«Some children can't deal with their frustration»

Mrs Mürner-Lavanchy, you are researching a new disorder in children. How can this be described?

The diagnosis of Disruptive Mood Dysregulation Disorder, or DMDD for short, is based on a disorder of emotion regulation. It describes children with a permanently sad and irritable mood and the resulting outbursts of anger and impulses.

What does that mean in concrete terms?

These children are easily irritable and very impulsive, which results in regular outbursts of anger. They are also often sad and unhappy.

This description may sound familiar to some parents, especially of younger children. Do they need to worry now?

Most probably not. The criteria for a diagnosis of DMDD are set very high. The tantrums must last a year or longer and occur at least three times a week. Between these outbursts, the child's mood is permanently irritable or angry most of the day, almost every day.

How many children are affected by DMDD?

The diagnosis is most common in six to nine-year-olds. It is estimated that three out of every 100 children are affected. We are referring to surveys from the USA. Among nine to twelve-year-olds, the figure is one to three per cent, depending on the study. However, due to different diagnostic concepts in Europe, fewer children in this country are likely to be diagnosed with this disorder than in the USA. The diagnosis is not recommended for children under the age of six.

Why is that?

At pre-school age, it can be assumed that tantrums, even several times a day, are completely age-appropriate and normal. And we wanted to avoid pathologising age-appropriate behaviour.

Affect control develops in children at this age.

That is correct. In terms of developmental psychology, impulsivity decreases from childhood to adolescence and cognitive control over emotions and impulses increases. It is assumed that the ability to inhibit, the ability to restrain oneself, develops first and then, over time, the cognitive ability to adapt.

Even as a toddler, a child realises: Mum keeps saying no, now I'm not going to do this or that, even though I really want to. In kindergarten, certain rules have to be followed and the demands of society increase. And a child becomes more and more able to cope with a situation that does not correspond to what they had imagined or to adapt their wishes and needs. This ability develops around the age of five or six.

Children with DMDD often come from families in which the parents also have other affective disorders, depression or anxiety disorders.

Do you have an example for us?

Imagine your daughter has to do her homework. You promise her an ice cream if she completes the tasks quickly and carefully. Your daughter is looking forward to it. But then you realise that you don't have any ice cream left in the house and offer her a biscuit instead. Your daughter agrees. A biscuit may not be what she was hoping for, but it's okay. This reaction requires a mental flexibility that many three or four-year-olds do not yet have.

And neither do older children with the disorder you describe.

Problems in affect regulation play a role in many mental disorders in childhood and adolescence, such as ADHD or oppositional defiant behaviour, in which children are very sensitive and quickly react angrily, as is the case with DMDD.

All children have to learn to deal with moments of frustration and not get angry when they don't get something or their wishes are not immediately granted. However, children who are prone to DMDD are unable to do this, or only to a very limited extent, even in later childhood.

What are the causes?

There are not yet many studies on this, but similar problems have been found time and again in psychopathology. It is usually various situations in the family that trigger stress: family pressures, interpersonal difficulties, trauma, for example triggered by the death of a family member or the separation of parents. Such stress-inducing situations can have an impact on a child's development. For example, one study found that postnatal depression in the mother was associated with a higher probability of developing DMDD.

Are children from families with a lower socio-economic status more frequently affected?

That is correct. In families where there tend to be fewer resources, these stress factors occur more frequently.

Is there a genetic component to DMDD like there is to ADHD?

Yes, that can be assumed. The interaction of genes and the environment plays a role. What we have seen is that children with DMDD often come from families in which the parents also have other affective disorders, depression, anxiety disorders. The fact that the disorder runs in the family increases the likelihood that the siblings or a sibling will also be affected.

It is important for me to emphasise that children do nothing wrong with DMDD.

What consequences does their quick-tempered, impulsive behaviour have for the children?

Based on research into related disorders, we assume that there is a cycle. The children repeatedly experience frustration and are unable to regulate it. In addition, these boys and girls have an increased tendency to perceive threats or negative stimuli. They experience a lot of frustration and almost selectively choose stimuli from their environment that have a negative impact on them. And this then creates a cycle that can lead to even more frustration and aggression. This then triggers symptoms of constant irritability and frequent outbursts of anger.

Can you tell us about a case?

During my work as a clinical neuropsychologist, I came across a case that I would probably assume to be DMDD in retrospect. The parents came to me with their almost seven-year-old daughter for a comprehensive neuropsychological assessment as part of her school enrolment. Her nursery school teachers, occupational therapist and speech therapist were sceptical about her starting school.

She was diagnosed with ADHD, attention problems, but also perceptual difficulties and other cognitive abnormalities. Neither parents, teachers nor school psychologists could say what was actually wrong with the child. The girl was permanently sad and easily irritable, had many and serious outbursts of anger - in the most inappropriate situations, as her mother reported. She wasn't popular either and didn't really make friends anywhere. The whole situation was very difficult for the girl.

What do these children do wrong in group settings?

It is important for me to emphasise that these children are not doing anything wrong. It has not been conclusively clarified whether these children have difficulties in socialising per se or whether their depressed mood and tantrums put other children off and make them unattractive as play partners. Who wants to play with someone who blows up at every little thing?

This behaviour is certainly also stressful for the parents. If the two-year-old throws himself on the floor screaming, the environment usually shows understanding, even with a four-year-old. But if the eight-year-old is constantly freaking out, acceptance is unlikely to be far off.

You're right about that. These children who are diagnosed with DMDD at the age of seven or eight usually show a temperament that goes in this direction from an early age. This is usually tolerated at home in the family system, but then becomes a problem when the child goes to nursery or school and constantly clashes with this system and is unable to adapt. In the worst case scenario, these children cannot be educated in a mainstream school.

It is not enough for an eight-year-old to have a tantrum from time to time to be diagnosed with DMDD.

You mentioned earlier that the six to nine-year-old age group is the most affected. After that, the frequency decreases. Does the disorder develop over the years?

Unfortunately, no. The symptoms subside, but the problems for the individual do not diminish. The tantrums themselves are no longer as bad, but there is an increased risk of problems in the social and health areas and in relation to risk behaviour, which continues into adulthood. There is also an increased susceptibility to affective disorders such as depression or anxiety disorders. So I would rather speak of a shift in symptoms.

How is a child with DMDD treated?

As there are still no treatments specifically developed for this disorder, existing psychotherapy methods, such as programmes for children with ADHD or dialectical-behavioural therapy, tend to be used as building blocks. Psychotherapy usually focuses on the child's behaviour and generally involves the child's environment to a large extent.

Does the child's environment primarily mean the parents?

That is correct. Parents are always involved and coached in psychotherapy. One important aspect is teaching them about emotions and emotional development. And then there's the practical side: how do you behave in the event of a tantrum? How do I guide my child through it? What strategies are there for me as a mum or dad to keep my cool?

These are questions that are discussed in such a parent coaching session. And I would like to emphasise this once again: In order to receive such a diagnosis, very severe manifestations of these symptoms must be present. It is not enough for an eight-year-old to have a tantrum from time to time. If these do not occur constantly and have a massive and lasting impact on the life of this child or his parents, they must be seen in the context of normative behaviour.

But these situations also need to be mastered. What advice would you give parents?

Whose children do not suffer from such pronounced symptoms? It seems important to me to accept the situation as it is, to accept it as normal. When my son had his first tantrums, I was also a bit taken aback and irritated at first, I looked around in some situations and asked myself who was noticing. It's exhausting and tedious.

An adult can also get angry. That in itself has no disease value.

My background knowledge helps me personally: The child is just learning to regulate emotions. This is an important developmental step. It's allowed to be angry now! And I signal to him that I take it seriously and don't turn away. And I also let my son rage sometimes without trying to stop this behaviour straight away, which I don't always succeed in doing. Even an eight-year-old or a nine-year-old can get angry, even an adult can. That in itself has no pathological value.

But isn't it very difficult to diagnose DMDD? After all, there are many mental disorders in which those affected are prone to impulsive behaviour and outbursts of anger.

You are right. There are other developmental abnormalities or diagnoses that can trigger such tantrums, such as autism spectrum disorder. That's why, when investigating DMDD, it's important to make sure that these symptoms don't have any other neurological or somatic causes. Children who are diagnosed with DMDD usually also have another disorder. Depending on the study, almost 90 percent of children with DMDD also have a disorder of oppositional defiant behaviour.

Are outbursts of anger also central to this disorder?

Correct, although these occur less frequently. These children are also easily irritable. However, this symptom of irritability is not necessary for the diagnosis - but it is for DMDD. This means that children who have DMDD often also suffer from oppositional defiant behaviour disorder because fewer criteria need to be met. But the reverse is not true. DMDD is a very serious diagnosis of child behaviour.

There are certainly different perceptions of what behaviour puts a heavy strain on everyday family life. What is a severe tantrum? Parents who have a rather calm temperament will certainly answer this question differently to those who are very temperamental.

Teachers and therapists can also assess situations differently. And the extent to which the stress is perceived by the child themselves also varies. When making a diagnosis, diagnostic guidelines are usually followed in which the criteria for a particular disorder are listed. If a child fulfils the criteria for DMDD, it can be assumed that the level of distress is very high on all sides.

You can criticise this pigeonhole system, but it can make it easier for children to get the right diagnosis.

How do you deal with the criticism that the diagnosis of DMDD is just another «pigeonhole» to categorise children?

What children achieve in society today and how they have to adapt is a big issue. But the children we are talking about here are really struggling. You see, a few years ago, the rate of bipolar disorder in children exploded in the USA because no better label was found for this symptomatology than bipolar disorder.

However, it was later realised that DMDD has little to do with bipolar disorder and that the children were sometimes even treated incorrectly. Even if this pigeonhole system can be criticised in its entirety, studies have shown that it can also be helpful, even relieving, for children to receive the correct diagnosis. After all, this also forms the basis for the right treatment.