DMDD: Extreme Tantrums and Irritability

Occasional tantrums and irritability are normal parts of childhood, but some kids have frequent, extreme tantrums — at an age when most kids have outgrown them — and are irritable most of the time. Those are signs that they might have what’s called disruptive mood dysregulation disorder, or DMDD. It’s a mouthful of a name, but the key words are “disruptive,” which refers to behavior like tantrums and outbursts, and “dysregulation,” which means that these kids can’t manage their emotions in an age-appropriate way.

Kids who have DMDD have usually had, from infancy, a difficult temperament. They have had a hard time self-soothing, and trouble adapting to changes without getting upset or losing their temper. As toddlers, they’ve been strong-willed and difficult to manage. And by grade school age, they’re still having tantrums that are no longer developmentally appropriate.

As one mother of a 12-year-old boy put it to Sarper Taskiran, MD, a child and adolescent psychiatrist at the Child Mind Institute, “I have an intelligent 12-year-old who tantrums like a five-year-old — severe, full-blown tantrums with slamming doors, crying, making fists and banging on the table.”

In between tantrums, children with DMDD are usually irritable. They have a short fuse, and low frustration tolerance. Parents often describe feeling like they are walking on eggshells around these kids to avoid setting them off.

“We typically see kids in our center beginning at 8 to 10 years old,” says Stephanie Samar, PsyD, a clinical psychologist at the Child Mind Institute, “but they’ve been having trouble with these symptoms for a while and may have tried therapy in the past. They often come because the parents are at a breaking point — they’re burnt out and they’re not sure how to handle it anymore.”

Children who have DMDD start with very big emotions that they have poor control over. They experience feelings more powerfully than other kids, and lack self-regulation skills. As Dr. Taskiran puts it, “Too much gas and not enough brakes.”

Another factor that triggers irritability and tantrums is that children with DMDD have difficulty reading facial expressions. They tend to perceive neutral faces more negatively, and slightly negative faces as severely judgmental or even hostile, and they react by acting out.

This is different from kids on the autism spectrum, who often don’t respond to facial expressions. These kids misinterpret them. “If the teacher has a headache or is preoccupied when they greet the child in the morning,” says Dr. Taskiran, “the child with DMDD gets alarmed, thinking, ‘There’s something wrong with me. They’re angry at me. They’re going to reprimand me.’ ”

DMDD is sometimes confused with oppositional defiant disorder, or ODD, because the behavior of kids with DMDD can look, superficially, like ODD. They may be disrupting the classroom, yelling a lot, not following directions. But the difference is that their behavior is not aimed at defying authority. “Clearly they just can’t handle their mood,” says Dr. Taskiran. “That’s the issue.”

He notes that teachers, parents and psychiatrists will say of a kid with DMDD that “Oh, you know, they’re different, they’re not really spiteful, they’re not really vindictive. They can’t really help it.” And kids with DMDD often apologize for their tantrums. “They’re often shocked after the tantrums, like, ‘Why did I do this?’ ”

If a child’s behavior is a threat to others, Dr. Taskiran notes, it unlikely that it’s a case of DMDD. Kids with DMDD might, in the heat of things, throw something, not looking where it’s going, and someone might get hurt. But it wasn’t their intention.

The tantrums of kids with DMDD are also different than the kind children on the autism spectrum have. A tantrum of an autistic child is more internal, observes Dr. Taskiran. “They are trying to self-soothe, reacting to something that has disrupted their own internal environment. It’s less verbal, or they repeat the same thing over and over.”

In kids with DMDD a tantrum is more external, directed at whatever person or situation has triggered them. Usually it involves yelling at someone or something, in protest of something that’s been, or being, done to them.

For a diagnosis of DMDD a child must have:

• Severe temper outbursts, either verbal (yelling), behavioral (physical aggression) or both
• Outbursts are out of proportion to the provocation, and inappropriate for the child’s age
• Outbursts occur on average three or more times a week
• The mood between temper outbursts is persistently irritable or angry most of the day
• These symptoms have been present in at least three settings, for 12 months or more
• The child can’t be younger than 6 or older than 18, and the onset of symptoms must have been before 10

The reason DMDD can’t be diagnosed before a child is six — even though parents usually say the behavior was present in toddlers — is that tantrums are still part of normal development at that point. Clinicians don’t want to accidentally include kids who might just be maturing somewhat more slowly than their peers. And the symptoms must have developed before age 10 because if a child suddenly develops this pattern of symptoms in, say, the fifth grade, it’s probably something other than DMDD, such as a response to adversity of some sort, at home, at school, with peers.

Until 2014, kids who exhibited this pattern of extreme tantrums and irritability were diagnosed with pediatric bipolar disorder. Though their symptoms weren’t episodic — mania alternating with depression — as in adult bipolar disorder, they were expected to develop mature bipolar disorder as they aged. But that usually didn’t happen. In fact, kids with DMDD are more likely to develop anxiety or depression as adults.

Kids with DMDD often get an earlier diagnosis of ADHD or anxiety, notes Dr. Samar, since the emotional extremes can read as impulsivity, or fight-or-flight responses.

Symptoms of DMDD change as children grow and develop. When they are elementary school age, there are a lot of tantrums, at home and at school. The tantrums may continue in middle school. But as kids become adolescents, the tantrums are less physical outbursts than interpersonal ones, volatility in relationships, Dr. Taskiran says.

By late adolescence, or early adulthood, the lashing out has diminished, but the extreme emotions are still there, and they become internalized as anxiety or depression.

The goal in treatment of DMDD is to enable kids to regulate their mood and handle their emotions without extreme or prolonged outbursts. Cognitive behavior therapy and parent management training are often used with these kids with some effect. But now clinicians are using dialectical behavior therapy, or DBT, with more success. DBT was created for adults, but has been adapted for adolescents and pre-adolescents. The programs for children include Dialectical Behavioral Therapy for Children, or DBT-C, and a modified program known as Mood Masters®, which was created at the Child Mind Institute.

In DBT, therapists validate the emotions people are experiencing (rather than telling them they shouldn’t be feeling that way) and then help them develop skills to cope when the emotions become too intense to manage. Both DBT-C and Mood Masters teach emotional regulation, mindfulness, distress tolerance and interpersonal effectiveness skills, which are combined with  parent management training, which  teaches parents skills to help their kids rein in their disruptive behavior.

DBT-C and Mood Masters teach DBT skills to parents as well as kids, so they can help their children practice using them — and use the skills themselves. “When you have an 11-year-old having an angry outburst for 30 minutes, the parents need to be skillful and manage their own emotional response in this situation,” explains Dr. Samar. “We found it to be very helpful for these families.”

For school, kids can be taught skills to defuse situations that upset them, and their 504s or IEPs can be modified to accommodate them — for instance, to allow them to leave the classroom to splash water on their face then come back feeling a bit more regulated.

If therapy and parent training are not available, or not effective alone, medication can be prescribed. To manage the volatile emotions of kids with DMDD, doctors prefer to use an anti-depressant with mild side-effects, like an SSRI. To help kids with the top-down self-control, Dr. Taskiran says he may prescribe a stimulant medication, which helps kids rein in impulses.

If that combination of medications fails, he adds, he might move on to a low dose of an atypical antipsychotic, such as Risperdal.

When behavioral problems are creating a crisis in the family or in school, it’s not uncommon for clinicians to go directly to prescribing Risperdal for children with DMDD. “Parents come in with a sense of urgency that this needs to be fixed right away,” says Dr. Taskiran. “Otherwise they’re going to be kicked out of school, or they’ll have to be sent to residential treatment.” These decisions should be made carefully, as Risperdal can have serious side-effects.

Dr. Taskiran adds that kids with DMDD can be very difficult for families to deal with, and can result in a lot of conflict between parents. When they’re trying to manage huge tantrums, differences in child-rearing practices are heightened, and it may feel as if the family is falling apart. Sometimes just getting a clear diagnosis can be a big relief.

That’s an important point, says Dr. Taskiran. “Children with DMDD are often not understood well, even by mental health professionals. Parents are at a loss. Once they understand what it is, and what can you do — that they’re not powerless — they see the light at the end of the tunnel.”

And it can be a relief to the children, too, adds Dr. Samar. “These kids are really capable of changing. It can be very intense, but once they know the way to manage themselves and get control back, they can be very motivated and successful.”

And she notes that their emotional sensitivity can, when harnessed a different way, be a strength for them. “I think it’s really a gift,” she notes. “As much as they get this rap for being irritable and angry all the time, they’re actually incredibly strong and talented kids who just need a different way of managing that emotion. They’re great kids and great families.”