August 19, 2015

A Diagnostic Dilemma: The Child With Aggressive Outbursts

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Robert L. Findling, MD, MBA

Johns Hopkins University/Kennedy Krieger Institute, Baltimore, Maryland


Clinicians who work with children frequently come across a particularly vulnerable group of youngsters. The following vignette describes a “typical” patient in this group:

Jordan is an 8-year old boy who has just gotten suspended from 1st grade for the 2nd time (and it’s only October) for fighting. He was accidentally bumped by a classmate while waiting in a line and responded by angrily striking the classmate multiple times. You learn from his parents that similar events happen elsewhere. In fact, this youngster had to change preschools several times due to his aggression. Although Jordan is a bit more fidgety than other children his age, what is really causing him trouble is his “short fuse” and “explosions” that often culminate in destruction of property or physical aggression against others. No external circumstances readily explain these chronic difficulties. The patient’s mother describes Jordan’s temperament as “sweet” and “kind,” but, as her son’s aggressive behaviors continue over time, she notes that her child is becoming more surly and mean-spirited. When you interview the child, he initially comes across as irritable and defiant, but, with time, he becomes kinder. Jordan sadly expresses that he knows that his peers, teachers, and even his family think of him as being “bad.”

When the dysfunctionally aggressive child is brought to clinical attention, a key challenge is to apply a diagnosis or diagnoses that best suits this child. The patient may meet diagnostic criteria for attention-deficit/hyperactivity disorder, but that diagnosis does not seem to get at the core of what the key difficulty is for children like Jordan—violent, affectively-charged reactions to minor provocations.

At one time, this child could have been given the diagnosis of conduct disorder. Conduct disorder has been shown to be a valid diagnosis, even in preschool-aged children. However, this diagnosis isn’t commonly used to describe such children. Clinicians might not want to use this diagnosis as it may suggest that the child has premeditated antisocial behavior and/or is destined to develop antisocial personality disorder.

With these considerations in mind, using the DSM-IV diagnosis of bipolar disorder not otherwise specified might have seemed more appropriate to some clinicians. Several diagnostic features of bipolarity are manifest in these patients—irritability, impulsivity, distractibility, and risk-taking behavior.

These factors may have led, in part, to the increased use of a bipolar diagnosis in children. As a result of its increased use, concerns were raised about the overdiagnosis of bipolar disorder in youths. What is not clear is whether clinicians believed that these patients actually had the same diagnosis as seen in adults or rather that this diagnosis was simply the most suitable categorization based on practical considerations.

Subsequently, the diagnosis of disruptive mood dysregulation disorder (DMDD) entered the psychiatric nosology in the DSM-5. This mood disorder is primarily characterized by childhood-onset chronic irritability and temper outbursts. However, concerns have been raised about the utility of the DMDD diagnosis. Data suggest that DMDD has substantive overlap with disruptive behavior disorders and does not appear to be diagnostically stable over time.

Since DMDD is a mood disorder, one might expect that the onset of temper outbursts or tantrums would develop at the same time or after the onset of irritable mood. I rarely see such a patient. The much more common presentation is like the case vignette I described above—a child who becomes chronically irritable subsequent to the onset of temper outbursts.

We do not seem to have a satisfactory diagnosis in our current clinical nosology to describe this prevalent group of children. Ultimately, we need a precise, meaningful, and empirically based means by which to characterize these children.

Financial disclosure:Dr Findling in the last 12 months, has received research support from, acted as a consultant for, and/or served on a speakers’ bureau for Alcobra, American Psychiatric Press, Bracket, CogCubed, Cognition Group, Coronado Biosciences, Elsevier, Forest, Guilford Press, Johns Hopkins University Press, KemPharm, Lundbeck, Merck, NIH, Neurim, Novartis, Otsuka, Oxford University Press, Pfizer, Purdue, Roche, Sage, Shire, Sunovion, Supernus, Validus, and WebMD.

Category: ADHD , Bipolar Disorder , Mental Illness
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5 thoughts on “A Diagnostic Dilemma: The Child With Aggressive Outbursts

  1. This concern with diagnosis omits consideration (or at least presentation) of the environmental influences at work. Too often I’ve seen children labeled as neurologically/psychologically pathological before a thorough investigation of external influences is made. These are often factors which can be altered but which too often are so persistent as to eventually cause pathology, especially in children who may be temperamentally vulnerable.
  2. In the case described and the general discussion there seems to be an implied assumption that diagnosis would lead to appropriate treatment. It would seem more reasonable to do a functional assessment of the behavior and then using that information formulate a treatment plan. Then continue to collect data on the behavior and modify the plan as needed. Too often we think that diagnoses will lead to effective treatment when experience suggests that is simply not happening.
  3. My fear is that as health care providers, we are increasingly asked to provide evaluations based on shorter and shorter periods of time spent doing the evaluation. In fact 40-50 minutes is not unheard of. Ti address the problem, we need to gain as much information as possible, including presenting problem, developmental history, family history, environmental stressors, medical history, mental status exam, etc. Without the basics, accurate diagnosis and interventions are not possible. With the data you present, I would add the possibility of Impulse Control Disorder-NEC or Intermittent Explosive Disorder.
  4. or Oppositional Defiant Disorder….
    And I agree that many children are not easily diagnosed in one session. I use many Rule Outs in my evaluation.
  5. It would have been instructive to have been told what treatments were tried, what worked, and what didn’t. And I’m with “rdahmes”, besides considering the “usual suspects”: mood disorders, ADHD, etc., there seems to be a possible element of Disinhibition here – call it what you want: “Impulse Dyscontrol”, “Intermittent Explosive Disorder”, or whatever.

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