When filling out the “Psychiatric Diagnoses” section of the CFS 431A, it is important to include all psychiatric diagnoses, using the diagnostic terminology from the latest version of the DSM that the youth has at the time of submission. Please specify the type of diagnosis as well, if applicable (i.e., “F90.9 ADHD, unspecified” vs. “F90.0 ADHD, predominantly inattentive presentation”).

In cases where there is not a current DSM-V-TR diagnosis, please list the diagnosis that the youth is still being assessed for as “rule out” (r/o). Per Rule 325 of Title 89, a diagnosis is required for all children for whom DCFS is legally responsible for a diagnostic assessment, which includes a DSM diagnosis required for treatment. By making this specification, it can help reduce processing delays and inform DCFS consultants' recommendations.

part 325 administration of psychotropic medications to children for whom the department of children and family services is legally responsible (illinois.gov)

When submitting CFS 431-A Psychotropic Medication Request Forms, please attach the most up-to-date lab results available. These labs are essential for DCFS psychiatric consultants to assess the safety and effectiveness of the requested medications. Laboratory tests are recommended at least once a year but may be requested and reviewed every 6 months if indicated. CSP team members check the dates of all submitted labs. If labs are unavailable for the consultant’s review, the CSP team member will contact the submitter for up-to-date lab results.

Please ensure that labs are relevant to the medication. HgA1c, lipids, and fasting glucose levels should be included for atypical antipsychotic requests. If the youth is taking Lithium or Depakote, lithium or valproic acid levels are important indicators of the medication’s therapeutic level at the current dose. If obtaining a full panel is not feasible, provide the most critical labs related to the medication.

When uploading labs through the Online Portal, you must choose one of three options. Select “Yes” if labs are attached for the current request. Select “No” if labs are not available and provide the expected future date for the next lab order. Please note that this date cannot be in the past. Select “N/A” only if labs are not required for the specific medication requested and it is not time for annual labs to be submitted. If you are unable to download the lab results, under the “additional rationale” section, you can type in the name of the test, the result value, and the date it was taken.

Including appropriate labs can help expedite the review process and lead to faster consent completion.

Q: Can mood disturbances be related to ADHD?

A: Emotional dysregulation is a transdiagnostic symptom that has been associated with ADHD in both adult and youth populations. Deficient emotional self-regulation is a theoretical concept characterized by poor modulation of emotional responses with mood lability, low frustration tolerance, impatience, impulsivity, and aggressive outbursts. In a study conducted in 2025, Liu et. al¹ found that youth with ADHD showed significantly higher levels of emotional dysregulation when compared to a cohort of healthy control subjects. Results showed youth with ADHD were less likely to deploy cognitive reappraisal strategies than were youth in the control group to manage periods of emotional dysregulation. When treating youth with ADHD it is important to consider behavioral interventions and pharmacologic interventions that address emotional dysregulation in addition to other symptoms of the disorder such as hyperactivity and impulsivity.

Q: Are stimulant medications effective for youth with ADHD and emotional dysregulation?

A: Several studies have shown the effectiveness of stimulants in the treatment of irritability and emotional dysregulation in youth with ADHD.  The seminal multimodal treatment study of children with ADHD (MTA) showed that: 1) Treatments targeting ADHD symptoms are helpful for improving irritability in children with ADHD, and 2) Moreover, irritability does not appear to influence the response to treatment of ADHD².  Pan, PY, et al (2025)³ concluded in their study on the role of methylphenidate and aripiprazole in the treatment of emotional dysregulation in ADHD reported that for most patients with this comorbidity, methylphenidate significantly improved emotion dysregulation.  For a review, please see Brancati, GE, et al⁴.

Q: My request for an atypical antipsychotic medication for my patient with ADHD and DMDD was denied. The antipsychotic was meant to treat aggression and mood instability, why was this denied?

A: A study conducted in 2006 by E. Pappadopulos et. al⁵ found that methylphenidate was effective when treating aggressive behaviors in youth with a mean age of 10.4 years. The mean effect size was 0.9 with a sample of 844 youth. Methylphenidate was shown to be effective in the treatment of aggression in the context of attention deficit hyperactivity disorder with co-morbid disruptive behavior problems, whereas risperidone was found to have larger effect size when treating aggression related to conduct disorder and subaverage IQ.

In treating youth with comorbid ADHD and aggressive behaviors with a stimulant medication, it is recommended that the stimulant be titrated and optimized for the treatment of aggression symptoms prior to the initiation of an adjunct treatment.

Q: How effective are stimulants at treating aggression in youth with ADHD?

A: Blader and colleagues (2021)⁶ conducted a study looking at the stepwise treatment of ADHD and aggression.  The objective of the study was to compare the efficacy of risperidone, divalproex sodium, and placebo added to stimulant medication in treating aggression children whose aggression persisted after optimized stimulant treatment. They found that 63.6% of study completers experienced remission of aggression symptoms after optimization of their stimulant medications. Indeed, remission rates with stimulants alone were so impactful that the statistical power of their study on the use of adjunctive medications for aggression was reduced. The study concluded that risperidone and divalproex sodium may benefit patients with aggression refractory to first-line stimulant and behavioral treatments, but first line treatments should be optimized and behavioral interventions utilized prior to considering polypharmacy.

Q: Can stimulant medications be effective for youth with DMDD?

A: Central nervous system stimulants were associated with clinically significant reductions in externalizing symptoms and lead to improvements in patient’s moods in youth with ADHD and DMDD⁷. Most youth with comorbid ADHD and DMDD still exhibited significant symptoms suggesting that additional treatments may be needed.  Most researchers believe that youth with DMDD develop ADHD, depression and anxiety as older adolescents and adults.  Acting on this premise, Towbin and colleagues undertook a study to examine the effect of adding citalopram to methylphenidate in treating the severe irritability of youth with disruptive mood dysregulation disorder.  They found that citalopram had an effect size of 0.60 (p < 0.001) in the treatment of irritability in these youth.

References

1. Liu, Q., Feng, Y., Chen, W., Zhu, Y., Preece, D. A., Gao, Y., Luo, X., Dang, C., Wang, Y., Sun, L., & Liu, L. (2025). Emotion regulation strategy and its relationship with emotional dysregulation in children with attention-deficit/hyperactivity disorder: behavioral and brain findings. European child & adolescent psychiatry, 34(7), 2241–2252. https://doi.org/10.1007/s00787-025-02643-7

2. Fernandez de la Cruz, L at al.  Treatment of children with attention-deficit/hyperactivity disorder (ADHD) and irritability: results from the multimodal treatment study of children with ADHD (MTA). J Am Acad Child Adolesc Psychiatry. 54(1):62-70.e3, 2015 Jan. https://dx.doi.org/10.1016/j.jaac.2014.10.006.

3. Pan, PY & Yeh, CB.  The role of methylphenidate and aripiprazole in the treatment of emotion dysregulation in children with ADHD. Journal of Clinical Psychopharmacology. 45(4):356-363, 2025 Jul-Aug 01. DOI: 10.1097/JCP.0000000000002002

4. Brancati, GE et al. Revisiting stimulant use for emotional dysregulation in attention-deficit/hyperactivity disorder (ADHD). Expert Review of Neurotherapeutics. 23(11):981-994, 2023 Jul-Dec. doi.org/10.1080/14737175.2023.2263645

5. Pappadopulos E, et al.  Pharmacotherapy of aggression in children and adolescents: Efficacy and effect size.  J Can Acad Child Adolesc Psychiatry. 2006 Feb;15(1):27–39.  (Link)

6. Blader JC, et al.  Stepped treatment for attention-deficit/hyperactivity disorder and aggressive Behavior: A randomized, controlled trial of adjunctive risperidone, divalproex sodium, or placebo after stimulant medication optimization. J Am Acad Child Adolesc Psychiatry. 2021 Feb;60(2):236-251. doi: 10.1016/j.jaac.2019.12.009.

7. Towbin, K et al.  A double-blind randomized placebo-controlled trial of citalopram adjunctive to stimulant medication in youth with chronic severe irritability.  J Am Acad Child Adolesc Psychiatry. 59(3):350-361, 2020 03. https://dx.doi.org/10.1016/j.jaac.2019.05.015

To find out more visit the DCFS Guardian Consent Portal: guardianconsent.dcfs.illinois.gov

Questions? Please email: DCFS.IllinoisConnect@Illinois.gov