Cracking the Code on DMDD: Everything You Didn’t Learn in Your Counseling Program
Written by Jami Kirkbride. Jami is a licensed professional counselor, speaker, parent coach, founder of Parenting With Personality, and co-author of the book titled, “The You Zoo.” Her mothering journey with seven children has included the challenges of raising a child with a mental disorder. Her unique perspectives from both sides of the table offer hope and help both for parents searching for resources and other professionals as they seek to be the support parents and families need.
As a professional counselor, I figured I was equipped to navigate our son’s journey with mental health issues. Instead, our struggle was filled with desperate hours of research, numerous questions, consistent attempts to learn and fit pieces together, and then frustrated effort to educate different professionals along the way about what we were learning about Disruptive Mood Dysregulation Disorder (DMDD). Despite my best effort as a mental health professional to stay up-to-date on continuing education and changes with DSM-5, our struggles with interventions and treatments for our son’s mental disorder revealed I was uninformed on some of the most recent changes to the DSM-5. When I found that DMDD had not even existed when I went through my clinical program and licensure, I realized other colleagues may be in the same position.
As a result, other mental health professionals may not be up-to-date on this important change and how it might impact their work and the families they are assisting. I felt that my unique experience as both a mom of a child with mental health disorder and a professional might be helpful in relaying a few important perspectives that we may not see with children or families in an office setting for 50 minutes or have not had specific continuing education on some of the changes made. I asked myself, as a professional, what do I feel is important for my counseling and mental health colleagues to know about DMDD?
Addition of Disruptive Mood Dysregulation Disorder in the DSM-5
As those in mental health know, the collective efforts of international experts from many aspects of mental health have developed the Diagnostic and Statistical Manual of Mental Disorder. This manual serves as the primary and designated authority for doctors and clinicians working with psychiatric diagnoses, recommendations for treatment, insurance claims and payment to health care providers, and continued research. It continues to be updated over time with advancements in research, clinical and community health needs, and issues identified with the classification system or criteria of past editions.
One such change was made when the DSM-5 came out in 2013 and included the Disruptive Mood Dysregulation Disorder diagnosis. DMDD, which is characterized by chronic, severe, and persistent irritability in both adolescents and children, was added to address some of the concerns of the over-diagnosis and potential over-treatment of bipolar in children. (5th ed.; DSM-5; American Psychiatric Association [APA], 2013)
With discussion on the inclusion of DMDD, the experts noted that some of the children diagnosed with bipolar were growing up but no longer meeting the criteria of bipolar as adults, nor did they have a parent diagnosed with bipolar. Rather, these children were often seen with depression or anxiety disorders instead.
Prevalence of DMDD
Even though this newer diagnosis is still in its earlier stages and awareness still being raised, DMDD might not be that uncommon. While the inclusion of a newer diagnosis makes prevalence a challenge, studies suggest that between 2-5% of children and adolescents meet the criteria for DMDD. (APA 2013)
Chances are great that you may already be working with a child who meets this criterion, and you may not realize it. Studies at this point reflect that about 90% of children with DMDD meet the criteria for ADHD. Likewise, nearly 20% of those with ADHD qualify for a diagnosis of DMDD. (Masi 2016) A specific DMDD study done by Liebenluft (Great Smoky Mountains Study) indicated that one could find 58.2% of children with associated anxiety disorders and 16.4% with presentation of a depressive episode. (Liebenluft, 2003)
Criteria for Disruptive Mood Dysregulation Disorder (DMDD)
According to the DSM-5, specific criteria must be met for a diagnosis of DMDD. The specific and exact wording can be found in the DSM-5, as Disruptive Mood Dysregulation Disorder 296.99. The abbreviated version of criteria includes the following:
● Severe, recurrent temper outbursts that can manifest verbally or behaviorally but are out of proportion (as in duration or intensity) for the situation.
● Temper outbursts aren’t consistent with age and are outside the scope of what you would expect for the developmental level of the child (in severity, duration, or frequency).
● Temper outbursts are frequent, occurring three or more times per week, on average.
● Mood between outbursts is generally angry, annoyed, or irritable, as noticed by others (teachers, parents, and peers), the majority of a day and nearly every day.
The diagnosis also requires the following:
● Criteria must be present for 12 months or longer.
● Temper outbursts (as mentioned above) and persistent irritable mood occurs in two of three settings (home, school, with friends, or peers) and are severe in at least one of those settings.
● Diagnosis should not be made before the age of six or after the age of 18.
● The age of onset occurred before the age of 10.
● No period longer than one day during which the criteria, except duration, for a manic or hypomanic episode was met.
● The behavior does not occur exclusively during an episode of major depressive disorder, nor would it be better explained by another mental disorder (such as autism spectrum disorder, persistent depressive disorder, post-traumatic stress disorder, or separation anxiety disorder).
● The symptoms are not related to the physiological effects of a substance or another medical or neurological condition. (APA, 2013)
DMDD and Comorbidity
There can be confusion about diagnoses that can co-exist with DMDD. Major depressive disorder, attention deficit hyperactivity disorder (ADHD), conduct disorder, anxiety, and substance abuse disorders can co-exist. However, oppositional defiant disorder (ODD), intermittent explosive disorder, or bipolar disorder cannot co-exist. This child frequently exhibits verbal or physical aggression towards people and property. As a result, relationships can be a real struggle. This behavior might appear similar to a child with oppositional defiant disorder; however, this child might feel badly or exhibit some remorse after an outburst. They might not even remember what happened during an outburst.
Careful consideration of criteria is important so that you can be more accurate in your treatment plan and approach. In the case of meeting both criteria for ODD and DMDD, the DMDD diagnosis should be used. (APA, 2013) It is vital that children be carefully evaluated to receive the treatment that brings the best results for their personal health and specific mental disorder.
You may have a child already in your care that is not responding to ADHD treatment as you would have expected. Perhaps there is a child brought to you for counseling and has attempted many medications for anxiety, depression, moods, or ADHD, but is unable to find one that works consistently or at all. There may be a parent who has tried all the parenting approaches you’ve suggested, and despite good parenting practices, the child continues the mood instability and severe outbursts. You might have a child who is often emotionally dysregulated, but you can’t quite figure out what else is going on.
I suggest looking into the accuracy of the diagnosis and seeing if DMDD might be something to evaluate for. These are some of the roadblocks we personally experienced with our son. In addition, we were using biofeedback for ADHD and anxiety and getting some unexpected biofeedback results on the screen during the process.
Do your research to understand DMDD. Whether or not you have a client currently diagnosed or are considering a possible diagnosis for a child, you can be armed and ready with a good understanding of this disorder.
It is helpful to remember that in simplistic terms, this child’s system is virtually stuck in the fight-flight mode. Everything in their world is quickly and easily perceived as a threat. This overactive response is at the center of their emotional dysregulation. Additionally, their brains appear to struggle with rigid thinking (due to frontal lobe functions) and can complicate the process of helping them change their perceptions, even if not accurate. You can understand how this would impact a child’s life, learning, and relationships.
Familiarize yourself with this disorder, know what you are looking for, and understand how to distinguish it from the other disorders with similarities or overlap. Know how to rule out other similar conditions and the importance of obtaining a good family history of mental health. The following are a few examples of key things to know:
● DMDD tends to be more common than bipolar disorder and more prominent in boys
● Unlike usual childhood anger (as exhibited by being cold and quiet, with eyes squinted and mouth pressed tight), you will see explosive anger (as exhibited by loud behavior, glassy-look in wide eyes, teeth bared, tight muscles, clenched jaw, look of rage)
● Unlike bipolar, which has a high genetic component (and often a parent with the disorder), this is not the case with DMDD
● Unlike ODD or Conduct Disorder, following an incident, once the child with DMDD is no longer triggered or emotionally dysregulated, he will often feel remorse, be worn out, not remember what happened, and may direct anger at themselves for what happened
If you can get your hands on any materials on DMDD specific to the work of the late Dr. Larry Fisher or now retired Dr. Dan Matthews, I highly recommend it. They have done some great studies and education behind the diagnosis and treatment of DMDD, including Matthews’ Protocol, a brain-based treatment that targets the root cause of DMDD. As a result, many of these kids are experiencing miraculous results.
Dr. Fisher was featured in an informative collection of videos prior to his sudden death that truly opened my eyes to DMDD and treatment recommendations. Revolutionize DMDD, a new non-profit, has legally obtained Dr. Fisher’s videos to continue to educate families and those in the medical community about this disorder.
Watch Dr. Fisher's presentation on DMDD here: https://youtu.be/CnsiRaqBBTE
Get an evaluation by a doctor. Start by referring the child to a doctor, psychiatrist, and/or psychologist for evaluation. You will want to make sure that there are no underlying medical problems contributing to the behaviors or issues causing concern. While there is not a diagnostic assessment specific to DMDD, there are other inventories or assessments used for anxiety and depression that you can find useful to start putting pieces together. The process of elimination may be necessary as you consider the layers of issues and overlap that exist with many of these symptoms. (i.e., Frontal lobe or executive functioning challenges, impulsivity, aggression, etc.)
As mentioned above, RDMDD.org and some of the DMDD support groups offer information on finding doctors who are knowledgeable on the brain-based treatment. These doctors may be a great resource to both consult as well as refer.
Have a parent log outbursts and mood. The way a child presents in the office versus at home or school is likely to differ, and for these children, it can be a vast difference. Have parents initially keep a log of the severe outbursts that are taking place, including the duration, severity, and what is happening prior to the severe tantrum or aggression. Also, keep track of moods between outbursts. This will help both you and the parent see the data a bit more objectively and factually. It will also be useful when discussing this with medical professionals.
The important distinction of DMDD from other diagnoses will be the chronic and persistent irritable mood that is consistently present between outbursts or severe tantrums. This child will exhibit extremely low frustration tolerance, and will have difficulty with emotional regulation, behavioral control, and distress tolerance. Having a mood or behavior log will help track some of these very things. (This may not be something you choose to continue, as it can be very overwhelming to a parent who is already feeling quite consumed and exhausted. Just gathering the data can be helpful to work effectively.)
Consider often overlooked sensory processing issues. Many parents or even counselors have not heard a lot about sensory processing issues, and it can be a huge factor for these children. Become knowledgeable about this layer and encourage parents to pursue information or evaluation through an occupational therapist that understands them well. It can offer some essential missing pieces as parents try to manage the outbursts and things that trigger their child. Quieting these issues or addressing these needs can go a long way toward reducing the number of severe tantrums that are taking place due to these triggers. As parents learn to trace back what was happening prior to the outbursts, they may start to make sense of the things that tend to trigger their child. Often, the triggers are things that other children may filter out or not be affected by.
Coordinate efforts between parents and professionals new to DMDD. Work collectively with parents and other professionals to get a clear picture of the child’s presentation and how it fits the criteria. Working with newer diagnoses will require us to communicate openly and show willingness (and sometimes boldness) to educate professionals who may not know the details or have experience working with this disorder, whether that entails a therapist, school counselor, doctor, or other medical professionals.
It was already discussed above that this child will have an over-reactive response, as their systems are essentially stuck in the fight or flight mode. Treatment will include addressing that over-active sense of threat and how to learn some emotional control, ways to self-calm, re-framing, and appropriate expression. Once calmed and functioning better, there will also be issues to address with the executive functioning skills we often see with frontal lobe dysfunctions. Helping educate parents will also be an important part of the process, as parenting this child is not just your average parenting task!
Treatment for DMDD
There is currently no FDA-approved treatment for DMDD. There are, however, a few avenues that have been used in the treatment of DMDD (based largely on what has been successful with similar diagnoses or symptoms associated, such as depression, anxiety, OCD, and ADHD), including the following:
● Counseling or therapy-- DBT-C is a modification to DBT for children under the age of 12 who may not be developmentally ready to understand or learn all the DBT skills. It may include a parent or caregiver module instead of group therapy to learn mindfulness, emotional regulation, and tolerance for frustration through validation and skill development. CBT is another therapy that teaches how to manage thoughts, feelings, and coping skills for emotion as they learn to re-label distorted perceptions that may trigger outbursts. Also, family counseling may be helpful.
● Medications such as antidepressants, anti-anxiety, stimulants, or atypical antipsychotics are often prescribed since some symptoms are similar to other disorders. However, that doesn’t mean it can help DMDD. The brain-based treatment (previously the Dr. Matthews’ protocol) has been helping children with dramatic results. Using an anti-seizure medication (Trileptal) and amantadine (anti-viral medication) to quiet the amygdala and better “engage” the frontal lobe.
● Patient and caregiver training- learn skills for relaxation, coping, socialization, communication, anger management, stress management, etc.
● Parent training to teach parenting strategies and predictable approaches that can be effective in validating, connecting, training, and managing a child with these significant needs and intense emotions (training, counseling, coaching, etc.)
● Computer-based training (such as biofeedback or facial expression training)
As a counselor, I do not prescribe medications or advise on medications, but I do want to say that it will be hard to make much progress with other strategies until a child achieves stability. In fact, their ability to even reason and understand cannot kick in until they have achieved a certain level of calm. Medications might be necessary to achieve that. Seeing informed doctors and prescribing professionals familiar with DMDD really is a crucial step to consider from the start in order to utilize medications that help the child achieve this stability sooner and can allow skills training/therapy to be more effective.
I reiterate that our child and family’s experience with our child’s mental health issues had been an arduous, exhausting, and heart-aching battle. And as I said above, I won’t advise on medications. I do, however, want to relay our personal experience with the above-mentioned Matthews’ Protocol. Our child has been able to think, function, problem solve, understand, relate, and manage relationships in a significantly improved way since we started the treatment a year ago. This brain-based treatment gets to the root cause in the brain by calming the seizure-like activity responsible for the rages. He had been previously struggling with suicidal ideation, impulsivity, overreactive sensory responses, emotional dysregulation, and even verbal and physical aggression. He is like a different child. As he said in his own words, “It’s like a miracle, mom! I don’t even think about wanting to be dead anymore. Those thoughts are totally gone! For the first time life feels fun.”
You can find more information about this specific treatment and helpful information for therapists and medical providers on Revolutionize DMDD’s website, www.RDMDD.org.
Prognosis for DMDD
As you might envision, children who live in this constant state of feeling threatened and stuck in fight or flight mode experience a tumultuous life. Diagnosed with DMDD, they are likely to endure most, if not all, of the following:
● Difficult family relationships due to the strain the disorder puts on the child and family
● Difficulty in learning
● Challenges with behaviors in social settings
● Struggles with peers and friendships
● Behavior issues in the classroom or school setting
● Possible hospitalizations (aggression, mood instability, suicidal issues, etc.)
● Possible development of depression and anxiety as DMDD progresses
Left untreated, the child with DMDD is also at risk for the following:
● Risky behaviors
● Violent relationships
● Increased hospitalizations
● Involvement with law enforcement
However, with proper treatment, interventions, skills training, therapies, and medications, children can have a chance to function with more emotional control, learn coping skills, and reduce the anxiety and depression they experience. Forging these new neural pathways can open up a new world to them and even allow the possibility to slowly titrate off medications (one of the benefits mentioned in the study of the Matthews’ Protocol) and outgrow some of the symptoms once experienced.
Parent Support With DMDD
Many of these parents have exhausted themselves with research, learning, and therapies, only to be treated as though their child behaves this way due to poor, ineffective, or damaging parenting. They will benefit greatly from being validated for their hard work and efforts. They will also need your help in understanding that the journey will require a different parenting approach than what they’ve known, consistent strategies, and practical tools, as well as a strong support system to get through it. Their own anxiety is likely remarkably high living with a child who can often feel like a stick of dynamite, and may suffer from PTSD as a result. Offer them reassurance, encouragement, and resources for the difficult journey. You might even encourage them to consider their own individual counseling, parent coaching, or parent education (which is DMDD informed) to support them as they navigate their child’s diagnosis.
As a mental health professional, I have a passion to help educate others about the DMDD diagnosis. Our family’s personal experience, coupled with my professional experience, gives me a unique perspective on the struggles these children and families are facing. I understand the need to supply adequate intervention and treatment to these children as well as education and support to parents. The two avenues together can help set these families on a totally different trajectory. I encourage you to expand your knowledge on this subject. Give support and understanding when you are approached by a parent concerned about this disorder or questioning a possible diagnosis. Developing strong teamwork and communication with parents will be key to treating a child with DMDD successfully.
This article can in no way answer every question you might have, but there is some great literature out there. A favorite book of mine that resonates with the DMDD community and within my own family is Poppy and the Overactive Amygdala by Holly Provan and Eric Provan. This children’s book is also perfect for adults, especially teachers, therapists, and anyone who needs to understand the inner workings of a child’s brain during emotional dysregulation and what it feels like to them. My child’s response after we read the book together gave him validation of what he felt but was never able to articulate. And, it was eye-opening to me as well. The more we can understand DMDD, the sooner healing can begin.
Resources you might find helpful:
Revolutionize DMDD, www.rdmdd.org
ADDitude magazine (link-- Disruptive Mood Dysregulation Disorder: DMDD and ADHD Symptoms (additudemag.com) )or National Institute to Mental Health. (link- (NIMH » Disruptive Mood Dysregulation Disorder (nih.gov) )
1. Beyond Behaviors: Using Brain Science and Compassion to Understand and Solve Children’s Behavioral Challenges by Mona Delahooke, PhD.
2. Parenting a Child Who Has Intense Emotions: Dialectical Behavior Therapy Skills to Help Your Child Regulate Emotional Outbursts and Aggressive Behaviors by Pat Harvey
3. Disruptive Mood Dysregulation Disorder (DMDD), ADHD and the Bipolar Child Under DSM-5: A Concise Guide for Parents and Professionals, by Todd Finnerty
4. Disruptive Mood: Irritability in Children and Adolescents, by Argyris Stringaris, Eric Taylor
5. The Explosive Child, by Ross Greene
What You Need to Know in A Glance:
Symptoms of DMDD—
● Chronic and persistent irritability, anger, or annoyance nearly every day
● Severe tantrums that include verbal or physical aggression
● These tantrums are beyond the scope of what you would expect for age, situation or cause and present in two of three settings (i.e., school, home, with friends)
● Intense outbursts or tantrums that take place at least 3 times per week
● Symptoms have been ongoing for a year or longer
● Most common, ADHD, as studies reflect that about 90% of children with DMDD meet the criteria for ADHD, and that nearly 20% of those with ADHD would qualify for the DMDD diagnosis. (Masi 2016)
● Depression and anxiety disorders can be comorbid or may develop later
● Medications, behavioral therapies, skills training, parent training, computer-based brain training, and/or a combination of these
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.) Washington, DC: Author.
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
Liebenluft E, Charney DS, Towbin KE, Bahngoo RK, Pine DS (2003) Defining clinical phenotypes of juvenile mania. Am j Psychiatry 160: 430-437.
DSM-5. Disruptive Mood Dysregulation Disorder. https://images.pearsonclinical.com/images/assets/ basc-3/basc3resources/DSM5_DiagnosticCriteria_DisruptiveMoodDysregulationDisorder.pdf