Outbursts by children when frustrated or when asked to do something they don’t want to do, are among the most common behavioural complaints voiced by parents. But severe outbursts, beyond the typical tantrums of children, may be a sign of a mental health disorder. They may be suffering from disruptive mood dysregulation disorder (DMDD), characterised by a persistently irritable or angry mood with intermittent extreme temper outbursts. It is a rare, relatively new and complex diagnosis that can be easily missed. “The behaviour of a child with DMDD is always disproportional to the circumstances that may have triggered the outbursts and is always disruptive, causing destruction to property, and can also result in injury – either to the child or someone else – when the child acts out,” says Dr Paul Sussman, a psychiatrist at Akeso Randburg – Crescent Clinic. “Because of the obvious level of destruction and the possibility of harm being inflicted on others, it is essential to see past the judgement that is usually elicited by the behaviour, and to identify it as a red flag that should alert the parents to seek help for their child.” Dr Sussman stresses that tantrums are a normal part of most developing children, and that the reactions that occur when a child has DMDD have to be clearly disproportional to the circumstances, making it important to consult an experienced psychiatrist who can apply the criteria for diagnosis with good clinical insight. DMDD is generally not a chronic, long-lasting disorder if optimally managed. It presents in childhood, most commonly between the ages of 6 to 12, but symptoms can be resolved within six to nine months from the start of effective treatment. Pharmacological treatment may assist, but psychosocial intervention is of paramount importance. The earlier treatment begins, the more the risk factors of DMDD can be reduced, Dr Sussman stresses. “These include the social fallout resulting from tantrums, and the difficulties in coping in the school environment as the child struggles with authority and with academic performance. Behavioural outbursts often result in expulsion from schools, the breakdown in parent-child relationships within the home environment, and the collapse of other relationships because of the high level of discord and destruction these outbursts cause.” These risk factors only make the problems worse for the child who is left feeling isolated from all support systems and slipping further and further behind in their developmental milestones. This impacts negatively on the child’s prognosis, triggering more negative feelings which, in turn, trigger further outbursts of anger. When is DMDD diagnosed? The onset of the disorder needs to be before the age of 10 years The individual must be between the ages of six and 18 years The symptoms need to be present for 12 months or more The symptoms cannot subside for longer than three months at a time Symptoms need to impact two or more environments of the child’s life (home, school, social) and must be extreme in at least one setting Symptoms cannot be better explained by another mental disorder, nor a manifestation of substance use or a general medical disorder. Because DMDD often co-exists with other disorders, it is regularly under-detected and is attributed to other psychiatric disorders with symptoms that mimic those of DMDD and also present in childhood. “An accurate diagnosis requires a high level of expertise,” says Dr Sussman. “It’s essential to consult an experienced child psychiatrist who is able to differentiate the symptoms from those that present in co-morbid illnesses such as attention deficit hyperactivity disorder (ADHD), so that the psychiatrist can give the child and their family accurate guidance and treatment.” In South Africa, DMDD goes largely undetected because it is a relatively new disorder identified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). “Because it is an uncommon disorder, co-morbid disorders – most notably ADHD, oppositional defiant disorder, anxiety disorders, depressive disorders, autism spectrum disorder, and possibly others – are diagnosed and treated instead. If the child responds positively to the treatment for one of these disorders, the presentation of DMDD may be missed.” Children may also be unable to get access to the correct care because their families are reluctant to reach out for psychiatric help, Dr Sussman explains. “Many parents see children as an extension of themselves,” he says. “Childhood illness thus often feels like a reflection on them as parents; when you add to this the stigma related to psychiatric illnesses, the result is that parents will either delay consulting a professional, or even avoid it altogether. We need this to change, particularly with regard to DMDD which can be treated effectively.” How is DMDD treated? Because there are many factors that can lead to DMDD, treatment requires an approach that takes into account biological, psychological and social factors, and thus the intervention of a multi-disciplinary team. “Medication is effective in the management of symptoms, but not without the commitment of the child and the family to therapy,” Dr Sussman says. “This is essential to help in understanding what factors trigger the outbursts and how the parents can adapt and change the familial environment to reduce the triggers. Close engagement with the child’s school can also help to create a better understanding of their needs, as well as better management of the factors in the school setting that may affect the child. In this way it becomes easier to ensure that the child can achieve optimal performance and reach normal developmental milestones.” What to look out for It is important that before a diagnosis of DMDD is made, all other mental disorders have been excluded by a child psychiatrist (or by another suitably qualified professional), as well as any behaviour that may result from substance use or a general medical condition. The risk factors that predispose a child to DMDD include a family history of psychiatric disorder, substance use, marital discord, divorce and exposure to trauma. These all contribute to an unpredictable family environment. A stressor within the individual’s world, such as gender or other identity issues, can also trigger outbursts, which is why treatment cannot be one-dimensional. “We appeal to people to not ignore or justify overt aggressive outbursts in children, explaining it away by saying ‘they are going through a lot and having a tough time’,” says Dr Sussman. “Rather, use the crisis as an opportunity to meet with a child psychiatrist or another suitably qualified professional, who can help to ensure a holistic programme of treatment for the child. This will minimise the long-term effects of DMDD on both your child and your family.” “This is a disorder that can be managed,” he adds. “It is important to stress that support from the child’s family and community are essential. Just as you would seek help from a professional if your child was physically ill, you should do the same if they are suffering from a psychiatric disorder. We need to be as accepting that these symptoms exist and can be treated. This change in attitude will improve the child’s prognosis by allowing for them to get the best care.” Ends. About the Akeso Group: Akeso is a group of private in-patient psychiatric hospitals, and is part of the Netcare Group. Akeso provides individual, integrated and family-oriented treatment in specialised in-patient treatment facilities, for a range of psychiatric, psychological and addictive conditions. Please visit www.akeso.co.za, email firstname.lastname@example.org, or contact us on 011 301 0369 for further information. In the event of a psychological crisis, please call 0861 435 787 for assistance.