Disruptive mood dysregulation disorder (DMDD) is a newer mental disorder diagnosis that was introduced in the DSM-5, published in 2013 (American Psychiatric Association). It affects school-aged kids, and is characterized by explosive tantrums and severe irritability. Before DSM-5, kids with these symptoms would’ve been diagnosed with pediatric bipolar disorder. Namely, it was believed that these kids would go on to have bipolar disorder as adults.
However, this wasn’t the case: Bipolar disorder isn’t common in kids with DMDD. Rather, the disorders that kids with DMDD commonly develop in adulthood include anxiety and depression.
DMDD often co-occurs with oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD).
Because DMDD is a relatively new diagnosis, the research on it is limited. However, the research is promising, and helpful treatments are available. The first-line treatment is psychotherapy, followed by medication.
With treatment, your child can feel better and their irritability and tantrums will decrease. And your relationship will get stronger, too.
According to a 2018 overview article on disruptive mood dysregulation disorder (DMDD), early studies seem to support cognitive-behavioral therapy (CBT) with parent training as a first-line treatment for DMDD. CBT is an evidence-based treatment for various mental illnesses, such as depression and anxiety. In CBT, kids learn to identify the early warning signs of their anger and effectively manage it before it spirals out of control. Parents learn to identify what triggers their kids’ anger, successfully respond to their tantrums when they do happen, and reinforce positive behaviors.
According to the Child Mind Institute, dialectical behavior therapy for children (DBT-C) is being used more often today with more success. DBT also is an evidence-based treatment for a variety of disorders, including borderline personality disorder, depression, anxiety, substance abuse, and eating disorders.
In DBT-C, adapted specifically for kids 7 to 12, the therapist validates your child’s emotions, and helps them learn to cope effectively when emotions become too intense. They teach you and your child emotional regulation, mindfulness, distress tolerance, and interpersonal skills. For instance, kids learn how to become aware of their thoughts and feelings in the present moment, reduce the intensity of their emotions, and be assertive in their relationships.
Parents learn strategies that are specific to their child, along with how to help their child practice DBT skills on a daily basis.
Interpretation bias therapy (IBT) also may be helpful in conjunction with therapy. Specifically, studies have found that kids with severe irritability are more likely to judge ambiguous faces as fear-inducing or threatening. Consequently, researchers believe that these biases might maintain irritability. In other words, when kids see others as threatening, they react as if they’re threatened, and lash out. IBT trains kids to shift their interpretations to happy judgments.
Medications for DMDD
No medications have been approved by the U.S. Food and Drug Administration (FDA) to treat disruptive mood dysregulation disorder (DMDD). But doctors might still prescribe a medication “off label” if symptoms are severe and disruptive.
Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), can reduce irritability and boost mood. SSRIs are generally safe and effective. Common side effects may include headaches and stomach aches, which are usually short term. However, SSRIs do carry a risk of suicidal thoughts and behaviors in kids and teens, which is why doctors must carefully monitor these medications.
DMDD also commonly co-occurs with ADHD, which means your child might already be taking a stimulant. In addition to helping to bolster attention, stimulants also can reduce irritability. (Learn more about stimulants in this article on ADHD treatment.)
If a child is in crisis and their behavior is physically aggressive (toward others or themselves), a doctor might prescribe risperidone (Risperdal) or aripiprazole (Abilify). Both are atypical antipsychotics that are FDA-approved for treating irritability and aggression in kids with autism spectrum disorders, helping to calm them down.
While these medications can be highly effective, they can cause significant side effects. Risperidone can lead to substantial weight gain, along with metabolic, neurological, and hormonal changes. For instance, it may increase blood sugar, lipids, and triglycerides, upping the risk for diabetes. It also may increase the production of a hormone called prolactin, which can lead to amenorrhea, breast enlargement, production of breast milk, and bone loss in girls. And it can cause breast growth (gynecomastia) in boys. However, in many cases, the medication has nothing to do with the gynecomastia, and it’s actually a product of normal puberty.
Aripiprazole (Abilify) has fewer side effects, such as less weight gain. It also suppresses prolactin and sometimes is prescribed in conjunction with risperidone. Along with risperidone, aripiprazole can cause repetitive, involuntary movements called “tardive dyskinesia” (which might become permanent).
Careful monitoring is critical with antipsychotics (and really any medication). For instance, your doctor should have your child tested for levels of prolactin and glucose before they start their medication. And prolactin should be tested regularly thereafter for the first few months. Also, your child should receive lab testing and a physical exam every year. If your child doesn’t receive any testing, request it.
The Child Mind Institute cited a quote from Canadian researchers from this article on evidence-based recommendations for monitoring the safety of atypical antipsychotics in kids and teens: “Clinicians who are unprepared to monitor children for side effects should choose not to prescribe these medications.”
Communicate regularly with your child’s doctor about any side effects or concerns. Remember that this is a partnership, and your doctor should be listening to what you have to say. After all, you know your child best. In addition, whatever medication your child is prescribed, it’s imperative that they (and you) participate in therapy.
Self-Help Strategies for Parents
As a parent, you might be feeling overwhelmed and helpless around your child’s difficult, explosive behavior. You might be wondering, what the heck do I do? Again, the key is to find effective psychotherapy. These tips also can help:
- Work closely with your child’s school, and seek accommodations. Tell them about their diagnosis. Your child will likely be eligible for an individualized education plan (IEP). For this plan, you, along with your child’s teacher, school psychologist, and school administrators, come up with a plan to help minimize their outbursts and maximize their school performance. For instance, your child might be permitted to discreetly leave the room to go to a “safe place” to calm down. They might be given additional time to complete assignments.
- Focus on your own reactions. It’s incredibly hard to stay calm when your child is having an intense tantrum, yelling in your face, and throwing everything in sight. But staying calm is critical. Learn strategies to soothe yourself. This might include anything from practicing deep breathing to leaving the room for a few minutes to participating in physical activities to relieve stress and boost mood over time.
- Be consistent with rules and routines. Tantrums can happen when there’s inconsistency, unpredictability, and too much flexibility. That is, yesterday, your child was allowed to watch 1 hour of TV. Today, you’re only letting them watch 30 minutes. This can be confusing. Of course, being consistent is hard. But it gives kids much needed structure and predictability, and it simplifies expectations. If you have a partner, sit down together, and come up with your family and household rules regarding common issues, such as screen time, bedtime, and homework.
- Try to pick up on patterns. Your child’s outbursts might seem random, but often they do have specific triggers, which you can work on minimizing. Take note of each of your child’s tantrums, including what preceded it, how they reacted, what you (or another caregiver) did, and what happened after the tantrum subsided. This also is important information for your child’s psychologist and the school to know.
- Seek out reputable resources. For instance, you might find the book The Explosive Child by psychologist Ross W. Green, Ph.D, to be helpful. He views explosive kids as not attention-seeking or manipulative but as lacking specific skills in problem solving and frustration tolerance. (This article on ADDitude.com provides a primer.) You also might find it helpful to read blogs written by parents of kids who struggle with irritability and anger.
- Remember you’re not alone. In addition to reading blogs by parents, seek out online or in-person groups with parents of kids with similar issues and concerns. This is a great way to trade tips, and build connection, and remember that many, many parents are also in the same boat. To find a group, ask your child’s psychologist, or check out Facebook.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Bosworth, T. (2016, February 6). Aripiprazole may suppress prolactin in boys who develop gynecomasta while on risperidon, other atypical antipsychotics. Clinical Psychiatry News. Retrieved from https://www.mdedge.com/psychiatry/article/106368/pediatrics/aripiprazole-may-suppress-prolactin-boys-who-develop.
Haller, S.P., Stoddard, J., MacGillivray, C., Stiles, K., Perhamus, G., Penton-Voak, I.S…Brotman, M.A. (2018). A double-blind, randomized, placebo-controlled trial of a computer-based interpretation bias training for youth with severe irritability: a study protocol. Trials, 19, 1, 1-9.
Miller, C. DMDD: Extreme tantrums and irritability. Child Mind Institute. Retrieved from https://childmind.org/article/dmdd-extreme-tantrums-irritability/.
Miller, C. What parents should know about Risperdal. Child Mind Institute. Retrieved from https://childmind.org/article/what-parents-should-know-about-risperdal/.
Perepletchikova, F., Nathanson, D., Axelrod, S.R., Merrill, C., Walker, A., Grossman, M….Walkup, J. (2017). Randomized clinical trial of dialectical behavior therapy for preadolescent children with disruptive mood dysregulation disorder: Feasibility and outcomes. Journal of the American Academy of Child & Adolescent Psychiatry, 56, 10, 832-840.
Tapia, V., John, R.M. (2018). Disruptive mood dysregulation disorder. The Journal for Nurse Practitioners, 14, 8, 573-578.