Diagnosing disruptive mood dysregulation disorder: Integrating semi-structured and unstructured interviews

Abstract

The newest iteration of the Diagnostic and Statistical Manual–fifth edition (DSM-5), is the first to include the diagnosis of disruptive mood dysregulation disorder (DMDD). The assessment and diagnosis of psychopathology in children are complicated, particularly for mood disorders. Practice can be guided by the use of well-validated instruments. However, as this is a new diagnosis existing instruments have not yet been evaluated for the diagnosis of DMDD. This study seeks to provide a method for using existing structured interview instruments to assess for this contemporary diagnosis. The Children’s Interview for Psychiatric Syndromes (ChIPS) and the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) are reviewed and existing items consistent with a diagnosis of DMDD are identified. Finally, a case is presented using both measures and applying the theoretical items identified to illustrate how one might use these measures to assess DMDD. Limitations and future directions are discussed.

Keywords

Disruptive mood dysregulation disorder assessment child and adolescent mood disorder psychopathology

The assessment of psychopathology in children is complex. Mood disorders can be particularly complex due to variations in symptom presentation and development (Mash & Barkley, 2007). Additionally, symptom overlap is quite common in childhood mood disorders. These factors are implicated in diagnostic complexity in childhood mood disorders (de Mesquita & Gilliam, 1994). It is crucial that the assessment process includes a nomothetic and ideographic approach in all the systems the child is a part of (Leffler, Riebel, & Hughes, 2015). Most often this information is acquired from a clinical interview. However, these interviews can be unreliable and are vulnerable to bias (Frick, Barry, & Kamphaus, 2010). Generally, inter-rater reliability between clinicians for assessment and diagnosis of psychopathology in children is low (Galanter & Patel, 2005). However, agreement can be increased by using structured or semi-structured interviews (Galanter & Patel, 2005). Rate of agreement between providers using clinical interviews has been reported as part of various studies and ranges from 83.3% to 91.2% (Pellegrino, Singh, & Carmanico, 1999).

To reduce the impact of clinician idiosyncrasies and increase diagnostic validity, reliability, and clarity, standardized diagnostic structured and semi-structured interviews were developed (Frick et al., 2010). Structured and semi-structured diagnostic interviews assemble questions for symptomatology based on diagnostic categories and also provide a template for inquiry. Structured interviews provide clinicians exact wording and procedures for interpreting responses without much opportunity for follow-up questioning or clarification. This rigidity results in higher agreement on diagnoses across providers and reduces the use of heuristics in assessment practices (Leffler et al., 2015). Literature suggests that agreement in diagnoses between clinical interviews and structured/semi-structured interviews is generally low (Jensen & Weisz, 2002).

A 2009 meta-analysis of both adult and child samples conducted by Rettew, Lynch, Achenbach, Dumenci, and Ivanova (2009) evaluated agreement between diagnoses from a clinical evaluation versus standardized diagnostic interviews using the kappa statistic. The findings suggest that agreement between clinical interviews and standardized interviews was moderately too low for the majority of disorders. This suggests that broadly, clinical evaluations and standardized interviews often result in differing diagnosis but both may have a place in clinical assessment. Disruptive mood dysregulation disorder (DMDD) is a new diagnosis introduced in the latest edition of the Diagnostic and Statistical Manual–fifth edition (DSM-5; American Psychiatric Association, 2013). The criteria as defined by the DSM-5 can be found in Table 1.

Table 1.

Diagnostic and Statistical Manual–5 criteria for disruptive mood dysregulation disorder (American Psychiatric Association, 2013).

Criteria	Description
A	Severe recurrent temper outbursts manifested verbally (e.g. verbal rages) and/or behaviorally (e.g. physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.
B	The temper outbursts are inconsistent with developmental level.
C	The temper outbursts occur, on average, three or more times per week.
D	The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g. parents, teachers, peers).
E	Criteria A through D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all symptoms in Criteria A through D.
F	Criteria A and D are present in at least two of three settings (i.e. at home, at school, with peers) and are severe in at least one of these.
G	The diagnosis should not be made for the first time before the age of 6years or after age 18years.
H	By history or observation, the age at onset of Criteria A–E is before 10years.
I	There has never been a distinct period lasting more than one day during which the full symptoms criteria, except duration, for a maniac or hypomanic episode have been met.
J	The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g. autism spectrum disorder, post-traumatic stress disorder, separation anxiety disorder, persistent depressive disorder).
	Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned.

DMDD was endorsed by DSM-5 work groups to address concerns that children with severe irritability and temper outbursts were being inappropriately diagnosed with bipolar disorder and to encourage future research on this clinical population (First, 2007). The diagnosis is based on a broad phenotype of pediatric bipolar disorder described by Leibenluft, Charney, Towbin, Bhangoo, and Pine (2003), coined severe mood dysregulation (SMD). Symptoms of DMDD and SMD differ with the latter requiring symptoms of chronic hyperarousal (e.g. insomnia, agitation, distractibility, racing thoughts, flight of ideas, pressured speech, or intrusiveness) (Axelson et al., 2012).

The 3-month prevalence rates of DMDD range from 3.3% to 0.8% (Copeland, Angold, Costello, & Egger, 2013). As this is the first iteration of the DSM to include DMDD, there are few empirical studies examining DMDD. Furthermore, there is little literature regarding the assessment of DMDD. Notably, the symptoms of DMDD are not unfamiliar or unique to children referred for psychological services. As such, many existing instruments (e.g. structured interviews, self-report measures, checklists) provide questions that assess for these symptoms; however, they are not currently structured around the DMDD phenotype. For example, Axelson and colleagues (2012) used specific items from semi-structured interviews; specifically, a combination of the Schedule for Affective Disorders and Schizophrenia for School-age Children–Present and Lifetime version (K-SADS-PL), the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U K-SADS), and items to screen for developmental disorders to assess for symptoms of DMDD retrospectively for research purposes (Axelson et al., 2012). While there have been edits to the K-SADS-PL to include a section to assess the symptoms of DMDD it has not been validated and is not readily available for researchers and clinicians. For example, as a result of limited validity and availability a recent large multisite study assessing bipolar disorder and other affective disorders in children and adolescents that the second author (J.M.L.) is co-leading did not utilize the K-SADS-PL DMDD section to assess DMDD.

As symptoms of DMDD are not new or unique but re-ordered, we can use existing measures with some modification to assess. The current article attempts to demonstrate how professionals might go about assessing the presentation of DMDD using the Children’s Interview for Psychiatric Syndromes (ChIPS) or the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) (Sheehan, Shytle, Milo, Janavs, & Lecrubier, 2009; Weller, Weller, Fristad, Rooney, & Schecter, 2000). Additionally, we present a case in which a patient was administered the ChIPS and the MINI-KID within a 2-month period in independent assessment clinics and also received clinical interviews. Item responses are reviewed in the context of a diagnosis of DMDD. It is of note that no diagnosis should be made based on any one instrument in isolation; instead, psychological assessment should be “an activity by which the clinician integrates test findings with information from the personal, educational, and occupational histories as well as from the findings of other clinicians” (Matarazzo, 1990). Consequently, using any current instruments to evaluate DMDD will require additional query and/or a clinical interview.

Method

The authors reviewed the ChIPS and the MINI-KID to identify theoretically what item endorsement may be consistent with the diagnostic criteria of DMDD. Items identified by the authors were then compared to items endorsed on these measures by a child diagnosed with DMDD and symptoms reported in two separate unstructured clinical interviews conducted by board certified child and adolescent psychiatrists with the child and parents.

ChIPS

The ChIPS is a structured interview for children aged 6–18 years that assesses 20 disorders as defined by the Diagnostic and Statistical Manual–fourth edition (DSM-IV) and includes both a parent and a child version (Weller et al., 2000). The parent and child versions are identical in structure and format. They differ in verbiage and pronoun use. We will refer to the ChIPS for this article. Additionally, there are two sections that assess psychosocial stressors such as abuse and neglect. Each diagnostic section includes questions about onset, duration, and impairment. The ChIPS has been demonstrated to be a reliable and valid measure and is appropriate to be used as a screening or diagnostic measure (Weller et al., 2000).

MINI-KID

The MINI-KID is a structured diagnostic interview used to assess children and adolescents ages 6 to 17 on psychiatric disorders presented in the DSM-IV and the International Classification of Diseases–Tenth Revision (ICD-10). This measure can be administered to a child or adolescent with or without parent involvement. Similar to the ChIPS, this instrument presents symptoms in diagnostic modules or sections. The MINI-KID has demonstrated acceptable reliability and validity as well as a high level of sensitivity and specificity (Sheehan et al., 2010).

Items for DMDD from ChIPS and MINI-KID

There are a number of items in various diagnostic sections on the ChIPS and the MINI-KID clinicians might examine to assess for criteria for DMDD. Items are listed by criteria and diagnostic section in Tables 2 and 3.

Table 2.

Children’s Interview for Psychiatric Syndromes (ChIPS) items relevant for Diagnostic and Statistical Manual–5 criteria for DMDD by diagnostic section.

DMDD criteria	ChIPS
DMDD criteria	Diagnostic section	Item	Description
A.	ODD	1a	“Does your child get upset and lose his/her temper if things don’t go his/her way?”
		6	“Is it easy for other people to make your child mad?”
		8	“When someone makes him/her angry, does your child get even?” “How?”
	CD	10a	“Has he/she ever hurt someone badly in a fight . . .”
		12	“Has he/she ever damaged any property . . .”
	Dep/Dys	A: 2a–d	“When he/she feels [___], does he/she get into arguments? Does he/she yell, cry, or get upset easily? Does he/she get into fights a lot {for example, slamming doors, throwing or breaking things, having a short or bad temper}?”
B.	ODD	1a	See above
		6
		8
	CD	10a	See above
	CD	12
	Dep/Dys	A: 2a–d	See above
C.	ODD	1a or 1b	“Does your child get upset and lose his/her temper if things don’t go his/her way?”“Does he/she throw big temper tantrums pretty often?”
	ODD	Duration #1 and #2 for 1b	“Does he/she throw big temper tantrums pretty often? . . . “when did this begin? . . . is he/she still having trouble with this?”
	Dep/Dys	2c–d	“Does that happen almost every day?”“Does that last most of the day?”
D.	ODD	7	“Is your child angry [mad, resentful] a lot of the time?”
	ODD	6	“Is it easy for other people to make your child mad?”
	Dep/Dys	2a–d	“Does he/she feel more cranky [crabby, grumpy, snappy] than usual?”
E.	ODD	Duration #1, 3 for 1a–b	“Does your child get upset and lose his/her temper if things don’t go his/her way? Does he/she throw big temper tantrums pretty often? . . . has this been going on for at least 6months?”
		Duration #1, 3 for 6	“Is it easy for other people to make your child mad? . . . has this been going on for at least 6months?”
		Duration #1, 3 for 7	“Is your child angry [mad, resentful] a lot of the time? . . . has this been going on for at least 6months?”
	Dep/Dys	Duration #1 for 2a–d	“When he/she feels [___], does he/she get into arguments? Does he/she yell, cry, or get upset easily? Does he/she get into fights a lot {for example, slamming doors, throwing or breaking things, having a short or bad temper}? . . . When did this begin?”
F.	ODD	Impairment: ⩾2 of 3 settings
F.	Dep/Dys	Impairment: ⩾2 of 3 settings
G.	Met by use of the ChIPS
H.	ODD	Duration #1 for 1a–b	“Does your child get upset and lose his/her temper if things don’t go his/her way? Does he/she throw big temper tantrums pretty often? . . . When did this begin?”
		Duration #1 for 6	“Is it easy for other people to make your child mad? . . . When did this begin?”
		Duration #1 for 7	“Is your child angry [mad, resentful] a lot of the time? . . . When did this begin?”
	Dep/Dys	Duration #1 for items #2a–d	“When he/she feels [___], does he/she get into arguments? Does he/she yell, cry, or get upset easily? Does he/she get into fights a lot {for example, slamming doors, throwing or breaking things, having a short or bad temper}? . . . When did this begin?”
I.	Mania/Hypomania	Does not meet criteria
J.	Separation anxiety disorder	Screen for presentation based on diagnostic section
	Stress disorders	Screen for presentation based on diagnostic section
	Screen for intermittent explosive disorder and autism spectrum disorders, no diagnostic sections available
K.	Substance abuse	1b	“Has your child ever smoked marijuana . . . how much/how often?”
		1c	“Has your child ever smoked anything else?”
		2	“Has he/she ever drunk beer, wine, or liquor . . . how often?”
		3	“Has he/she ever used any other drugs to get high . . . what kind . . . how often?”
		4	“Has he/she ever sniffed . . . glue, gasoline, butane, aerosols, or anything else to get high . . . how often?”
		Impairment 1a	“Has using . . . caused your child trouble at home?”

DMDD: disruptive mood dysregulation disorder; ODD: oppositional defiant disorder; CD: conduct disorder.

Table 3.

Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) items relevant for Diagnostic and Statistical Manual–5 criteria for DMDD by diagnostic section.

DMDD criteria	MINI-KID
DMDD criteria	Diagnostic section	Item	Description
A.	ADHD	O1	“Has anyone . . . ever complained about your behavior or performance in school?”
	ODD	Q1	“Has anyone . . . ever complained about your behavior or performance in school?”
		Q2a	“Have you often lost your temper?”
		Q2b	“Have you often argued with adults?”
		Q2c	“Have you refused to do what adults tell you to do? Refused to follow rules?”
		Q2f	“Have you often been ‘touchy’ or easily annoyed by other people?”
		Q2g	“Have you often been angry and resentful towards others?”
		Q2h	“Have you often been ‘spiteful’ or quick to ‘pay back’ somebody who treats you wrong?”
B.	Additional query for above item endorsement
C.	ODD	Q2a	See above
D.	ODD	Q2g	See above
	MDD	A1a	“At any time in your life did you feel sad or depressed? Felt down or empty? Felt grouchy or annoyed? Did you feel this way most of the time for at least 2 weeks?
	MDD	A1b	“For the past two weeks did you feel this way, most of the day, nearly every day?”
	(Hypo) manic episode	D2a	“Has there ever been a time when you were so grouchy or annoyed for several days, that you yelled or started fights with people outside your family? Have you or others noticed that you have been more grouchy than other kids, even when you thought you were right to act this way?”
	(Hypo) manic episode	D2b	“Are you currently feeling grouchy or annoyed most ofthe time?”
	PTSD	K5b	“In the past month have you been moody or angry for no reason?”
E.	Additional query for above item endorsement
F.	Additional query for above item endorsement
G.	Met by use of the MINI
H.	Additional query for above item endorsement
I.	(Hypo) manic episode	Does not meet criteria
J.	Separation anxiety disorder	Screen for presentation based on diagnostic section
	PTSD	Screen for presentation based on diagnostic section
	PDD	Screen for presentation based on diagnostic section
	Intermittent explosive disorder
K.	Substance dependence/abuse (non-alcohol)	Screen for presentation based on diagnostic section
	Alcohol dependence/abuse	Screen for presentation based on diagnostic section
	Rule out medical, organic or drug causes for all disorders	Screen for presentation based on diagnostic section

DMDD: disruptive mood dysregulation disorder; ADHD: attention-deficit/hyperactivity disorder; ODD: oppositional defiant disorder; MDD: major depressive disorder; PTSD: post-traumatic stress disorder; PDD: pervasive developmental disorder.

ChIPS

More detailed explanations of the items in Table 2 are provided for clarification. Items 1a, 6, and 8 of the oppositional defiant disorder (ODD) diagnostic section can be used to asses for Criterion A. In order to be suggestive of DMDD, answers to these questions should indicate that the tantrums or behaviors are grossly out of proportion to the situation or provocation in intensity or duration or both. Conduct disorder (CD) items 10a and 12 may indicate the intensity of tantrums and assess physical aggression. Additionally, depression/dysthymia diagnostic section items 2bi–iii evaluate specific behaviors which can also provide information when assessing Criterion A. Criterion B for DMDD can be assessed subjectively by the clinician regarding the descriptions provided for ODD items 1, 6, and 8, CD items 10a and 12, and items 2bi–iii from the depression/dysthymia diagnostic section. ODD items 1a and 1b are appropriate measures for Criterion C. Duration questions 1 and 2 regarding responses to item 1b may assist in determining frequency of outbursts. Items 2c–d from the depression/dysthymia diagnostic section can also provide insight into the frequency of tantrums. It may be necessary to do further query to determine if the cranky mood and/or the behaviors are occurring daily and throughout most of the day. Assessing for Criterion D may be achieved by multiple items on the ChIPS. Specifically, ODD items 7 and 6, and depression/dysthymia item 2a can be used to asses Criterion D but only if the irritable or cranky mood persists most of the day nearly every day independent of the temper outbursts. Thus, the mood should be frequent to constant. Duration of the irritable mood is assessed in item 2d of the same section and can be used to determine if the mood persists throughout the day.

The ChIPS provides questions on duration for each diagnostic section. This question should be reviewed in each diagnostic section for items endorsed that are consistent with Criteria A through D. If symptoms have been present for 12 or more months, without any break in symptoms for 3 or more months then Criterion E is satisfied. This can be assessed in part, using duration item #3 for items in the ODD section numbers 1a–b, 6, and 7. Additional querying is required to ensure that there has not been a period of 3 or more months without symptoms present. Criterion F requires that Criteria A through D occur in at least two settings. Similar to the duration items, the ChIPS has impairment items for each diagnostic section that assess areas of impairment. This should be assessed for the items in the depressive/dysthymic section and the items the child meets criteria for in the ODD section. Criterion G should be met if one is using the ChIPS as the measure is intended for use with children aged 6–18 years. Duration questions should also provide insight into satisfying Criterion H.

Criteria I, J, and K involve evaluation of symptoms with consideration of other disorders. Criterion I can be assessed utilizing the Criteria Section of the Mania/Hypomania diagnostic section. If criteria have been met for a manic or hypomanic episode then Criterion I is not met and a diagnosis of DMDD is not appropriate. In order to meet Criterion J, behaviors must not occur only during an episode of major depressive disorder and are not better explained by another disorder. If the child meets Criteria A through D for DMDD, the clinician should carefully review all disorders the child meets criteria for and determine whether any of the symptoms listed in A through D are better accounted for by another disorder. Of note, DMDD can coexist with major depressive disorder, attention-deficit/hyperactivity disorder (ADHD), CD, and substance use disorder. However, it is important in these cases that symptoms of DMDD be independent of symptoms of other disorders. Criterion K requires that the symptoms are not the direct result of any substances, medical, or neurological conditions. DMDD can occur with a substance use disorder; however, symptoms must not be attributed only to the effects of the substance. The ChIPS diagnostic section for substance abuse can be used as a method of evaluating the influence of any substances on symptoms. Should substance use items 1–4 be endorsed, the clinician must use additional inquiry to clarify that any symptoms meeting criteria for DMDD occur outside the context of substance use. Additionally, impairment items in this section indicating that use of substances has caused trouble may be an indicator that symptoms of DMDD occur in the context of substance use.

There are a number of disorders which cannot co-occur with DMDD, specifically, intermittent explosive disorder (IED), ODD, or bipolar disorder. The ChIPS can be utilized for differential diagnosis by examining the disorders the child has met criteria for. In terms of differential diagnosis with IED, there are a few key diagnostic differences. The first is regarding frequency of temper outbursts. Item 1b from the ODD section is a good way to determine frequency of outbursts. Another difference is duration of symptoms. Outbursts should be occurring for at least a 12-month period in order to meet criteria for DMDD but only 3 months for IED. Finally, IED requires that a maximum of three outbursts in a 12-month period result in aggression that causes damage or injury. Item 10a of the CD section and items 2bi–iii from the depression/dysthymia section can both be used as a guide for determining if the intensity of outbursts is more consistent with DMDD or IED.

MINI-KID

Items O1 and Q1 from the attention deficit hyperactivity and ODD sections respectively may be helpful in assessing Criterion A as a child with recurrent tantrums will likely endorse these items. Additionally, in the ODD section items (referring to the past 6 months) Q2a–c, f–h may give an indication about the presence of temper outburst. In order to assess for developmental inappropriateness of temper outbursts, additional query will be needed as the MINI-KID does not provide any items that would assess for this. Criterion C can be assessed somewhat by reviewing item 2a from the ODD section but additional query is required to determine exact frequency. Items A1a, b of the major depressive episode section ask about feeling “grouchy or annoyed” which might be used to assess irritability. Additionally, item Q2g from the ODD section may give some indication of mood between outbursts. In the (Hypo) manic episode module, items D2a and D2b are items that describe an irritable or angry mood. Endorsement of these items may speak to an irritable mood between temper outbursts. Finally, item K5b in the post-traumatic stress disorder (PTSD) section may also be endorsed by individuals experiencing irritability or anger consistent with a diagnosis of DMDD. However, it is important that additional query be used to determine that the patient is reporting irritability and that it is observable by others. There are no appropriate items to assess for Criteria E, F, and H on the MINI-KID and thus will require additional query. Criterion G should be met if a provider is using the MINI-KID as the age range is 6–17 years. In order to evaluate Criterion I, one could consult the (Hypo) manic episode section to determine whether the individual at any time met criteria for a manic or hypomanic episode. Criterion J concerns ensuring that symptoms are not better accounted for by other diagnoses; using the MINI-KID it would be possible to assess for the other diagnoses that are accounted for by their respective modules. However, DMDD can co-occur with some diagnoses and there is no diagnostic section for IED, thus again, additional query will be needed to evaluate Criterion J. Criterion K seeks to ensure that symptoms are not due to substance use, another medical or neurological condition; using the MINI, diagnostic sections Substance dependence/abuse, Alcohol dependence/abuse, and Rule out medical, organic, or drug causes for all disorder should be consulted and examined closely should a child or adolescent endorse items in these sections.

Case

The following case seeks to illustrate the evaluation of a 9-year-old Caucasian female ultimately diagnosed with DMDD. Names and identifying information have been changed to protect the identity of the patient. Katie (pseudonym) initially presented to an outpatient-based pediatric anxiety specialty clinic for assessment of anxiety disorders and was evaluated by a board certified child and adolescent psychologist and a board certified child and adolescent psychiatrist working independently. Subsequently, she presented to an outpatient-based specialty clinic for the evaluation of pediatric mood disorders and was assessed by a board certified child and adolescent psychologist and a board certified child and adolescent psychiatrist. The four evaluations were conducted within 1 month of each other with both sets of psychologists and psychiatrists engaging in a case conference for diagnostic conclusions in their respective areas.

Presenting complaints

Katie and her parents presented to the pediatric anxiety specialty clinic due to concerns about Katie’s anxiety which began when she was in kindergarten. During that time she was diagnosed with depression after a period of often worrying that she would get into trouble, confessing inconsequential things (e.g. Dropping a pencil), and making regular negative statements (e.g. “I hate myself,” “I am an idiot”). Additionally, in response to limits or when she dropped an item she responds with disproportionate anger and engages in more externalizing behaviors such as hitting others, throwing things, yelling, hitting herself, and head banging. Katie was also described by her parents as being hyperactive from a young age. In terms of anxiety symptoms, Katie’s parents report that she experiences anxiety related to being away from her mother and being at school, worries often about family and friends’ safety, seeks reassurance for decisions she makes, and experiences panic attacks. Furthermore, Katie prefers things to be balanced and engages in behaviors such as chewing food the same number of times on each side of her mouth. Katie’s parents also reported that she experiences significant difficulty falling and staying asleep, Sleep concerns arecurrently being treated with medication. They report three occasions during which she went approximately 48 hours without sleep, was intently focused on performing karate in her room, and had silly speech.

A total of 1 month following her evaluation in the anxiety disorders clinic, Katie and her parents presented to a specialty pediatric mood disorders clinic. With regard to depressive symptoms, Katie endorsed fatigue, low self-esteem, and feeling down sometimes when thinking about a deceased pet ferret. She denied suicidal ideation; however, her parents reported one occasion of a suicidal statement. Katie reported the incident was provoked by anger. Other depressive symptoms were denied. In terms of manic symptoms, Katie and her parents denied excessive elation, giddiness, or happiness. Katie reported that she feels irritable nearly all day, most days. Her parents reported that Katie’s irritability has been present since she was about 4 years old and results in defiant behaviors inconsistent with her age. Her irritability has led to destruction of property and violence toward others; specifically, she tore up her brother’s favorite stuffed animal and kicked another child at school. She endorsed often hitting her parents, daycare provider, and brother. On one occasion, she stayed awake all night and then slept 2 hours the next day. She and her parents also reported an incident about 3 months before the evaluation during which Katie stayed up for about 40 hours with an excessive amount of energy, performing karate. During this incident, she had elevated mood, a decrease in inhibition, and goal directed behavior. Symptoms of CD, specific phobia, social phobia, separation anxiety, generalized anxiety, obsessive–compulsive disorder, PTSD, dysfunctional eating, elimination disorders, tic disorders, and psychosis were denied.

History

Katie was the product of an uncomplicated pregnancy and birth. Her mother received standard prenatal care and all of her developmental milestones were achieved within normal limits. She displayed normal temperament until age 1 year when she began having more difficulty with compliance; however, her parents in retrospect see this may not have been too different from other children. She connected easily with her parents and caregivers. Additionally, she was able to develop and sustain meaningful relationships with peers and teachers. Around age 4, she began demonstrating difficulty complying with requests at home and school and became emotionally upset when limits were set. This behavioral pattern became concerning to her parents and resulted in initiating outpatient therapy.

Katie resides with her parents, 4-year-old brother, and 11-year-old sister. She described mostly positive relationships with both her parents but a conflictual relationship with her brother. She is in the third grade and prior to this year she earned mostly As. This year her grades have dropped to Cs and Ds. Katie reportedly gets along well with her teacher, but struggles to maintain relationships with peers. She reported that she has three friends at school and that at times she hits or kicks when they do not do what she wants. Katie also shared that she is regularly sent to the administrator’s office due to behavioral difficulties and non-compliance. Occasionally, she goes to the school nurse office to calm down. Katie’s immediate family mental health history is unremarkable. Her extended family history is significant for a relative with depression and another relative with a history of psychotic symptoms and numerous hospitalizations. Additionally, Katie’s two cousins struggle with emotion regulation and one is diagnosed with Asperger’s disorder and a learning disability.

Katie’s medical history is unremarkable. Katie has been treated with multiple psychopharmacological medications in the past to manage her irritability and outbursts. Specifically, she has had trials of Abilify, Seroquel, Geodon, Vyvanse, Adderall XR, Focalin, Celexa, Lamictal, and Intuniv. At the time of the initial evaluation in the anxiety disorders clinic, Katie was taking Intuniv, Melatonin, Quillivant XR, Trileptal, and Zoloft. At the time of the second evaluation in the pediatric mood disorders clinic, Katie was prescribed Kapvay, Quillivant XR, Trileptal, and Zoloft.

Assessment

As a part of the standard assessment in the pediatric anxiety disorders clinic, Katie and her family were administered sections of the MINI-KID by a child and adolescent board certified psychologist. The sections of the MINI-KID administered are consistent with the focus of that clinic and included the separation anxiety disorder, social phobia, specific phobia, panic disorder, agoraphobia, generalized anxiety, obsessive–compulsive disorder, PTSD, major depressive episode, attention deficit hyperactivity disorder, and ODD diagnostic sections. Based on this structured interview, Katie met criteria for ODD, ADHD-combined type, generalized anxiety disorder, separation anxiety disorder, and specific phobia of spiders. Based on the responses given during the unstructured portion of the evaluation, Katie was given a diagnosis of mood disorder not otherwise specified (NOS) in addition to those identified by the MINI-KID.

A total of 1 month following her assessment in the anxiety disorders clinic, Katie and her family were evaluated in a mood disorders clinic and were administered the ChIPS. Based on their responses to the ChIPS, Katie met criteria for ADHD-combined type and ODD. In addition to these, based on information gathered during unstructured clinical interviews Katie was also given diagnoses of generalized anxiety disorder by history and DMDD.

Application of theoretical items to case

As can be seen in Table 4, based on the use of the items theoretically identified by the authors to be consistent with DMDD and the ChIPS, Katie would meet criteria for DMDD. In contrast, based on the items identified for use from the abbreviated version of the MINI-KID in isolation, as can be seen in Table 5, Katie does not meet criteria for DMDD.

Table 4.

Disruptive mood dysregulation disorder criteria endorsed by Katie and her family using the ChIPS and Mood clinic unstructured interview.

DMDD criteria	ChIPS criteria	Unstructured interview
A.	☒ ODD 1a	“daily irritability since age 4 . . . in all settings . . . which results in outbursts which are excessive to her development”^a “more than 3years of angry outbursts”^b
	☒ ODD 6
	☒ ODD 8
	☐ CD 10a
	☐ CD 12
	☒ Dep/Dys A: 2a–d
B.	☒ ODD 1a	“daily irritability since age 4 . . . in all settings . . . which results in outbursts which are excessive to her development”^a “parents are debilitated by level of symptoms”^b
	☒ ODD 6
	☒ ODD 8
	☐ CD 10a
	☐ CD 12
	☒ Dep/Dys A: 2a–d
C.	☒ ODD 1a or 1b	“daily irritability since age 4 . . . in all settings . . . which results in outbursts which are excessive to her development”^a
	☒ ODD Duration 1, 2 (1b)
	☒ Dep/Dys A: 2c–d
D.	☒ ODD 6	“daily irritability”^a “angry most of the time”^b
	☒ ODD 7
	☒ Dep/Dys A: 2a–d
E.	☒ ODD Duration 3 (1a–b)	“daily irritability since age 4 . . . in all settings . . . which results in outbursts which are excessive to her development”^a “nothing has been a true control of symptoms”^b
E.	☒ Dep/Dys Duration 1
F.	☒ ODD Impairment ⩾ 2 of 3 settings	“daily irritability since age 4 . . . in all settings . . . which results in outbursts which are excessive to her development”^a
F.	☒ Dep/Dys Impairment ⩾ 2 of 3 settings
G.	☒ Patient is 9years old
H.	☒ ODD Duration 3 (1a–b)	“daily irritability since age 4 . . . in all settings . . . which results in outbursts which are excessive to her development”^a “more than 3years of angry outbursts”^b
H.	☒ Dep/Dys Duration 1 (2a–d)
I.	☒ Mania/Hypo (Does not meet criteria)	“regarding manic symptoms, she denied excessive elation, giddiness, or happiness”^a “not truly grandiose during period of increased energy . . . episode likely triggered by combination of (medication)”^b
J.	☒ Separation anxiety disorder (Does not meet criteria)	“denies symptoms of . . . separation anxiety disorder, PTSD . . . ”^a
	☒ Stress disorders (Does not meet criteria)
	☐ ODD (Does not meet criteria)
K.	☒ Substance abuse (Does not meet criteria)	“ . . . she is in good health . . . does not have . . . history of significant medical problems”^b “Katie’s medical history is unremarkable”^a

DMDD: disruptive mood dysregulation disorder; ODD: oppositional defiant disorder; CD: conduct disorder; ChIPS: Children’s Interview for Psychiatric Syndromes; PTSD: post-traumatic stress disorder.

Table 5.

Disruptive mood dysregulation disorder criteria endorsed by Katie and her family using the MINI-KID and Anxiety clinic unstructured interview.

DMDD criteria	MINI-KID criteria	Unstructured interview
A.	☒ ADHD O1	“she also developed anger issues, hitting herself, banging her head, screaming, yelling, throwing things, hitting others . . . is quickly out of proportion to the situation”^a “Katie has longstanding difficulties with behavioral dyscontrol” “her parents say . . . she can [be] prone to ‘wigging out’” “she can become quite agitated when she is angry” “Katie will frequently have angry outbursts when things are not going her way . . . sometimes she does not need much of a trigger at all” “girl with significant reactivity”^b
	☒ ODD Q1
	☒ ODD Q2a
	☒ ODD Q2b
	☒ ODD Q2c
	☒ ODD Q2f
	☒ ODD Q2g
	☒ ODD Q2h
B.
C.	☒ ODD Q2a	“[outbursts] happen when she does not get something she wants . . . other times will happen for other reasons”^a
D.	☒ ODD Q2g	“her parents say she can either be calm and pleasant or more typically angry, irritable, and prone to ‘wigging out’”^b
	☐ MDD A1a
	☐ MDD A1b
	☐ Mania D2a^c
	☐ Mania D2b^c
	☐ PTSD K5b
E.		“Their [her parents] concerns began approximately 3 years ago . . . ”^a “Katie has longstanding difficulties with behavioral dyscontrol”^b
F.		“has behavioral problems at school as well”^b
G.	☒ Patient is 9 years old
H.		“Their [her parents] concerns began approximately 3 years ago . . . ”^a “They [her parents] felt that her temperament was excellent up until one year of age”^b
I.	☐ (Hypo) manic episode^c	“ . . . she had an episode that certainly could have been a manic episode although it is not clear that she met sufficient symptoms . . . ”^a “she has also had a history of some depressive symptoms and what sounds like a manic episode . . . ” “she has had what sound like perhaps two manic episodes . . . another episode where she went without sleep for a sustained period”^b
J.	☐ Separation anxiety disorder (Does not meet criteria)	“she meets criteria for ODD and ADHD . . . GAD, separation anxiety, and has a specific phobia . . . third area of concern is a bipolar disorder”^a
	☒ PTSD (Does not meet criteria)
	☐ Pervasive developmental disorder (Does not meet criteria)^c
	☐ ODD (Does not meet criteria)
K.	☐ Substance dependence/abuse (non-alcohol)^c ☐ Alcohol dependence/abuse^c ☐ Rule out medical, organic or drug causes for all disorders^c	“she is in overall good health”^b

DMDD: disruptive mood dysregulation disorder; ADHD: attention-deficit/hyperactivity disorder; ODD: oppositional defiant disorder; PTSD: post-traumatic stress disorder.

Psychologist.

Psychiatrist.

Diagnostic module not administered.

Conclusion

Discussion

As the DSM is revised and diagnosis are changed or added, guidance for professionals for using these new diagnoses is needed. While this article does not hope to comprehensively address the new diagnosis of DMDD, it does aim to provide a method for using existing structured interview instruments to assess for the diagnosis and provide suggestions for future alterations to these instruments. It is important that caution be used when utilizing these instruments to evaluate diagnosis for which they have not been validated. As has been described in the text, both the ChIPS and the MINI-KID have positive and negative qualities when assessing for the presentation of DMDD.

The case of Katie reviews a 9-year-old Caucasian female presenting to both a pediatric anxiety disorders clinic and pediatric mood disorders clinic for evaluations within a 1-month period. Katie’s responses on the MINI-KID and the ChIPS were compared to the theoretical items identified as consistent with DMDD. Katie met criteria for DMDD based on her item endorsement on the ChIPS. Furthermore, the unstructured or clinical interview portion of the assessment supported a diagnosis of DMDD. If the complete version of the MINI-KID with all modules is used, we would be able to utilize the theoretical items identified. However, there was not enough information from the version of the MINI-KID administered to comprehensively evaluate these items. Notably, with the inclusion of the information gleaned from unstructured portions of the evaluation in the pediatric anxiety clinic there is some data that is inconsistent with a diagnosis of DMDD (e.g. a manic episode), while other reports are consistent. Overall, Katie’s case supports the need for existing measures to reorganize criteria to allow for the assessment of DMDD. Furthermore, it may be possible for professionals to use existing measures in addition to unstructured interviews to assess for DMDD prior to the inclusion of a DMDD section in structured and semi-structured instruments. Items on the ChIPS will likely provide a good screen of symptoms consistent with DMDD. However, the ChIPS is somewhat diagnostically narrow and was initially developed as a screening measure (Leffler et al., 2015; Rooney, Fristad, Weller, & Weller, 1999). For example, the ChIPS does not assess for IED. This is particularly important for evaluation of DMDD as a diagnosis of IED and DMDD cannot co-occur. Therefore, additional query and/or clinician interpretation will be needed to determine more specifically if criteria for DMDD are met (e.g. the developmental inappropriateness of outbursts, the proportionality in intensity, and/or duration of the outbursts).

Perhaps most notably, the MINI-KID does not provide items concerning duration of symptoms, context of symptom presentation, or age of onset of symptoms. This is all necessary information to make a diagnosis of DMDD and thus represents a weakness in its use for assessment of DMDD in its current form. Additionally, utilizing the MINI-KID for the diagnosis of DMDD is limited due to the content of the rule-in questions. While these questions may be consistent with the respective diagnosis for some diagnoses they do not map onto actual diagnostic symptoms as defined by the DSM-5. For example, the screening question for diagnostic categories of ADHD, ODD, and CD is “has anyone (teacher, baby sitter, friend or parent) ever complained about your behavior or performance in school” (Sheehan et al., 2009). While this may likely have occurred as a consequence of symptoms and may also speak to impairment, this does not address any specific diagnostic symptom.

Limitations for our case

The case presented for this study was limited in a number of ways. As Katie was evaluated in clinics that targeted specific diagnostic clusters (i.e. anxiety disorders or mood disorders), the clinicians within each pediatric clinic may have exhibited confirmation bias related to their respective clinics. Additionally, the complete MINI-KID was not given thus; we do not have a comprehensive example of the theoretical items identified for the MINI-KID for the evaluation of DMDD. The MINI-KID and ChIPS are also somewhat limiting as they are not as comprehensive as other structured and semi-structured interviews such as the Diagnostic Interview Schedule for Children Version IV (structured) or the Schedule for Affective Disorders and Schizophrenia for School Aged Children (semi-structured). Furthermore, the study is limited by the inclusion of only one case example. This limits the ability to generalize the use of these measures in evaluating DMDD. A final limitation is that in the pediatric anxiety disorders clinic, both the child and the parents were seen by both providers. In contrast, in the pediatric mood disorders clinic the psychiatrist met with Katie’s parents and the psychologist met with Katie. Thus, information was not provided by all the same informants in each clinic. Literature suggests that there is inconsistency in reports based on the informant (Jensen et al., 1999; Lauth et al., 2010).

Future directions

The publication of DSM-5 (American Psychiatric Association, 2013) and the introduction of the new diagnosis of DMDD bring about the need for ongoing research on this disorder broadly. Ongoing research might include validation of the theoretical composite method described in this study with a larger population. Additionally, existing structured and semi-structured interviews will need to be revised to include the new diagnoses in the DSM-5. As previously noted, many of the existing measures already include items consistent with DMDD; however, they are not organized under this diagnosis. Furthermore, studies evaluating reliability and validity of these instruments for the diagnosis of DMDD are needed. Additionally, studies should include interview formats that are used in research settings as well as those used more often in clinical settings.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author biographies

Emily A McTate, PhD, is an Attending Pediatric Psychologist in the Department of Clinical Psychology and Behavioral Medicine at Cincinnati Children’s Hospital Medical Center working in the Cancer and Blood Diseases Institute and an assistant professor at the University of Cincinnati. She completed graduate school at Saint Louis University, pre-doctoral internship at University of Louisville School of Medicine and Kosair Children’s Hospital, and post-doctoral fellowship at Mayo Clinic in Clinical Child and Pediatric Psychology.

Jarrod M Leffler, PhD, ABPP, is a Consultant in the Division of Child and Adolescent Psychiatry and Psychology and Assistant Professor at Mayo Clinic where he is the director of the Child and Adolescent Integrated Mood Program (CAIMP) and co-director of the Pediatric Mood Clinic, the Pediatric National Clinic, and Pediatric Transition Program. He received his Ph.D. in clinical psychology from Saint Louis University. He completed his internship at Harvard Medical School and the Children’s Hospital, Boston, and his two-year fellowship in child and adolescent mood disorders at Ohio State University.

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