# Evidence-based assessment/Rx4DxTx of DMDD

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# Resources for the assessment and treatment of disruptive mood dysregulation disorder (DMDD)
## New and Controversial: Disruptive Mood Dysregulation Disorder

An increasing number of pediatric bipolar disorder diagnoses and their subsequent use of pharmacological interventions called for change regarding professionals’ understanding of persistent irritability in children and adolescents. Because of the impairment of functioning and distress associated with the presentation of such irritability and anger, the American Psychiatric Association responded to the call for change with the creation of the disruptive mood dysregulation disorder (DMDD) diagnosis. But its establishment has led to a variety of disputes, including debate as to whether or not DMDD is a unique disorder. Due to the new and controversial nature of the DMDD diagnosis, further research is needed, especially regarding its prevalence and the use of evidence-based assessment and treatment techniques. The goal of this paper is to help increase awareness of what is known about DMDD, while also addressing important aspects of the disorder that are in need of further investigation.
The disruptive mood dysregulation disorder, or DMDD, diagnosis is relatively new, appearing first in the DSM-5. The DMDD diagnosis in DSM-5 captures extreme, chronic irritability that is punctuated by recurrent severe mood outbursts, all of which must have occurred for over a year. DMDD emerged amidst much controversy surrounding the classification of chronic, severe irritability as its own disorder, rather than as a symptom of bipolar spectrum disorders. In order to understand the present state of the DMDD diagnostic criteria, I must first discuss how DMDD emerged as a new diagnosis. Pediatric bipolar disorder presents very differently than adult bipolar disorder, and it was theorized that in children, mania could appear as severe non-episodic irritability with punctuated periods of rapid cycling and temper outbursts. With this wider conception of childhood mania, or broad criteria of bipolar disorder, diagnosis with bipolar disorder became more common in children, causing much concern amongst academics about how chronic irritability should actually be categorized. This concern prompted research in Severe Mood Dysregulation (SMD) disorder, which is marked by chronic irritability, reoccurring outbursts, and hyperarousal. Early research concluded that SMD should be delineated from bipolar spectrum disorders, as it those meeting SMD criteria had differing longitudinal trajectories, comorbidities, and neurocognitive correlates than those meeting pediatric bipolar spectrum disorder criteria. Though other studies have come to the opposite conclusion of—or have otherwise contrasted—these foundational findings, the DSM-5 created DMDD diagnostic criteria by modifying the original SMD criteria to create a diagnosis of chronic irritability separate from bipolar criteria.
Many see the emergence of the DMDD diagnosis as a result of discrepancies between operationalization of bipolar disorder symptoms, and do not see DMDD as a separate diagnosis from bipolar disorder. Much of this disagreement is because there is not very much evidence to support DMDD as a separate construct, as much of the research that lead to DMDD’s development was substantiating SMD as a unique construct, not DMDD. Nevertheless, because DMDD is in the DSM-5, the DMDD diagnosis is still given to children expressing chronic, severe irritability who may also fit another, similar diagnosis. In response to the skepticism raised about the DMDD diagnosis, and the poor scientific evidence supporting it as a unique diagnosis, the International Classification of Diseases 11th Revision (ICD-11) did not choose to include DMDD as a diagnosis. Instead, ICD-11 considers chronic irritability and anger a specifier under ODD. This decision was made in accordance with research indicating that many children diagnosed with DMDD would have already met ODD criteria, and are unlikely to develop bipolar disorder later on; additional research indicated models of ODD corroborating this chronic irritability specifier.

## Diagnostic Criteria, Prevalence, and Comorbidity
### Diagnostic Criteria

Classified by the DSM-5 as a type of depressive disorder, DMDD is characterized by two primary components: temper outbursts and chronic irritability. The DSM-5 describes temper tantrums to be either verbal or physical outbursts of frustration that are both inappropriate for a child’s stage of development and out of proportion to the situation in which they occur. These outbursts must occur frequently, at least three times per week, and in at least two settings, such as at home and at school. The second component, chronic irritability, refers to the child’s behavior in between outbursts. This irritability must be persistent and characteristic of the child, its non-episodic nature helps separate DMDD from pediatric bipolar symptomology. Despite the growing controversy surrounding the DSM and its categorical approach, especially surrounding its use when diagnosing children with mood disorders, it still remains to be the most popular handbook used by clinicians. To be diagnosed with DMDD, symptoms must occur for at least one year, with no more than three months’ symptom free.The minimum age of diagnosis is 6 and symptoms must begin occurring before the age of 10. Prior to the establishment of DMDD, those experiencing chronic irritability/anger may have been diagnosed with severe mood dysregulation (SMD). The primary difference between the two is DMDD’s exclusion of the hyperarousal criteria of the prior SMD diagnosis. It is also important to consider that while DMDD can be diagnosed in conjunction with major depressive disorder (MDD), attention-defect hyperactivity disorder (ADHD), conduct disorder, and/or substance use disorders, it cannot be diagnosed in conjunction with oppositional defiant disorder (ODD) or bipolar disorder.
By creating the category of DMDD, the hope was that children exhibiting these symptoms would receive a more accurate diagnosis, which would thus decrease the amount of diagnoses they would have previously received. Several researchers and clinicians have expressed doubt regarding the validity and use of such a diagnosis. While DMDD may have been introduced to resolve both the controversy and misuse of the diagnosis of pediatric bipolar disorder, DMDD has been criticized for lacking established diagnostic reliability and research evidence. Although, there has since been concerns that this has made diagnosing children more difficult, which was the opposite of what was supposed to occur. Since DMDD is so similar to other conduct disorders, namely ODD, it has proved difficult for psychologists to diagnose children based solely on symptoms. This presents a distinctive opportunity for use of RDoC when attempting to diagnose DMDD. Through applications of these constructs, psychologists could obtain a more accurate diagnosis and be sure that the symptoms they are seeing are in fact Disruptive Mood Dysregulation Disorder.

### Prevalence

Due to the novelty of the DMDD diagnosis, more research is needed to establish its prevalence in both community and clinic-referred samples. However, the prevalence rate has been agreed upon by several researchers. Copeland, Angold, Costello, and Egger applied DSM-5 diagnostic criteria of DMDD to questionnaire and interview information gathered from community samples of youth, ages 2-18 through the Duke Preschool Anxiety, Great Smoky Mountain, and Caring for Children in the Community studies. It is important to note that the structured psychiatric interviews used by Copeland and colleagues were not originally designed for the diagnosis of DMDD and that, although DSM-5 criteria requires symptoms to be present for one year, this study only used a 3-month window to minimize recall bias of parents and youth. Copeland et al. estimated DMDD prevalence to be between 0.8 and 3.3% in community samples. In contrast to this estimated low community prevalence, it has been suggested that as many as one third of the youth in clinical settings meet DMDD criteria.
Although Copeland et al. did not find gender differences in the diagnosis of DMDD, they did note that, in general, boys reported temper outbursts in a larger number of settings, compared to girls. Temper outbursts and irritable mood appeared to be common for most children in the studies, but Copeland et al. reported that the consideration of frequency, duration, and the amount of settings in which symptoms were present helped to distinguish between typical and pathological behavior. This finding is supported by other literature suggesting that some severe tantrums and child irritability may be associated with typical development during preschool, and that the prevalence of DMDD may decrease with age. There is not a lot of information available regarding whether or not variations in race/ethnicity exist.

### Common Comorbidities

Although the estimated prevalence of DMDD may be relatively low, the presence of comorbid diagnoses is not. In their evaluation of DMDD prevalence in 3 community samples, Copeland et al. found that most DMDD cases met criteria for at least one other psychiatric disorder, and that that the most comorbid diagnoses were other depressive disorders and ODD. Mayes et al. supported the findings of Copeland et al., showing ODD and depression were comorbid with DMDD in a community sample, and they also found it to be comorbid with ADHD, CD, and anxiety disorders. Further support of the association between DMDD and ODD was found during a retroactive study of the prevalence and comorbidities of DMDD when Freeman et al. reported that the majority of participants, ages 6-18, in a clinical setting, who met criteria for DMDD met diagnostic criteria for ODD as well. Through the use of Child Behavior Checklist (CBCL) questionnaires and the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), researchers observed similar patterns of externalizing behaviors, such as breaking rules and expressing aggression, in youth meeting diagnostic criteria for DMDD and ODD. This overlap in associated behaviors may point to a shared mechanism, causing emotional and behavioral dysregulation, underlying both disorders. It is also a source of some debate surrounding DMDD, as critics of the disorder argue that it does not have enough unique features from ODD to warrant a different diagnosis. Using this approach, Evans et al. proposed that the ICD-11 categorize current DMDD symptomology as a subtype, ODD with chronic irritability-anger, rather than having it persist as a unique diagnosis.
As previously mentioned, one of the justifications for the creation of the DMDD diagnosis was to prevent over diagnosis of pediatric bipolar disorder, suggesting that a high amount of overlap exists between symptoms of DMDD and bipolar disorder. Freeman et al. actually found the opposite, that those with DMDD were significantly less likely to be diagnosed with bipolar disorder, further calling into question the validity of the new diagnosis.
Another interesting finding regarding DMDD is its association with autism. Due to the fact that many of the symptoms of DMDD are also relevant to autism (irritable mood, outbursts), individuals with autism have reported significantly higher rates of DMDD rates. There is still yet to be extensive evidence on this finding as to what may explain the high rate.

## Developmental Course

There has not been a lot of community-based longitudinal studies of DMDD. It is evident that DMDD has high rates of comorbidity with other psychiatric disorders, such as ODD, which may result in an increased risk for impaired functioning and distress across the lifespan. Dougherty et al. utilized a variety of developmentally appropriate assessment tools to learn more about the developmental path of DMDD, by evaluating its presence in a community sample of children at ages 6 and 9. Global functioning, peer relations, and service use were also assessed at age nine to analyze the impact of DMDD symptomology on multiple aspects of life. Dougherty and colleagues found that the number of children meeting DMDD criteria decreased, from 7.6% of six year olds to 1.3% of nine year olds, supporting the idea that DMDD prevalence decreases with age. Although the number of DMDD cases decreased, DMDD at age six was predictive of having DMDD three years later and DMDD at age six was predictive of decreased functioning, increased use of educational support services and outpatient treatment, and exclusion from peers at age nine.
After observing the decrease in DMDD criteria met from ages 6 to 9, Dougherty et al. sought to learn more about the potential of multiple developmental pathways of DMDD, with irritability remaining pathologic, or not. Dougherty and colleagues followed up their previous research by examining what environmental circumstances at age 6 might be considered risk factors for the persistence of the disorder years later. Compared to those who did not continue meeting DMDD criteria at age 9, children whose DMDD persisted showed higher levels of externalizing symptoms, functional impairment, parent-reported stubborn and hurtful behaviors, and expression of negative affect. Children of mothers with a history of depression were more likely to continue meeting DMDD criteria at age 9 than those without, possibly suggesting a heritable component of the disorder.
Existing literature on long-term outcomes of irritability suggests that childhood irritability is predictive of various forms of psychopathology in adulthood including MDD, generalized anxiety, and dysthymia. It also suggests that childhood irritability is associated with long term impairment in occupational and social settings. Copeland et al. looked at data from the Great Smoky Mountain study to see if there was a relationship between meeting DSM-5 criteria for DMDD during childhood and functional outcomes of adulthood. Functional outcome information was obtained from adults who had a history of DMDD, history of another psychiatric illness, or no psychiatric history, through structured interviews and included questions about adult health functioning, engagement in risky behaviors, and educational, financial, and social functioning. Key findings of this study were that those who met DMDD criteria during childhood were significantly more likely to also meet DMDD criteria during adulthood, compared to individuals without a history of DMDD, supporting the DSM-5 age of onset criteria. It has also been observed that DMDD can play an important role in the development of other disorders as the child ages so longitudinal studies would be very useful so that the developmental course of the disease can be illuminated and further examined. By comparing those who met DMDD criteria during childhood, those who suffered from another psychiatric disorder during their youth, and adults with no history of psychiatric illness, those with DMDD were the most likely to meet criteria for multiple psychiatric disorders during adulthood. Of the three groups, participants with a history of DMDD were least likely to have graduated high school or college, experience job security, and the most likely to live in poverty. Such findings led researchers to conclude that DMDD is a serious childhood disorder that is highly associated with other psychiatric disorders, and that consequences of the disorder do not simply disappear with time. Its effects are long-lasting and can impair multiple domains of functioning across the lifespan.

## Evidence-Based Assessment

DMDD debuted with the release of the DSM-5, but to this point there is no well-renowned assessment tool of high validity and reliability designed for the diagnosis. The majority of existing research on DMDD has relied on assessment tools designed for other psychiatric disorders. Although it is not ideal, the overlap in symptoms between DMDD and many other childhood disorders, has enabled researchers to utilize components of existing methodologies. Most studies agree that a combination of structured and semi-structured interviews should be used along with more functional assessment. McTate and Leffler evaluated the use of two semi-structured interview instruments, the Children’s Interview of Psychiatric Syndromes (ChIPS) and the Mini- International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) in the diagnosis of DMDD. Both assessment tools can be administered to youth ages 6-17, address symptomology of a wide variety of disorders, and have empirical support as reliable and valid measures. McTate and Leffler found that, although neither assessment tool fit DMDD perfectly, they were able to pull sections from each measure that played into the DSM-5 diagnostic criteria. One weakness of these measures is that the ChIPS and MINI-KID do not include follow up questions about the frequency, duration, and settings of irritable behaviors, which are important features of the diagnosis. A potential solution could be combining the use of these semi-structured methods, to get the general picture, with unstructured interviews to find out specifics that would not otherwise be covered.
Previous research has used a version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children, the K-SADS-PL, to retroactively diagnose DMDD. While semi-structured interviews are useful for gathering information about the symptoms that are present, both a symptomatic and functional assessment should also be used. Axelson and colleagues argue that utilization of the K-SADS-PL enables evaluation of 4 domains of the diagnosis, including “clinical phenomenology, delineation from other diagnoses, longitudinal stability, and association with parental psychiatric disorders”. Among other DSM-5 diagnostic criteria, the K-SADS-PL evaluates the presence of severe, recurrent temper outbursts, and the expression of chronic irritability, through anger or resentfulness, in between tantrums. A weakness of this measure is its focus on symptomology in the previous 6 months, conflicting with the 12-month requirement described by DSM-5. Since then, the K-SADS-PL has been edited specifically for DMDD, but it does not yet have empirically supported validity to be used by clinicians. Pieces of varying assessment tools address diagnostic criteria, but currently, no single measure has been designed and organized specifically for DMDD. Future evidence-based support of the updated K-SADS-PL could be a productive step to answer some of the big questions that remain around DMDD.
Checklists and rating scales such as the Child Behavior Checklist (CBCL) are more cost-effective and easier to administer compared to interviews. With the CBCL, informants complete a 113-item questionnaire about common emotional and behavioral problems in youth ages 6 to 18. However, information may be overlooked with this method. “Temper outbursts” can be interpreted in various ways by parents depending on their child’s disruptive behavior patterns, so being able to obtain details from parents about their child’s particular reactions to negative stimuli may be more useful.

## Evidence-Based Treatment

There is a lot of controversy surrounding the best evidence-based treatment that should be used to treat DMDD. This is mostly due to the fact that most clinicians struggle with whether DMDD should be treated based on the externalizing symptoms of the disorder or the mood portion of the symptoms. There is much more research that has been conducted examining treating SMD, bipolar disorder, and conduct disorder based on the idea that these disorders can be treated as mood disorders. The treatment options are divided based on treating the two main characteristics of SMD separately which includes temper and aggression.Similar to what was said about evidence-based assessment of DMDD, currently no evidence-based treatment exists that is specific to the disorder. Because of the overlap in presentation and symptoms with externalizing disorders and mood disorders, variations of existing treatments can be used to address needs of those suffering from DMDD. The U.S. National Institute of Mental Health (NIMH) explains that a combination of psychological and pharmacological techniques has been used to treat individuals with DMDD. NIMH argues that psychological treatments may include psychotherapy, parent training, and computer-based hostile attribution training and that pharmacological interventions may include use of stimulants, antidepressants, or atypical antipsychotics.
Benarous and colleagues performed a systematic review of both the completed and in progress clinical trials for interventions targeting severely dysregulated mood, in youth with SMD and DMDD. Based off the assumption that youth with severe irritability might be predisposed to have a hostile attribution bias, or misinterpret ambiguous facial expressions as negative. Stoddard et al.completed multiple experiments. They supported the presence of hostile attribution bias in youth with DMDD, showed that a computer program could be used daily to train participants to shift interpretations of ambiguous facial expressions from negative to more positive, and happy, and finally completed an open control trial whose findings suggest that engagement in four interpretation bias interventions resulted in decreased irritability, and implicated neurobiological alterations to parts of the brain associated with fear and decision-making. Although the evidence found here is promising, further research needs to be done, with larger samples, to replicate its efficacy, before being put in practice.
Waxmonsky et al. introduced a new psychosocial treatment designed for youth with comorbid ADHD and SMD. Treatment for ADHD and impaired mood (AIM) was a 9-week program that combined CBT focused on affect regulation with parent intervention training administered to 7 families of boys meeting criteria for ADHD and SMD. All but one family completed all 9 sessions and the program resulted in decreased levels of parent-reported externalizing behaviors characteristic of ADHD, ODD, and CD. This treatment program had a small/medium effect on different aspects of parenting, increasing parental involvement and reducing use of corporal punishment. These changes were associated with child reports of improved interactions with their parents, which is one technique researchers hypothesized would lead to increased functioning. This was also supported by their findings, as functional impairments decreased throughout the course of the study. Although the diagnostic criteria of DMDD and SMD are somewhat different, techniques used in this intervention program may be generalized to the treatment of youth with DMDD in the future.
Dialectical Behavior Therapy (DBT) is another psychotherapeutic method that has been used to treat DMDD. Several studies have shown the effectiveness of DBT for mood dysregulation in patients with depression, bipolar disorder, and ODD. Perepletchikovia et al. (2017) conducted a study on DMDD patients using DBT Adapted for Preadolescent Children (DBT-C), which included the 4 standard components of adult DBT (individual therapy, skills training, phone coaching calls, and therapist team consultation) and also added a parent training component. Treatment with DBT-C after 32 weeks resulted in significantly better functioning levels decreased severity compared to the control group. The DBT-C treatment had a positive response rate of 90.4% and no patient dropouts; researchers attribute the high retention and positive outcomes to the parent training component.
There are also several psychotherapies for which there is preliminary evidence of their efficacy in reducing irritability and other DMDD symptoms. Parent Management Training (PMT) has been shown to be effective for addressing irritability and anger. PMT primarily aims to equip parents with skills to increase their children’s positive behaviors and eliminate negative behaviors, like temper outbursts, through active ignoring. Many meta-analyses have shown PMT to be helpful for disruptive behavior disorders short term, and help increase prosocial behavior longer term. While few studies examine he efficacy of PMT on DMDD, the preliminary results from a few studies show the it is likely efficacious. Cognitive Behavioral Therapy may also be effective for irritability associated with DMDD, especially CBT that has been adapted previously for aggressive behavior, anger, and irritability (e.g., Anger Coping Program, CBT for Anger and Aggression in Children). It is important to note that many recent reviews suggest that rather than treating DMDD or irritability in isolation, it should be treated with careful consideration of the other conditions that are also present, as DMDD does not often occur in isolation. Stringaris et al. offer a simple algorithm for deciding treatment for irritability in DMDD in the context of the other disorders with which it is comorbid.
With regards to pharmacological approaches, Benarous et al. delineate that the two strategies that have been tested are the use of one medication, either a psychostimulant or an atypical antipsychotic, or the combination of a psychostimulant with a serotonergic antidepressant. Krieger et al. found that the use risperidone, an antipsychotic, was an effective method to decrease irritability, decrease negative symptoms of depression and ADHD comorbidities, and increase global functioning. Although the results of this study highlight the benefits of risperidone use, it is also important to consider the potential severe side effects, associated with the use of antipsychotics. Weighing the benefits and consequences of this class of drugs may suggest they only be used in very severe cases, if individuals do not first respond to psychological treatments and other forms of medication.
In terms of evidence for antidepressants in addressing DMDD, one meta-analysis examined the effect of antidepressants, which are typically used for anxiety and depression, on irritability. This study concluded that antidepressants have small to medium benefit for irritability, oppositionality, and aggression in children, the hallmark symptoms of DMDD. However, as there were not many studies that actually examined the desired symptoms, and the ones that did often mixed these participants with participants have a wide variety of other diagnoses, it requires further examination when there is more extant literature examining irritability as the main outcome. One study published since this meta-analyses of note found evidence that citalopram, an SSRI anti-depressant medication, may be helpful for reducing irritability, especially when adjunct to stimulant medication or in youth resistant to stimulant medication alone.
In contrast, the use of psychostimulants, is associated with much less risk and is commonly used to reduce aggressive and other externalizing symptoms associated with ADHD. Because of the similarities in emotional dysregulation and high rates of comorbidity between DMDD and ADHD, Winters et al. administered Concerta, a long-acting methylphenidate (MPH) psychostimulant, to youth with comorbid diagnoses of DMDD and ADHD. Administration of MPH resulted in a moderate decrease in child reported irritability and mood and a large increase in emotional regulation reported by participants’ parents. Although some participants reported an increase in irritability, Winters et al. suggest that this is probably due to individual differences, and that the overall benefits of the use of MPH are promising. Further research needs to be done, to see if decreases in irritability also occur in children presenting DMDD without ADHD.

## DMDD and Sleep

The amount of sleep that a child gets on a daily basis can affect their mood, health and academic performance in school. Sleep disturbance is a transdiagnostic concern, and is experienced widely in many disorders directly adjacent to DMDD (e.g., depression, anxiety, ADHD). Dually, sleep problems are a risk factor for a wide range of internalizing and externalizing disorders, including mood disorders such as depression and disruptive behaviors such as ADHD and ODD, that commonly overlap with DMDD. Chronic lack of sleep can even lead to anxiety, depression and other mood disorders. This has led to speculation about the potential benefit of normalizing sleep patterns to those with chronic irritability and temper outbursts, like those with DMDD. Several pieces of evidence corroborate this speculative connection. Sleep loss impairs top-down functioning and emotional regulation, key deficits in those with DMDD. Irritability and aggression are two of the main symptoms of DMDD and children with DMDD have a high comorbidity rate with mood disorders so it is important to understand the link between DMDD and sleep. Sleep deprivation has long been associated with impairment of functioning, especially with regards to emotional regulation.
Legenbauer and colleagues evaluated the relationship between sleep habits and affective and behavior dysregulation in German children, ages 8-11. Parent and child reports of sleep were measured through the Cologne Sleep Questionnaire, information of child affect and behavior was obtained through the Strengths and Difficulties Questionnaire (SDQ) and the CBCL. Children with clinical and subclinical levels of affective and behavioral dysregulation reported more problems with sleep than their healthy counterparts. These problems included having more “restless legs” than those with less affective and behavior dysregulation, supporting another study that found high levels of motor activity during sleep in youth with DMDD, through the use of actigraphy.
Although actigraphy does not provide detailed information about rapid eye movement (REM) sleep like polysomnography (PSG), its relatively easy utilization may make it a good measure of activity and total sleep time in future studies of sleep in youth with DMDD. Compared to the short duration of most studies using PSG, actimeters enabled sleep/wake cycle measurements for 9 days, with minimal interruption of daily routines. In contrast, Waxomonsky and colleagues utilized PSG and self-report measurements to assess the relationship between cardinal symptoms of DMDD and sleep disturbance. Information obtained through parent support showed that the two most common reported sleep problems in those with DMDD were associated with falling asleep, and experience of restless sleep, but they also found no relationship between sleep dysfunction data from the PSG and DMDD symptomology. These results may support existing literature that argues sleep impairment is more associated with the other psychiatric disorders highly associated with DMDD, rather than the new and controversial diagnosis itself.
In an additional study that examine sleep architecture using actigraphy in children with DMDD, it was observed that during the final third of a night’s sleep, the children with DMDD showed significant increases in movement, a period typically marked by a greater proportion of REM sleep, and therefore minimal movement. Delaplace et al. suggest this this may indicate that children with DMDD have impaired motor regulation during REM, which would cause impairment of REM sleep. REM sleep is important for emotional memory consolidation, and REM abnormalities are associated with other disorders marked my emotional dysregulation (e.g. depression, PTSD). Though this finding has not been corroborated by any other studies, it does provide some preliminary evidence linking a specific kind of sleep disturbance to DMDD, and provides a foundation for future neurobiological and intervention research. Thus, sleep therapy or medications that increase sleep such as melatonin, could be used for youth with DMDD as a way to decrease the behavioral aspects of DMDD including irritation and aggression. This form of therapy along with other pharmacological therapies could lead to a reduction in both irritation and aggression and also increase the academic performance of children with DMDD.

## DMDD and Diet

In regards to diet as a potential treatment for DMDD, this has not yet been conducted in a study; however, there have been studies conducted which test nutrients and ADHD. Since ADHD is comparable to DMDD, these results can be thought to potentially have a similar impact on children with DMDD. Hurt et al. found that certain nutrients and vitamins have resulted in an effect on an individual with ADHD. Multivitamin supplements were found to have a relationship with an improvement in non-verbal intelligence, continual attention, and remaining still. Additionally, these researchers tested supplementation of essential fatty acids, iron, zinc, and magnesium, but the results were not significant. Sinn discussed trials of participants with ADHD who received a high rate of zinc supplementation and found positive results regarding social interactions, impulsive behaviors, and hyperactivity, which could be potentially promising for those with DMDD. The idea behind these nutrient supplementation is that children who have ADHD or a similar conduct disorder may also have lower levels of zinc, iron, or other nutrients, which could be contributing to the negative behavior.
Supplementary research regarding ADHD and diet has been conducted through looking at how it may cause binge eating or loss of control with diet. Research has suggested that there may be some sort of association between ADHD and obesity. This is thought in part to be due to the fact that ADHD symptoms often include impulsive behavior, acting out, and an effect on reward processing, which is very similar to DMDD. ADHD has already been found to have a relationship with binge eating in adults, but is still being researched in children, which is the age that DMDD affects. Researchers have found that adolescents (beginning at age 12) with ADHD (both diagnosis or symptoms) show higher rates of binge eating compared to those with no diagnosis / symptoms. The reason behind this relationship is still being researched, but it can be concluded that the same results may be present in individuals with DMDD as well, since the pathways behind the two disorders are very similar.

## Resources

Coping with the symptomology and associated features of DMDD can be very stressful, both for the individuals receiving the diagnosis and their families. Below is a list of resources, at the local and national level, that can help concerned parents learn more about the disorder, find community support, and even possible providers of treatment.
| Resource | Basic Information |
| Child Mind Institute | This is one of the first hits to follow of a google search of “Disruptive Mood Dysregulation Disorder”, so it is probably one of the first sources a concerned parent would see. The section “DMDD: What to Look for” is especially useful because it can help parents begin to distinguish if their child’s behavior is typical or may be pathological. |
| Fast Facts | This handout is helpful because it provides a lot of information in a concise way. It also helps guide parents “next steps” if they think their child may be displaying DMDD symptoms and offers links to more information, including websites for the National Alliance on Mental Illness and Mental Health America. |
| Online Community Support | This is a link on the handout described above; it is an online community that offers to support to parents of kids with mood disorders. |
| Local Clinic | Here is the link to a local provider who offers DBT, CBT, and Behavioral Parent Training, all of which have been considered as psychological treatment strategies for DMDD. |
| NIMH DMDD webpage | This resource can be used by parents to learn more about signs and symptoms, risk factors, types of treatments, and potential open clinical trials to participate in. |
| Anger Trigger Analysis | This resource includes a link to various worksheets for students or children to identify anger triggers. The Calm Down Strategies worksheet could be especially helpful for children with DMDD by presenting short-term strategies that may help them calm down. |
| Tips for Educators | This resource is geared towards educators and tips for teaching children with DMDD. This site involves strategies for staying calm and patient, as well as ways to help the child succeed. |
| NAMI Resource | This is a resource that should help parents decipher what is normal and what is not normal emotional development in their child. NAMI is usually a good resource, and this resource seems to fill in gaps that others don’t capture. |
| Kati Morton Video | Kati Morton is a popular YouTuber and LCSW who provides information about different mental health concerns. Her summary on DMDD is probably commonly looked at by the general public, and also is pretty accurate in the way it reflects research. |
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