ADHD, Bipolar, DMDD

Running head: ADHD, BIPOLAR DISORDER, AND DMDD 1

Assessing ADHD, Bipolar Disorder, and DMDD Throughout Childhood

Emily R. Shlafer

Western Washington University

ADHD, BIPOLAR DISORDER, AND DMDD

Abstract

It is widely known that diagnosing mental disorders in children is problematic. This can

be due to absent clinical records, frequently comorbid disorders, or a simple lack of

understanding regarding how pathologies manifest in children, which can lead to

misdiagnosis. This study addresses these concerns by tracking the development of several

cohorts of children aged 4 through 17. The children in this study will have one or more of

the following diagnoses: Attention deficit hyperactivity disorder (ADHD), bipolar

disorder, or the relatively new diagnosis of disruptive mood dysregulation disorder

(DMDD). Interviews will be conducted using items from the Kiddie-Schedule for

Affective Disorders and Schizophrenia (K-SADS), as well as parent reports. Assessments

will occur every two years in order to obtain as much clinical information as possible, as

well as to track any changes that may occur in the prevalence of these disorders over

time. I hypothesize that, as the study progresses, an increasing number of children will

meet criteria for DMDD. If this is in fact the case, this will hold important implications

for future research, particularly when determining a course of treatment for children with

behavioral problems. Additionally, the increased prevalence of DMDD could establish a

basis for the emergence of more diagnoses that are targeted toward the specific

developmental psychopathologies of children.

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Assessing ADHD, Bipolar Disorder, and DMDD Throughout Childhood

Often in the field of psychology, diagnosing mental illness in children is

problematic in nature. This is due to several reasons. The first, and perhaps the most

significant, is that mental pathologies manifest differently in children than they do in

adults. Symptoms often present themselves in different ways, or for different periods of

time, and some symptoms may not emerge until children are older. For instance, affective

disorders often look much different in children than in adults. This is because children do

not yet have a baseline personality for “normal” functioning due to rapid development of

the brain, as well as because our knowledge of children’s pathologies is limited due to

lack of available research. Additionally, diagnosing mood disorders in children is

difficult without extensive knowledge of the family history, which can often be

challenging to procure within clinical settings. Without appropriate context, it is

troublesome to determine whether a child’s behavioral issues are due to a mental

disorder, as opposed to poor or age-inappropriate functioning (Algorta, Youngstrom,

Phelps, Jenkins, Youngstrom, & Findling, 2013).

When assessing children’s mental health, symptoms of one disorder are often

comorbid with another, making it difficult to tease out varying pathologies (Pendergast et

al, 2014). An example of two disorders with significantly overlapping symptoms is that

of bipolar disorder and attention deficit hyperactivity disorder (ADHD). Bipolar disorder

is characterized by the tendency to cycle between states of mania and depression, and

ADHD is defined by the inability to hold one’s attention for long periods of time and

becoming easily distracted. Because these two disorders tend to manifest in similar ways,

especially in young people, children are often given a comorbid diagnosis of both

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disorders (Rydén et al, 2009). It has become increasingly accepted that ADHD and

bipolar are often co-occurring in children, and therefore more instances of young people

with both disorders are becoming prevalent. Even with appropriate diagnostic tools,

separating these two pathologies can be difficult, and one disorder can be easily mistaken

for the other (Arnold et al, 2011). Researchers have undergone efforts to piece apart these

two distinct pathologies, such as by measuring the cortical thickness of children who

have comorbid bipolar disorder and ADHD compared to bipolar disorder alone (Hegarty

et al, 2012). Nonetheless, there are few studies that delve into the complexities of

distinguishing these two disorders, and research on this topic is still in its infancy.

The lack of research on childhood mental illness has made it more difficult to

tease apart the varying pathologies of bipolar disorder and ADHD than it would be in

adults. Because of this generalized lack of understanding regarding mental pathologies in

children, there has been increased interest in the phenomenology of ADHD and bipolar in

young children. These increased diagnoses are controversial in nature, mainly due to the

fact that there are not yet clear guidelines for identifying these disorders in children, and

thus diagnoses of bipolar or ADHD can be hastily made according to adult guidelines and

without consideration of alternatives. In order to address these concerns, the Diagnostic

Statistical Manual work group has created a new pathology for the latest edition of the

manul, termed disruptive mood dysregulation disorder (DMDD) (American Psychiatric

Association, 2013). This disorder was included in the DSM-5 primarily to reduce false

diagnoses of bipolar, as well as other mood disorders, in children, as treating children for

bipolar when no such condition is present can have irreversible consequences.

Characteristics of the new DMDD diagnosis include: Severe, recurrent verbal or

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behavioral outbursts, outbursts that are inconsistent with the child’s developmental level,

outbursts two or three times a week that are observable by others, and onset before the

age of ten (Margulies, Weintraub, Basile, Grover, & Carlson, 2012). Essentially,

publishers of the DSM made an effort to identify symptoms that are often wrongfully

attributed to bipolar disorder and assign them the new label of DMDD in order to offer a

diagnosis for behavioral problems that is more suitable for children and based less on

adult-specific criteria.

The fact that a new disorder was introduced in the DSM-5 (American Psychiatric

Association, 2013) simply to address concerns of rampant misdiagnosis raises several

important questions. How many children who have been given a diagnosis of bipolar

disorder or ADHD are actually afflicted with these pathologies? How many of these

diagnoses are simply due to improper diagnostic procedures? Will the new diagnosis of

DMDD help to reduce the phenomenon of false diagnoses of these disorders in young

children? And, perhaps most importantly, how can researchers distinguish these

pathologies from as early of an age as possible in order to determine the best possible

course of treatment?

The aim of the current research is to attempt to tease out the separate diagnoses of

bipolar disorder, ADHD, and the new diagnosis of DMDD. Because DMDD was created

in response to the potentially harmful implications of over-diagnosis of affective

disorders in children, I hypothesize that many children who have been diagnosed with

ADHD and/or bipolar disorder will also fit the guidelines for DMDD. This experiment

will help determine which children are truly affected by these pathologies, based on

whether or not they carry the symptoms into early and late adolescence. This will be

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determined by means of clinical interviews conducted among various groups of children

at several points in their development, along with their parents, with the intention of

determining which of the original diagnoses remain constant throughout their childhood

and adolescence.

This experiment will be longitudinal and cross-sectional in nature. Three groups

of children will be studied over the course of their development; one group of children

that has been given a diagnosis of ADHD, one that has been given a diagnosis of bipolar,

and one that has been given a diagnosis of DMDD. Children with comorbid diagnoses

will be placed in all of the corresponding groups that match their multiple diagnoses. This

information will ideally be obtained via clinical records if possible; however, since

records of developmental psychopathology are often sparse, an alternative means of

procuring information will be parent reports. The study will begin as early as possible, in

early childhood, in order to obtain as much information as possible regarding the

children’s individual developmental histories. The study will also be cross-sectional;

different age ranges of children will be measured in order to determine how these

pathologies manifest at various points in development. I will study these groups of

children from early childhood until late adolescence, in order to account for as many

developmental factors as possible.

In order to tease out the separate diagnoses of bipolar, ADHD, and DMDD, I will

administer diagnostic clinical interviews to parents (ideally both mothers and fathers

when available) and children based on the DSM-5 guidelines for identifying these

disorders. Additionally, I plan to supplement this with parent-report measures, with the

addition of self-report measures when the children reach early adolescence. I believe that,

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as the children in the study progress throughout their developmental years, it will

gradually become easier to determine which children have been wrongly diagnosed with

bipolar disorder or ADHD, and would instead benefit from a less severe diagnosis of

DMDD. Because over-diagnosis of mood disorders is such a commonly occurring

problem, I believe that many children who have been diagnosed with either bipolar

disorder or ADHD would easily fall under the diagnostic guidelines for DMDD. Ideally,

identifying this misdiagnosis early will benefit these children’s long-term prognosis, in

the sense that they will receive appropriate treatment that is based on careful

consideration of developmental context.

Method

Participants

A total of 1500 children will be recruited from the Longitudinal Assessment of

Manic Symptoms (LAMS) study. This was a 2011 longitudinal study that documented

the rate and sociodemographic correlates of youth with elevated symptoms of mania

(Horwitz et al, 2010). In addition, participants will be recruited from local ADHD support

groups, and psychiatric wards to participate in this research experiment. There will be

500 children who have met criteria for a diagnosis of bipolar disorder, 500 children who

have met criteria for a diagnosis of ADHD, and 500 children who have met criteria for a

diagnosis of DMDD. Children with a comorbid diagnosis of more than one of the

aforementioned disorders will be placed in all of the groups that correspond to their

pathology; for example, a child with a comorbid diagnosis of ADHD and bipolar disorder

will be evaluated in both the ADHD group and the bipolar disorder group. Ideally, there

will be an approximately equal number of male and female participants. Ages will range

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from 4 to 17 years old, with as diverse of an ethnic population as possible from a variety

of socioeconomic statuses.

Material

The primary diagnostic tool for this experiment will be the Kiddie-Schedule for

Affective Disorders and Schizophrenia (K-SADS), a revised version of the SADS

designed specifically to assess affective disorders in children aged 6 to 18 (Kaufman et

al, 2009). Created by the same researchers who developed the Research Diagnostic

Criteria (RDC), this measurement will include items aimed at children for measuring

ADHD (“Was there ever a time when you got out of your seat a lot at school? Did you

get into trouble for this?”), and mania/hypomania (“Was there ever a time you were so

irritable and angry that you exploded?”), in addition to items directed at

parents/caregivers (“When your child was young, were you able to take him/her to

church? Restaurants?”). Responses will be gauged on a 3-point scale, ranging from

“never occurring” to “frequently occurring,” essentially. A response option of “0” will

also be available in the event of unattainable information. Diagnoses will be determined

based on the frequency with which children and their parents indicate higher scores on

the administered items, ideally with as many examples of specific behaviors or symptoms

as possible. According to K-SADS guidelines, as subthreshold manifestations of

symptoms are insufficient to count toward the diagnosis of a disorder, further inquiry

may be warranted in certain cases.

Because DMDD is a new diagnosis that has only been present since the release of

the DSM-5, there is no current clinical assessment tool for the disorder. For the purposes

of this experiment, an assessment tool constructed by the National Institute of Health

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(NIH) will be used to measure DMDD, which comprises several criteria of the K-SADS

(Kaufman et al, 2009) that closely match the DSM-5 (American Psychiatric Association,

2013) diagnosis for DMDD. These criteria include: Severe recurrent temper outbursts,

chronic irritability, duration of symptoms, impairment in more than one setting, absence

of episodes of elated mood plus manic symptoms lasting more than one day, and

symptoms not occurring exclusively during a psychotic or mood disorder or are better

accounted for by another disorder (Axelson et al, 2012). Because the K-SADS is only

approved for assessment in children aged 6 through 18, measurement of ADHD, bipolar

disorder, and DMDD in 4 and 5-year-olds will rely primarily on existing clinical records

and parent reports. In addition to the K-SADS, parent reports of children’s behavior and

changes that occur overtime will also be taken into consideration. Parents will be asked to

note any differences in their child’s behavior that may have occurred from one

assessment to the next, with a focus on the frequency and duration of observed

symptoms. Parents’ responses will gauge whether their children’s symptoms have

increased, declined, or remained consistent in number, and if the children’s symptoms

have lightened, become more severe, or remained consistent in intensity. Questions will

consist of a checklist based on DSM-5 criteria, and will include items such as “Does your

child have a hard time remaining focused or sitting still?” and “How frequently does your

child go into rages (seemingly uncontrollable temper tantrums)?”

Procedure

This experiment will be cross-sectional in nature, as children in different age

groups will be assessed for diagnoses of ADHD, bipolar disorder, and DMDD. The study

will also be longitudinal, as it will follow these children throughout their childhood and

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adolescence. Initially, 4 and 5-year-old children will be assessed for ADHD, bipolar

disorder, and DMDD by means of existing clinical records, as well as parent reports of

children’s conduct and behavior. Specifically, parents will be asked to gauge the intensity

and duration of observed symptoms in their children, with consideration as to whether or

not they feel that their originally administered diagnosis remains appropriate. When the

children reach 6 years of age, items from the K-SADS will be used. The K-SADS

assessment will be administered to children and their parents every two years, until the

children reach age 17, in order to account for as many developmental changes and

milestones as possible that may influence the course of their various pathologies.

The initial assessment group will be comprised of children ranging from 4 to 15

years of age, in order to account for the various differences in how ADHD, bipolar

disorder, and DMDD may manifest at different points in development. Each subgroup of

500 children will have approximately equal numbers of children of each age. With the

exception of the 4 and 5-year-old participants whose information will be obtained via

clinical records and parent reports, children and parents will be administered interview

questions from the K-SADS. Children in each group will be measured according to both

the ADHD and the bipolar disorder scales in the K-SADS in order to determine if a child

no longer fits one diagnosis and instead meets more criteria for another. In addition, all of

the participants will be administered the NIH-constructed assessment of DMDD.

Following the initial assessment, interviews will occur every two years, ideally

with as many members of the same cohort as possible. For the children who were 15 at

the time of the initial assessment, the second assessment will be their final interview, as

this study is designed only to measure developmental psychopathology through late

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adolescence. While interviews will be structured identically in each assessment,

researchers will be noting differences in symptoms that may have occurred in the same

children overtime, if any, and whether or not children with a diagnosis of either ADHD

or bipolar disorder would be better suited for a diagnosis of DMDD. By the end of the

study, it will be noted if the groups for ADHD, bipolar disorder, and DMDD have

remained constant in numbers, or if greater or fewer children have ended up with a

DMDD diagnosis as opposed to ADHD or bipolar disorder.

Proposed Analyses

One independent variable in this study will be the two assessment tools, which

will be comprised of the K-SADS and parent reports. Parent reports will be collected at

the same time K-SADS interviews are conducted, and will give researchers an idea as to

whether the child’s behavior at home has remained consistent within the boundaries of

their original diagnosis. The ages of the children who participate will also be an

independent variable. Dependent variables will be the resulting diagnoses of ADHD,

bipolar disorder, and DMDD, as well as the observation of whether or not the participants

continue to meet criteria for these disorders as they age into middle childhood,

adolescence, and late adolescence. Because this is a longitudinal study, I will be

examining the data every two years, and my final analysis will compare the results of

children from age 4 to their results at age 17.

Specifically, I will be looking to see if, based on K-SADS and parental reports of

children’s behavior, the participants’ diagnoses have remained consistent over time. I will

observe any trends or patterns that may have occurred over the years that I have

conducted this study, taking into account that these disorders may manifest differently as

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the children have aged. Additionally, I will draw comparisons across diagnostic groups to

see if there are greater changes in one group compared alongside others. This will be

measured based on quantitative analysis of the combined children’s and parent’s answers

to questions from the K-SADS, as well as a qualitative review of parent reports regarding

the consistency of the children’s pathologies over time.

Discussion

The goal of my study is to examine various cohorts of children over the course of

their development who have been given a diagnosis of ADHD, bipolar disorder, DMDD,

or a comorbid diagnosis of two or more of these pathologies. I hypothesized that many of

the children who have been given a diagnosis of ADHD and/or bipolar disorder would

end up meeting criteria for DMDD, based on the fact that ADHD and bipolar disorder are

often over-diagnosed. Additionally, DMDD is a new diagnosis that has not yet gained

much footing, so I would expect rates of diagnosis to increase in the years following the

release of the DSM-5.

My incentive for conducting this research was based on previous research that has

alluded to the problematic nature of diagnosing mental disorders in children. In a 2013

study, Algorta and colleagues noted that the difficulty of diagnosing children often comes

from inadequate clinical records, which would provide a substantial context to determine

children’s pathologies. In my study, I strive to fill this gap in background information by

diagnosing children from as young of an age as possible, and following them every 2

years in order to obtain a sufficient amount of material on mental health histories. My

goal is to reduce rates of misdiagnosis by obtaining as much background information on

the children as possible.

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Comorbidity has also been an issue in the realm of diagnosing children’s mental

illnesses. This is mainly because symptoms often overlap, which makes determining

exact pathologies troublesome, in addition to the fact that children do not yet have a

baseline for “normal” behavior (Pendergast et al, 2014). This study attempts to overcome

the problems caused by comorbid diagnoses by examining how specific disorders may or

may not change in terms of how they look in children throughout their development.

Because of the dynamic and persistently changing nature of developmental

psychopathology, I will probably find that symptoms tend to fluctuate over time, and that

children who have been diagnosed with one or more disorder(s) may end up meeting

diagnostic criteria for DMDD.

The DSM-5 work group’s creation of the DMDD diagnosis was an answer to

concerns of rampant over-diagnosis of ADHD and bipolar disorder in children. My study

will attempt to see how many children with ADHD and/or bipolar disorder will meet the

criteria for a diagnosis of DMDD. I theorized that a large number of children in the study

would meet criteria for this new diagnosis. Because DMDD is still an emerging

diagnosis, I predicted that rates would gradually increase as awareness about the disorder

becomes more widespread. This will have potentially significant implications for future

research regarding the diagnosis of mental illnesses in children. Because a diagnosis of

DMDD is more targeted toward children and involves treatment options that are not as

heavy, this will give parents means to regulate their children’s behavior without the

potentially damaging long-term effects of ADHD and/or bipolar disorder medication.

Additionally, if the results of this study show a shift in diagnoses over time from ADHD

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and bipolar disorder to DMDD, this will greatly improve prognosis in children who may

have been originally misdiagnosed, or who do not have any pathologies whatsoever.

In addition to potentially improving the course of development for children who

are afflicted with behavioral problems, this study may also help to aid in our

understanding of the dynamic and changing nature of mental illness in children. DMDD

is unique in the sense that it is a diagnosis aimed specifically at children, so it will be

interesting to observe changes in the frequency with which it is diagnosed over time. If

my hypothesis is correct and a diagnosis of DMDD tends to fit children better as the

study progresses, this could open the door to more diagnoses in future editions of the

DSM that account for all of the intricacies and potential problem areas of this area of

developmental psychopathology, mainly those stemming from over-diagnoses of

behavioral disorders and problems associated with comorbidity.

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ADHD, Bipolar, DMDD