Disruptive Mood Dysregulation Disorder (DMDD)

It is perfectly normal for children to experience temper tantrums every now and then while growing up. It is a normal part of the growing up process, and most parents also become rather skilled in anticipating situations that are likely to trigger such an emotional outburst or episode in their child. However, if you find that your child is throwing tantrums that seem way out of proportion, are happening frequently, and/or are difficult to control, you may consider consulting your child’s doctor to have your child evaluated for a condition known as disruptive mood dysregulation disorder (DMDD). Here’s everything you need to know about disruptive mood dysregulation disorder (DMDD).

What is Disruptive Mood Dysregulation Disorder (DMDD)?

Every child acts out and has temper tantrums every now and then. It is a normal part of growing up. Most parents soon become experts in anticipating these temper tantrums and outbursts and are well capable of handling any such emotional episodes in their children.(1,2) However, if your child is exhibiting these tantrums that are becoming very frequent, appear to be out of proportion, and are becoming more and more difficult to control, you should consider having your child evaluated by a child specialist or a mental health professional for disruptive mood dysregulation disorder (DMDD).(3,4,5)

Disruptive mood dysregulation disorder is a type of psychiatric condition and is usually only diagnosed in children. The primary signs and symptoms of this condition include emotional dysregulation, behavioral outbursts, and irritability. Outbursts typically appear in the form of severe temper tantrums.

The condition was first introduced in 2013 and then defined in the first edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This condition was recently developed as a diagnosis to help doctors reduce the over-diagnosis of bipolar disorder in children.(6,7)

What are the Symptoms of Disruptive Mood Dysregulation Disorder?

Even though disruptive mood dysregulation disorder is a reasonably current condition, it is classified as a depressive disorder. The common feature of all types of depressive disorders is that there is a clinically significant impairment in the patient’s mood. In such cases, the term mood is typically used to describe a person’s internal emotional experience. In children with disruptive mood dysregulation disorder, the mood impairment or mood disturbances can be observed in the form of irritability and anger.(8) The main symptoms of disruptive mood dysregulation disorder that distinguish it from other psychiatric conditions include:

  1. Severe Temper Tantrums: Your child may have severe temper tantrums that may appear in the form of verbal outbursts such as screaming and yelling. Behavioral outbursts like being physically aggressive towards people, animals, or things are also commonly observed.
  2. Outbursts Occur At Least Three Or More Times In A Week: While this does not have to be a hard and fast rule, but it is likely that your child will not qualify for being diagnosed with disruptive mood dysregulation disorder if they have two or fewer tantrums in one week. A child who usually has more than two outbursts in a week is more likely to be diagnosed with disruptive mood dysregulation disorder.
  3. Level Of Temper Tantrums Are Not Considered Normal For The Child’s Age: It is common for toddlers to experience a meltdown and for older kids to yell when things don’t go as per their wish. However, in children with disruptive mood dysregulation disorder, these tantrums are not what you would typically expect for a child’s age in terms of how bad the episodes are or how frequently they occur. For example, one would not normally expect a 10-year-old to frequently start destroying property when angry.(9,10)
  4. Tantrums Can Occur In Various Settings: If your child only has temper outbursts in certain conditions, like with just the babysitter or one parent, they are unlikely to be diagnosed with disruptive mood dysregulation disorder. For diagnosing a child with disruptive mood dysregulation disorder, the symptoms need to be present in at least two to three settings, including at home, at school, or with classmates or friends.
  5. Angry And Irritable Mood Between Tantrums: In children with disruptive mood dysregulation disorder, it is often seen that even when the child is not having an outburst, they may appear to be disturbed for most of the day, almost every day. It is common for parents to continually feel like they are ‘walking on eggshells’ to avoid an emotional outburst or episode.

Apart from these above symptoms, a doctor will diagnose a child with disruptive mood dysregulation disorder if:

  • The child is between the ages of 6 to 17 years, and diagnosis is not made before or after this age range.
  • Their mood disruptions have been present for the better part of one year.
  • The symptoms have been present before the age of 10 years.

In the end, a child is only going to be diagnosed with disruptive mood dysregulation disorder if their tantrums are not happening due to any other condition, like a developmental disability, autism spectrum disorder, or as an effect of substance abuse. (11,12)

How is Disruptive Mood Dysregulation Disorder Different from Bipolar Disorder?

Disruptive mood dysregulation disorder was only recently classified as a diagnosis in order to help doctors and psychologists to reduce the over-diagnosis of pediatric bipolar disorder. One of the key characteristics of bipolar disorder in children is also the presence of manic or hypomanic episodes.(13)

A manic episode can be defined as a period of irritable, elevated, or expansive mood. Additionally, a person is also likely to have a sudden increase in energy. They may show a sudden interest in multiple activities. Hypomanic episodes can be defined as less severe versions of these manic episodes. A person with bipolar disorder does not necessarily always experience manic episodes. They may also experience bouts of depression, marked by episodes of mania. The manic episodes also do not necessarily have to be a part of their day-to-day functioning.

While bipolar disorder and disruptive mood dysregulation disorder may both cause irritability, but children with disruptive mood dysregulation disorder tend to persistently angry and irritable, even when there is no full-blown outburst present. Meantime, in children with bipolar disorder, the manic episodes tend to come and go. You must ask yourself whether your child is perpetually in a bad mood or if they seem to have bouts of bad mood interspersed with ordinary mood. If they have a persistent bad mood, they might have disruptive mood dysregulation disorder. If it is out of the ordinary, a doctor is more likely to consider a diagnosis of bipolar disorder.

Furthermore, the key symptom of disruptive mood dysregulation disorder is irritability, while an episode of mania may also include the following symptoms:

  • Extreme excitement
  • Sleeplessness
  • Euphoria, or extreme positive emotion
  • Goal-directed behavior

Remember that differentiating between bipolar disorder and disruptive mood dysregulation disorder is not going to be easy and should only be done by a professional. If you suspect either of these conditions, you should talk to your child’s doctor first.

What are the Risk Factors of Disruptive Mood Dysregulation Disorder?

A 2014 study carried out on over 3200 children in the age range of 2 to 17 years found that the percentage of children who met the diagnosis criteria for disruptive mood dysregulation disorder was between 0.8 and 3.3 percent.(14) Disruptive mood dysregulation disorder is a condition that is often more commonly observed in children than in teenagers.(5)

While the specific risk factors for disruptive mood dysregulation disorder are still being researched, it is believed that children with this condition have temperamental vulnerabilities and are more prone to the following at a very young age itself:

Moodiness

Anxiousness

Difficult behavior

Irritability

It is also likely that they have previously met the diagnostic criteria for the following conditions:

Having a family member with any type of psychiatric condition is known to increase the risk of disruptive mood dysregulation disorder. Male children are also more likely to present with this condition. Children with disruptive mood dysregulation disorder are more prone to experience:

  • Social difficulties, such as having a difficult time making friends(15)
  • Family conflict
  • School suspensions
  • Live in settings of economic stress

How is Disruptive Mood Dysregulation Disorder Diagnosed?

This condition is diagnosed by a doctor, psychologist, or a nurse practitioner. Diagnosis of disruptive mood dysregulation disorder can only be made after a thorough assessment, which should involve interviews with the parents or caregivers, an observation or meeting with the child, school visits, interviews with the teachers, babysitters, or any other caregivers who are part of the child’s life and spend a significant amount of time with them. A family history, a child’s personal history, and genetic history are also looked at carefully before making a diagnosis.

What is the Treatment for Disruptive Mood Dysregulation Disorder?

The treatment for disruptive mood dysregulation disorder revolves around helping children deal with their symptoms and involves psychotherapy or behavioral interventions, medications, or a combination of both therapy and medications. Most doctors prefer to first explore the non-medication treatments first. Though the treatment is not specifically designed for treating disruptive mood dysregulation disorder, but these options are commonly used for treating various mental health disorders and challenges in children. Here are some of the approaches used to treat disruptive mood dysregulation disorder:(16)

Behavioral Interventions and Psychotherapy

When you go for psychotherapy, both parents and children will meet with a therapist every week to work on and come up with better ways of relating to one another. In older children, individual therapy, such as cognitive behavior therapy, has been found to be helpful in making them learn to think more effectively and to respond better to situations that upset them and eventually cause an outburst. There are also other therapy approaches that focus on empowering the parents to help develop better parenting strategies and interact in a better and calmer way to their child.

Medications

There are various medications that are commonly prescribed for the treatment of behavioral and emotional problems in children. Your doctor/psychiatrist will discuss the pros and cons of each of the medications before prescribing them. Commonly used drugs for treating disruptive mood dysregulation disorder include stimulants, antidepressants, and atypical antipsychotics.(17)

Conclusion

It is important to remember that the most effective approach and intervention for any type of behavioral and emotional problems in children involve parents and their other caregivers. Since this condition impacts the manner in which the children interact with their family members, other adults, and their classmates and friends, it is crucial to keep these relationships in mind while treating the child.

If left untreated, disruptive mood dysregulation disorder can end up developing into a non-bipolar or unipolar depression or anxiety disorders as a child reaches adulthood or even during late adolescence. As is the case with most mental health conditions in children, the best outcome only happens when the diagnosis and treatment occur at the earliest.

If you believe that your child may be experiencing disruptive mood dysregulation disorder, you should talk to their doctor and get a professional assessment done. Your family doctor can further refer you to a specialist, such as a psychologist or a psychiatrist. The specialist will be the one to conduct a formal assessment, which may be done at a hospital, a private office setup, or at a specialized clinic. In some cases, the assessment may even be made at your child’s school by the school psychologist. Remember, that the earlier the diagnosis happens, the earlier you can start treatment and intervention to help your child deal with their emotions better.

References:

  1. Axelson, D., Findling, R.L., Fristad, M.A., Kowatch, R.A., Youngstrom, E.A., Horwitz, S.M., Arnold, L.E., Frazier, T.W., Ryan, N. and Demeter, C., 2012. Examining the proposed disruptive mood dysregulation disorder diagnosis in children in the Longitudinal Assessment of Manic Symptoms study. The Journal of clinical psychiatry, 73(10), pp.1342-1350.
  2. Copeland, W.E., Angold, A., Costello, E.J. and Egger, H., 2013. Prevalence, comorbidity, and correlates of DSM-5 proposed disruptive mood dysregulation disorder. American Journal of Psychiatry, 170(2), pp.173-179.
  3. Tourian, L., LeBoeuf, A., Breton, J.J., Cohen, D., Gignac, M., Labelle, R., Guile, J.M. and Renaud, J., 2015. Treatment options for the cardinal symptoms of disruptive mood dysregulation disorder. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 24(1), p.41.
  4. Copeland, W.E., Shanahan, L., Egger, H., Angold, A. and Costello, E.J., 2014. Adult diagnostic and functional outcomes of DSM-5 disruptive mood dysregulation disorder. American journal of psychiatry, 171(6), pp.668-674.
  5. Dougherty, L.R., Smith, V.C., Bufferd, S.J., Carlson, G.A., Stringaris, A., Leibenluft, E. and Klein, D.N., 2014. DSM-5 disruptive mood dysregulation disorder: correlates and predictors in young children. Psychological Medicine, 44(11), p.2339.
  6. Roy, A.K., Lopes, V. and Klein, R.G., 2014. Disruptive mood dysregulation disorder: a new diagnostic approach to chronic irritability in youth. American Journal of Psychiatry, 171(9), pp.918-924.
  7. Margulies, D.M., Weintraub, S., Basile, J., Grover, P.J. and Carlson, G.A., 2012. Will disruptive mood dysregulation disorder reduce false diagnosis of bipolar disorder in children?. Bipolar Disorders, 14(5), pp.488-496.
  8. Roy, A.K., Lopes, V. and Klein, R.G., 2014. Disruptive mood dysregulation disorder: a new diagnostic approach to chronic irritability in youth. American Journal of Psychiatry, 171(9), pp.918-924.
  9. Tudor, M.E., Ibrahim, K., Bertschinger, E., Piasecka, J. and Sukhodolsky, D.G., 2016. Cognitive-behavioral therapy for a 9-year-old girl with disruptive mood dysregulation disorder. Clinical case studies, 15(6), pp.459-475.
  10. Andrade, B.F., Sorge, G.B., Na, J.J. and Wharton-Shukster, E., 2015. Clinical profiles of children with disruptive behaviors based on the severity of their conduct problems, callous–unemotional traits and emotional difficulties. Child Psychiatry & Human Development, 46(4), pp.567-576.
  11. McTate, E.A. and Leffler, J.M., 2017. Diagnosing disruptive mood dysregulation disorder: Integrating semi-structured and unstructured interviews. Clinical child psychology and psychiatry, 22(2), pp.187-203.
  12. Bruno, A., Celebre, L., Torre, G., Pandolfo, G., Mento, C., Cedro, C., Zoccali, R.A. and Muscatello, M.R.A., 2019. Focus on Disruptive Mood Dysregulation Disorder: A review of the literature. Psychiatry research, 279, pp.323-330.
  13. Krieger, F.V. and Stringaris, A., 2013. Bipolar disorder and disruptive mood dysregulation in children and adolescents: assessment, diagnosis and treatment. Evidence-based mental health, 16(4), pp.93-94.
  14. Copeland, W.E., Angold, A., Costello, E.J. and Egger, H., 2013. Prevalence, comorbidity, and correlates of DSM-5 proposed disruptive mood dysregulation disorder. American Journal of Psychiatry, 170(2), pp.173-179.
  15. Lin, Y.J., Tseng, W.L. and Gau, S.S.F., 2021. Psychiatric comorbidity and social adjustment difficulties in children with disruptive mood dysregulation disorder: A national epidemiological study. Journal of Affective Disorders, 281, pp.485-492.
  16. Tourian, L., LeBoeuf, A., Breton, J.J., Cohen, D., Gignac, M., Labelle, R., Guile, J.M. and Renaud, J., 2015. Treatment options for the cardinal symptoms of disruptive mood dysregulation disorder. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 24(1), p.41.
  17. Loy, J.H., Merry, S.N., Hetrick, S.E. and Stasiak, K., 2017. Atypical antipsychotics for disruptive behaviour disorders in children and youths. Cochrane database of systematic reviews, (8).

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