Disruptive Mood Dysregulation Disorder in Juvenile Justice

Diagnostic Home for DMDD

Our goal was to determine whether, in a juvenile justice population, DMDD had fewer differences when compared with mood disorders or to DBD. Consistent with our hypothesis, we found that, for youths in justice system contact, DMDD was much more closely related to mood disorders than to DBD.

The study findings expand our understanding of the nosology of DMDD in two important ways. First, our results help clarify the epidemiology of DMDD, including its greater concordance with other mood disorders rather than with DBD. Even among those in juvenile justice settings, with their overall increased likelihood of externalizing disorder and SUD, those with DMDD are clearly less different compared with mood disorders than they are compared with those meeting criteria for DBD, who do not have DMDD. From a clinical perspective, some externalizing behaviors such as temper outbursts or irritable or angry mood (each of which might lead to juvenile justice involvement) overlap with symptoms of DMDD; however, those with DMDD are distinct from those with DBD, and identifying this condition is feasible in this population. Compared with those with DBD, youths with DMDD were twice as likely to report a past suicide attempt, increasing the risk of future suicide attempts and illustrating the critical importance of comprehensive identification and treatment. Fortunately, there are several well-studied treatment modalities available to address the risk of suicide.^31,32

From another perspective, it has been noted that children of depressed mothers have significantly higher rates of oppositional defiant disorder, in addition to other psychiatric disorders than do children of nondisordered mothers.^33,34 This has been interpreted to reflect less than ideal maternal parenting or socioenvironmental deficits secondary to the mother's symptoms of depression.³⁵ Our work suggests the possibility that the connection between maternal depression and childhood ODD may reflect an underlying genetic predisposition for mood disorders, and children of depressed mothers may actually be more precisely diagnosed with DMDD.

Epidemiology of DMDD in Juvenile Justice Settings

In this study, of those cases in CPMHJJ's Archive, 3.3 percent met retrofitted criteria for DMDD. Five previous studies have created retrofitted DMDD diagnoses according to various methods and have reported its prevalence to range from 0.12 to 9.0 percent in community samples to 26.0 to 31.0 percent in mental health settings (where, presumably, all youths carry some diagnosis).^5,–,8,23 Our prevalence in the juvenile justice setting was consistent with rates reported in community samples, both of which include youths not preselected for disorder.

We also found that, compared with those endorsing DBD without mood disorder, those meeting criteria for DMDD were more than twice as likely to be female (41.7% versus 18.4%). In contrast, in the earlier community report of younger children (9–13 years old), DMDD was twice as common in males (3.6%) as in females (1.9%).⁵ Our study's higher prevalence among females reflects that girls in justice system contact differ from girls in community samples in several ways. Compared with their peers in the community, females in juvenile justice settings report higher rates of past abuse, higher rates of witnessing family violence, more caregiver transitions during early and mid-childhood, and higher rates of engaging in delinquent activities with friends.^36,37 Here, even in a justice sample with elevated rates of traumatic exposure, both female gender and a higher rate of PTSD (a likely marker for a history of abuse), are also more common in youths with DMDD. Our work suggests that a gender paradox may be operating that would explain these findings. In a gender paradox, the group (here, girls) that displays a problem (here, juvenile justice contact) that is generally more common in another group (here, boys) presents with higher levels of correlated adverse or impairing conditions than does the other group.³⁸ Thus, girls who appear in juvenile justice settings would be more impaired across co-occurring dimensions than would boys who appear in those settings, so that girls would show elevated rates of a range of mental health disorders.^39,40

In earlier reports using data from CPMHJJ's Archive, we found that girls endorsed higher rates of ODD, anxiety, mood disorders, including major depressive disorder, and social and specific phobia, than did their male counterparts.^27,41 Because our retrofitting of DSM-IV elements to define DMDD drew completely upon ODD symptoms, it would be expected that females would also be more likely to meet criteria for DMDD. We noted with interest that, compared with youths with DBD, those with DMDD were less likely to report substance use disorders. It is possible that although youths with DMDD were irritable, they were less likely to self-medicate with substances than were their DBD peers. Recognizing the co-occurrence of irritability and depression in girls with juvenile justice contact, treatment approaches for them that address this profile have been used⁴² for several years.

Comorbidities in DMDD

As a new disorder in the DSM-5, DMDD's expected comorbid psychiatric diagnoses are beginning to be described. In our sample, justice-involved youths with DMDD reported higher rates of SUDs than did those with mood disorders other than DMDD. Compared with those with DBD, youths with DMDD were more likely to meet criteria for PTSD. About 21 percent of those adolescents with DMDD had comorbid PTSD; similarly, 20 percent of those with mood disorders reported comorbid PTSD. This result is in stark contrast to those with DBD, fewer than two percent of whom reported comorbid PTSD. This further similarity with mood disorders adds support to DMDD's classification as a mood disorder. These novel associations add to the clinical understanding of this diagnosis.

Overlap Between Irritability and DMDD

Irritability (usually a key feature of the DMDD profile) has a stronger phenotypic relationship with depression than with delinquency in adolescents.⁴³ Conversely, headstrong or hurtful behaviors in adolescents have been shown to be more strongly related to delinquency than to depression.⁴⁰ Clinicians and other staff working in juvenile justice settings need to recognize that the symptoms of DMDD, including irritable mood, are likely to be indicative of a mood disorder, rather than aggression or authority-challenging behavior. Changing clinicians' and staff's thinking about these behaviors may be a substantial challenge, given that service providers, teachers, and parents have all been found to under-recognize the symptoms of mood disorders in children and adolescents who also present with externalizing symptoms.^44,–,46 The risks associated with not recognizing these behaviors as mood symptoms are even more considerable, given the increased risk of a history of attempted suicide in those meeting retrofitted criteria for DMDD.

Effective treatments for youths in secure care have been described.⁴⁷ A systematic review of treatment studies relying on randomized controlled trials among incarcerated youths offered recommendations for those youths who diagnosed mood disorders or anxiety disorders, or risk of self-harm⁴⁷: in those secure settings, group-based cognitive behavior therapy has been found to be efficacious.⁴⁷ Further research is needed to clarify whether, given their shared diagnostic category, the treatment for MDD is similar to that for DMDD. There are National Institute of Mental Health (NIMH)–funded studies (Clinicaltrials.gov identifiers: NCT00794040 and NCT01714310) that are investigations of the combination of SSRI plus stimulant to treat severe mood dysregulation.⁴⁸

DMDD Predicts Adult Diagnostic and Functional Outcomes

In addition to understanding the epidemiology and comorbid psychiatric diagnoses of DMDD, it may be important clinically to consider the long-term correlates and outcomes of youths with DMDD. A single, prospective, population-based study has examined whether those meeting criteria for DMDD in childhood are at increased risk of adult diagnostic and functional outcomes.⁵ In that study, compared with those with a non-DMDD diagnosis or with no childhood diagnosis, young adults with a history of childhood DMDD reported increased rates of anxiety and depression and were more likely to meet criteria for one or more adult disorders than their counterparts with no DMDD or no childhood diagnoses.⁵ In addition, those with a history of DMDD were more likely to have higher self-reported rates of sexually transmitted diseases, tobacco smoking, and susceptibility to contagious illness.⁵ Furthermore, those with childhood DMDD experienced higher rates of poverty, had elevated risk for risky or illegal behaviors, and had lower educational attainment over their lifetimes, suggesting that they may carry a worse prognosis than those with other childhood psychiatric disorders. By providing treatment for those with DMDD, we may be able to intervene on a trajectory that likely includes poverty and lower educational attainment. An externalizing behavior of some sort may have led an adolescent to juvenile justice contact, but underlying symptoms of internalizing disorder may be present and treatable.

Study Limitations

One limitation of our study is that, in retrofitting a DMDD diagnosis, we were unable to map symptoms exactly onto the DSM-5 diagnosis. We were unable to capture the DMDD symptom of “severe, recurrent, temper tantrums that are grossly out of proportion to the situation (Ref. 1, p 156). In basing our diagnostic category on ODD-based proxies (e.g., “about how often do you lose your temper”), our criteria likely reflect a less intense condition than DMDD. Our method for retrofitting was comparable, however, with the most stringent previously published work in this area.^7,8,23

Drawing a DMDD proxy diagnosis completely from ODD diagnostic criteria may also have overestimated the true comorbidity of DMDD and DBD. Included in our retrofit DMDD diagnosis are its hallmark symptoms (temper outbursts and angry or irritable mood). Although we captured duration of symptoms longer than six months, DSM-5 criteria describe symptom duration longer than 12 months. Our DMDD proxy diagnosis was also unable to capture setting, age at onset, or exclusionary criteria. Despite these limitations, DMDD shares more commonality with depressive disorder diagnoses than with DBD.

Finally, reduced statistical power may have weakened our ability to detect significant differences between those with DMDD and those with mood disorders (without DBD or DMDD), because of the relatively smaller sample sizes (although both were above n = 200) of these two groups. The absence of significant differences between these groups does not necessarily imply equivalence.