David’s Story
Dave is a 10-yo youth who has always had a spirited temperament. He is always easily irritated and easily triggered to have tantrums, on a daily basis, several times a day. Triggers for anger include making any sort of requests that take him away from a preferred activity (e.g. if parents ask him to get off the TV and come for dinner), or if he has a wish and parents say no (e.g. he wants to have another cookie and parents say no.) As he is getting older, his tantrums are harder to manage as he gets bigger. He has kicked holes in the walls and broken his door.
Parents have tried various parenting strategies (including making clear expectations with positive/negative rewards), but nothing so far seems to work.
Does your child/youth have:
- Angry outbursts and explosions that are easily triggered by day-to-day expectations?
- Seem to be angry and irritable most of the time, for at least the past year?
If so, then read on to learn more…
About Anger
Everyone gets angry from time to time. Anger is a natural reaction when people feel under threat, or when they feel something is unfair. Anger serves to let us know that something isn’t quite right, and can be a helpful signal for people to take action. If you never get angry, there is a risk you may get taken advantage of by others.
On the other hand, if a person is constantly angry and irritable, this tends to cause problems at home, work or school. And it may be a condition such as disruptive mood dysregulation disorder (DMDD)...
What is Disruptive Mood Dysregulation Disorder (DMDD)?
According to the Diagnostic Statistical Manual (DSM-5), DMDD is defined as the following:
- Severe, recurrent verbal or behavioural angry outbursts out of proportion to the situation
- Not appropriate to the developmental level, i.e. it would not be abnormal for a toddler to have tantrums; however, tantrums in a school-aged children.
- Happen on average three times a week
- Happens in at least two settings, i.e. home, school, peers.
- Persistent irritable or angry most of the day, early every day, between outbursts
- At least 12 months (symptom free periods not exceeding 3 months a year)
- Onset <10 years old (diagnosed >6 years but <18 years old)
- Not due to bipolar disorder (such as hypomania or mania)
- Not occurring during periods of major depression
- Not due to substance use, medications or another mental health condition
DMDD is a relatively new diagnosis. It was created in an effort to better help those with severe anger. Prior to this diagnosis, people with severe, longstanding anger were often felt to have bipolar disorder, thus started on bipolar medications. As a result, the diagnosis of DMDD was created to help find better ways of supporting such individuals.
The Role of “Easy Dopamine”
Parents often report that their child/youth are triggered by the following:
- Asking the person to stop doing a preferred activity (e.g. if parents ask him to get off the TV)
- Asking the person to start doing some other daily routine (e.g. come to the dinner table, do homework, do chores)
- When the person wants something (e.g. wants to watch TV, or wants something with sugar).
One theory for such outbursts is the following:
- When a person is using a recreational screen (e.g. video game or TV), or when eating high sugar foods, the brain receives a small dose of pleasure chemicals, specifically dopamine.
- Human brains crave things that provide dopamine, which is the same chemical that other addictive things give us (such as cocaine, opioids, marijuana, alcohol, etc.)
- When a person with DMDD is asked to stop using their TV (or denied another cookie), it is understandable that their brain becomes upset, because now they are losing their source of dopamine.
Frequently Asked Questions (FAQs)
Question: Why label someone with DMDD? Doesn’t everyone get angry from time to time?
Answer: It is true that everyone gets angry from time to time. DMDD is more than just normal anger. DMDD refers to those people who have severe, recurrent anger, to the point it causes problems in their lives. Studies show that people with DMDD go on to experience significant problems in their lives as they grow older. The good news, is by identifying those with DMDD, this gives opportunities to provide support and help with their anger.
Question: Is DMDD the same as bipolar?
Answer: DMDD describes people who have long standing anger most of the time. On the other hand, with bipolar, people have distinct episodes where they have symptoms. Making the distinction is important, as treatments are different for bipolar (such as possibly requiring mood stabilizers such as lithium).
Other Conditions Where Anger can be Seen
Anger can be seen in many situations and brain conditions, in addition to disruptive mood dysregulation disorder (ASD). Others include stress, depression, anxiety, attention deficit hyperactivity disorder (ADHD), sensory processing problems and autism spectrum disorder (ASD), to name just a few.
Self-Help: Caregiver Strategies for DMDD
Healthy parent style, i.e. authoritative parenting, which includes:
- Having healthy expectations
- Having limits on behaviours, e.g. no physical aggression
Are there problems that arise around daily routines? If so, write down your child’s routine on paper. Ensure there is a nice, visual schedule for the child so that they can understand what happens during their day.
Example of a Visual Schedule
7 AM |  | Morning / Wake up Routine
|
8 AM |  |
|
8:30-2:30 PM |  |
|
Transition warnings
- Use a timer (such as a simple egg timer or stove timer that can count down).
- Use a visual timer (which shows the time visually left)
Consider self-regulation programs.
- Self-regulation is the ability to regulate, or manage stresses and emotions that one can stay in calm (i.e. “green zone”). Life is stressor, and many stresses and triggers can get us upset (i.e. “yellow zone”), or completely overwhelmed, perhaps even in a fight/flight mode (i.e. “red zone”). Self-regulation is about learning what triggers someone, and what strategies work to help someone get back to the green zone.
- Programs include:
- How Does Your Engine Run?
- Zones of Regulation
Connection before direction
- The theory with connection before direction, is that with certain kids, it is imported to connect with them first, prior to give them instructions, or direction (or correction).
- Previously
- Parent: “Time for dinner!”
- Child: “Just 5 more minutes!”
- Try instead
- Parent: “Hey, how’s it going?”
- Child: “Good. Check out the cool castle I made!”
- Parent: “Wow, very cool. I like the turret very much.”
- Child: “I know, that took me a long time.”
- Parent: “Awesome. It’s dinner in a few minutes. Do you want to stop playing now, or in a few minutes?”
- Child: “A few minutes.”
- Parent: “Sounds good.”
Empathy for the child’s anger.
- Child: “I want another cookie!”
- Parent: “I’m sorry but you’ve had enough. You can have another tomorrow. If you’re going to be like this, I’m not buying any more cookies.”
General lifestyle strategies
- Ensuring healthy sleep ideally 8-11 hours a day for children/youth.
- Ensuring adequate nature time, ideally at least 1-hr daily for children/youth. This is derived from studies on eye health, showing that at least 1-hr outside is required to help prevent nearsightedness.
- Limiting screen time. If there are angry outbursts when asked to stop using screen time, then it suggests a mild screen addiction. The child’s brain has become accustomed to the ‘easy dopamine’ that the screen time provides. And when the screentime is removed, the withdrawal of ‘easy dopamine’ leads to anger and frustration.
- Encourage non-electronic activities. Having people do non-electronic activities (such as spending time outdoors in nature) helps them rewire their brains to make their own dopamine, as opposed to become dependent on easy dopamine.
Are You Wondering if Your Child has Wondering DMDD?
Does your child have excessive anger, that hasn’t responded to various interventions? Start by seeing your primary care provider (family physician, paediatrician, nurse practitioner) about your concerns. They can start by ensuring that there aren’t any medical problems contributing, and help with referrals and next steps.
How is DMDD treated?
Are there other conditions (such as ADHD, learning disabilities, mood/anxiety problems, sensory processing problems, etc.)?
- If so, then it will be important to ensure that those conditions are being treated, with non-medication or medication treatments.
Are there problems with sensory processing?
- Is the person triggered by too much sound, light, touch, smell or other senses? If so, the person might benefit from seeing an occupational therapist (OT).
Are there problems with motor issues?
- Does the person have trouble with fine motor, i.e. problems with handwriting, printing, using their fingers?
- Does the person have problems with gross motor, e.g. problems learning to ride a bicycle, playing sports, being clumsy (such as bumping into things or dropping things)? If so, the person might benefit from seeing an occupational therapist (OT).
Non-Medication Treatments for DMDD
- Collaborative and proactive solutions (CPS) (or the Collaborative Problem Solving (CPS) approaches may be helpful
- Teaching self-regulation, such as by using programs such as:
- Zones of Regulation
www.zonesofregulation.com - How Does Your Engine Run
www.alertprogram.com
- Zones of Regulation
Medication Treatments for DMDD
When non-medication strategies are unsuccessful, medications can sometimes be helpful for DMDD. Medications are prescribed by a doctor, such as a family physician, paediatrician or psychiatrist.
For More Information
The Whole Brain Child: 12 Revolutionary Strategies to Nurture Your Child’s Developing Brain, by Dr. Daniel Siegel and Tina Bryson.
Lives in the Balance. Website by Dr. Ross Greene that talks about the Collaborative and Proactive Solutions (CPS) approach.
https://www.livesinthebalance.org/my-explosive-child
Think:Kids
Website by Dr. Stuart Ablon, which talks about the Collaborative Problem Solving (CPS) approach.
References
Roy AK, Lopes V, Klein RG. Disruptive Mood Dysregulation Disorder: A New Diagnostic Approach to Chronic Irritability in Youth. Am J Psychiatry. 2014;171(9):918-924. doi:10.1176/appi.ajp.2014.13101301
Disruptive Mood Dysregulation Disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/disruptive-mood-dysregulation-disorder-dmdd/disruptive-mood-dysregulation-disorder.shtml. Published 2017. Accessed October 11, 2019.
About this Document
Written by the eMentalHealth.ca Team.
Disclaimer
This information is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your qualified expert or health provider. Always contact a qualified expert or health professional for further information in your specific situation or circumstance.
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