at a
research diagnostic conference using all informa-
tion for each child on the presence of explosiveness
and irritability. Final DSM-IV diagnoses were
assigned for ADHD, ODD, anxiety or depressive
disorders, bipolar disorder, and a category that
included PDD, mild mental retardation and psy-
chosis not otherwise specified as those conditions
were so frequently comorbid. These best-estimate
diagnoses (31) were based on current (i.e., afflicting
the child at that time) rather than lifetime (condi-
tions occurring in the past) information. The
consensus meeting was attended by the medical
(DM) and program directors (SW) and two senior
psychiatric nurses (JB and PJG) who worked daily
with the children. Ratings used for irritability,
explosiveness and diagnoses were: 0 = not pres-
ent, 1 = present by history but not observed,
2 = clearly present but mild, 3 = moderate, and
4 = very severe.
We report data on DSM-IV diagnoses and
DMDD in two ways. The first uses only information
supplied by the parent ⁄ caregiver, as that is what is
available in outpatient settings to community clini-
cians and potentially emulates how DMDD might
be diagnosed in that context. The diagnosis of
DMDD was made on the basis of parent descrip-
tions of irritability and explosiveness (often ⁄ very
often) from the CASIÕs ODD and mania sections
and the frequency, severity (i.e., what the child does
during the outburst) and duration of outbursts from
the Rages Inventory.
The second approach uses behavior as directly
observed on the unit in children. We reasoned that
this was the Ôgold standardÕ. Consensus ratings of
observed irritability and explosiveness (ratings of 2
to 4) were used at the research diagnostic confer-
ence to assign a diagnosis of DMDD and final
ratings for other disorders as well. DMDD was
diagnosed when the child was both irritable and
explosive and did not have exclusionary criteria for
the diagnosis. Exclusionary diagnoses were those
from the best-estimate consensus meetings. The
reliability of these ratings, in terms of differences
between the ratings assigned by the medical and
clinical directors was assessed for a third of the
subjects (n = 27). Counts of explosive behaviors
recorded on the hospitalÕs mandatory Ôincident
sheetÕ were used to judge how often they occurred
per week. The final issue is whether DMDD would
better explain children who might have otherwise
been given a bipolar diagnosis. We addressed this
by examining rates of DMDD diagnoses and other
diagnoses in children with elevated CMRS-P
4
scores, i.e., children at risk of being given a bipolar
diagnosis.
Results
There were 82 admissions between August 2009
and August 2010. The mean age (standard
deviation) of the children was 9.8 (2.1) years;
76.8% were male; 75.6% were white; 72% lived
with at least one biological parent. The mean
length of stay was 38.4 (24) days [median
33 days]. The majority had been hospitalized
more than once (53%); 70% were ÔclassifiedÕ for
educational modifications, though the average IQ
was 100.3 (18.4) for the 66 children who had
been tested.
The average CMRS-P score for the 80 parents
who completed it was 20.7 (10.1) and 46 (57.5%)
had scores in the ÔmaniaÕ range (20 or higher). The
correlation between the CMRS-P with eight par-
ent-rated manic symptoms from the CASI used in
earlier research (22) was r = 0.82 (p <0. 001).
Reliability between the medical and unit director
based on 27 admissions was k = 0.72 for irrita-
bility and k = 1.0 for explosiveness. For diagnos-
tic categories, it was k = 0.61 for mood and
anxiety disorders, k = 0.72 for developmental
disorders (PPD and mild mental retardation) and
k = 1.0 for ADHD and ODD.
Twelve children were interviewed with the K-
SADS-PL (23) because they had been specifically
referred to the inpatient unit with a bipolar
diagnosis and ⁄ or because parents provided sug-
gestive symptoms during the history. Table 1
summarizes their K-SADS-PL diagnoses, best-
estimate diagnoses, CMRS-P scores and DMDD
status. Three children were never explosive in-
hospital, six were irritable and explosive but had
other reasons for not receiving a DMDD diag-
nosis (manic, depressed, psychotic, autistic), and
three were given a DMDD diagnosis in addition
to their ADHD ⁄ ODD. Three children were
ultimately diagnosed with bipolar I disorder;
two were in a current manic episode during
hospitalization; one had been hospitalized in the
past for a manic episode but pica was the reason
for current admission. Hypomania and bipolar
disorder not otherwise specified were not
observed or diagnosed during hospitalization,
though a past history was not ruled out.
Although there was considerable agreement
between K-SADS-PL and best-estimate diagno-
ses, the latter often included conditions not
elicited by the K-SADS-PL (learning disorders,
autism spectrum disorders, trichotillomania,
schizotypal personality disorder, and pica).
 Disruptive mood dysregulation disorder in children

Table 1. Comparison of Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version (K-SADS-PL) and best-
estimate diagnoses including disruptive mood dysregulation disorder (DMDD) in hospitalized children with possible bipolar disorder (BP)

Reason for CMRS-P K-SADS-PL

Case # K-SADS-PL score diagnosis Best-estimate diagnosis DMDDa

1 (age 12) Prior admit for mania; 27 Mania, ADHD, BP-I recurrent, ADHD, 2
current manic symptoms ODD, GAD ODD, GAD, Lang
2 (age 11) Rapid speech, flight Mania, ADHD, BP-I ⁄ mania, ADHD, GAD, 2
of ideas ODD, GAD, OCD, trichotillomania
OCD
3 (age 8) Mood lability with possible 20 MDD, ODD, MDD remitted, ODD, GAD, reading 3
elation; referred for BP social phobia disorder, Lang, disorder of written
expression
4 (age 10) Severe agitation 38 MDD, ADHD, MDD, ADHD, ODD, Lang, IQ 84 2
ODD
5 (age 7) Community BP diagnosis 38 ADHD, ODD, ADHD, ODD, math disorder, 3
CD, tics disorder of written expression
6 (age 12) Described self ‘superhappy’ 7 ADHD, OCD ADHD, OCD, psychosis NOS 0
sometimes
7 (age 14) Community BP diagnosis 19 ADHD, ODD, Schizotypal personality 2
psychosis NOS, disorder, GAD
separation anxiety,
GAD
8 (age 11) Past episode of mania 19 ADHD, ODD, ADHD, ODD, pica, OCD 0
OCD trichotillomania, Lang
9 (age 9) Parent concern 40 ADHD, ODD, CD ADHD, ODD, Asperger’s 2
disorder
10 (age 11) Community BP diagnosis 33 ADHD, ODD, enuresis, ODD, ADHD, PDD NOS, chronic 2
chronic motor tic disorder motor tic disorder; Lang
11 (age 8) Hyperactive with 33 ADHD, ODD, CD ADHD, CD, anxiety NOS, Lang 3
hallucinations
12 (age 7) Hyperactive with n ⁄a ADHD, ODD, GAD ADHD, ODD, severe language 0
hallucinations disorder
by history

ADHD = attention-deficit hyperactivity disorder; BP-I = bipolar I disorder; CD = conduct disorder; CMRS-P = Child Mania Rating
Scale–Parent version; GAD = generalized anxiety disorder; Lang = mixed expressive ⁄ receptive language disorder; MDD = major
depressive disorder; NOS = not otherwise specified; OCD = obsessive compulsive disorder; ODD = oppositional defiant disorder;
PDD = pervasive developmental disorder.
a
DMDD key: 0 = not explosive; 2 = irritable and explosive but exclusionary diagnosis; 3 = irritable, explosive and no exclusionary
diagnoses.

line 1) and their children were thus not eligible for

DMDD from parent interview information (Table 2)
a DMDD diagnosis. However, the remaining 56
Of the 82 parents in the sample, 26 described (68.3%) children were described as having both
neither irritability nor explosiveness or reported severe irritability and superimposed explosive out-
only one of these symptoms (Table 2, column 1, bursts that had been occurring several times a week
(50% reported daily outbursts) for at least 1 year
(Table 2, column 1, line 2). This behavior had been
Table 2. Rates of disruptive mood dysregulation disorder (DMDD) by the reason for hospitalization. Parents reported
parent report and inpatient unit ratings that at home, outbursts often lasted for more than
Parent Unit 30 min and consisted of threats, insults, throwing
information information things, property destruction, and physical aggres-
(n = 82) (n = 82) sion. Onset of these behaviors in all children had
begun in infancy or preschool and thus met the
No DMDD criteria, 26 (31.7) 50 (61.0)
n (%)
DMDD onset prior to age 10 years criterion.
Chronic irritability and 56 (68.3) 32 (39.0) Of those children who were both irritable and
explosiveness, n (%) explosive, and might be described as having broad
DMDD but disorders 31 (37.8) 19 (23.2) DMDD, 31 (37.8%) were kept from meeting
that preclude the diagnosis DMDD criteria because of exclusionary diagnoses
DMDD 25 (30.5) 13 (15.9)
of mood, psychosis, developmental disorder or
5
Margulies et al.

post traumatic stress disorder (Table 2, column 1, Table 3. Disruptive mood dysregulation disorder (DMDD) diagnosis in
line 3). Ultimately, 25 (30.5%) children met full children with parent-reported manic symptoms on the Child Mania Rating
Scale-Parent version (CMRS-P)
DMDD criteria from parent interview information
(Table 2, column 1, line 4). Inpatient
Parent-reported unit-rated
behaviors in behaviors in
DMDD based on observations in hospital children children
with CMRS-P with CMRS-P
When children were actually observed on the score ‡ 20 score ‡ 20
inpatient service, 32 of the 82 children were rated (n = 46) (n = 46)
as being both irritable and explosive (Table 2,
No DMDD criteria, 8 (17.4) 26 (56.5)
column 2, line 2). However, over half had disorders n (%)
that precluded a DMDD diagnosis (Table 2, col- Chronic irritability 38 (82.6) 20 (43.5)
umn 2, line 3) leaving only 13 (15.9%) with actual and explosiveness
DMDD. Using current DSM-IV criteria, 11 of broad DMDD, n (%)
these 13 DMDD children (84.6%) had comorbid DMDD, but disorders 17 (37.0) 12 (26.1)
that preclude the
ADHD and ODD. diagnosis
Validating the ratings of irritability and explo- DMDD 21 (45.7) 8 (17.4)
siveness, actual rates of rage outbursts and Ôtime
outsÕ were significantly higher in children who had
the DMDD diagnosis compared to those without. risk of being called bipolar because of possible
Rage outbursts per day (number of rages divided Ômanic symptomsÕ described by parents would have
by length of stay) were 0.49 (0.38) versus 0.11 been given the diagnosis of DMDD. See Table 3,
(0.36) (t = )4.72, p < 0.0001). Time outs were 1.0 column 1, line 4.
(5.8) versus 0.33 (0.33) (t = )5.3, p < 0.0001). As seen in Table 3, column 2, most children
Children with DMDD were somewhat more whose parents reported manic symptoms on the
impaired at admission, judging by their C-GAS CMRS-P (n = 26, 56.5%) did not meet strict
scores [18.5 (8.4) versus 24.6 (13.0), t = 2.09, p = criteria for DMDD when actually observed during
0.040], as well as at discharge [47.1 (7.3) versus 52.2 hospitalization, leaving 20 who did. Only eight
(9.2), t = 2.28, p = 0.025]. children (17.4%) were rated as having moderate to
severe irritable mood and explosive behavior, and
did not have other conditions that Ôbetter
Would DMDD reduce the frequency of a bipolar diagnosis?
explainedÕ their symptoms.
(Table 3)
In Table 4, best-estimate diagnoses are shown
When a CMRS-P score ‡ 20 was used as a screen for the entire sample (column 1), for those with
for bipolar disorder, a sample (n = 46) was Ôbroad DMDDÕ (column 2), for those with manic
obtained of whom 38 (82.6%) were chronically symptoms ⁄ elevated CMRS-P scores (column 3)
irritable and explosive according to their parentsÕ and for those with Ôbroad DMDDÕ with elevated
history. Seventeen of these 38 children (37%) were CMRS-P scores (column 4). Children with Ôbroad
not diagnosed with DMDD, however, because they DMDDÕ (i.e., explosive ⁄ irritable children) with or
had exclusionary diagnoses (Table 3, column 1, without manic symptoms had high rates of
line 3). Therefore, 21 of the 46 (45.7%) children at ADHD, ODD and combined ADHD plus ODD.

Table 4. Best-estimate diagnoses in inpatient sample as well as those with irritable, explosive behavior disruptive mood dysregulation disorder (broad DMDD)
as defined by inpatient unit ratings

Total sample Broad DMDD CMRS-P ‡ 20 Broad DMDD with CMRS-P ‡ 20

(n = 82) (n = 32) (n = 46) (n = 20)

Any developmental disorder 22 (26.8) 9 (28.1) 14 (32.6) 7 (35.0)

Any ADHD 52 (63.4) 26 (81.2) 33 (71.7) 18 (90.0)
Any severe ODD 57 (69.5) 30 (93.8) 35 (76.1) 18 (90.0)
Any mood ⁄ anxiety disorder 41 (50.0) 13 (41.9) 19 (42.2) 7 (36.8)
Any BP-I 3 (3.7) 1 (3.1) 1 (2.2) 0 (0)
Comorbid ADHD and ODD 42 (51.2) 25 (78.1) 27 (58.7) 17 (85.0)
Comorbid ADHD and mood 23 (28.0) 10 (32.3) 14 (31.1) 7 (36.8)

Values are indicated as n (%).

ADHD = attention-deficit hyperactivity disorder; BP-I = bipolar I disorder; CMRS-P = Child Mania Rating Scale–Parent version;
ODD = oppositional defiant disorder.

6

A significant minority had mood and anxiety
disorders as well as developmental disorders.
Although combined ADHD and ODD was very
common in explosive children, the converse was
not true. That is, of the 42 children with comorbid
ADHD and ODD, only 11 (26.2%) had DMDD.
Similarly, of the 27 children with manic symptoms
(elevated CMRS-P scores) who had ADHD and
ODD, only six (22.2%) had DMDD (not shown).
Discussion
This study addressed four questions. The first was
how often children with parent-reported irritability
and explosiveness serious enough to require hos-
pitalization met criteria for DMDD; the second
was whether direct in-hospital observation would
verify that the child indeed had problems encom-
passed by DMDD. Thirdly, we examined what
other conditions were afflicting the children.
Finally, we addressed the question of how many
children who might have been given a diagnosis of
bipolar disorder based on irritable, explosive
behavior and manic symptoms would have quali-
fied for a DMDD diagnosis.
Chronic irritability and explosiveness occurred
in two-thirds of children brought by parents for
psychiatric hospitalization. However, DMDD, as
explicitly defined by explosive behavior and super-
imposed on a chronically irritable mood, and not
accounted for by other mood or developmental
disorders, occurred in slightly less than one-third of
our psychiatrically hospitalized children by parent
report and only 15.9% of observed children. These
data suggest to us that while the concept of
DMDD is reasonable, it will not account for the
majority of children with explosive behaviors who
get hospitalized. This is largely explained by the
fact that the exclusionary diagnoses account for
more than half of the irritable, explosive children.
On the other hand, DMDD does select a subset of
children who had lower C-GAS scores on admis-
sion and discharge and, by definition, had more
rage outbursts and time outs (manifestations of
their irritable, explosive moods) in hospital than
other children with severe behavior problems.
It is not clear whether DMDD is a distinct
condition. While the majority of children with
DMDD had comorbid ADHD and ODD, the
converse wasnÕt true. Only a quarter of children
with comorbid ADHD ⁄ ODD met criteria for
DMDD. Thus, DMDD may be a more severe
form of comorbid ADHD and ODD or a separate
entity which includes a comorbid mood component
as we found in a third of cases. Follow-up data of
children with mood symptoms of ODD (32), and
Disruptive mood dysregulation disorder in children
extrapolated severe mood dysregulation (33) sug-
gest that there is an important anxiety ⁄ depressive
component underlying the irritable and explosive
behavior, possibly suggesting that something more
than uncomplicated ADHD ⁄ ODD is occurring.
Children with parent-rated manic symptoms (i.e.
CMRS-P scores ‡ 20), who might be at risk of
receiving a diagnosis of bipolar disorder, would get
a diagnosis of DMDD based on parent symptom
information in about half (45.7%) of cases. How-
ever, when rigorously diagnosed with extended
observation, only 17.4% of children would actually
receive a DMDD diagnosis. If indeed DMDD is a
true entity, we suspect that, like bipolar disorder,
it, too, will be overdiagnosed. The advantage of
this over a bipolar diagnosis depends on what one
considers the implications and treatment of bipolar
disorder in childhood to be (e.g., lifetime medica-
tion treatment) and whether that is an advantage
over a condition that as yet has no provenance. If it
causes a treatable condition like ADHD to be
overlooked, it will be a decided disadvantage. On
the other hand, if it becomes a target for the
development of new treatments for irritable, explo-
sive children, there might be a positive outcome. At
present, there is no apparent way to target treat-
ments for explosive behavior since there is no
agreed-upon way to classify it.
There are several limitations to these data. The
first is the premise that high scores on the CMRS-P
scale represent children who are at risk to get a
bipolar diagnosis. Not all children with a high
CMRS-P score would be given a bipolar diagnosis,
so we may be magnifying a problem. However,
while we have repeatedly reported that rates of
manic symptoms are much higher than rates of
actual bipolar I disorder (22, 34–37), a mania
diagnosis is more likely in the presence of many
parent-rated manic symptoms than in their ab-
sence. For instance, while the effect sizes varied
among all of the mania scales for youth, manic
children invariably scored significantly higher on
those same scales (38). In the recent Longitudinal
Assessment of Manic Symptoms study, while only
25% of a large sample of youth with a positive
screen on the General Behavior Inventory had a
bipolar spectrum disorder, many fewer (8.1%) had
a bipolar spectrum disorder with a low screen score
(39).
There is some support for our premise from an
earlier sample from this program which revealed
that when a parent reported manic symptoms
(which is what the CMRS-P catalogs), regardless
of other information, the odds ratio (confidence
interval) of a community clinician making a
bipolar diagnosis was 5.6 (2.45, 12.0) (34). In our
7
Margulies et al.
outpatient program where reasons for referral are
systematically recorded, in 332 outpatients less
than age 13 years, referral to Ôrule out bipolar
disorderÕ was 4.5 (confidence interval: 1.9–11.1)
times more common where the CMRS-P score
was ‡ 20 compared to < 20 (27% versus 7%)
(unpublished data).
In the absence of information on exactly how
clinicians make the diagnosis of bipolar disorder
(40), we think the use of the CMRS-P is a
reasonable way to speculate about how effective
DMDD would be in deflecting children with
chronically explosive, irritable behavior with manic
symptoms from a presumably erroneous bipolar
diagnosis that they are at risk of receiving. Even if
only a half or a third of children with high CMRS-
P scores received a false positive diagnosis of
bipolar disorder because of their irritable, explo-
sive and moody behavior, the likelihood is that if
DMDD criteria are strictly followed, this alterna-
tive condition would not provide a better diagnos-
tic home for the majority of children, somewhat
defeating its raison d’etre.
Another limitation is the absence of structured
or semi-structured interviews for most children.
There are three reasons for this. First, there is no
longer funding for a separate interviewer as we had
in times past using the K-SADS-E (e.g., 21, 22, 35)
on the inpatient unit. The treating clinician is able
to use a structured review of symptoms, via the
CASI, to be thorough, however. Second, the unitÕs
past experience with both the symptom inventory
guided diagnosis and other structured interview
validation of the CASI suggests that little is missed
in terms of present psychopathology. Finally, the
best-estimate diagnosis is made at the end of a
month-long hospitalization when all the informa-
tion, including daily observations on the ward and
in school, is assembled. That renders information
from parent-reported symptoms prior to hospital-
ization less valuable. We cannot rule out the
possibility that the child may have had past
ÔepisodesÕ of subthreshold manic symptoms, the
elicitation of which requires long and painstaking
interviewing. However, if these were not witnessed
when the child was irritable and explosive (41), we
submit that bipolar NOS is not explaining the
ÔmoodyÕ behavior.
Assessment of irritability has only recently
been a focus of research and methods by which
it should be observed and rated have not been
described (42). The exercise of critically observing
irritability in children on the inpatient unit
underscored the fact that, like any other symp-
tom, it is a dimension that goes from absent to
severe. It was sometimes difficult not to be
8
tautological in rating; i.e., if a child has many
outbursts he is, by definition, irritable and the
two ratings are significantly correlated (r =
0.594, p < 0.000). That is one of the reasons
that reliability, though acceptable at k = 0.71,
was lower for irritability than it was for explo-
siveness. By selecting children who were often
(versus sometimes) moderately to severely grou-
chy and irritable, we may have underestimated
that symptom. Using ÔsometimesÕ increased the
number of children with DMDD very little (15.9
to 17.3%).
Data were gathered on an acute inpatient unit
and may not generalize to an outpatient setting.
However, in the Stony Brook outpatient clinic a
similar rate was found: 44.7% of children with
CMRS-P scores ‡ 20 appeared to meet criteria
for DMDD. However, unlike the inpatient serv-
ice where 57.5% of children had elevated CMRS-P
scores, only 27.0% of a sample of 332 outpa-
tients did (43).
In conclusion, a proposed DSM-V entity which
encompasses symptoms of chronic explosiveness
and irritability identifies an important and com-
monly found group of severely disturbed children.
Where the diagnosis of bipolar disorder is made
only by using parent-reported manic symptoms,
the rate of bipolar disorder diagnosis would be
reduced by about half, though when irritability and
explosiveness are rated in a structured environ-
ment, the rates are drastically reduced. The overall
utility of the DMDD diagnosis and whether it
would prevent children from receiving other and
better-defined diagnoses remains to be seen.
Disclosures
GAC has received grant funding from GlaxoSmithKline and
Bristol-Myers Squibb. DMM, SW, JB, and PJG have no
conflicts of interest to report.
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