• DMDD

Disruptive Mood Dysregulation Disorder

Disruptive Mood Dysregulation Disorder (DMDD) is a condition defined by chronic anger and irritability and explosive, often violent tantrums that occur several times per week. DMDD is a somewhat new diagnosis; it appeared in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013. The condition was identified, in part, in response to clinicians’ concerns about the misdiagnosis and over-diagnosis of bipolar disorder (BD) in young children. Children with DMDD do not have the manic episodes that children with BD exhibit. In addition, therapies and medications used to treat BD and DMDD are different, making it paramount that the conditions not be confused. 

The causes of DMDD are still being studied, but the condition is thought to be triggered by neurological abnormalities such as chronic migraines, nutritional deficiencies, abnormalities in brain chemistry, early childhood trauma, and/or parental history of mental illness. 

DMDD is diagnosed in children as young as six and under the age of 18. Prior to age six, their explosive tantrums may be considered an aspect of their development. For diagnosis, the hostile interactions must occur with both peers and authority figures; in other words, the tension cannot be the result of a given relationship but must be a product of the child’s inability to regulate themselves in most settings. The symptoms must appear three or more times per week, for 12 months or longer. 

Children with DMDD often confuse neutral expressions or other innocuous triggers as threats. This may be due to a malfunctioning of the brain’s amygdala, which regulates emotional behavior. When triggered by these feelings of danger, they may respond with far more intensity than required. 

Children with DMDD also have poor executive function skills due to an immature prefrontal lobe in comparison to other children their age. This contributes to problems with planning, emotional regulation, and inhibition. DMDD makes children appear angry and irritable and have explosive outbursts in all environments - not just at home. Secondary characteristics of DMDD include poor working memory, poor visual-spatial reasoning, poor planning and organization skills, and a short attention span. Children with DMDD often are unable to understand the needs of others when they’re under distress, and they have a very low tolerance for frustration. 

DMDD is often co-diagnosed with ADHD and anxiety disorder and depression, which makes treatment decisions complex. When dealing with comorbid conditions, DMDD is usually addressed by therapeutic interventions and while the symptoms of the other condition are addressed pharmacologically. As children with DMDD may be a risk to themselves and others, it is critical that they receive help as soon as possible. 

It is critical that children with Disruptive Mood Dysregulation Disorder receive help, as they may be a risk to themselves and others.

Conventional Treatment

​Standard treatment of DMDD includes therapy and medications that help moderate emotional outbursts and help executive function. Medications are often prescribed to treat violent explosive outbursts and therapy and parent/teacher coaching help children learn emotional self-regulation, which are discussed in more detail below. Extreme caution must be used in prescribing pharmaceuticals to treat DMDD, as many have severe side-effects; it is important to seek out experienced clinicians for your child’s treatment team.  

Medication for DMDD usually falls into three classes: 

  • Stimulants - these include methylphenidate (brand name Ritalin)
  • Antidepressants - such as fluoxetine (brand name Prozac)
  • Antipsychotics - these include risperidone (brand name Risperdal)

Lithium, an “antimanic” drug (one that stabilizes abnormal brain behavior) may also be prescribed to stabilize mood. Prescription drugs have significant side effects and contraindications; make sure you are working with an experienced pediatric psychiatrist when incorporating them into your treatment plan. 

With treatment, many children with DMDD outgrow the primary symptoms of aggression and irritability. However, as adults, they may be at greater risk for anxiety, depression, and mood disorders. 

Support

At The Brain Possible, our goal is to empower you to take a holistic approach to your child’s treatment. Below are ways in which you can support several aspects of your child’s recovery; before embarking on any, be sure to discuss them with your trusted health care providers.

Emotional/Social

Cognitive behavioral therapy (CBT) is often prescribed to help children identify anger triggers and develop “scripts” or new ways of responding to them. Dialectical behavior therapy for children (DBT-C) is especially effective for children with DMDD. In this therapy, the therapist validates the child’s difficult emotional experience and trains caregivers to do the same. Then, they help the child develop alternative views and coping mechanisms. 

In parent management training (PMT), parents learn how to reinforce positive behavior, set boundaries, and withdraw attention from negative behavior. PMT is also known to positively impact the mental health of parents and caregivers. Since DMDD exacts a toll on siblings and parents, the entire family can benefit from family systems therapy, in which the family members can examine their individual and collective experiences and empathize with each other’s experiences. 

Adlerian play therapy has been successful in the treatment of younger children with DMDD. During these sessions, the therapist works to understand and affirm the positive aspects of a child’s personality through play. 

Promising studies have shown the effectiveness of computer-based training to help children learn how to interpret others’ expressions. This helps children learn the emotional context behind neutral expressions so that they don’t interpret them as angry, thus triggering a threatened response.

Children with DMDD have found emotional comfort in canine therapy and equine-assisted or hippotherapy, which can help them regulate their emotions and experience trust and closeness as they form bonds with animals and their therapeutic helpers.

Intellectual

Since DMDD can make interactions with school peers and teachers especially fraught, it’s important to include a child’s teachers and school administrators in her treatment plan. Weekly calls to discuss disruptions, social conduct, and academic progress are common. Medication side-effects may also impact school performance; children can be prepared to understand how their treatment plan might affect their work and social lives.

Nutritional/Environmental

As a child having a tantrum may be of danger to herself and others, caregivers can attempt to move a child to a safe room while they have their outburst, where dangerous objects have been removed.  

Nutritional deficiencies are thought to contribute to the development of DMDD; ensuring that your child has the recommended amount of iron, vitamin B12, and folate is recommended for neurological health. 

Physiological

Homeopathy, which uses doses of plant and mineral essences to target symptoms, has been credited in anecdotal reports to help stabilize the behavior of children with DMDD. In particular, German Chamomile is thought to calm children’s nervous systems.