Most parents consider disproportionate the their children’s tantrums when they deny any of their requests without realizing that in most cases it is just another phase of child evolution. A new psychiatric entity now includes symptoms such as pathological tantrums and irritability in minors diagnosed until recently with bipolar disorder.
As explained by Dr. Soledad Romero Cela, from the Child and Youth Psychiatry Service of the Hospital Clínic de Barcelona, Disruptive mood dysregulation disorder tries to respond to a group of pediatric patients with symptoms of chronic irritability and high reactivity to frustrations who in many cases were diagnosed with bipolar disorder.
In the 1990s a group of psychiatric specialists in bipolar disorder revised the criteria to include those children and adolescents with chronic irritability with outbursts and severely impaired functioning within the category of bipolar disorder, which led to a very significant increase in the number of diagnoses of this pathology.
“In theory it was considered that symptoms such as chronic irritability, hyperactivity, rapid thinking or emotional overflow could be the way in which the manic phase of bipolar disorder presented among the little ones. However, in the studies that They followed up on the minors, over the years no episodes of mania were detected, but major depression or anxiety were detected”, Romero explains.
Around the year 2001, a group of researchers from the National Institute of Mental Health (NIMH) in the United States conducted a study comparing cases of boys with bipolar disorder in which the disorder was well defined with those in whom these symptoms of severe chronic irritability and mood dysregulation were present.
The NIMH experts discovered that there were differences in the evolution, at the level of response to drug treatment, neuroimaging tests also yielded different results and also there was no response to treatment with lithium, the first-line drug in bipolar disorder. Differences in gender and associated comorbidities also suggested a entity other than bipolarity.
Controversial inclusion in the dsm-5
This single study led to the inclusion of disruptive mood dysregulation disorder (DDEA) in the latest version of the international reference manual for the diagnosis of psychiatric pathologies (DSM-5), which appeared in 2013. This inclusion as an independent pathology continues to create great controversy in clinical practice since it is only based on the work of a single group of experts.
The criteria that appear in the psychiatric manual They are the presence of serious emotional outbursts not consistent with the level of development, lack of behavioral and verbal control, and disproportionate responses to situations of daily life. The mood in these children is persistently irritable or sad for most of the day.
To make the diagnosis, this behavior must persist for at least one year with a period of no more than 3 months without symptoms. In addition, these symptoms must be present in at least two of the three most important areas of the child, such as home, school, and their circle of friends.
The diagnosis cannot be made before 6 years of age, since it is considered that these behaviors may be more frequent among the youngest, nor above 10 years of age.
“Even the terminology to be used to define the disorder isIt is still not well coined in Spanish. The term disruption is included because it refers to disproportionate anger and tantrums, and dysregulation to appeal to chronic irritability that alters mood,” Romero explains.
The controversy over its appearance in the DSM-5 is also fueled by the fact that the diagnostic criteria established by the American NIMH group are different from those included in the psychiatric manual, in which, for example, the existence of hyperexcitability (insomnia, motor restlessness, distractibility, verbiage or intrusiveness, among others).
hyperactivity and oppositional disorder
What the NIMH researchers found in their study among children diagnosed with bipolar disorder was that those with DDEA symptoms were predominantly male who also had evidence of attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder.
The current DSM-5 criteria, different from those of the NIMH in some respects, associate DDEA to a much lesser extent with ADHD, but they do consider oppositional defiant disorder and major depression to be comorbidities present in the pathology.
Oppositional defiant disorder, which occurs in 70% of DDEA cases, constitutes more of a behavioral problem than a disease, since it involves a lack of behavioral control that can be treated with educational measures. However, DDEA does not have to be present in minors with the oppositional disorder and if this happens, it is in a small number of cases.
“What needs to be clear is that DDEA is a psychiatric disorder in which minors are very affected in all areas and require a high use of services (mental health, medicine, social and educational services)”, Romero clarifies before the possibility that there are parents who associate exaggerated tantrums from their children with a possible disorder.
For Romero, the key is to make a differential diagnosis that includes the personal history that the child has gone through and is going through. “You may be experiencing a family conflict, have a learning disability, have been a victim of mistreatment or abuse or go through a trauma. You must go beyond uncontrolled tantrums and chronic irritability, see what is happening to you and find the root of the problem,” Romero asserts.
Psychotherapy against dysregulation and disruption
In a normal tantrum, the child’s overreaction to a given situation later gives way to a normal mood. In children with ADD there is a disproportionate reaction to a situation and the mood that these disruptive states persistently leave behind is negative. These pathological tantrums develop in all the social and family spaces of the child.
According to Romero, there is a lack of studies on how the treatment works in these minors, who are usually prescribed drugs to irritability and depression.
“The drugs are important when there are disabling symptoms, but then the role of psychotherapy is fundamental, since they are children and they are in a continuous phase of learning,” clarifies the specialist, who points to the importance of psychosocial learning in all areas that surround the child, be it their home, school or circle of friends.
For Romero, it is key to help children understand what is happening to them and provide parents and children with guidelines to control irritability and know how to handle tantrums.