Exploring Disruptive Mood Dysregulation Disorder

J.D. is an 8 year-old male student at Central Philadelphia elementary school whom is diagnosed with Attention-Deficit Hyperactivity Disorder. J.D. was referred by his physician to receive psychiatric inpatient treatment following incidents that occurred at school where he portrayed disruptive mood dysregulation. Schoolteachers informed his mother that he is highly disruptive in class and has trouble following directions and that sometimes he will want to accomplish the task and other times he doesn’t seem to understand it. His mother reported that he exhibits severe frustration, oppositionality, aggression, and hyper-arousal. She says that J.D.’s frequent frustration often results in prolonged outbursts at home that turn violent. Sometimes he has to be removed from class when this happens at school because his behavior becomes dangerous to his peers and himself. When parents or the classroom aide have to resort to restraining him, he occasionally becomes even more agitated and aggressive. His mother reported that he made one comment about hurting himself before and when asked about it, J.D. denied it. His mother informed us that she was concerned for her son’s wellbeing and overall safety. He is exhibiting behavior as a result of Disruptive Mood Dysregulation disorder and Attention- Deficit Hyperactivity disorder that is detrimental to himself, his family, and his peers. He will need to be introduced to relaxation techniques, impulse control, anger management, and distractive physical activity where he can use his energy in a positive way.

The purpose of this case study is to identify the background of Disruptive Mood Dysregulation disorder, as well as the nursing assessment, diagnoses, potential outcomes, and goals. In addition, nursing interventions and the assessment of a child with Disruptive Mood Dysregulation will also be discussed.

Disruptive Mood Dysregulation disorder (DMDD) is a mental disorder in children and adolescents characterized by extreme irritability, anger, and frequent, intense temper outbursts that are disproportionate to the situation and cognitive-behavioral development. JD, among other children with Disruptive Mood Dysregulation, experience severe impairment that requires clinical attention for unipolar depression, rage, and outbursts. The prevalence of all mental health disorders in childhood and adolescents range from 1.8% to 39.4% in low-middle income homes. According the Journal of Affective Disorders, after evaluating 3,563 subjects at 11 years old, the prevalence of DMDD is 2.5%. This data correlates to the risk factors including maternal mood during pregnancy, maternal depression during the first years after birth, and low maternal education. To be diagnosed with DMDD, a child must have symptoms steadily for 12 or more months. These symptoms include irritability and anger for most of the day- nearly every day, verbal and behavioral temper outbursts at an average of three or more times per week, and trouble functioning due to irritability in more than one place (e.g., home, school, with peers).

Disruptive Mood Dysregulation disorder is a new diagnostic entity to the DSM-V primarily due to the concerns over pre-maturely diagnosing bipolar disorder in young children. Studies have found that when these children grow up, they do not experience manic episodes and severe depression. Considering that pediatric bipolar disorder is, many times, misdiagnosed in children with DMDD, the nurse should obtain an order to review lab tests to look for any significant evidence of bipolar disorder. Although there are no anatomic findings in a standard brain imaging in bipolar disorder, new techniques in neuro-imaging provide clues about what is different in the brains of individuals with bipolar disorder. SPECT and PET scans are frequently used for early functional imaging.

Oppositional Defiant Disorder (ODD) is also very closely related to DMDD but the difference is the symptom threshold for DMDD is higher since it is considered more severe. If a child meets both criteria for Oppositional Defiant Disorder and Disruptive Mood Dysregulation Disorder then they should only be diagnosed with DMDD. Thyroid function tests can be utilized to rule out hypothyroidism, which mimics depression and a blood test can be performed to check for any exogenous toxic materials or if other medications are being used that can cause J.D. to experience physiological derived depression and uncontrolled frustration. Regardless of how chronic irritability is classified into a diagnosis, it can be extremely impairing and requires treatment. Risk factors associated with Disruptive Mood Dysregulation disorder are not black and white; therefore there is a need for more research. However, we are aware of some successful methods used to treat children undergoing this disorder, which correlate to the treatment of similar disorders including anxiety, oppositional defiant disorder, major depressive disorder, and attention deficit hyperactivity disorder. Mental health nursing treatments include counseling, parent training, and cognitive-behavioral therapy. Pharmacological interventions should be considered second and they include stimulants, antidepressants, and atypical antipsychotic medications. However, these interventions will be later discussed in the case study.

Role of the Nurse in the Nursing Process

Assessment First and foremost, it is imperative to do a thorough initial assessment on the patient including subjective and objective data. Upon admission, a nursing assessment and interview must be performed. The nurse should obtain a psychosocial and family history from the patient due to possible genetic correlation. After these components of the assessment are completed, it is important to ask the child about his experiences and his understanding of the disorder. Nurses should identify issues that lead to power struggles, including when they began and how they are handled. They should assess the severity of the disruptive behavior and its impact on the child’s life at home, at school, and with peers. Nurses should also assess how the child responds to limits and being told “no”, having to wait, share, or end a favorite activity. Assessing the child’s consequential development for the ability to understand how his behavior impacts others is important alongside of assessing the child’s level of anxiety, aggression, anger, and hostility toward others and the ability to control negative impulses. It is also important to perform a mental status exam (MSE) to further assess J.D.’s judgment skills, orientation, attention span, memory, and appearance. The nurse should convey empathy in a respectful and non-judgmental manner to establish a strong rapport and foundation of trust with the patient. By performing the MSE, the nurse will gain insight into the patient’s perception of the problem, possible delusions and hallucinations, thought content and processes. The nurse should pay special attention to any potential suicidal or homicidal ideation due to the patient’s frequent inability to control his frustration and aggression. The nurse can determine suicidal intent by asking “Do you plan to kill yourself?” and “How do you plan to do it?” Direct, close-ended questions are appropriate in this instance. Patients who have access to a plan are at higher risk than ones who do not. Children with disruptive mood dysregulation can experience severe depressive states, which makes them at risk for suicide. The nurse should obtain a verbal or written contract from the client agreeing not to harm himself and agreeing to seek out staff in the event that such ideation occurs. Discussing suicidal feelings with a trusted individual provides a degree of relief to the patient. A contract helps the discussion happen and also places some of the responsibility for his safety on himself.

The medical diagnosis for J.D. is Disruptive Mood Dysregulation Disorder (DMDD). He exhibits symptoms on a multi-dimensional level including aggression, chronic-prolonged frustration, and outbursts that are inappropriate to the severity of the situation and his developmental stage. According to the DSM-V, there are two similar diagnoses with related symptoms including pediatric bipolar disorder and oppositional defiant disorder. Those disorders will be ruled out first because J.D. does not experience any hallucinations, delusions or manic depression. However he does experience irritable mood, defiance towards authoritative figures, and violent aggression, which falls in line with the diagnosis of Oppositional Defiant Disorder. Although this disorder would be examined first for diagnosis, J.D. experiences the same symptomology due to a mood disorder, which is the difference between the two diagnoses. Children with ODD have intent behind their behavior, they want to anger or scare someone but with DMDD, they may elicit the same responses with no purpose to be vindictive.

The DSM-4 refers to Disruptive Mood Dysregulation disorder as a first axis diagnosis as evidence by the patient’s tendency to get aggressive with peers and family which requires immediate inpatient services. There is no evidence for a need of the second axis because J.D. does not have a personality disorder. The third axis refers to his medical condition in which does not apply to this specific individual. The fourth axis refers to J.D.’s psychosocial stressors while in school. The inability to carry out tasks and his aggression presented during class impairs his social relationships. Axis five is related to his level of functioning, which is measured at a 35 on the GAF scale between 0-100. His behavior is considerable influenced by frustration and irritability, which impairs his functionality in school, home, and with peers. The priority nursing diagnosis for this patient would be risk for self-injury related to Disruptive Mood Dysregulation disorder as evidenced by having to be removed from the classroom due to the inability to control tantrums and throwing himself on the ground or punching walls. The second priority nursing diagnosis is defensive coping related to Disruptive Mood Dysregulation disorder as evidenced by acting out aggressively in classrooms when he feels incapable of expressing feelings, for example, threatening other students or throwing a book.

The patient will demonstrate the ability to control aggressive impulses and delay gratification. Patient will also demonstrate a reduction of tantrums, temper reactions, or other acting-out behaviors.

Expected short-term outcomes include the following: patient will demonstrate a reduction in irritable mood and aggression by discharge, patient will demonstrate breathing techniques to help calm himself by discharge, patient will accept responsibility for negative behavior by discharge, and patient will report any feelings of aggression to staff immediately following the next three days. The patient will attend and participate in counseling and cognitive-behavioral sessions while in the hospital. The patient will also only have to be redirected by the nurse once per day instead of three times by discharge.

Long-term expected outcomes for J.D. include: patient will be kept safe from self-harm and other directed harm while in the hospital, patient will interact with others using age-appropriate and acceptable behavior when returning back to school, patient will demonstrate and report positive stress-reduction strategies while in the classroom, and patient will attempt to communicate to authoritative figures when he feels like he is going to have an outburst of frustration so he can be strategically removed from classroom.

Nursing Interventions

The priority nursing diagnosis for J.D. includes risk for self-injury and aggression, so it is imperative for the nurse’s course of action to be centered on protection. It is important for the nurse to remain in control of the environment so using one-to-one observation to monitor rising levels of agitation help promote safety and determine emotional and situational triggers. External controls are often needed to prevent acts of aggression. Setting clear and concise limits in a calm, non-judgmental manner and reminding the patient of the consequences of acting out helps them gain a sense of security with clear limits and calm staff who follow through on a consistent basis. When limits are realistic and enforceable, patient-nurse manipulation can be minimized. There are also many ways that nurses can help alleviate certain symptomologies of Disruptive Mood Dysregulation disorder. One includes intervening early to calm the patient and defuse potential accidents when the nurse infers that the patient is getting stressed out or agitated. Learning can take place before the patient loses control therefore new ways to cope can be discussed and practiced. Since patients with DDMD exhibit disruptive behaviors when feeling frustrated, the nurse should redirect their expressions of these feelings into non-destructive, age appropriate behaviors by channeling excess energy into physical activities. Learning how to modulate the expression of feelings and using anger constructively is essential to obtaining self-control. Since J.D. has Attention-Deficit Hyperactivity Disorder on top of Disruptive Mood Dysregulation Disorder, he exhibits impulsivity and if he feels impulsive to be aggressive then this behavior must be intervened accordingly. The nurse should make use of a behavior modification program that rewards patients for seeking help with handling feelings and controlling impulses to throw tantrums. Rewarding J.D.’s behaviors can foster self-esteem and positive reinforcement for appropriate behaviors. To target the second priority nursing diagnosis of defense coping is to avoid power struggles and “no win” situations because therapeutic goals are lost in power struggles and can often result in the patient taking revenge on staff and peers. Nurses should also allow the patients to question their limits within reason. Perhaps giving a simple, clear explanation for the request can benefit the patient’s sense of autonomy and power. This rationale is tailored to the developmental age and promotes socialization. Sometimes patient’s may need a second line of therapeutic management through pharmacological interventions. If indicated, the usage of medications can help reduce anxiety, rage, aggression, and modulate moods. The nurse will be required to perform parent education on the specific drug. Parent education would include safe dosing, side effects, contraindication, adverse effects, and printed out copies of the information presented and a number to call if any questions/concerns arise. Certain drugs, like stimulants, can be suitable for children to treat irritability. There is some evidence that shows CNS stimulants were associated with clinically significant reductions in rage and conflict along with small improvements in mood. However most recipients of CNS stimulants still exhibit severe impairment so this indicates that they will need additional treatment. Antidepressants are also sometimes used to treat irritability, aggression, and disruptive behaviors in children. Many times antidepressants are not successful in treating the irritability component of DMDD but they significantly improve mood. Children must be closely assessed, specifically when they begin taking antidepressants due to a higher risk for suicidal ideation. Children with very severe outbursts that involve physical violence towards others and property get prescribed an atypical antipsychotic medication. Risperdone, for example, is one of the many FDA-approved drugs for treating irritability. Some side effects associated with these drugs include suicidal ideation, weight gain, metabolic abnormalities, dyskinesia, and hormone changes. Patients and families of minors should always be educated on the side effects and potential risks of taking medications and advised by educated healthcare providers on the warning of each specific drug to help keep them safe.

Through both psychological nursing and pharmacological interventions, J.D. began to report the reduction of constant irritability and anger by circling a positive facial expression that correlates to his current mood by day 2. He started a new medication regimen of Risperidone and Escitalopram to effectively improve his mood and feelings of irritability that lead to aggression. J.D. is able to recite the limits and expectations of him when asked to by the staff. He performs every day activities with reduced signs or reports of agitation and aggression. He also explained that when he feels himself beginning to act out, he takes a walk and helps the staff clean the community rooms. This shows he is putting his excess energy to use by being productive and not destructive. J.D. reports, “I finally feel like I am making some friends” and also, “It makes me feel good when I accomplish a task my therapist gives”. This emphasizes and promotes self-esteem, which allows for him to feel more confident going back to school and asserting himself appropriately with his peers. As J.D. moves forward, the nurses will have to keep educating him on being more aware of his actions toward others when leaving the hospital. Although J.D. has made significant progress, nurses must constantly change and initiate new goals to accomplish. One goal may be accepting responsibility for his prior actions and writing an empathetic apology to the teachers, family members, and peers he may have hurt in the process.

Nursing Implications

Nurses need to know that this is a relatively new diagnosis and it is very evident that we do not have nearly the amount of research and answers on Disruptive Mood Dysregulation disorder as we should. We do know that Disruptive Mood Dysregulation Disorder is extremely similar to pediatric Bipolar disorder and Oppositional Defiant disorder to the point that many clinicians are unwilling to recognize DMDD as an independent disorder. As nurses, we must be aware of the severity in children’s irritable moods and advocate for them when it looks like it is going to become violent. The most significant gap in education is that parents commonly excuse children with DMDD as just being the “problem child” but in reality, it is an actual mood disorder that needs intervention, care, and management to help the prognosis of their everyday life. They are diagnosed with this disorder between 6-18 years of age meaning that it is the most impressionable time of their lives. As nurses, we must set boundaries and expectations of how to manage anger and cope with agitation in a healthy way. There should also be more research on how nurses can implement adaptive coping mechanisms for children specifically with DMDD. Most of the information applied to plan of care for patients with Disruptive Mood Dysregulation disorder is derived from taking bits and pieces of other related illness. If we are going to acknowledge DMDD as its own unique diagnosis then we, as nurses, should be educated on how to formulate an exclusive care plan specific to the disorder.

Conclusion

Disruptive Mood Dysregulation Disorder is a pediatric diagnosis characterized by extreme, prolonged outbursts of anger, aggression, and intense irritability. J.D. was diagnosed after exhibiting these behaviors for over 12 months and immediately after his behaviors turned aggressive, he was committed to inpatient care to gain mood stability and overall safety. Once safety and stability are achieved, nursing staff must begin directing a J.D.’s care plan towards symptom management, psychotherapy, cognitive-behavioral therapy, and pharmacological treatments if indicated by the physician. In addition to an acute care plan, the nurses working directly with J.D. must create new goals and positive coping strategies for managing irritability to better the prognosis for J.D.’s every day life.