Currently, there are camps debating this dilemma within child psychiatry. Some of the roots of this controversy began with the identification of a subset of children with ADHD who also had additional comorbidity related to their mood. Some were comorbid with depression and did not respond well to their ADHD medication. Clinicians began to wonder – especially as they looked more closely – whether these children really did have ADHD, or did they have a mood disorder that included depression and behaviors that included irritability and agitation? This generated more questions: Did the behaviors come and go? Were their hyperactive symptoms really part of a manic mood? Is this an early form of bipolar disorder in childhood or early adolescence, especially with a relevant positive family history?
Clearly, these children were miserable. They were very difficult to raise because of their mood swings. Some displayed quite agitated temper tantrums that did not seem to make sense; they got upset over something minor or even out of the blue without explanation (again, an internally generated irritability and agitation).
In an effort to help these patients and their families, some child psychiatrists tried medication that was not typical for ADHD. They wanted to determine, for example, if medication that was indicated for mood disorders and even bipolar disorders in adults could stabilize these childhood behaviors. The ultimate goal was to help these children function better at home and school, and to live more happily.
In fact, some of the children responded to medications that were not for their original diagnosis of hyperactivity. Some people began calling those children "bipolar."
As often happens in medicine, some may have expanded the use of that term beyond its initial precision. These children didn’t have the family history, their depression was not as severe, or maybe their irritability could be explained through a more thorough evaluation.
As the number of children who were being diagnosed as bipolar increased, their age range went younger and many of them received powerful medications.
Others clinicians felt that this adult diagnosis was being inappropriately stretched to apply to children. They agreed that there are children who seem to have irritability, agitation, and violent temper tantrums, and to be very disruptive and difficult to manage at home and school. But they didn’t want to use an adult term to describe this behavior, or to call these children ADHD because they didn’t fit that diagnosis. The clinicians began using the term DMDD: These children were "dysregulated" because their moods were not regulated in the developmentally expected manner, and because temper and irritability were among the manifestations.
Additional guidance may come from the working groups for the DSM-5. As they prepare for it, experts are debating that we shouldn’t call kids with these symptoms bipolar, but rather DMDD, and that we should try to study them within that framework. But that view is not unanimous and the answer is not yet final.
Dr. Michael Jellinek is a professor of psychiatry and pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.)–Wellesley Hospital and chief of clinical affairs, Partners HealthCare. He said he has no relevant disclosures.