Childhood irritability and tantrums are a challenge for parents. All children have their rough spells; but for some, irritability and anger seem to be always close to the surface.

According to Ellen Leibenluft, a research psychiatrist at the National Institute of Mental Health (NIMH), irritability in children is common; it is one of the most frequent reasons that parents seek professional help for their children. Irritability is often present in anxiety disorders, post-traumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD), depression, developmental disorders (like autism) and bipolar disorder. For some children though, severe irritability is the defining feature of their mood and behavior.

Until recently, children with persistent irritability were often wrongly given a diagnosis of bipolar disorder. In bipolar disorder, irritability and the energized activity that goes with it occurs in episodes; that is, the irritability and energized activity lead the child to feel and act in ways that are clearly different than how the child usually acts and feels.

For many children with irritability, the irritable mood is there most of the time or nearly all the time for a year or longer.

As a result of the research on children with irritability, DSM-5, the manual used by mental health practitioners to make diagnoses, now has a new diagnostic term: disruptive mood dysregulation disorder (DMDD). DMDD is a condition in which a child feels irritable and angry and has frequent, intense temper outbursts. While irritability often starts in very young children, DMDD is not diagnosed in children younger than six. The following symptoms must be present for a diagnosis of DMDD.

  • Irritable or angry mood most of the day, nearly every day.

  • Severe temper outbursts (verbal or behavioral) on average of three or more times a week that are out of keeping with the situation and the child's developmental level.

  • Trouble functioning due to irritability in more than one place, for example, home, school and with peers.

  • Children with severe irritability are regularly easily frustrated and explode with a minor setback, or after having been denied something they want. Parents may feel they are always “walking on eggshells” to avoid provoking a tantrum. The family may avoid doing things they find enjoyable because they fear (or know) their child will have an outburst. Highly irritable children have trouble in school or with friends; they may get fewer invitations for play dates and social activities.

A parent dealing with these issues can talk with a teacher or the child's pediatrician, or have the child evaluated by a mental health professional. Intervening early with DMDD can make a difference, not only for the short term, but in the child's future, too. Children with DMDD have a greater risk for depression and anxiety as adults. Many also have difficulties as adults when it comes to completing educational goals, socializing and being in the work force.

Treatment is aimed at helping the child identify when he or she is beginning to feel angry before acting on it. This kind of cognitive-behavioral treatment helps a child develop strategies for dealing with and tolerating frustration. Parent training can help parents recognize situations that could provoke an outburst and take steps to prevent it. Parent training encourages parents to listen to the child in order to identify what he or she finds difficult, be predictable and consistent with their children and to reward positive behavior.

Research using functional brain imaging at NIMH has also shown that when irritable children see a facial expression that displays emotion that is ambiguous (isn't clearly angry or happy), they are likely to interpret that as angry and they pay particular attention to angry faces. Compared to children without DMDD, they also show differences on scans that reflect brain activity in specific regions when processing these facial emotions. Based on this work, NIMH researchers have developed a computer game to train children to view neutral faces in new ways. A small preliminary study suggests that changing the child's perception of angry faces would help those who have problems with anger. Currently a larger study is underway to provide a more scientifically rigorous test of this approach.

NIMH is also studying whether medication can help with DMDD. The types of medications commonly used include drugs like stimulants (used to treat ADHD), antidepressants and anti-psychotic medications.

Expanding the arsenal of treatments is an important goal of the research at NIMH. “We're trying to understand what's going on in the brains of these children and why they have more difficulty tolerating frustration than other children,” says Dr. Leibenluft. “In the end, we want to be able to help children and their families when the child is struggling with this kind of problem.”


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Charlotte Armstrong is a science writer with the National Institute of Mental Health. nimh.nih.gov