The DSM-5 criteria for DMDD overlook children with context-specific impairing irritability

Last updated 15 March 2021

Impairing irritability is common in children with attention deficit/hyperactivity disorder (ADHD), but little is known about its prevalence across contexts. Now, data from a study recently published in Child and Adolescent Mental Health have shed light on the prevalence of context-specific irritability in ADHD and how it varies depending on parenting practices and sleep problems.

“This study found its origins in our clinical experience with children with ADHD, where we have encountered extremely severe cases of irritability that only manifests in one specific context — typically in the family setting but sometimes in the classroom”, explains study author Thomas Villemonteix. “Yet there is an important gap in the DSM-5 when it comes to identifying and studying this group of patients. Indeed, the diagnosis available for severe irritability, disruptive mood dysregulation disorder (DMDD), requires symptom manifestations to be present in at least two of three settings (at home, at school, with peers). As such, cases of severe irritability only present in one specific setting are excluded.”

To determine the prevalence of context-dependent irritability in ADHD, the researchers asked parents of a group of 170 children with ADHD aged 6-11 years, to complete a semi-structured interview and questionnaire assessing irritability – once at baseline and again after 1 year. They were also asked to complete a parent-report questionnaire that evaluated parenting practices and sleep problems.

Interestingly, the researchers found that the prevalence of severe irritability restricted to the family setting (what they referred to as ‘family-restricted DMDD’) was as high as the prevalence of severe irritability present in multiple contexts (DMDD). These findings suggest that a relatively large severely impaired population might be overlooked by the DSM-5. Additionally, although parenting practices were more dysfunctional for children with irritability, they did not differ for children with family-restricted compared to cross-situational irritability, indicating that this important correlate does not distinguish between groups.

Villemonteix explains that one reason for excluding family-restricted manifestations of irritability from DMDD could be an assumption that these manifestations represent temporary phenomena. However, the data from this study reveal that these family-restricted manifestations of irritability seem to be as stable over time as cross-situational manifestations of irritability.

“An important implication of our findings is that the DMDD criteria might need to be revised to include cases of severe irritability that is restricted to specific contexts”, proposes Villemonteix. “Of course, such a change can’t be based solely on our study that has only analysed on single informant (parent) reports: our findings must now be replicated using a multi-informant approach.”

Referring to

Courbet, O., Slama, H., Purper-Ouakil, D., Massat, I. & Villemonteix, T. (2020), Context‐dependent irritability in Attention Deficit/Hyperactivity Disorder: correlates and stability of family‐restricted versus cross‐situational temper outbursts. Child Adolesc. Ment. Health. doi: 10.1111/camh.12399


Impairing irritability: characterized by a chronic proneness to anger that is inconsistent with the child’s developmental level and has a negative impact on their daily lives.

Disruptive mood dysregulation disorder: chronic, persistent irritable/angry mood accompanied by regular temper outbursts. Symptoms must have a negative impact in at least two of three settings (at home, at school, or with peers).