What is DMDD?

All children are prone to the odd temper tantrum from time to time, but if your child is exhibiting severe temper tantrums that are difficult to control, extremely frequent, and seemingly out of proportion to the situation at hand, you may want to consider having them evaluated for Disruptive Mood Dysregulation Disorder (DMDD).

DMDD is a fairly recent diagnosis, appearing for the first time in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. The DSM-5 classifies DMDD as a type of depressive disorder, as children diagnosed with DMDD struggle to regulate their moods and emotions in an age-appropriate way. As a result, children with DMDD exhibit frequent temper outbursts in response to frustration, either verbally or behaviorally. In between outbursts, they experience chronic, persistent irritability.

DMDD was developed as a diagnosis in response to psychiatrists’ concern that bipolar disorder had been over-diagnosed in children. The disorder is based on the concept of severe mood dysregulation as a condition distinct from the typical episodic manic and depressive behavior of bipolar disorder. Many children originally diagnosed with pediatric bipolar did not experience the episodic mania (or elevated mood) associate with the condition.

DMDD Symptoms

DMDD significantly impairs a child’s mood, causing anger and irritability. This severe irritability has two prominent manifestations: frequent temper outbursts and a chronic, ill-tempered mood that is more or less constantly present between these outbursts. To be diagnosed with DMDD, a child must exhibit the following symptoms:

  • Severe recurrent temper tantrums: These may be verbal (yelling or screaming) or behavioral (physical aggression)
  • Temper tantrums that are inconsistent with the child’s age: With DMDD, the tantrums are not what you would expect in frequency and severity based on a child’s developmental level. For example, while you might consider it normal for toddlers to get down on the floor kicking and screaming occasionally, you wouldn’t expect to see this from an 11-year-old.
  • Outbursts occur frequently: Usually, you would expect to see an outburst at least three times on average.
  • The mood between outbursts is persistently irritable or angry: This may be observable by parents, family members, teachers, or peers.

In addition to the above symptoms, diagnosis requires that:

  • Symptoms have been present for at least a year, with the child not having a period lasting 3 or more months without showing symptoms.
  • The temper outbursts occur in at least two or three different settings.
  • The child is between 6 and 18 years of age.
  • The symptoms were present before the age of 10.

What’s more, a child will only be diagnosed with DMDD if the symptoms aren’t a result of another medical condition such as autism spectrum disorder, posttraumatic stress disorder, separation anxiety, and so on. Your doctor will also want to rule out the possibility that the symptoms attributable to the effects of any medication or substance.

Risk Factors for DMDD

As DMDD is a relatively new disorder, research is still being conducted to outline specific risk factors. However, one study of over 3,200 children aged between 2 and 17 years found that between 0.8 and 3.3 percent of children meet the criteria for DMDD.

Investigators have found that children with DMDD may have been more prone to difficult behavior, moodiness, and anxiousness from a young age. They may also have struggled to deal with frustrations and adapt to change without losing their temper.

DMDD is thought to occur more often in boys than girls, and in children who have a family member with a psychiatric condition.

Finally, children with DMDD are more likely to experience:

  • Family conflict
  • Difficulty in social settings
  • School suspensions
  • An environment of economic stress

DMDD vs Bipolar Disorder

DMDD was introduced as a diagnosis to address what psychiatrists considered to be the overdiagnosis of pediatric bipolar disorder. While the key feature of DMDD is irritability, the hallmark of bipolar disorder is the presence of manic or hypomanic episodes.

A manic episode is defined as a period of elevated, expansive or irritable mood, typically involving inflated self-esteem, racing thoughts, or difficulty maintaining attention. Hypomania refers to a less severe form of mania that isn’t so extreme as to cause impairment in daily functioning.

Although DMDD and bipolar disorder can both cause irritability, manic episodes tend to occur sporadically, while in DMDD the irritable mood is chronic and severe. Additionally, children with DMDD do not usually exhibit the euphoria, sleeplessness, and goal-directed behavior associated with mania. Differentiating between DMDD and bipolar disorder isn’t always so simple and a proper evaluation by a mental health professional is required to screen for both conditions.

Diagnosing DMDD

Only a medical doctor, psychiatrist, or nurse practitioner can make a diagnosis of DMDD. Before a diagnosis is made, the mental health professional will conduct a comprehensive evaluation of your

child’s symptoms in order to make an assessment. The assessment should involve a discussion with the caregivers and an observation or meeting with the child. It may be helpful to keep a log of your child’s temper outbursts and detail where and when they take place in the lead up to your appointment.

DMDD Treatment

  • Psychotherapy and Behavioral Interventions: Cognitive-behavioral therapy (CBT), a type of psychotherapy, is commonly used to teach children how to deal with thoughts and feelings that contribute to their feeling depressed, anxious, or irritable. The therapy also teaches coping skills for regulating anger and ways to identify and re-label the distorted perceptions that contribute to outbursts. Dialectical behavioral therapy for children (DBT-C) is another option that serves to teach children mindfulness, emotional regulation, and how to tolerate feelings of frustration. In DBT-C, instead of dismissing the child’s emotions, the therapist validates them in order to help the child develop skills to manage their feelings.
  • Parent Management Training: In parent management training, parents are taught specific strategies they can use when responding to a child’s outbursts in order to avoid reinforcing undesirable behavior, soothe the child, and reward positive behavior. Training also focuses on the importance of predictability and deploy consistent consequences when the child does not follow instructions. It is recommended that all caregivers who spend a significant amount of time with the child partake in training to help manage the child’s behavior.
  • Medication: If therapy and parent management training are not effective alone, medication may be prescribed to relieve the symptoms of DMDD. Stimulants, which can be used to help children control their impulses, and an antidepressant with mild side effects, like SSRIs, are typically the first step when medication seems necessary.

Self-Help Strategies for Parents

Psychoanalyst Laurie Hollman Ph.D., who specializes in parent-child relationships, stresses the importance of parents coming to terms with their own anxiety around their child’s behavior so they can remain calm in the face of their child’s outbursts. “If the parent can sustain the understanding that the outburst isn’t random, but rather uncontrolled communication with meaning they will be much more able to help their child,” she says.

Multiple studies show that such interventions can be effective. As such, you may want to seek support from a mental health professional for specific training on effective ways to respond to irritable behavior and improve your relationship with your child. Training also focuses on the importance of predictability, being consistent with children, and positive reinforcement.

“Children who like touch do well being held as they calm down even if they are flailing about. Children who find touch aversive do better with soft soothing tones from parents who empathize by quietly saying statements like, ‘I am with you,’ ‘I’m on your side,’ ‘let me stay beside you and hear what you want to say,’” advises Hollman.

“After the child calms and some time passes, depending on the age of the child, you can have a short conversation indicating you will help the child to say what’s on their mind if they can find some words instead of movements to get what is needed,” she says. “The aim is for the child to eventually internalize the parent’s calm and articulate themselves in words rather than actions.”

Positive reinforcement is also a significant aspect of parent training for dealing with DMDD outbursts. “When the child does even a moment of calming down positively reinforce it quickly by specifying precisely what the child did so they can repeat it and learn that skill,” says Hollman. But according to psychologist Kahina A. Louis, Ps.yD., using positive reinforcement is just as vital when children are not throwing tantrums and simply demonstrating positive behaviors. “Praise them for the specific thing they are doing well (i.e., “I am so proud of you for sharing with your sister”) and reward them with small tokens, such as stickers, change, snacks, at-home movie night, or extra play time, when they accomplish a task that you assigned them,” she suggests.

“Not only does this show the child affection and appreciation, it also teaches them that positive feelings follow positive behaviors. Setting up a routine chart, like a homework or chore chart, can also be helpful in structuring the schedule so that your child knows what is expected of him/her, in order to reduce the tantrums that are triggered by the daily rules or routine.”

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Last Updated: Oct 21, 2019