Disruptive Mood Dysregulation Disorder

Disruptive Mood Dysregulation Disorder (DMDD) is about emotional-behavioral management in children.  Reaching for more user-friendly semantics, FD refers to it as Calming Disorder, a seeming inability on the part of the child (hence the parent, too) to calm down.  DMDD is likely to be the latest flavor of the week, yet another label for children who are oppositional.  Willful.

We suppose that as these children age, as they grow into adults, they will be diagnosed as having Intermittent Explosive Disorder and treated with anger management.  Why we couldn't have used Intermittent Explosive Disorder with qualifiers: refer to children with a 1, adults with a 2, and a 1,2, or 3 to indicate the severity, is a mystery.  Perhaps the reason is that the temperament is chronic, not intermittent.

Here's the abstract.  I'll get to the article this week, but want to offer up a few thoughts regardless.  After all, they did ask me to be on the team to rewrite the DSM IV-TR.  Is it my fault that the page froze after checking "other" when asked for "type of license"?  I have two, and there was no way to communicate that. Calling in I was redirected, sent a new email.  But the link to the application didn't work a second time.

And life gets in the way.

Look for the article in PsychInfo if you have an academic affiliation. It might be on sale somewhere online if you don't.

Emotional dysregulation in disruptive behavior disorders.
Cole, Pamela M.; Zahn-Waxler, Carolyn
Cicchetti, Dante (Ed); Toth, Sheree L. (Ed), (1992). Developmental perspectives on depression.Rochester symposium on developmental psychopathology, Vol. 4., (pp. 173-209). Rochester, NY, US: University of Rochester Press, xix, 396 pp.

(The authors) present a view of disruptive behavior disorders as affective disorders and, from that perspective, discuss the emotional characteristics which are associated with the development of aggressive, antisocial behavior 
provide an overview of the disruptive behavior disorders, the history of the traditional segregation of behavior disorder from affective disorder, and the evidence and arguments for comorbidity of affective and disruptive disorders / consider possible developmental trajectories leading to these disorders / focus particularly on the role of emotion in early childhood and its implications for the development of deviant and aggressive behavior later in childhood and adolescence (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Seems to me we are looking for the prodromal, or warning signs of sociopathy, a disorder that defines what we have referred to as almost psychopathic in previous posts.

Parents are right to worry when their kids have symptoms of DMDD: uncontrollable tantrums, aggressiveness, an inability to manage emotion, an absence of empathy.  When they are cruel.  Dr. Cole has published on empathy in the past, and I think she is on the mark if she is thinking we have to teach children, all children, empathy.

We're talking about it right now because the DSM V is due out in 2013.  Teams of researchers, revisionists, are making all kinds of changes to what we commonly call disorders.  For example, Asperger's, childhood disorder in the current DSM IV-TR, has been known for decades to be characteristic of adults, too.   It is thought to be a spectrum disorder, on the spectrum of autism, and may lose its status as a disorder exclusive to autism.

According to yesterday's Wall Street Journal (Shirley S. Wang), "Aspie's" are up in arms about being subsumed autistic.  Not everyone likes the thought of being autistic, even if it is high functioning.  Yet, most of the "Aspie's" I treat tell me that they are very much in their own world.  They see the point.  More likely however, Adult Asperger's Disorder will make it into the DSM V, at least that is my hope.  Just a guess.

But back to our new flavor.  When we first recognized Bipolar Disorder in children, it amounted to medication, usually too much.  Manic kids were oppositional, hard to control by definition, and they suffered swings, clear signs of childhood depression.  Thus meds saved the day, theoretically, although those of us who work with a family model are generally reluctant to make that referral.

Children with Disruptive Mood Dysregulation Disorder are likely going to be over-medicated, too.  It doesn't take much to over-medicate children.  They are growing and changing all of the time.  And they are mini-emotional time-bombs under normal circumstances.  Having a motor that tends to puff and smoke at the worst possible times, it is understandable that parents are looking for help, lots of help, from that god of psychiatry, Big Pharma.

Thus we can only hope that parents remain patient, able to calm themselves, and bring little Joey to therapy.  If you are such a parent, stay in the room and learn strategies from the doctor/therapist.  The tried and true holding technique, grabbing the little tyke and holding her tightly (without hurting her) until she calms down, works for some kids, but as one reader puts it so well, restraining the child is:

 a tried and true way to exert dominance, lose the child's trust, and create permanent emotional scars.

I think we had both lose the phrase, tried and true, unless we can qualify them well.

Make sure no one is hurt no matter what you do.  Corporal punishment won't work, will work against you.  And although we are capable of holding, able to restrain children, being three times their size, we have to be careful. Not every child responds well to that.  If they are older, best to work on communicating in words, or in art, or play if holding is violently rejected.

There are other ways to treat DMDD.  Engage other siblings, certainly a second parent if one is around, or grandparents, aunts and uncles.  Use friends.  Use your people.  If you have none, find a support group.  Call the National Alliance on Mental Illness, NAMI.

Lose the idea that this is something shameful.  Get more into the idea that it takes a village to raise a child, because it does.

Behavioral modification won't always work, but try it early, start very, very young.  Even a two-year old needs to know the power structure in the family, that he is not the boss of you.  As a parent, you are the boss.

All of this assuming that marital dynamics lend themselves to the therapy, that the child isn't learning aggression in the home, a very big assumption.  And that the dyad at the top, Mom and Dad, or Mom and Mom, or Dad and Dad, have to have something of a working relationship themselves, must communicate, agree on a treatment plan.

It is most likely that children who will be diagnosed with DMDD, unfortunately, are identified patients, that their families are the patient, really, and that only a fraction, a tiny fraction of the children diagnosed in nursery, kindergarten, or elementary school, whichever system has booted them out, have the disorder.  If you hear the news: This child needs a psychiatric evaluation--it may not mean Disruptive Mood Dysregulation Disorder, no matter who slaps on the label.

I'll put myself out there and suggest that as a first line of attack, families need to find a good family therapist, not a psychiatrist, and leave the primary care physician alone about medicating the child.

When it is obvious that a child is dangerous, on the other hand, a team approach is surely necessary, with a primary care doctor, a child psychiatrist (go find one, good luck), and a therapist.  Sometimes  even hospitalization might be necessary.  Or so they're saying in the news today.



Teacher from the South said…
Interesting blog today. I have had adult (over 18 yrs. old ) students who have displayed what you have described as Intermittent Explosive Disorder (maybe I have it too when I am trying to fix a computer problem and HP transfers me 6 times before I get assistance).

Anyway, some of my colleagues believe that these students should be kicked out of school (temporarily or permanently). I let the person explode and then calmly and privately talk about the problem and other ways to deal with the situation as well as what are appropriate and inappropriate responses to frustrating situations. I don't think that kicking a student out of school will help a student who has a real problem and who is not just being manipulative or is not just being rude. I have also suggested that the student see a physician for medication if the student is truly unable to control his/her emotions.

Any other resources that you would suggest?

These students shouldn't be expected to change overnight nor do I believe that they lack the ability to change their behavior given an appropriate supportive environment.
therapydoc said…
Thanks Teacher.

Teaching is the hardest profession, seriously. I very much like your approach. Most of the time, like you, people have good reasons to lose their cool, and sometimes they have never been challenged, never really been told that it doesn't get them very far in life, in general.

If I were a teacher I'd ask, "Is it the work, or is something else?" Because if it is academics then perhaps the school can offer assistance. Most people will say, "Too much stress." Or that there are so many problems, or merely, they're having a bad day, a bad week, etc.

Then therapy is surely a recommendation.
I know that anger management groups/classes are good places to start.

Fact is, that there's a 12-Step program for rage-aholics, fabulous if you can find it, and it's free. Empathy and caring, all rolled into one.
Mound Builder said…
therapydoc wrote:

" The tried and true holding technique, grabbing the little tyke and holding her tightly (without hurting her) until she calms down, for example, is gold."

This means a lot to me because this is what I did with my younger daughter when she was little (she's all grown now). I didn't have anyone who told me this is what I should do, I just noticed from the time she was born that it seemed like her nervous system got jangled easily and that it wasn't easy for her to calm down. I noticed that she did best when she felt contained, like when I had her in a Snugli she was just as calm as could be and would sleep well, but putting her down in a crib, she would have a very hard time getting to sleep. Anyway, as she got older, when she had tantrums I would hold her, close and tight, until the tantrum was older, not so tight that it hurt her but so she would feel safer. And when she was calm again, then I'd let her get back to whatever she was doing. As she got older, gradually I would work to give her other tools, besides me, for calming herself. For instance, by the time she was 4 or 5, I would tell her she needed to go to her room until she could calm down and come back. As I said, she's all grown now. She has strong feelings at times, is quick to feel upset about injustice, for instance, so she is sometimes vocal. But she is also very loving and with a good head on her shoulders. Did I mention I love her? And I'm proud of her? And she does seem to have a handle on how to calm herself now most of the time. My older daughter wasn't like this at all. She was so laid back and calm it just wasn't ever an issue. Anyway, thanks for this post. Very interesting.
therapydoc said…
What a great share. Thank you so much.
Anonymous said…
We are the family to a 12 year old who is diagnosed properly with this ‘label’. Know that we are first and foremost a consistently abused family. Secondarily that we are strong in our emotional efforts not to be pulled offsides into the anger and fights that our loved one is determined to instigate. Third, that we are always on the defensive from society who is certain that despite three very well and even exceptionally proficient children are certain that all of her behavior problems stem from some upbringing problem that we now hide.
8-12 hours per day our daughter is with the norm (I first wrote ‘kind’, but that is not quite true) and uses social skills that she has been taught. She is very creative and incredibly proficient on the things she obsesses over. As parents we have spent entire seasons of her life using every parenting method published by all spectrums of ideological background and done so extensively under observation. Right now we are greatly blessed by a mountessouri school that has tolerated her behavior for 5 months without kicking her out.
When our daughter doesn’t like a change, or feels minor selfish inclinations, or eats one of the 37 foods she is sensitive too, or brought to shame over remembrance of former rages,….. she instigates a mind boggling argument in which her self centered pre-occupation comes seathing out. If everyone in her world is nice to her through it her selfishness is reinforced but she is able to pull out of it. The other half of the time she will transform into something akin to the ‘incredible hulk’ and enters a clinical rage.
Her rages can last from 20 minutes upwards to a couple hours and almost always end only if she get one of her syblings to start screaming or property is destroyed. What we are watching is complete lack of restraint common to most people in some regard that switches over to a chemical imbalance of some kind that demands stimulation from conflict. Counter intuitively, when she quickly moves to physical destruction, that violence somehow brings her to the fastest recovery. But that violence is never controlled and is always motivated by cruelty so we cannot find an outlet that is suitable.
Having survived 6 deployments into combat zones, I, her father am the only one that can withstand these rages and remain calm with consistency.
I appreciate the effort that goes into understanding my daughter, but what of the damage done to her siblings. Their things are consistently stolen, or even intentionally and cruelly destroyed. They cannot ever have play dates at our house, nothing they own will ever be safe, even when they cow tow to their sister and place no boundaries around what they are willing to do to serve her there is still a chance that she will stomp on their emotions and crush them with vile rage in a heart beat. The only way they can have any normal moments is when we arrange for them to be away from their sister. Never mind the segregation effects of this those problems are so minor compared to all the other damage that we will just have to write those off.
My wife holds out great hope that aggressive therepy, with ongoing medication, adolescents, or a miracle will help our daughter. I am pragmatically beginning research for where she could live in a facility that can better protect others when she ‘goes off’. In the meantime we have brought in social workers, counselors, psychologists, teachers, religious community, and extended family. All of whom eventually see the outbursts and then their council ceases. Very nice when they stop judging us, but we are still without solutions that contain any hope.

In the meantime, my wife and I try to pour love into our other kids, but they are developing psychological wounds that are beyond my reach as a loving dad.

I know that none of you have anything to offer us regarding our daughter, but do you have any ideas about how to protect our other kids emotionally?
therapydoc said…
I'm so sorry it took me so long to get back to you. It has been a busy winter.

Maybe you are the only one who can teach the kids to be calm during the rages, because my guess is that is the only thing that might ease her violent arousal, a very calm, steady response, with words you probably use, or no words. Maybe you have found silence is best.

But if responding to her rages with rage (verbal) works, then that isn't out of the question, as crazy as it might sound. We talk the talk, so to speak, of the other. But again, each child is different and it is likely you have tried everything and that rage exponentiates her rage.

If the three were my patients I would be teaching them self-relaxation (breathing, muscle-contraction, even counting) and meditation, although they have to be in a safe place, safe from her attacks if she gets physical to meditate. If you're religious, teach them to turn the whole situation over to God. Certainly they need to talk, which is why the most powerful thing might be "special time", best, if you can, to take each child away on a short trip, alone, just the two of you, if that is at all possible, to have a full block of uninterrupted time to chill, talk, and go over the pain. That may not be possible, but it is a great thing to do. Therapy, surely, for each of them, or even the three of them together, even if they protest. Therapy is key for them to have a place to be the center of attention, to talk about themselves. Best of luck, and by all means, let this community know what worked for you and what did not. We're interested.

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