Where is the line between tantrums and DMDD in children?

What is DMDD?

DMDD is a condition where kids are angry and irritable most of the day, most days of the week, with symptoms occurring consistently for at least a year. It’s thought to be quite rare, impacting roughly between one and three percent of all children, according to a 2025 meta-analysis. DMDD is characterized by severe physical and verbal outbursts at least three times per week that are out of proportion to the trigger and not expected for their age. The condition can only be diagnosed between the ages of six and 18 years of age, with symptoms typically starting before 10.

“It’s typical for kids to have outbursts, to be moody,” Dr. Crawford says. The difference with DMDD is that the behavior is more severe, more persistent, and more widespread.

In the mid-1990s, mental health practitioners began diagnosing a growing number of kids with bipolar disorder, a condition that causes manic episodes of extreme irritability and distress in adults, says Gabrielle Carlson, M.D., a pediatric psychiatrist who was one of the earliest researchers helping to define DMDD. But these kids weren’t showing the cyclical presentation characteristic of bipolar disorder. Instead, their behaviors were chronic, which practitioners chalked up to “developmental changes” that come with growing up. Psychiatrists prescribed kids the same second-generation antipsychotic drugs used in adults with bipolar disorder—which, though very effective when properly used, can cause complications like weight gain, fatigue, and an increased risk for type 2 diabetes and high cholesterol.

Some practitioners became concerned about medication overuse and believed kids required a yet-unnamed diagnosis. “We need a way to classify kids with severe irritability and outbursts. The question is, what do we call it?” explains Dr. Carlson, who specializes in bipolar disorder and depression and has been a professor of pediatrics and psychiatry at State University of New York at Stony Brook since 1985. DMDD was officially added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013.

As with many psychological disorders, DMDD is thought to be caused by a combination of genetic and environmental factors. It does tend to run in families, notes Dr. Crawford, particularly those with a history of mood disorders, schizophrenia, psychotic disorders, or neurodevelopmental disorders.

What does DMDD actually look like?

All kids struggle to control their emotions from time to time, but kids with DMDD are angry or irritable most of the time. Parents tell Dr. Carlson they’re constantly walking on eggshells around an eight-year-old who never outgrew the terrible twos, or that the school has been calling to report problem behavior since their child was three.

These strong emotional reactions can involve both physical and verbal aggression toward people or property. Outbursts are so frequent and extreme that they interfere with a child’s daily functioning: They may lose friends, or they’re sent home from school for disruptive behavior so often that they fall behind academically, Kritsas says.

Last year, Kritsas began working with Adam* shortly after the 13-year-old was suspended. When the school suspended him, “he lost it,” Kritsas says, raging verbally and physically at home and school. He slammed doors so hard they broke, punched holes in walls, and snuck out at night to destroy neighboring property.

Having outbursts both at home and at school is an important criteria for DMDD. When a child is uncontrollable at home but perfectly behaved at school, or the inverse, “it doesn’t mean that there isn’t a problem. But it’s not DMDD,” Dr. Carlson says. Adam, for example, was diagnosed with DMDD by another provider a few years earlier, when it was clear his severe moods and outbursts were impacting him at home, school, and in sports.

How is DMDD diagnosed?

Dr. Crawford likens frequent irritability and outbursts to a fever: They’re not the root of the problem, but rather a signal that something else is wrong. It’s a provider’s job to pinpoint the underlying cause.

Any licensed healthcare professional can diagnose DMDD, but your first step would generally be your pediatrician so they can rule out any medical issues that can cause irritability, like anemia and vitamin D deficiency. If your pediatrician doesn’t feel they have the expertise or information to diagnose DMDD themselves, they’ll refer you to a pediatric mental healthcare practitioner they trust.

When considering a DMDD diagnosis, the provider will also want to rule out any other stressful events that could be contributing to this behavior, like moving or changing schools. Because “anger almost always becomes the outlet” when kids struggle to cope with challenges, Kritsas says. They’ll also consider any other disorders that share symptoms of irritability and emotional dysregulation, such as anxiety, depression, schizophrenia, bipolar disorder, or attention deficit hyperactivity disorder (ADHD).

To make a DMDD diagnosis, your practitioner will talk to you and your child and assess how their symptoms match up to the diagnostic criteria. For many people, “it can be quite relieving and validating [to know] there is something in the DSM, because they know they’re not alone,” Dr. Crawford says.

DMDD vs. ODD

One diagnosis that often looks a lot like DMDD is oppositional defiant disorder (ODD), a condition where kids constantly challenge authority. While there can be some overlap in symptoms (such as frequent outbursts and anger), ODD looks like a persistent pattern of hostility, defiance, or vindictiveness. And, unlike DMDD, ODD can be limited to just one setting (for example, a child that only shows these symptoms at home). Another key difference: DMDD is a mood disorder—meaning it impacts both a child’s mood and behavior—while ODD is strictly a behavioral disorder. Because DMDD is considered more severe and persistent, it overrides an ODD diagnosis.

There is also a notable overlap between DMDD and ADHD, says Dr. Carlson. A 2021 study in the Journal of Affective Disorders estimated that between 20 to 30 percent of children with ADHD also meet the criteria for DMDD, but that most were likely to grow out of the DMDD diagnosis by age 10.

How is DMDD treated?

Treatment for DMDD usually involves a combination of therapy and medication. The goal isn’t to change your child’s temperament but to lower the intensity of their anger and outbursts, Kritsas says. Your therapist will identify your child’s triggers and teach them coping skills to deal with frustration. “Feeling angry towards parents or teachers or peers is normal. But how do we express that without throwing a desk or punching the wall? How do we communicate?” she says.

Therapy for DMDD often includes cognitive behavioral therapy (CBT), which helps someone to identify unhelpful thought and behavior patterns and learn better coping skills. Dialectical behavior therapy (DBT) can also be helpful, as it helps kids with big emotions understand how their thoughts impact how they feel and behave. Your therapist will reevaluate progress together with you and your child every few months and may cut back on therapy sessions as needed.

Medication (including antidepressants, stimulants, or, rarely, antipsychotics) may be necessary if your child is extremely irritable or anxious to “bring that down from a level 10 to a level six,” Dr. Crawford says. Lowering that emotional threshold can often help patients be more receptive to therapy, allowing them to better retain skills and apply them in future situations.

Therapy can be helpful for parents of children with DMDD, too. You’ll learn “co-regulation,” or how to remain calm during outbursts, like you would when soothing a crying baby. When your child sees that you don’t yell or get overly emotional in the face of frustration, they tend to follow. “They internalize that calmness over time. That’s the ultimate goal,” Dr. Crawford says.

Therapists may also recommend parent management training, Dr. Crawford adds, which helps parents learn how to set limits with consistent expectations and consequences. By offering limited choices and implementing practical tools that reinforce positive behaviors, like a rewards chart, parents can minimize the power struggles that often occur with DMDD.

In Adam’s case, a combination of medication, one-on-one therapy, and group therapy with other teenage boys made a big difference. Adam realized that his anger and outbursts were often triggered when hanging out with his previous social circle. “I don’t say this lightly: He’s done a really phenomenal job at putting himself around people who encourage more positive behaviors,” Kritsas says. Over the past year, he hasn’t had any major outbursts.

What to do if you're concerned about your child

As a psychiatrist who has treated many kids with DMDD, Dr. Crawford suggests first visiting your child’s pediatrician, who can assess whether their outbursts are within the realm of what’s expected at this age or potentially a sign of something more serious. Then they can refer you to a mental health professional they trust.

“Because DMDD can overlap with other diagnoses and children’s symptoms often present differently than they do in adults, it’s helpful to see someone who specializes in working with children and adolescents whenever possible,” Dr. Crawford says.

Be prepared to discuss:

• When your child’s behavior started
• How often outbursts occur
• Where they do (and don’t) happen
• What typically makes their behavior worse (or better)

Also jot down all medications your child has taken, including dosage and duration. “That really saves a lot of time, if you come armed with that information,” Dr. Carlson says.

And, crucially, don’t blame problematic behavior on being a “problem child.” Instead, focus on remaining curious and supportive, remembering that your child is doing the best they can with limited life experience. “There’s always something driving these types of behaviors, and it’s really up to us as adults to intervene rather than just writing the kid off,” Dr. Crawford says.

*Real name not shared to protect client-patient privilege