What Is Disruptive Mood Dysregulation Disorder?
A child who consistently acts cranky and moody, then flies into intense rages with seemingly no provocation might have Disruptive Mood Dysregulation Disorder. Find out how DMDD is related to ADHD, and how to distinguish its symptoms from bipolar disorder and oppositional defiant disorder.
What is Disruptive Mood Dysregulation Disorder?
Disruptive Mood Dysregulation Disorder (DMDD) is a condition in which children are persistently irritable, angry, or annoyed. These irritable moods are punctuated by intense temper tantrums that are disproportionate to the situation and more severe than the typical reaction of same-aged peers.
DMDD is a relatively new disorder. It first appeared in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. The new diagnosis grew out of a concern that some children were being diagnosed and treated for bipolar disorder when they didn’t meet the full criteria.
It’s normal for children to be moody, but children with DMDD spend most of their days in an irritable or annoyed state. This chronic irritability is interspersed with fits of rage that appear with little to no provocation. For example, something as seemingly inconsequential as being served a glass of milk instead of juice can provoke a screaming episode that lasts for a half hour or more.
Children with DMDD can become physically aggressive as well. They may throw things or become aggressive with their parents, friends, or siblings. Their behavior make families feel that they are walking on eggshells, never knowing when their child will erupt.
With DMDD, the symptoms go beyond normal irritability and typical childhood temper tantrums. They are so frequent and so severe that they become life-disrupting for both the child and his or her family.1
DMDD vs. Bipolar Disorder
DMDD has only existed as a unique diagnosis for a few years. It was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013, in an attempt to more accurately classify children who in the past would have been diagnosed with childhood bipolar disorder.
Between 1994 and 2003, the number of children diagnosed with bipolar disorder increased 40-fold.2 As researchers began to study these cases, they discovered striking differences in some of the children with chronic irritability.
For one, many of the children diagnosed with bipolar disorder did not have the alternating episodes of irritability and heightened mood, called mania, that are hallmarks of that condition. Instead, their irritability was more constant. “The key characteristic that distinguishes DMDD from bipolar disorder is persistent irritability,” says Steven Schlozman, MD, co-director of the Massachusetts General Hospital Clay Center for Young Healthy Minds, and assistant professor of Psychiatry at Harvard Medical School. “[They are] extremely irritable, out of proportion to the kinds of things that normally make children irritable.”
This subgroup of children was also much less likely to have a parent with bipolar disorder, which often runs in families. What’s more, they did not go on to develop bipolar disorder in adulthood, as is typical of children with the condition. “They were instead more likely to develop depression and anxiety,” says William French, MD, DFAACAP, associate professor in the University of Washington Department of Psychiatry and Behavioral Sciences.
Experts created the new diagnosis to avoid prescribing atypical antipsychotics, the standard bipolar disorder treatment, to children who didn’t fully meet the criteria. While these drugs can be very effective for bipolar disorder, they also can have serious side effects such as blurred vision, dizziness, and extreme fatigue.
Symptoms of DMDD
Children with DMDD alternate between extended periods of moodiness and temper outbursts. “It’s a combination of persistently irritable or annoyed mood that hangs on for an unusually long time, usually more than half of the child’s waking hours, and excessive or frequent temper outbursts,” explains James Waxmonsky, MD, division chief, Child Psychiatry at Penn State Health.
The rages are intense, they don’t fit the child’s developmental age, and they are completely out of proportion to the situation. They’re also a near-constant presence. “The temper outbursts have to occur, on average, three or more times a week,” Waxmonsky says. “So at least every other day parents are living with an excessive and sustained temper outburst. The child does not have to be physically aggressive to meet the diagnostic definition, but has to display verbal intensity to the point that it seems possible that the child might hit his or her parent or siblings.”
DMDD, ODD, and ADHD
DMDD has so much in common with both oppositional defiant disorder (ODD) and ADHD that it’s sometimes hard to tell these three conditions apart. Some 90 percent of children with DMDD meet the criteria for ADHD, and about 80 percent meet the criteria for ODD.3,4
DMDD, ODD, and ADHD all cause irritable behavior and temper outbursts. The difference is in the rate and intensity — these behaviors are less frequent and severe in children with ODD and ADHD.
“DMDD is the irritable symptoms of ODD expanded a little bit more,” Waxmonsky says. “Just about everyone who has DMDD is going to have ODD.”
Causes of DMDD
Researchers don’t know exactly what causes DMDD. It does not seem to stem from a traumatic event. “In fact, if you had a child in trauma, you’d be more likely to worry about a brief stress reaction or post-traumatic stress disorder,” Schlozman says. A history of chronic irritability does make children more likely to be diagnosed with DMDD, however.5
If you notice symptoms of DMDD in your child, parents should begin with a visit to their pediatrician, who should first screen for related disorders like ADHD and depression. The results of these tests will help determine your next steps. “The pediatrician may feel like this is beyond his or her scope and refer parents to a child psychologist or other mental health specialist,” French says.
Doctors diagnose DMDD based on the child’s age, the symptoms, and how long those symptoms have lasted. To qualify for a diagnosis, a child’s symptoms must have started between ages 6 and 10, and have lasted for a full 12 months.6
Children with DMDD are in a consistently irritable mood, and they fly into severe temper tantrums at least three times a week. They never go a day without showing symptoms of DMDD. And the symptoms have to appear in two out of three settings: at home, in school, and/or with their friends.7
Part of the diagnosis involves ruling out other, similar conditions, such as bipolar disorder, depression, and substance abuse. Children with a strong family history of bipolar disorder are more likely to be diagnosed bipolar, while those with more mood-related symptoms may receive a diagnosis of depression or another mood disorder, Schlozman says.
Treatment Options for DMDD
Because of the overlap with ADHD and ODD, many of the same treatments that work for these conditions are also helpful for DMDD. Typically, treatment consists of therapy, medications such as antidepressants and stimulant drugs, or a combination of the two. It can take several trials to find the right mix of treatments needed to improve your child’s mood and behavior. Parents are advised to continue working with their physician until an effective treatment plan is developed.
Disruptive Mood Dysregulation Disorder at a Glance
Comorbidity with ADHD
- About 90% of children with DMDD meet the criteria for ADHD; about 20% of those with ADHD qualify for a diagnosis of DMDD.8
- Persistently irritable mood nearly every day
- Intense temper tantrums three or more times per week
- Tantrums involve yelling, screaming, and sometimes physical aggression
- Symptoms have been ongoing for more than one year
Professional to See
- Start with a pediatrician, and then progress to a child psychiatrist or psychologist for further diagnosis and treatment as needed
Treatments & Medications
- Behavioral therapy, medications such as stimulants and/or antidepressants, or a combination of the two treatments
- National Institute of Mental Health
- Disruptive Mood Dysregulation Disorder (DMDD), ADHD and the Bipolar Child Under DSM-5: A Concise Guide for Parents and Professionals, by Todd Finnerty
- Disruptive Mood: Irritability in Children and Adolescents, by Argyris Stringaris, Eric Taylor
1 NIMH. Disruptive Mood Dysregulation Disorder. https://www.nimh.nih.gov/health/topics/disruptive-mood-dysregulation-disorder-dmdd/disruptive-mood-dysregulation-disorder.shtml
3 Roy KR, et al. Disruptive mood dysregulation disorder (DMDD): A new diagnostic approach to chronic irritability in youth. American Journal of Psychiatry. September 2014. 171(9): 918-924. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4390118/
4 Masi L, et al. ADHD and DMDD comorbidities, similarities and distinctions. Journal of Child and Adolescent Behavior. 2016. https://www.omicsonline.org/open-access/adhd-and-dmdd-comorbidities-similarities-and-distinctions-2375-4494-1000325.php?aid=83936
5 Child Mind Institute. DMDD: Risk Factors. https://childmind.org/guide/guide-to-disruptive-mood-dysregulation-disorder/risk-factors/
6 DSM-5. Disruptive Mood Dysregulation Disorder. https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_DisruptiveMoodDysregulationDisorder.pdf
7 DSM-5. Disruptive Mood Dysregulation Disorder. https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_DisruptiveMoodDysregulationDisorder.pdf
8 Masi L, et al. ADHD and DMDD comorbidities, similarities and distinctions. Journal of Child and Adolescent Behavior. 2016. https://www.omicsonline.org/open-access/adhd-and-dmdd-comorbidities-similarities-and-distinctions-2375-4494-1000325.php?aid=83936