Disruptive Mood Dysregulation Disorder

What Causes Disruptive Mood Dysregulation Disorder?

The cause of DMDD is not yet known. However, regardless of the root cause, some factors seem to put a child at increased risk for DMDD. Possible risk factors include:

• Genetics. Children with a family history of anxiety, depression, or substance use disorders are at increased risk of DMDD.
• Environment. Children exposed to a chaotic home life, substance abuse, or inconsistent attention from parents are more likely to have DMDD.
• Sex. Boys are more likely than girls to have DMDD.

Is Disruptive Mood Dysregulation Disorder Hereditary?

Children with a family history of specific mental health-related issues (anxiety, depression, substance use disorders) are more likely to have DMDD, suggesting that the disorder may have a genetic component. However, no specific gene or genes have yet been associated with DMDD. The condition could likely be caused by a combination of genetic predisposition and environmental factors.

How Is Disruptive Mood Dysregulation Disorder Detected?

DMDD is usually diagnosed by age 10, although symptoms might not appear until later in childhood. By definition, the disorder can only be diagnosed in children under age 18. Early warning signs can include:

• Persistent temper tantrums
• Persistent irritability or anger
• Annoyance, anger, or temper outbursts that are out of proportion to the situations that trigger them
• Problems getting along at school or with peers

How Is Disruptive Mood Dysregulation Disorder Diagnosed?

Diagnosis of DMDD begins with determining that the patient has a cluster of symptoms that meet the diagnostic criteria for the disorder. A doctor will start with a physical exam to rule out biological problems that may be causing symptoms. After these exams, if the doctor suspects that DMDD or another mental health-related issue is the cause of the symptoms, they may recommend a psychological or psychiatric assessment to solidify the diagnosis further.

Diagnostic steps may include:

• A physical exam. This exam aims to rule out physical conditions that could be causing the symptoms.
• Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.

The results of the psychological assessments will be compared to the diagnostic criteria for DMDD in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM criteria for DMDD include:

• The child exhibits severe temper outbursts at least three times a week.
• The child is irritable or angry most of the day, almost every day.
• The child’s outbursts are out of proportion to the situation.
• Symptoms begin before the age of 10.
• Symptoms have been present for at least 12 months.
• The child is between the ages of six and 18.
• Symptoms cause impairment in the child’s functioning in more than one context (e.g., home, school, or with peers).

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Disruptive Mood Dysregulation Disorder Treated?

There is no cure for DMDD. The diagnosis is relatively new, and doctors are still determining the best course of treatment. Medications and psychotherapy approaches used to treat similar disorders such as oppositional defiant disorder and ADHD are often prescribed. However, individual children respond differently to various therapies, and doctors may have to experiment with multiple treatment plans to find the one that works best for a particular child.

Medications

Drugs commonly used to treat DMDD include:

• Antidepressants
• Stimulants such as Adderall or Ritalin
• Atypical antipsychotics such as risperidone or aripiprazole

Psychotherapy

Types of therapy commonly used to treat DMDD include:

• Cognitive-behavioral therapy
• Family therapy
• Parent training

How Does Disruptive Mood Dysregulation Disorder Progress?

Without treatment, DMDD can produce complications. Long-term adverse effects of DMDD can include:

• Depression
• Anxiety
• Social isolation
• Lack of healthy interpersonal relationships
• Difficulty at school

How Is Disruptive Mood Dysregulation Disorder Prevented?

Given that the cause of DMDD is unclear, no definitive strategy for prevention is known. However, early intervention when a young child shows symptoms of DMDD can help prevent worse problems in the future. In all cases, parent involvement and training are essential for helping children cope with DMDD.

Disruptive Mood Dysregulation Disorder Caregiver Tips

Many people with DMDD also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with DMDD:

• DMDD is strongly associated with attention-deficit/hyperactivity disorder. About 90% of children with DMDD meet the diagnostic criteria for ADHD, and about 20% of those with ADHD also have DMDD.
• About 80% of children with DMDD also meet the diagnostic criteria for oppositional defiant disorder.
• Many people with DMDD also suffer from depression or anxiety disorders.

Disruptive Mood Dysregulation Disorder Brain Science

Researchers have attempted to find neurological explanations for problematic behaviors in people with DMDD. One study has found some differences in how the brains of children with irritable tendencies function compared to healthy brains. The key differences include:

• Children who exhibited high levels of irritability showed higher than normal activity in the frontal-striatal region of the brain when exposed to a frustrating situation. This part of the brain plays a role in attention, impulse control, and reward processing.
• The study’s authors theorized that the increased brain activity shows irritable children have to work harder to control themselves when frustrated.
• The increased activity was not affected by medications used to treat ADHD, suggesting that these commonly-prescribed medications may not effectively control chronic irritability.

Disruptive Mood Dysregulation Disorder Research

Title: Enhanced Support for Behavioral Barriers to Learning: An Evaluation of the SCHOOL STARS Program

Stage: Completed

Principal investigator: Courtney M. Brown, MD

Children’s Hospital Medical Center

Cincinnati, OH

This small pilot study will enroll children ages 5-12 with disruptive behavior problems at school. These children and their families will be offered an enhanced model of primary care, which includes pre-visit record review, standardized content of primary care visits, post-visit care coordination by the primary care team, and coordination of services between the primary care team and the school. We hypothesize that children receiving this enhanced model of care will achieve better behavioral outcomes at both school and home.

Title: Interpersonal Psychotherapy for Youth With Severe Mood Dysregulation

Stage: Completed

Principal investigator: Leslie Miller, MD

Johns Hopkins University

Baltimore, MD 

This research is being conducted to learn more about how to help teenagers with a sad or angry mood and emotional responses out of proportion to what would be expected in a situation. Together these symptoms are called Severe Mood Dysregulation (SMD), a research diagnosis, or disruptive mood dysregulation disorder (DMDD), a newer clinical diagnosis. Currently, there is no standard treatment for teens that have SMD/DMDD. These teens usually receive medication and some type of talk therapy. This research is being done to compare two types of talk therapy to see which is most effective in helping teens with SMD/DMDD. Investigators will compare treatment as usual (TAU) with Interpersonal Psychotherapy for Youth with Mood and Behavior Dysregulation (IPT-MBD). Investigators do not know if TAU and IPT-MBD work just as well or if one is better than the other. When this study is over, investigators hope there will be a better idea of how to study treatments for teens with SMD/DMDD.

For those participants who receive IPT-MBD, are prescribed an antipsychotic, and have significant improvement in symptoms, investigators will gradually taper the antipsychotic dose.

Title: Adapting DBT for Children With DMDD: Pilot RCT

Stage: Completed

Principal Investigator: Francheska Perepletchikova, PhD

Weill Cornell Medical College

White Plains, NY 

This study examines the feasibility and preliminary efficacy of Dialectical Behavior Therapy adapted to children (DBT-C). DBT-C, as compared to treatment-as-usual (TAU), is hypothesized to have a lower drop-out rate and higher treatment attendance and satisfaction. Further, DBT-C, as compared to TAU, will have a significantly greater reduction in symptoms of Disruptive Mood Dysregulation Disorder, including verbal and behavioral outbursts and angry/irritable mood.

Specific Aims:

I: Conduct Pilot Randomized Clinical Trial to evaluate feasibility and efficacy of DBT for children with Disruptive Mood Dysregulation Disorder (DMDD) as compared with Treatment-As-Usual (TAU) (up to 30 children and caregivers in DBT-C and up to 30 children and caregivers in the treatment as usual comparison condition).

Specific Aim 1: Examine the feasibility of DBT-C by evaluating the drop-out rates, number of sessions attended, and treatment satisfaction and any differences in these rates by groups, as well as therapist treatment adherence and competence.

Hypothesis 1: The attendance rate in DBT-C, as compared to TAU, will be at least 10% higher, and the drop-out rate will be at least 10% lower (primary feasibility endpoint). Further, DBT-C, as compared with TAU, will have significantly higher treatment satisfaction ratings by subjects (on the child and caregiver Therapy Satisfaction Questionnaires), and by therapists (on Therapist Satisfaction Scale), and higher patient compliance (on Psychosocial Treatment Compliance Scale). Therapist treatment adherence and competence, as measured by DBT-C Treatment Integrity Scale, will not fall below 80%.

Specific Aim 2: Examine preliminary efficacy of DBT-C in reducing symptoms of Disruptive Mood Dysregulation Disorder.

Hypothesis 2: Children in DBT-C condition as compared to TAU will have significantly greater reduction in irritability, anger, aggression, temper outbursts, and mood instability (on Clinical Global Impression – Improvement scale [primary categorical outcome]. Exploratory Aim 3: Examine the efficacy of DBT-C in improving adaptive coping skills, emotional and behavioral regulation, social skills, and reducing aggressive behaviors, affective reactivity, non-suicidal self-harm behaviors, suicidal ideations, suicidal attempts, and non-suicidal self-harm urges.

Hypothesis 3: Children in DBT-C condition as compared to TAU will have significantly greater improvement in adaptive coping skills (on the Children’s Coping Strategies Checklist), emotional and behavioral regulation (on the Emotion Regulation Checklist and Child Behavior Checklist – Dysregulation Syndrome), and social skills (on the Social Skills Rating Scale), and significantly greater reduction in aggressive behaviors (Measure of Aggression, Violence, and Rage in Children), affective reactivity (on the Affective Reactivity Index and Mood Symptoms Questionnaire). ), and greater reduction in non-suicidal self-harm behaviors (in Columbia Suicide and Self-Injury Severity Rating Scale [C-SSIS] self-injurious behaviors), suicidal ideations (in the C-SSRS suicidal ideation classification category), suicidal attempts (in C-SSIS suicide attempts category), and non-suicidal self-harm urges (in C-SSIS self-injurious urges, no suicidal intent category).

Exploratory Aim 4: Examine the efficacy of DBT-C in reducing the need for higher-level services.

Hypothesis 4: Children in DBT-C condition compared to TAU will have significantly fewer psychiatric hospitalization, emergency room visits, the total number of days inpatient, and residential care placements (on the Services Assessment Form).

Exploratory Aim 5: Examine whether parent emotion regulation moderates the relationship between intervention and outcomes, while parent ability to effectively cope with children’s negative emotions and children’s coping skills and emotion regulation mediate outcomes.

Hypothesis 5: Parents’ own emotion regulation (on the Difficulties in Emotion Regulation Scale) will moderate outcomes and parents’ ability to effectively cope with children’s negative emotions (on the Parental Response to Children’s Negative Emotions), children coping skills (on the Children’s Coping Strategies Checklist) and emotion regulation (on Emotion Regulation Checklist) will mediate outcomes.