Many children are diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), and such a diagnosis can be overwhelming for the child and his family. It can be even more stressful if your child is diagnosed with Disruptive Mood Dysregulation, which often is a disorder that accompanies ADHD.
Most of us know what a child is like who has ADHD. They have a lot of energy, are impulsive, have a hard time focusing or siting still. Boys typically are diagnosed with ADHD earlier because they may be disruptive at school. Girls, on the other hand, tend to be more complicated to diagnoses because they tend to hold it together while at school, since they are so concerned about how they are perceived by others.
Holding it together outside the home is not an easy task for children with ADHD. Pressure mounts, and when they are back home, in their safe environment, with the ones they love, their hair comes down, and like a shaken bottle of soda — they explode. This over the top pouring out of emotions is what professionals call Disruptive Mood Dysregulation Disorder (DMDD).
Mood Deregulation is a fairly newly diagnosis, identified just a decade ago. The cluster of symptoms associated with this disorder include low tolerance for frustration, angry outbursts, irritability, mood lability with both highs and lows, irrational fears and anxiety, including panic attacks, social phobias, obsessional thoughts and ritualistic compulsions.
In the past, kids with ADHD and DMDD were put into various diagnostic categories including, Oppositional Defiant Disorder, Conduct Disorder, Personality Disorders and Mood and Anxiety Disorders. Since the relationship between ADHD and the presence of the cluster of symptoms associated with DMDD was not recognized until recently, scientific research and targeted treatment protocols - both in terms of psychopharmacology and psychotherapy - have not been clearly defined and standardized. This lack of concrete treatment modalities often results in frustration on the part of psychiatrists, psychologists, families, and of cause, the child.
Psychiatrists will often try to treat the child with different medication cocktails such as stimulants, antidepressants, anti-anxiety medications and mood stabilizers. Psychologists often apply psychodynamic, cognitive behavioral, family systems and dialectical therapies as a means to help the child cope and the family endure.
It is not uncommon for a family, after exhausting numerous trials of medications and psychotherapy, to feel like nothing will ever work. It is no wonder children with ADHD and DMDD often feel frustrated with treatment. They, however, are not alone. Understandably their parents often feel the same way - frustrated, hopeless, alienated from friends and family who don’t get what they are living with, depressed and angry, as well as grappling with guilt and self loathing for their negative feelings toward their child.
In psychology, this parallel feelings between a child and parents is called projective identification. Projective identification is when the child, by their own negative behaviors, cause the parent to feel and then react negatively, which in turn makes the child feel rejected and bad about themselves, thus confirming the child’s feelings about him or herself, thereby reigniting his or her anger, self destructive and oppositional behaviors.
I believe it is this vicious circle of projected identification that reinforces the dysfunctional family dynamics and activates the repetition of the child’s emotional turmoil. The cycle must be stopped to allow all involved to get off this wheel of pain, dysfunction and hopelessness. In order to do so, I think the first step is to understand why the child reacts as she does. I believe, from an existential perspective, it is important to truly comprehend how the child thinks, feels and experiences the world from an early age.
I think it is wrong to view a child who thinks differently from the norm as “disordered.” They are not disordered, they are ordered differently than what is considered socially acceptable by today’s standards. They usually are able to think quickly, can hold multiple thoughts at the same time, see things from a different angle and have a keen sensitivity to environmental stimuli. In other words, children with ADHD often think outside the box. Thinking and behaving differently however — be it due to their impulsivity, executive function deficits, speech issues or sensitivity and creativity — can result in being ostracized by peers and even teachers, resulting in feelings of alienation for the child. I believe it is this psychological reaction to not fitting in that is at the core of the child’s mood dysregulation comorbidity. In essence, it is their keen awareness of being different that results in insecurities, anxieties and low self-esteem.
Since kids with ADHD are different, they cannot always be parented in the same way a neurotypical kid is parented. Even therapeutic interventions and parenting techniques tailored specifically for ADHD children can be difficult to administer or apply consistently, which can make positive outcomes a challenge to achieve. Kids with ADHD/DMDD typically do not react well to traditional parenting techniques that rely on correction, limit-setting, and punishment (or in today’s lingo “consequences”). For example, threatening to take the child’s electronics away for bad behavior might result in worse behavior, e.g., them throwing the iPad on the floor in a fit of rage or destroying their favorite stuff animal in the midst of a temper tantrum. Rather than react to the bad behavior, the parent needs to take a step back and ask what is truly causing the child to act out, and then empathize with those feelings. Parents of children with ADHD/DMDD need to try to turn their attention from their child’s provocative, dysregulated behavior, and try to maintain a stance of empathy. For many parents, this feels like a dramatic change in the child-parent relationship, and does not feel natural. It may be antithetical to the way you were raised or how your friends are parenting their children. Parents may feel like they are letting their kids “get away” with “bad behavior”. They are subjected to well-intentioned advice from family and others that they need to learn how to say “no” to their children, not “be their friend”, and never fail to impose consequences to unacceptable behaviors.
In most cases, I believe what you will find is an anxious child ridden with insecurities, fears of failure, and a deep-rooted sense of not being seen or heard, especially in a positive light. These kids get a lot negative attention due their anger and low frustration tolerance, however positive reinforcement by others is rare. This is understandable as it is hard to hug an angry porcupine, even if it is hurting and in need of love and attention.
If the child is activated, rather than react to the presenting behavior, you must be attentive to what underlies and triggers the negative actions, and focus on interventions that can comfort and reduce the child’s stress. For example, if the child misbehaves, rather than punish the child, comfort the child so she feels safe and understood in terms of her needs. Over time, by soothing, his or her high level of anxiety can diminish over time. You need to know when to disengage, ignore, or distract the child. There is no science to this and it relies on trial and error. Changing the topic or pulling the child in a different direction with a different activity or line of thinking can be helpful strategic tools. Sometimes the child needs a soothing activity, so rather than pull the iPad away as a punishment, let her use it in a positive manner such as listening to music or even mindful relaxation videos. Then, provide praise for engaging in self-soothing, and successfully lowering her own arousal level. This, then teaches the child that she can indeed have control of her emotions like other people do. Improving the child’s sense of self esteem is also important. Try to focus on the child’s successes and talents rather than focus on limitations and inadequacies. Children with ADHD/DMDD tend to demand a lot of attention. Try to be attentive of their needs to be seen and heard, and react positively, rather than annoyed at their neediness. These shifts in approach are hard and take practice and patience.
The good news is kids with ADHD can do better as they get older as neuronal networks mature. Older kids and adults may be more tolerant around people who are different or somewhat quirky. In fact many adults with ADHD, due to their ability to think outside the box, become the future innovators of change or models of excellence in their respective fields. The internet is filled with success stories of adults who excelled who had ADHD tendencies. For example, in sports Michael Phelps, Michael Jordon and Simone Biles, in entertainment Walt Disney and John Lennon, in technology Bill Gates and Sir Richard Branson. Perhaps as a parent of a young child with ADHD/DMDD there is light at the end of the tunnel — not the headlight of an oncoming train, but rather a fast paced shooting star.
Dr. Klein is a clinical psychologist who practices in Westport CT and also works remotely via video conferencing. He works with parents who are struggling with children who have ADHD and DMDD.
Dr. Martin Klein is a clinical psychologist who practices in Westport, Stamford and Fairfield CT. He specializes in individual therapy, Couples counseling and executive coaching.