JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY

Volume 26, Number 2, 2016

ª Mary Ann Liebert, Inc.
Pp. 101–106
DOI: 10.1089/cap.2015.0074

Disruptive Mood Dysregulation Disorder Symptoms

and Association with Oppositional Defiant and Other
Disorders in a General Population Child Sample

Susan D. Mayes, PhD, James D. Waxmonsky, MD,

Susan L. Calhoun, PhD, and Edward O. Bixler, PhD

Abstract
Objective: The new Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) diagnosis, disruptive mood
dysregulation disorder (DMDD), has generated appreciable controversy since its inception, primarily in regard to its validity
as a distinct disorder from oppositional defiant disorder (ODD). The goal of our study was to determine if the two DSM-5
DMDD symptoms (persistently irritable or angry mood and severe recurrent temper outbursts) occurred independently of
other disorders, particularly ODD. Other DSM-5 DMDD criteria were not assessed.
Methods: Maternal ratings of the two DMDD symptoms, clinical diagnosis of ODD using DSM-5 symptom criteria, and
psychological problem scores (anxiety, depression, oppositional behavior, conduct disorder, and attention-deficit/
hyperactivity disorder [ADHD]) on the Pediatric Behavior Scale were analyzed in a population sample, 6–12 years of age
(n = 665).
Results: The prevalence of DMDD symptoms (irritable-angry mood and temper outbursts both rated by mothers as often or
very often a problem) was 9%. In all, 92% of children with DMDD symptoms had ODD, and 66% of children with ODD had
DMDD symptoms, indicating that it is very unlikely to have DMDD symptoms without ODD, but that ODD can occur without
DMDD symptoms. Comorbid psychological problems (anxiety, depression, conduct disorder, and ADHD) in addition to
ODD did not increase the risk of having DMDD symptoms beyond that for ODD alone. Only 3% of children with psycho-
logical problems other than ODD had DMDD symptoms.
Conclusions: Our general population findings are similar to those for a psychiatric sample, suggesting that DMDD cannot be
differentiated from ODD based on symptomatology. Therefore, it is important to assess all DSM criteria and to examine for
comorbid psychopathology when considering a diagnosis of DMDD. Our results support the recommendation made by the
World Health Organization’s International Classification of Diseases, 11th Revision (ICD-11) panel of experts that DMDD
symptoms may be more appropriately classified as an ODD specifier than a separate diagnosis.

Introduction symptoms for at least 12 months (without a symptom-free period of

‡3 consecutive months) in two or more settings (at home, at school,

T he Diagnostic and Statistical Manual of Mental Dis-

orders, 5th ed. (DSM-5) created the new diagnosis of dis-
ruptive mood dysregulation disorder (DMDD) ‘‘to address the
or with peers) with onset before age 10.
DMDD is a controversial diagnosis for several reasons. First, the
symptoms of persistently irritable or angry mood and severe re-
considerable concern about appropriate classification and treatment current temper outbursts overlap with those for oppositional defiant
of children who present with chronic, persistent irritability relative disorder (ODD), whereas irritability is a criterion for multiple
to children who present with classic (i.e., episodic) bipolar disor- disorders (Safer 2009; Mayes et al. 2011; Stringaris 2011; Lei-
der’’ (American Psychiatric Association 2013, p. 157). DSM-5 benluft et al. 2012; Roy et al. 2014). Even though the DSM-5
DMDD diagnostic criteria are severe recurrent temper outbursts definition for ODD includes the two core DMDD symptoms, it
that are out of proportion to the situation, inconsistent with de- specifies that DMDD but not ODD can be diagnosed if a child
velopmental level, and occurring on average three or more times meets criteria for both, therefore failing to acknowledge the addi-
per week, plus persistently irritable or angry mood for most of the tional symptoms seen with ODD such as argumentative, defiant, or
day nearly every day. Additional criteria include the presence of vindictive behavior. Second, DMDD diagnostic reliability was

Department of Psychiatry, Penn State College of Medicine, Hershey, Pennsylvania.

Statistical Consultant: Susan D. Mayes.
Funding: This study was supported by National Institutes of Health grants RO1 HL063772, MO1 RR10732, and CO6 RRO16499.

101
102 MAYES ET AL.

poor in DSM-5 field trials (Regier et al. 2013). Third, the evidence study of the prevalence of sleep disorders in children (Bixler et al.
base for DMDD was derived primarily from studies of the construct 2009). Intelligence quotients (IQs) ranged from 71 to 147 (mean
of ‘‘severe mood dysregulation’’ (SMD), which differs from DMDD. 106.3, SD 13.1). In all, 52.6% were male, 80.5% were white, and
Considering the absence of ‘‘peer-reviewed research prior to the 48.9% had a parent with a professional or managerial occupation.
DSM-5 proposal.limited reliability, a lack of psychiatric consen- Questionnaires were sent home to the parents of every elementary
sus, and very high rates of overlap with other disorders,’’ the World school student in 18 public schools in three school districts
Health Organization’s International Classification of Diseases, 11th (n = 7312), with a 78.5% response rate. From the 78.5% completing
Revision (ICD-11) task group ‘‘recommended that WHO not accept the questionnaires, 1000 children were invited for further evaluation
DMDD as a diagnostic category in ICD-11..Specifically, the group in the sleep laboratory using stratified random sampling so that the
has proposed that ICD-11 include a specifier to indicate whether or sample matched the original survey group in age, gender, race, and
not the presentation of ODD includes chronic irritability and anger’’ risk of sleep-disordered breathing. Seventy percent of the invited
(Lochman et al. 2015, pp. 31–32). Further, research supports sepa- families (n = 700) agreed to participate. Parent consent and child
rating irritability and the behavioral components of ODD, in part assent were obtained. The 665 children in our study were those from
because behavioral symptoms are more likely to predict later anti- the original sample of 700 who were 6–12 years of age and had
social problems, and irritability is more likely to predict later de- complete IQ and Pediatric Behavior Scale (PBS) (Lindgren and
pression and anxiety (Stringaris 2011; Burke 2012; Leibenluft et al. Koeppl 1987) data.
2012; Leadbeater and Homel 2015).
Little is known about the prevalence of DMDD symptoms and
Instrument and variables
their comorbidity with other disorders. Previous studies investi-
gated SMD, which requires hyperarousal and allows for a sad rather Mothers rated their children’s behavior during the past 2 months
than only an irritable interval mood. In a study of 6-year-olds, only on a four point scale (0 = not at all or almost never a problem,
47% meeting criteria for DMDD had SMD, and 58% of those with 1 = sometimes a problem, 2 = often a problem, and 3 = very often a
SMD had DMDD (Dougherty et al. 2014). Therefore, research problem) on the two PBS (Lindgren and Koeppl 1987) items that
findings cannot be generalized across these two constructs. Cope- assess the two DSM-5 DMDD symptoms. The PBS items are ‘‘ir-
land et al. (2013, 2014) analyzed temper outbursts and ‘‘negative ritable, gets angry or annoyed easily’’ and ‘‘loses temper, has temper
mood’’ (‘‘the frequency of depressed, sad, irritable, or angry mood tantrums.’’ Ratings on these items were combined to obtain a total
or low frustration threshold,’’ 2013, p. 173), which, according to DMDD irritable-angry mood plus temper outburst score. Children
this definition, also differs from DMDD because of its inclusion of were classified as to whether or not irritable-angry mood and temper
sadness and depression. One study of 6-year-olds in a community outbursts were both rated by mothers as often or very often a problem
sample (Dougherty et al. 2014) assessed ‘‘anger, irritability, an- and if both were rated as very often a problem. A formal DSM-5
noyance, or low frustration tolerance’’ (p. 3) without mention of diagnosis of DMDD could not be ascertained in individual cases
sadness and depression, consistent with DMDD symptoms as cur- because symptom onset, setting, and duration were not assessed.
rently defined by the DSM-5. Dougherty et al. (2014) found that 8% Independent variables were raw scores on the PBS subscales
met criteria for DSM-5 DMDD. The majority (60%) of these measuring attention-deficit/hyperactivity disorder (ADHD), CD,
children had a comorbid emotional or behavioral disorder, most anxiety disorders, depressive disorder, and oppositional behavior.
often ODD (55%). In a large psychiatric sample of 6–12-year-olds, The oppositional behavior score does not include the DMDD
26% had DMDD symptoms and almost all children (96%) with irritable-angry mood and temper outburst items and, instead, con-
DMDD had ODD or conduct disorder (CD) (Axelson et al. 2012). sists of only four items: Disobedient, uncooperative, argumenta-
This redundancy and the finding that DMDD did not have a distinct tive, and defiant (similar to the oppositional behavior dimension of
course, outcome, long-term stability, or associated family history of ODD). Children were considered to meet DSM-5 symptom criteria
mood or anxiety disorders led the authors to conclude that DMDD for ODD if four or more of the eight PBS items corresponding with
cannot be differentiated from disruptive behavior disorders. the eight DSM-5 ODD symptoms (which by definition included the
Given the potential overlapping symptoms between DMDD and irritable-angry and temper outburst items) were rated by mothers as
ODD as well as other disorders, the purpose of our study was to often or very often a problem, matching the number of symptoms
determine if the DSM-5 DMDD symptoms of irritable-angry mood and severity level specified by the DSM-5 for ODD (n = 85). Other
and temper outbursts occurred independently of other disorders in a ODD criteria (6 months’ duration and symptoms occurring at least
general population sample of 6–12-year-olds. Other DSM-5 once per week) were not assessed. This ODD definition has been
DMDD criteria regarding duration, onset, and cross-domain im- used to classify children with ODD in previous publications
pairment were not assessed. Our study expands the age range of the (Mayes et al. 2012a, 2015a, 2015b). Also identified were children
Dougherty et al. (2014) community sample that was limited to 6- with PBS subscale T scores >65 (more than 1.5 SDs above the
year-olds, and matches the age range of the Axelson et al. (2012) mean) on oppositional behavior without the two overlapping
psychiatric sample, allowing us to determine if our findings are DMDD irritable-angry mood and temper outburst symptoms
similar to those for a younger community sample and similar to a (n = 80), ADHD (n = 152), CD (n = 40), anxiety disorder (n = 78),
same-age psychiatric sample. Based on the limited research and depressive disorder (n = 82).
available, we hypothesize that DMDD symptoms do not occur in- The 165 item PBS has been used to diagnose and measure psy-
dependently of other established disorders, particularly ODD. chological problems in several published studies, and validity studies
show that the PBS differentiates diagnostic groups (Wolraich et al.
Methods 1994; Nichols et al. 2000; Conrad et al. 2010; Mayes et al. 2011;
Mattison and Mayes 2012; Mayes et al. 2012a,b). Internal consis-
Sample
tency for the PBS subscale scores is high, with a median coefficient
The sample comprised 665 children, 6–12 years of age (mean age of 0.91 (Lindgren and Koeppl 1987). The PBS corresponds well with
8.7, SD 1.7) who participated in a population-based epidemiologic established measures. In a general population study (Bixler et al.
DMDD SYMPTOMS IN A GENERAL POPULATION SAMPLE 103

2009), the correlation between the anxiety-depression subscale score overlapping DMDD items of irritable-angry mood and temper
on the Child Behavior Checklist (Achenbach 1991) and on the PBS outbursts (Table 2).
was 0.72 ( p < 0.001), and the correlation between the Child Behavior Only 18 children met symptom criteria for ODD and scored at or
Checklist and PBS ADHD score was 0.78 ( p < 0.001). In another below a T score of 65 on the ADHD, depression, CD, and anxiety
study, children whose mothers rated short attention span or dis- subscales. Of these 18 children with ODD symptoms only, 12
tractibility as often to very often a problem on the PBS scored sig- (66.7%) had DMDD symptoms often and none had them very often
nificantly lower on the Gordon Diagnostic System (Gordon 1983) (Table 3). For the 67 children who had ODD with other psycho-
Vigilance and Distractibility subtests (t = 3.7 and 3.3, p < 0.001) than logical problems, 65.7% had DMDD symptoms often or very often
did children who were not rated as often inattentive or distractible and 11.9% had DMDD symptoms very often. Only 4 of the 153
(Mayes et al. 2014). Norms (raw scores and T scores) are available children (2.6%) with psychological problems other than ODD had
for 600 children 6–12 years in the standardization sample (Lindgren DMDD symptoms often or very often and only 1 (0.7%) had
and Koeppl 1987). DMDD symptoms very often. These children all had anxiety and/or
depression. Therefore, the risk of having DMDD symptoms was far
Data analyses greater for ODD than for other psychological problems (25.3 times
greater for DMDD symptoms often or very often and 17.0 times
Descriptive statistics were used to summarize the data. Differ-
greater for DMDD symptoms very often).
ences in DMDD symptom frequencies between children with and
All Spearman correlations between the DMDD score (irritable-
without psychological problems were analyzed using Fisher’s exact
angry mood plus temper outbursts) and each of the psychological
test and risk ratios. The relationship between the DMDD score and
problem scores were significant ( p < 0.001). The strongest rela-
scores on the oppositional behavior (ODD symptoms without the
tionships were between the DMDD score and the PBS oppositional
two overlapping DMDD symptoms of irritable-angry mood and
behavior score (i.e., ODD symptoms without the two overlapping
temper outbursts), ADHD, CD, anxiety, and depression subscales
DMDD symptoms of irritable-angry mood and temper outbursts)
were determined using Spearman correlations and explained vari-
and the PBS CD score, with correlations of 0.63 and 0.56, re-
ance. All tests of significance were two tailed.
spectively (explaining 39.6% and 31.4% of the variance). Corre-
lations between DMDD scores and depression (0.49), ADHD
Results
(0.48), and anxiety (0.36) were lower, explaining 23.7%, 22.6%,
The prevalence of DMDD symptoms (irritable-angry mood and and 13.0% of the variance, respectively.
temper outbursts both rated as often or very often a problem by
mothers) was 9.2% (61 of the 665 children). Of the 61 children with
Discussion
DMDD symptoms at this level, 91.8% met symptom criteria for
DSM-5 ODD and all but one (98.4%) either met DSM-5 ODD In our general population sample, 9% of the 6–12-year-olds had
symptom criteria or had a T score >65 on the PBS ADHD, de- DMDD symptoms often or very often and 1% had DMDD symp-
pression, CD, or anxiety subscale (Table 1). This sole child had a toms very often. Dougherty et al. (2014) found that 8% of 6-year-
depression T score of 62 (1.2 standard deviations above the mean). olds in a community sample met DSM-5 DMDD criteria. The
Using a DMDD symptom threshold of very often, nine children DSM-5 estimates that 2–5% of children and adolescents meet
(1.4%) had DMDD symptoms. All of these children had additional DMDD criteria. Our results suggest that variation in the frequency
psychopathology, which, in all but one case, was ODD combined threshold leads to appreciable differences in the prevalence of
with ADHD (with or without CD, anxiety, or depression). DMDD symptoms. Using the very often threshold yields symptom
Among the 238 children who had symptoms of ODD, ADHD, frequencies less than the Dougherty et al. (2014) findings and the
CD, anxiety, and/or depression, 25.2% had DMDD symptoms often DSM-5 estimate. More research is needed to determine the most
or very often and 3.8% had them very often. In contrast, only one of appropriate threshold for diagnosing DMDD. This is important not
the 427 children (0.2%) without symptoms of ODD, ADHD, CD, only to evaluate information provided by parents during the diag-
anxiety, or depression had DMDD symptoms often or very often, nostic interview, but also to interpret scores on rating scales, which
and none had symptoms very often (Fisher’s p < 0.001). The risk of are used by most clinicians in diagnostic evaluations. Un-
having DMDD symptoms often or very often was 126.0 times fortunately, diagnostic reliability for existing DMDD criteria is
greater in children with than without other psychological problems. poor. The degree to which two clinicians agreed on a DMDD di-
The majority of the 85 children with ODD had DMDD symptoms agnosis in DSM-5 field trials was unacceptably low at two of the
often or very often (65.9%), as did 52.5% of children with a T score three sites, in contrast to good to very good agreement on diagnoses
>65 on the PBS oppositional subscale that did not include the two of autism, ADHD, and ODD at all sites (Regier et al. 2013).

Table 1. Frequency of Psychological Problems in the 61 Children with Disruptive Mood

Dysregulation Disorder Symptoms (Irritable-Angry Mood and Temper Outbursts Rated
Often or Very Often a Problem by Mothers)

Pediatric Behavior Scalea T score >65

DSM-5 ODD diagnosis Opposition ADHD Depression CD Anxiety Any psychological problemb

91.8% 68.9% 65.6% 37.3% 29.5% 26.2% 98.4%

a
None of the Pediatric Behavior Scale (PBS) subscale scores included irritable-angry mood or temper outbursts as items.
b
Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) oppositional defiant disorder (ODD) diagnosis or T score >65 on the PBS
attention-deficit/hyperactivity disorder (ADHD), depression, conduct disorder (CD), or anxiety subscale.
104 MAYES ET AL.

Table 2. Frequency of Disruptive Mood Dysregulation Disorder Symptoms (Irritable-Angry Mood

and Temper Outbursts Rated Often or Very Often a Problem by Mothers) in Children with Psychological Problems

Pediatric Behavior Scalea T score >65

DSM-5 ODD diagnosis Opposition CD Depression ADHD Anxiety Any psychological problemb

65.9% 52.5% 45.0% 28.0% 26.3% 20.5% 25.2%

a
None of the Pediatric Behavior Scale subscale scores included irritable-angry mood or temper outbursts as items.
b
Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) oppositional defiant disorder (ODD) diagnosis or T score >65 on the
Pediatric Behavior Scale (PBS) attention-deficit/hyperactivity disorder (ADHD), depression, conduct disorder (CD), or anxiety subscale.

In both our community sample and that of Dougherty et al. et al. (2013) definition of DMDD included sad and depressed mood,
(2014), the majority of children with DMDD symptoms had ODD. whereas the DSM-5 requires the interval mood be only irritable or
Our percentage of children with DMDD symptoms often or very angry, which may explain the discrepancy in findings.
often who met the symptom criteria for ODD (92%) was consistent Given these combined results, all children presenting with
with the 96% with ODD/CD reported in a psychiatric sample of 6– DMDD symptoms should be evaluated for the presence of other
12-year-olds (Axelson et al. 2012) but was higher than the ODD clinical disorders, especially ODD, that may underlie the DMDD
percentage in the Dougherty et al. (2014) study, perhaps because our symptoms and require treatment. However, the DSM-5 prohibits a
children were 6–12 years and not only 6 years of age. In the Axelson diagnosis of ODD if a child meets criteria for both ODD and
et al. (2012) study, 26% of the psychiatric referrals had DMDD DMDD, which is counterintuitive. A diagnosis should not stop at
symptoms. Likewise, in our study, 25% with ODD symptoms or a T DMDD, as this would fail to recognize the argumentative, defiant,
score >65 on the PBS CD, depression, ADHD, or anxiety subscale or vindictive behaviors that are commonly a part of ODD and
had DMDD symptoms often or very often. All children in our study impact the prognostic course (Stringaris and Goodman, 2009).
whose mothers rated irritable-angry mood and temper outbursts as Moreover, little is known about DMDD treatment in contrast to
very often a problem had ODD or an elevated score on the PBS CD, ODD and other disorders that commonly present with DDMD
depression, ADHD, or anxiety subscales, and all but one child with symptoms. For children with disruptive behavior, empirical evi-
irritable-angry mood and temper outbursts often or very often a dence supports parent training programs for preschool children and
problem had ODD or an elevated score on the PBS CD, depression, parent training and child training cognitive-behavior interventions
ADHD, or anxiety subscales. Therefore, our general population for school-age children, as well as multicomponent treatment ap-
study suggests that DMDD symptoms do not exist in isolation from proaches for delinquent adolescents (Eyberg et al. 2008). For
other established disorders, particularly ODD, consistent with find- children with autism and ADHD, behavioral interventions are ef-
ings for a psychiatric sample (Axelson et al. 2012). fective in decreasing tantrums, irritability, and aggression (Wax-
Irritable-angry mood and temper outbursts are commonly re- monsky et al. 2008; Matson 2009; Waxmonsky et al. 2013).
ported by parents of children with a variety of disorders, including Further, stimulant medication has been shown to reduce irritability
autism (Mayes and Calhoun, 1999, 2011) and ADHD (Waxmonsky in children with ADHD (Waxmonsky et al. 2008; Fernandez de la
et al. 2008). Therefore, it is important to consider comorbidity Cruz et al. 2015) and atypical antipsychotics are effective in de-
when assessing for DMDD. Comorbid ODD accounted for the co- creasing irritability in children with autism (Arnold et al. 2003;
occurrence of DMDD symptoms with other psychological prob- Shea et al. 2004; Marcus et al. 2009; Owen et al. 2009;).
lems in our general population sample, as did ODD and CD in a
clinical sample (Axelson et al. 2012). The most common diagnosis
in a sample of 5–9-year-olds referred with severe and frequent Limitations
temper outbursts (Roy et al. 2013), was ODD (88%). In contrast, a The purpose of our study was to determine if the two DSM-5
high rate of co-occurring depression, in addition to ODD, was re- DMDD symptoms (irritable or angry mood and temper outbursts)
ported in the Copeland et al. (2013) study. However, the Copeland occurred independently of other disorders, particularly ODD. Other
DSM-5 DMDD criteria including frequency (temper outbursts
Table 3. Frequency of Disruptive Mood Dysregulation occurring an average of three or more times per week), chronicity
Disorder Symptoms (Irritable-Angry Mood (symptoms present for at least 12 months without a symptom-free
and Temper Outbursts Rated Often or Very Often period for ‡3 consecutive months), settings (present in at least two
a Problem by Mothers) in the Total Sample of three settings: At home, at school, and with peers), and age at
onset (before 10 years of age) were not assessed. Therefore, we can
DSM-5 DSM-5 ODD Psychological No ODD only report on symptom frequency (based on ratings by mothers of
ODD with other problemsa or other their child’s DMDD symptoms during the past 2 months) and not
diagnosis psychological with no psychological
diagnostic prevalence. In addition, this study only examined
only problemsa ODD problemsa
(n = 18) (n = 67) (n = 153) (n = 427) symptom prevalence at a single time point; therefore, we cannot
comment on the stability of reported symptoms. In a follow-up
66.7% 65.7% 2.6% 0.2% study of 376 children in our general population sample (Mayes
a
et al. 2015c), only 29% with DMDD symptoms at baseline had
T score >65 on the Pediatric Behavior Scale (PBS) attention-deficit/ DMDD symptoms at follow-up 8 years later, and only 45% with
hyperactivity disorder (ADHD), depression, conduct disorder (CD), or
anxiety subscale. DMDD symptoms at follow-up had DMDD symptoms at baseline
DSM-5, Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; (55% new cases). Axelson et al. (2012) also reported low stability
ODD, oppositional defiant disorder. for DMDD symptoms in a psychiatric sample. Of those with baseline
DMDD SYMPTOMS IN A GENERAL POPULATION SAMPLE 105

DMDD symptoms, 53% continued to have DMDD symptoms at 12 Bixler EO, Vgontzas AN, Lin H-M, Calhoun S, Vela-Bueno A, Fedok
month follow-up, and only 19% had DMDD symptoms at 12 and at F, Vlasic V, Graff G: Sleep disordered breathing in children in a
24 month follow-ups. Given the poor agreement among clinicians on general population sample: Prevalence and risk factors. Sleep
DMDD diagnoses as currently defined by the DSM-5 (Regier et al. 32:731–736, 2009.
2013), future research needs to consider all of the DSM-5 DMDD Burke JD: An affective dimension within oppositional defiant disorder
criteria across multiple assessment points using an array of mea- symptoms among boys: Personality and psychopathology outcomes
surement procedures to identify the most appropriate methods for into early adulthood. J Child Psychol Psychiatry 53:1176–1183,
measuring DMDD symptoms and objectifying the diagnosis. 2012.
Conrad AL, Richman L, Lindgren S, Nopoulos P: Biological and
Conclusions environmental predictors of behavioral sequelae in children born
preterm. Pediatr 125:e83–e89, 2010.
In our study, DMDD symptoms did not exist independently of Copeland WE, Angold A, Costello EJ, Egger H: Prevalence, co-
other psychological problems, with ODD explaining the majority of morbidity and correlates of DSM-5 proposed disruptive mood
the association between DMDD symptoms and comorbid psycho- dysregulation disorder. Am J Psychiatry 170:173–179, 2013.
pathology. The lack of evidence for a unique and separate DMDD Copeland WE, Shanahan L, Egger H, Arnold A, Costello EJ: Adult
symptom cluster does not support the DSM-5 conceptualization of diagnostic and functional outcomes of DSM-5 disruptive mood
DMDD as a distinct disorder. Our study showed that it is very un- dysregulation disorder. Am J Psychiatry 171:668–674, 2014.
likely to have DMDD symptoms without ODD, but 34% of children Dougherty LR, Smith VC, Bufferd SJ, Carlson GA, Stringaris A,
with ODD did not have DMDD symptoms. These results concur with Leibenluft E, Klein DN: DSM-5 disruptive mood dysregulation
the suggestion to conceptualize DMDD as a diagnostic specifier for disorder: Correlates and predictors in young children. Psychol Med
ODD (Lochman et al. 2015). 44:2339–2350, 2014.
Eyberg SM, Nelson M, Boggs SR: Evidence-based psychosocial
Clinical Significance treatments for children and adolescents with disruptive behavior.
J Clin Child Adoles Psychol 37:215–237, 2008.
Our findings argue against the DSM-5 rule prohibiting a diag-
Fernandez de la Cruz L, Simonoff E, McGough JJ, Halperin JM,
nosis of ODD and allowing only a diagnosis of DMDD when a child Arnold LE, Stringaris A: Treatment of children with attention-
meets criteria for both ODD and DMDD. Strict adherence to this deficit/hyperactivity disorder (ADHD) and irritability: Results from
rule may lead to clinically significant behavior concerns not being the Multimodal Treatment Study of Children with ADHD. J Am
identified or targeted for intervention. The majority of children in Acad Child Adoles Psychiatry 54:62–70.e3, 2015.
our study with disobedient, uncooperative, argumentative, and Gordon M: The Gordon Diagnostic System. DeWitt, NY: Gordon
defiant behavior had DMDD symptoms. If these children met full Systems; 1983.
DMDD criteria, their clinically significant oppositional behavior Leadbeater BJ, Homel J: Irritable and defiant sub-dimensions of
would not be recognized diagnostically, according to DSM ODD: Their stability and prediction of internalizing symptoms and
guidelines. Therefore, it seems prudent to note the presence of both conduct problems from adolescence to young adulthood. J Abnorm
the ODD and DMDD symptoms, as is done for the presence of Child Psychol 43:407–421, 2015.
comorbid conditions in other DSM-5 disorders. Leibenluft E, Uher R, Rutter M: Disruptive mood dysregulation with
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Disclosures Suppl. 1:77–81, 2012.
Lindgren SD, Koeppl GK: Assessing child behavior problems in a
Over the past 3 years, Dr. Waxmonsky has received research
medical setting: Development of the Pediatric Behavior Scale. In:
funding from the National Institutes of Health (NIH), Noven and
Advances in behavioral assessment of children and families. Edited
Shire; served on the advisory board for Noven and Iron Shore phar-
by R.J. Prinz. Greenwich, CT: JAI; 1987; pp 57–90.
maceuticals; and performed continuing medical education (CME) Lochman JE, Evans SC, Burke JD, Roberts MC, Fite PJ, Reed GM, de
talks funded by Quintiles. Janssen has also donated medication for la Pena FR, Matthys W, Ezpeleta L, Siddiqui S, Garralda ME: An
one of his trials. The other authors have no disclosures to declare. empirically based alternative to DSM-5’s disruptive mood dysre-
gulation disorder for ICD-11. World Psychiatry 14:30–33, 2015.
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