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Objective: Attention deficit hyperactivity disorder (ADHD) is a commonly diagnosed psychiatric disorder in children. Since there is a debate about the over-diagnosis of bipolar disorder (BP) in childhood and facilitating research on pediatric BD, Leibenluft et al(2003) described a clinical syndrome called severe mood dysregulation (SMD). The hallmark of SMD is extreme, impairing, and chronic irritability, accompanied by hyperarousal symptoms. In DSM-5, this disorder is renamed as Disruptive Mood Dysregulation Disorders (DMDD) and hyperarousal symptoms are removed from the criteria for avoiding over-diagnoses among children and adolescents with ADHD. Comorbidity with ADHD and DMDD is very common in children and adolescents and reported as 86.9%. DMDD diagnosis refers to children with persistent irritability, hyperarousal, and emotional reactivity and temper tantrums that lack other cardinal manic symptoms such as elevation. There has been increasing debate surrounding the diagnostic relevancy of DMDD and other manic-like symptoms in children with ADHD. However, there has been little investigation into the impact of these symptoms on the efficacy of ADHD treatments or into the development of treatments specifically for DMDD. In this study, we aimed to present a case series in terms of the effectiveness and safety of methylphenidate in children, who are diagnosed as having DMDD and ADHD.
Method: In collaboration with J.Kaufman, Ph.D., Leibenluftetal, developed modifications to the Schedule for Affective Disorders and Schizophrenia (K-SADS-PL) to ensure that DMDD could be diagnosed reliably. Cases who applied to Child and Adolescent Psychiatry Department of Dokuz Eylul University School of Medicine with the symptoms of ADHD and DMDD, and whose diagnostic confirmation according to KSADS-PL was provided as ADHD and DMDD and currently under follow up in our clinic were recruited to study. Their sociodemographic data, treatments, the using time, doses and adverse effects of methylphenidate were evaluated retrospectively by child psychiatrists.
Results: There were nine cases, who were diagnosed as ADHD and DMDD, they were all male. The average of their ages was 13.55, the average age with these diagnoses first evaluated was 8.44. The mean follow-up period was 45.11±26.84 months and the range was 2 and 86 months. Eight of nine cases had reported adverse effects with methylphenidate. Increasing irritability had been seen in all cases and increasing tantrums had been observed in five cases. Methylphenidate(MPH) treatment was tried once in eight of nine cases but only one of them used MPH twice and irritability was seen for two times during the period of usage of MPH.
Conclusion: Research on the pathophysiology and treatment of children with DMDD and ADHD is very important for cases and their families. The evidence-based knowledge is insufficient for clinicians on whether children with DMDD and ADHD should first receive stimulants and behavior therapy for ADHD or mood stabilizers for mood dysregulation. In the present study, MPH was not tolerable for children, who were diagnosed as ADHD and DMDD and MPH usage increased the irritability clearly but in Waxmonsky’s study MPH and behavior therapy were both found tolerable and effective treatments for children with ADHD and DMDD; and in addition, they determined that additional treatments might be needed to optimize their functioning.