New Diagnosis for Our Kids: The DSM-V and DMDD
The DSM is the classification of mental disorders in the United States. Clinicians, insurers, legislatures, the FDA and educators use it. The fifth edition is due to be released next spring, and it has many ramifications for our children with mood disorders.
One of the most significant proposals for Balanced Mind families is the proposed inclusion of a new diagnosis for children called Disruptive Mood Dysregulation Disorder (DMDD). I attended a full day symposium at the annual meeting of the American Academy of Child & Adolescent Psychiatry (AACAP) in late October in order to address our parent’s strong interest in this matter. Many of the members of the Child Work Group of the DSM-V were on the panel.
In summary, DMDD is severe, chronic irritability, lasting most of the day, every day, for at least a year. It can be contrasted to bipolar disorder, which is characterized by distinct episodes of mania and depression.
The field trials for DMDD, where the proposed diagnoses are tested for reliability and validity, resulted in a rating of “good*.” Why the asterisk? While two of the smaller study sites produced “unacceptable” results, those sites had a high proportion of outpatient children. The larger site where there was a high percentage of children who were inpatients resulted in a “very good” rating. Since this illness is characterized by its severity, it was theorized that a population of inpatient children, whose illnesses are more severe, would yield more diagnoses for DMDD.
The APA is now in the final stages of deciding whether to include DMDD in the main section of DSM-5, as opposed to Section III, which contains “provisional” diagnoses. Stay tuned… We hope to share that with you by the end of this year.
While speaking with many of the researchers and child psychiatrists at AACAP, I learned that their opinions are almost as varied as our parents. Many clinicians think that that DMDD will finally give many of their young patients a “diagnostic home.” They are referring to children who are severely ill, but do not meet criteria for bipolar disorder. Conversely, some researchers worry that the underlying research for DMDD only took place at one site, and should be replicated at several sites before it’s included in the DSM-V. While that research was done at the world-renowned NIMH, and is very highly regarded, the research was done on a slightly different syndrome called Severe Mood Dysregulation.
I know this can be frustrating for parents. If the experts can’t agree, what does that mean for my child? Remember that researchers constantly refine and improve our understanding of these illnesses. That means they will often disagree with one another, challenge each other’s theories, and try to prove or disprove their own, or other’s hypotheses. In other words, it’s their job to debate one another, instead of resting on their laurels. Do not be discouraged!
Look where that debate has taken us since the founding of The Balanced Mind Foundation in 1999 when only a handful of studies existed , and a scarce few children received treatment for their severe mood disorders. We now have hundreds of studies on children and a proposal to further refine and categorize a large group of children in two in order to better define their symptom clusters and better inform treatment. We know a lot more about the safety of treatments for children, several treatments have received a FDA indication for use in children, and we have a treatment protocol for children with bipolar disorder.
Is the DSM-V perfect? No, but its an improvement. Science is by nature evolutionary, and we still have much to learn about the nature and treatment of our children’s mood disorders. As Helena Chmura Kraemer, Ph.D., a Professor of Psychiatry at University of Pittsburgh who heavily influenced the field trial design of the DSM-V, stated, “How does one distinguish between a disorder and a diagnosis? A disorder is the disruption of normal physical or mental functions; a disease or abnormal condition. A diagnosis is an opinion that a disorder exists.”
And so it goes with psychiatric illnesses. Until we have a biomarker, diagnosis is an opinion based on observation of a cluster of symptoms. This is one reason why psychiatric illnesses are so highly controversial; until we have a biomarker, like a blood test or a brain scan, doctors are making informed opinions based on observations.
The Balanced Mind’s mission is to inform and support you. Please post your comments here so that those who are making the final decision on the fate of DMDD can hear parents’ voices.