Flailing, screaming, the occasional kick or punch — temper tantrums are a noisy but normal part of childhood development. Most of the time, a parent’s endurance of the Terrible Twos (and Threes) is rewarded with a tapering off of extreme emotional out-bursts as a child begins preschool and then kindergarten. For some kids, though, severe tantrums beyond the toddler years can indicate a host of deeper issues.
Persistent tantrums are one of the symptoms doctors use to diagnose children with learning disabilities and Attention Deficit Hyperactivity Disorder (ADHD). But regular, intense tantrums can also be a sign of lesser known, burgeoning mood disorders, including the recently identified “Disruptive Mood Dysregulation Disorder,” or DMDD. In May, DMDD was added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (known better as the DSM-5), the latest version of the 61-year-old manual used by doctors to diagnose psychiatric problems.
Many of the criteria for DMDD revolve around tantrums — verbal rage or physical aggression “grossly out of proportion” to the situation, happening three or more times a week. We’re not talking about typical toddler tantrums, though: DMDD only applies to children ages six to 18. And doctors aren’t rushing to diagnose every tantrum-prone kid as mentally ill — the designation is so new that the doctors interviewed for this story were still educating themselves about what exactly the disorder was, and none had yet worked with a DMDD patient. (For most kids, it would probably take months, or even a year, of observation and non-medicated treatment before they would receive an official diagnosis.)
The addition of a new disorder to the DSM-5 has reignited the conversation about when, and if, labelling a child’s behaviour as an official disorder is beneficial. Some doctors appreciate the use of medical terminology, saying that diagnoses help them offer better care to children and families, and can connect patients to services and resources. Other medical practitioners say a rush to label childhood behaviours causes undue worry — they don’t want desperate parents assuming their difficult child surely has a serious mood disorder or mental illness. Still others say that the grab bag of diagnoses out there medicalizes normal variations in kids’ behaviour.
Alice Charach, head of the neuropsychiatry team at the Hospital for Sick Children in Toronto, assesses about 50 children every year, helping them find the care and specialists they need. She explains that the DMDD label came out of long-term studies on the first children diagnosed as bipolar, in the late 1990s and early 2000s. Five or 10 years later, a large chunk of them weren’t classically bipolar (alternating deep depressions with high energy and excitement, also known as mania), but still struggled with issues like depression, anxiety or ADHD. Charach says the new category is a way to group children who are having obvious difficulties, but whose symptoms don’t exactly match a bipolar diagnosis. She also thinks the DMDD addition will allow doctors to help patients deal with their issues early on. (Some DMDD may experience more serious mood and aggression problems as they grow older.)
“Diagnoses are a shortcut for communicating what’s going on — describing the child’s symptoms, the context, the prognosis and recommended interventions,” she says. The DMDD checklist includes 11 characteristics, including temper outbursts at least three times a week, and an angry or irritable mood at most other times. Clients must also lack another identifiable disorder, and must not have had a manic episode lasting longer than a day.
Critics of the DSM say the manual has a history of stigmatizing normal ranges of human behaviour. (Homosexuality, for example, was listed as a “mental disorder” until 1986.) European doctors often argue that it puts too much focus on chemical biology and medicine, and not enough on emotions and drug-free treatments. Many doctors use the World Health Organization’s disease classifications, which does not currently list DMDD (though it has been proposed for inclusion in the next version), instead of or along with the DSM. In the US, official diagnoses from the DSM-5 are often necessary for insurance funding. That’s less crucial here in Canada, although some children do need medical diagnoses to qualify for extra help and programs in school.
Some experts in the children’s mental- health field are apprehensive about the DMDD designation. “I wouldn’t go near it,” says psychiatrist Jane Garland, head of the mood and anxiety disorders clinic at BC Children’s Hospital in Vancouver. “Most of these issues just distract parents — it makes them go to the worst-case scenario. And I don’t think parents need to be concerned about it at this point.” Garland doesn’t believe that a diagnosis or label will change day-to-day management strategies for families struggling with their kid's atypical behaviour. “It’s not about the diagnosis; it’s about what you do for the child. You handle tantrums the same way.” She also thinks labels diminish parents’ confidence, ham- pering their ability to deal with the problem. She points out that there is no medical definition of a “tantrum,” and that each parent must decide what’s bearable, and what’s not. (Her criteria for troublesome tantrums include almost daily rages lasting longer than half an hour.)
One practical resource she often recommends is the 2000 book The Explosive Child, and its “Collaborative Problem Solving” approach, a technique coined by its author, Ross Greene, a Harvard Medical School professor. Greene argues that understanding, anticipating and empathizing with a child’s challenging behaviour is the key to managing it. (Traditional rewards and punishments won’t work.)
While mood stabilizers, such as lithium, are the norm for a diagnosis of bipolar disorder, drug-free therapy is likely the first line of care for children suffering from DMDD, says Brendan Andrade, a clinician and research scientist with child, youth and family services at the Centre for Addiction and Mental Health in Toronto. Andrade hasn’t yet treated a child with DMDD, but he designs and leads therapy groups for children ages six to 12 with tantrum-like issues and related conditions, such as Oppositional Defiant Disorder (a pattern of hostility toward authority). “In most cases, medication is not the first option,” he says.
Through structured activities and discussions, he uses 15 weeks of sessions to teach children emotional regulation skills for coping with their feelings, especially the strong ones. While it might seem a great task to get a chronically irritable kid to regular group therapy, Andrade has actually found that many of them grow attached to their peers. “These are kids who don’t have a lot of friends, and don’t have the successes other kids do,” he says. “This is the first time many of them really feel connected, and some don’t want to leave the group.” Andrade says it’s more useful for children and families to think about the entire emotional process, rather than just “removing a tantrum.” Most of the clients he works with have overlapping issues that need to be dealt with simultaneously.
Callum Ingrouille, a little boy in Vernon, BC, is a good case study for understanding how mood disorders, and behavioural and developmental issues, can be interconnected. Although Callum, who’s three, was not ultimately diagnosed with DMDD (he was found to be on the autism spectrum), some of his symptoms were similar, including frequent, intense tantrums.
His mom, Cheryl Ingrouille, can recount dramatic freak-outs, one of which ended in a trip to the emergency room for stitches. The worst was the time he lodged himself, screaming, under a set of airplane seats, his body so rigid that Ingrouille had to wait until every other passenger had disembarked before she could crawl under the seats to pull him out. “Trying to reason with him is pointless and ridiculous, because it’s like he can’t even hear you,” she says. Her daughter, who is 15 months older than Callum, was always much easier to reason with and calm down, but Ingrouille still thought Callum was within the normal range of Terrible-Twos behaviour. Paired with his inflexibility and delayed speech, however, doctors ultimately diagnosed him with an autism spectrum disorder.
It took about six months for Callum to get a diagnosis. After another six months on a waiting list, he’ll soon start daily therapy. Working with Callum’s medical team and interacting with other families and friends suffering from childhood rages has helped Ingrouille and her husband cope with their worries and frustration. Even if a label doesn’t make Callum’s mood problems magically disappear, his family appreciates the support that came with his diagnosis and treatment plan. “One woman told me that her son’s severe tantrums are down to about once a year,” says Ingrouille, with relief in her voice. “I have heard that it does get better.”
A version of this article was published in our August 2013 issue with the headline "The shapes of wrath," pp. 44-6.