Psychiatrically hospitalized children with multiple rages have complex, chronic neuropsychiatric disorders and have failed prior conventional treatment. One third of children with rages had been given a bipolar diagnosis prior to admission. However, only 9% of children with rages were given that diagnosis after careful observation.

Although DMDD does decrease the rate of diagnosis of bipolar disorder in children, how much depends on whether history or observation is used.

Angry outbursts, sometimes called “rages”, are a major impetus for children's psychiatric hospitalization. In hospital, such outbursts are a management problem and a diagnostic puzzle. Among 130 4-to-12 year olds successively admitted to a child psychiatry unit, those having in-hospital outbursts were likely to be younger, have been in special education, have a pre-admission history of outbursts, and a longer hospital stay. Three subsets of behaviors, coded as they occurred in 109 outbursts, expressed increasing levels of anger; two other subsets expressed increasing levels of distress. Factor structure, temporal organization and age trends indicated that outbursts are exacerbations of ordinary childhood tantrums. Diagnostically, children with outbursts were more likely to have language difficulty and a trend towards ADHD. Outbursts of children with anxiety diagnoses showed significantly more distress relative to anger. Outbursts were not especially associated with our small sample of bipolar diagnoses.

Objective-To examine the safety and efficacy of liquid risperidone to reduce duration of rages in children with severe mood dysregulation (SMD) or possible bipolar disorder (BP).Method-There were 151 admissions of 5-12 year old children to a psychiatric inpatient unit. Diagnostic information and history of prior rages were obtained at admission. In hospital, a first rage outburst was treated with seclusion. If a 2 nd rage occurred, the child was offered liquid risperidone to help him/her regain control. Risperidone dose was increased by 0.02 mg/kg for any successive rages. Duration of unmedicated and last medicated rage were compared. Rage frequency in children with SMD and several definitions of BP were compared.Results-Although 82 of 151 admissions were prompted by rages, they occurred during only 49 hospitalizations, and occurred more than once in only 24. In 16 multiply-medicated children duration of rages dropped from a baseline of 44.4± 20.2 minutes to 25.6 ± 12.5 minutes at the child's last dose. Neither SMD nor any definition of BP influenced rage response in this small sample. The average liquid risperidone dose was 0.02 mg/kg. All but 2 children also took atypical antipsychotics daily. No adverse events were observed.Conclusions-Liquid risperidone may be a safe and effective way to shorten the duration of rage episodes regardless of diagnosis. However, definitive conclusions cannot be drawn in the absence of a placebo control as children were also receiving other behavioral and psychopharmacologic treatments.