Disruptive Mood Dysregulation Disorder (DMDD)

This article provides a comprehensive overview of disruptive mood dysregulation disorder, including the primary symptoms, causes, risk factors, best treatment options, as well as specific support for parents of children with this disorder.

Key Takeaways:

• Disruptive mood dysregulation disorder is a mental disorder in children and adolescents characterized by intense irritability and tantrums, which has negative impacts at home, in school, and in relationships with others.

• This disorder not only causes stress for the child, but also everyone else involved, such as parents, siblings, and peers.

• This disorder can be managed with professional treatment and specific strategies to support parents and children. Early intervention is key for best outcomes.

Understanding Disruptive Mood Dysregulation Disorder

Disruptive mood dysregulation disorder (DMDD) is a mental health disorder diagnosable in children aged 6 to 18. The primary characteristic of DMDD is chronic, intense, persistent irritability, which is highlighted by frequent and persistent outbursts or tantrums.^[1][2]It is also characterized by difficulty for a child or adolescent to function in two or more places or environments.

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), this disorder falls under the category of depressive disorders, which includes disorders that are highlighted by sad, empty, or irritable moods, along with changes that affect one’s ability to function.

DMDD is a relatively new diagnosis, as it was introduced first into the DSM-5 in 2013. It was largely introduced as a way to help differentiate between pediatric bipolar disorder (PBD) and chronic irritability, given that research identified distinct symptoms for these disorders. In turn, it was designed to promote more specific and effective treatments.

Who Does it Affect?

DMDD affects children and adolescents. It can only be diagnosed in individuals aged 6 to 18. Also, the age of onset for DMDD must occur before age 10, whether that’s through observation (if the child is still 10 or younger) or through historical account (if they’re over 10).^[1]

How Prevalent is DMDD?

DMDD rates vary depending on the specific age group and methods used, with a range between 0.12 and 5.26%. On average, DMDD prevalence is 2.5 to 3%. It is more common in younger children compared to adolescents, and prevalence rates are also higher in boys than girls.^[1][3]

DMDD vs Oppositional Defiant Disorder (ODD)

DMDD shares similar symptoms with oppositional defiant disorder (ODD), especially outbursts and behavioral disruptions. DMDD also has a very high comorbidity rate with ODD, with some studies suggesting rates of greater than 90%.^[1]

With that said, DMDD is distinct from ODD due to the presence of negative mood and irritability. The outbursts and tantrums in DMDD stem from irritability, whereas in ODD, they more often result from a desire for defiance and rebellion against authority.

The majority of children with DMDD also meet criteria for ODD, but only around 15% of children with ODD meet the criteria for DMDD. This is in large part due to the added negative mood component in DMDD.

Causes of DMDD

There are no official causes of DMDD, although there are many established risk factors. This includes genetics, trauma and other environmental factors, social-emotional regulation, and certain brain processes.

A family history of depression and bipolar disorder (BPD) may increase the risk of developing DMDD. Certain genetic factors may also increase the likelihood of irritability, especially for males, although the exact factors aren’t completely identified.^[1][4]

Early trauma may also play a role in the development of DMDD. This includes psychological abuse, neglect, and the death of a family member, among others. Family dynamics and other related environmental factors have an influence on DMDD as well. Children with a history of family conflict, stress, or unstable relationships may be more likely to develop DMDD.^[4]

Lastly, DMDD is associated with differences in social-emotional regulation and certain brain processes. For example, studies have shown that children with DMDD have abnormal reward processing, which could impact anger and outbursts. In addition, children with DMDD often have social-emotional processing difficulties, such as with face-emotion recognition and emotion labeling. They also often have decreased cognitive flexibility, which is the ability to adapt one’s thinking and behavior to changing situations or circumstances.^[2][5]

DMDD Symptoms

DMDD symptoms are all centered around chronic, intense, persistent irritability, or negative mood. The main symptoms of DMDD are:^[2][4][6]

• Physical aggression, such as hitting, biting, or throwing things

• Verbal outbursts/aggression, such as yelling or screaming

• Intense physical tantrums or verbal outbursts that seem disproportional in intensity or duration to the situation or provocation

• Tantrums or outbursts that occur several times per week

• Physical or verbal outbursts that are age-inappropriate (i.e., reactions are ones that would be expected only in much younger individuals)

• Irritability, anger, or negative/low mood most or all of the time

• Inability to control extreme emotions

• Easily frustrated

• Irritability and related symptoms have gone on for at least a year

• Trouble functioning at school, home, or other areas (due to outbursts and tantrums)

Parental Stress

Parents or caregivers of children with DMDD experience high levels of stress; in fact, it’s often significantly higher than that of parents of children with other mental disorders. The frequent and intense tantrums and outbursts significantly strain relationships and make it very difficult to foster healthy parent-child interactions. In addition, the unpredictable nature of the child’s behavior makes it hard for parents or caregivers to know exactly how to respond to the child and how to properly parent them, which can exacerbate stress and worry.^[7]

Classroom Disruptions

DMDD often leads to classroom disruptions. Children with DMDD often have outbursts, throw things, and act aggressively towards others, whether that’s through physical aggression (e.g., hitting, biting) or verbal (e.g., yelling, name-calling). These disruptions make it much more difficult to create an effective classroom environment for all students, which can also lead to reduced academic performance.^[4][6]

Diagnosing DMDD

Diagnosing DMDD involves a comprehensive mental and behavioral exam, which includes the use of interviews, assessments, and possibly behavioral observations. These are all used in conjunction with diagnostic criteria from the DSM-5 to create an official diagnosis.

When diagnosing psychological disorders, it’s important to rule out biological causes or identify them so your provider can include them in the treatment plan. Your doctor will first conduct a general physical exam to assess the child’s health. This may also include lab tests to make sure there are no physical causes for the disorder, such as a neurological disorder or substance use.

If DMDD is suspected, your doctor will refer you to a psychologist, psychiatrist, or other qualified mental health professional for the most accurate diagnosis. As part of the evaluation, they will first rule out disorders that can’t coexist with DMDD, which include intermittent explosive disorder (IEP) and bipolar disorder (BPD). Also, if individuals meet criteria for both DMDD and ODD, only a diagnosis of DMDD is given. They will also evaluate for mental health conditions that cause similar symptoms, such as depression and anxiety.^[3][4]

After this, a mental health professional will implement a clinical interview to understand more about your child’s symptoms and behavioral history. This often includes the use of questionnaires, and may also require reports from teachers and other individuals heavily involved in the child’s life, to gain a more complete picture.^[3]

DMDD DSM-5 Diagnostic Criteria

The mental health professional uses all of this information and compares it to the diagnostic criteria in the DSM-5. DMDD diagnosis requires the following:

• Severe, recurrent physical or verbal outbursts that are disproportional in intensity or duration to the situation or provocation

• Outbursts are inconsistent with age or developmental level

• Outbursts occur three or more times per week, on average

• Irritable or angry mood most of the day, nearly every day, and is noticeable by others

• Symptoms are present for at least 12 months

• Symptoms occur in at least two of three settings (e.g., home, school, with friends) and are severe in at least one of these

• Diagnosis should not be made before age 6 or after age 18

• The age of onset of symptoms is before age 10 (which is recognized through observation or history

• There has never been the presence of full manic or hypomanic symptoms lasting more than one day

• Symptoms do not occur exclusively during major depressive disorder and are not better explained by another mental disorder

• It can’t coexist with ODD, IEP, or BPD. If ODD criteria are also met, diagnosis should be DMDD.

• Symptoms are not caused by substance use or medical or neurological condition

Risks and Complications

DMDD has many negative impacts, especially significant disruptions to the child’s family, school, and peer relationships. Children with DMDD often have poorer school performance, a hard time with sports or any social-related activities, and significant stress and disruptions with their family and home life. As a result, DMDD negatively impacts not only the individual but everyone around them.^[6]

Children with DMDD also have higher rates of comorbid disorders, such as conduct disorder and ADHD. Research suggests that between 20 and 80 percent of children with DMDD have ADHD, and another study found that 98.4% meet criteria for ODD, ADHD, conduct disorder, depression, or anxiety. They are also at a greater risk of developing mental health issues later in life, especially anxiety and depression.^[1][4]

Treatment Options for DMDD

DMDD is typically treated with psychotherapy, either alone or in combination with medication. This is often coupled with specific intervention programs tailored to the unique circumstances and needs of each child.

Psychotherapy

Psychotherapy is often the first choice of treatment. Common types of psychotherapy used to treat DMDD include cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and parent management training.

CBT helps address the maladaptive thoughts and behavior patterns that result in irritability and tantrums. For example, this therapy helps children to recognize their own frustration, cope with anger, and change the way they perceive various situations and events.^[4][6]

DBT specifically focuses on managing emotions and improving interpersonal skills. In this therapy, children learn to become more aware of their emotions and respond non-judgmentally, while also learning techniques to self-soothe themselves. In addition, DBT helps children improve their interpersonal skills, such as communication and conflict resolution, to improve their relationships with others.^[4]

Parent management training helps parents learn how to read and respond to irritable behaviors. Through this training, parents learn to recognize behaviors that often precede a tantrum, so that they can intervene before it fully develops. It also focuses on using effective behavioral responses, especially positive reinforcement for appropriate behaviors.^[4][6]

Medication

Medication may also be used to treat DMDD. Typically, medications are used primarily to address comorbid disorders within DMDD, rather than DMDD by itself. If DMDD is still present, then additional medications are considered.

Medications that may be used for DMDD include:^[3][4]

• Stimulants: These are used to help reduce irritability

• Antidepressants: This includes selective serotonin reuptake inhibitors (SSRIs) or serotonin noradrenaline reupputake inhibitors (SNRIs), which are used to help with mood and irritability.

• Atypical antipsychotics: These are designed to reduce aggression and irritability

• Anticonvulsants: These are used to help decrease aggressive behaviors

Living with DMDD

In addition to professional treatments, there are also many things that can make daily life a bit easier for yourself, your child, and everyone else around them. If your child has DMDD, consider some of the following techniques:

• Practice open communication

• Take breaks when things are escalating, and come back to it later

• Establish a consistent daily routine

• Set clear rules, expectations, and boundaries

• Parents and caregivers should also be consistent with their responses to behaviors

• Use stress management strategies (for the child, parents, and anyone else affected)

• E.g., deep breathing, yoga, spending time outside, meditation

• Partaking in enjoyable activities to relax and boost mood

Support for Parents of Children with DMDD

Parenting a child with DMDD can be very stressful and may often lead to feelings of frustration, despair, and helplessness. Fortunately, parents and caregivers can find support through several avenues, such as:^[6]

• Specific support groups with other parents of children with DMDD

• You can find support and community groups through DMDD.org or by searching for resources within your zipcode

• Open communication with your child’s mental health professional to learn learn as much as possible about DMDD

• Communicating with your child’s teacher(s), school psychologist, and/or counselor

• This can help generate specific plans and accommodations to improve school behaviors and performance

• Stress management and communication strategies mentioned above

Final Thoughts

Children with DMDD experience many difficulties at home, in school, and in their relationships with others. This disorder not only affects their own mental well-being, but it also causes a lot of stress for those around them, which makes early and effective treatment an essential component.

The good news is that DMDD and many of its resulting problems can be addressed through a comprehensive treatment plan, which includes professional therapy, parent training, open communication with all involved individuals, and specific support strategies.