Should Temper Tantrums Be Made Into a DSM 5 Diagnosis?
Psychology Today
by Allen J. Frances, M.D.
October 11, 2011A recent front page story by Shari Roan in the Los Angeles Times explores the heated controversy over the DSM 5 proposal to include a Disruptive Mood Dysregulation Disorder [DMDD] in DSM 5. I very much oppose the inclusion of this new ‘disorder’- fearing that DMDD would medicalize temper tantrums in children and run the risk of exacerbating the already shameful overuse of antipsychotics.
When it comes to DMDD, everyone agrees on one thing only- that it is based on the thinnest possible research support; studies by one lone group for a mere six years. DMDD was largely dreamed up by the DSM 5 work group. They are trying to deal with a real problem – the massive overdiagnosis of childhood bipolar disorder and its attendant stigma and overprescription of potentially dangerous medication. But the proposed solution will create its own set of unintended consequences with the likely increase overprescription of medication for the new and inviting target of temper tantrums. And we are talking about lots of kids- estimated at 3% now and likely to grow to many more once the diagnosis is official and drug companies get their hands on it.
The right solution to the childhood bipolar fad is so much simpler and safer. DSM 5 should include a warning black box in its definition of Bipolar Disorder alerting clinicians to the dangers of overdiagnosis and overtreatment in children. My advice to child psychiatrists- tame the fad you have already created and please don’t create another fad of a new ‘disorder’ that can so easily be misused. No one denies that irritable children are a problem, but let’s not prematurely and blindly invent essentially meaningless, but potentially very dangerous labels for them.
The truly incredible thing about child psychiatrists is their inability to learn from their past experience of fad creation. These are the people who brought us the three main fads of the past fifteen years- childhood bipolar, attention deficit disorder, and autism. And now they recklessly suggest a potential fourth in DMDD. DSM 5 clearly needs some adult supervision with this thought in mind- beware nosologists bearing new and untested child diagnoses.
This brings us to the most dispiriting chapter in this sad story. The DSM 5 ‘scientific review group’ has proven not to be scientific and seems incapable of careful reviewing. Most remarkably, it has approved DMDD on tissue thin evidence and with no consideration of risk. A porous filter indeed. This highlights the obvious necessity for independent and evidence based reviews [say by the Cochrane group] to ensure the scientific integrity and safety of DSM 5 suggestions.
DMDD was largely dreamed up by the DSM 5 work group. They are trying to deal with a real problem – the massive overdiagnosis of childhood bipolar disorder and its attendant stigma and overprescription of potentially dangerous medication.
The idea that bipolar illness can begin in childhood caught hold in the last decade. The number of outpatient visits for children diagnosed with bipolar disorder mushroomed from fewer than 200,000 a year in 1995 to 800,000 in 2003, according to a 2007 study in Archives of General Psychiatry. The study reinforced the notion that childhood bipolar disorder had become a fad diagnosis."The diagnosis means exposure to pretty potent medications," said Dr. Jan Fawcett, a psychiatrist at the University of New Mexico School of Medicine in Albuquerque. "And, if the diagnosis holds, it means lifetime exposure to these medications." Such children often receive drugs like lithium or Depakote, which can cause severe weight gain, sedation and involuntary muscle contractions. They aren’t prescribed antidepressants or stimulants, which could worsen the condition in children who are truly bipolar. If the diagnosis is incorrect, however, children are deprived of drugs that could alleviate their anxiety or depression.
"We had to do something about it," said Dr. David Shaffer, a child psychiatrist at Columbia University in New York and member of an American Psychiatric Assn. work group that proposed adding disruptive mood dysregulation disorder to the Diagnostic and Statistical Manual of Mental Disorders, the book that forms the bedrock of psychiatry. That would allow doctors to reclassify a significant portion of children who are considered bipolar, he said.
The volatile 6-year-old had worked herself into a frenzy as she tried on outfit after outfit, rejecting each as unacceptable. The tantrum at full bore, she scooped up a pile of clothes and hurled them at the front door… The clock ticked past the school’s 8 a.m. bell. [Her mother] pulled her wailing child into her arms and held her on the couch. After several minutes, [She] stopped, took a breath and announced that she was ready to go to school.
It is a maze to negotiate. I started off as a parent seeking answers, then discovered by connecting the dots because everything I read had the same names in the abstracts, the Biederman gang kept showing up in my research, and my blog evolved from writing abt my daughter locked in psych wards with forced haldol injections to the corruption of how this whole thing goes, and basically as a result discovered I’d be lied to by doctors, who had been duped themselves by the KOLs, and essentially back at square one without answers and with a child mamed from the drugs that were prescribed. All that since 1999, and that’s why I started my blog to sort out WTF happened, and I began a series “the evolution of a diagnoses from OCD-ADHD-bipolar ” because I then lined up year by year the abstracts, the drugs approved and the very order by approval that the docs were rxing the meds…like risperdal to zyprexa then to abilify to seroquel and then the ‘last resort’ clozaril.
It is from being one of those beginning searching for answers parents that got me to the place i am in blogging now and each day it seems more scandal is exposed. The internal documents get leaked out, the dollars for docs shows up, wow it turned out to be worse than me just scratching my head thinking ,wow there’s that Biederman, Findling, Delbello, Wozniak, Thase, Spencer, gang again, now it is wow that Biederman guy’s deposition is wild, he compares himself to GOD.
I’m a product of the medication platform psychiatry stands upon for the treatment of mental illness in America, a person standing in the back of the room asking Fuller Torrey why he just said Haldol was an anti viral med and not an antipsychotic when he touted it for SZ due to that being from a virus from cat poop…. imagine me standing there in 2006, hearing that quack who was then deemed the foremost authority of the subject!
Honestly, if psychiatry was my profession and this much scandal and BS was flying around, I would have changed careers.
What I don’t get about the mother in the L.A. Times story, is why she would want to believe her child has a “disorder,” and all that is implied by that label, rather than choose to believe she has a normal child with “transition problems” or whatever you want to call it. I just don’t get why she and so many other mothers insist on a diagnosis, as if a diagnosis changes anything. That is truly sick, and says something about the mother, but also about the larger society that has encouraged this sickness. “As doctors quarrel, parents like Alves struggle with the lack of medical options.” Lack of medical options? There is no lack of medical options. There is a lack of what used to be considered common sense. Chances are this kid will always be painfully shy, but there are ways to work with that that don’t involve heavy duty drugging.
The article says:
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“I feel in limbo right now,” Alves said one afternoon, cuddling her painfully shy daughter. “Having a diagnosis would help me know what direction to take.”
I feel I was insane as a child, spewing angry outbursts that went on and on and on. That’s why I enjoy this quote from a psychiatrist because it makes a point that childhood IS mental illness to some degree or another. “Every child in America entering school at the age of five is insane because he comes to school with certain allegiances to our founding fathers, toward our elected officials, toward his parents, toward a belief in a supernatural being, and toward the sovereignty of this nation as a separate entity. It’s up to you as teachers to make all these sick children well – by creating the international child of the future”
Dr. Chester M. Pierce, Psychiatrist, address to the Childhood International Education Seminar, 1973
I forgot to add the most important thing I did learn the last decade…. that the behaviors that never existed before my child was erroneously dx’ed and given medications for the wrong dx, only happened as a direct result of the medications, the suicidal thinking, the agitation, aggression, 100 lb weight gain, was ALL from the meds. Doctors noted she reacted to medications severely, and in the end that was the conclusion of that experiment, of n=1.
Behaviors then in kids on meds get more meds tossed at them to counter the side effects of the other meds, this is what parents need to pay attn to the most, because as in Cogentin for example given to my daughter for the tremors from Lithium, increased psychosis, and cogentin has psychosis listed as a side effect as many of the psych meds do….. many doctors and parents will not take the psychiatric side effects of these meds seriously and realized their kids (even adults obviously) can be acting the way they are BECAUSE OF THE MEDS.
Another tip for parents reading: my child reacted to many med classes the same way she did to SSRI’s…. keep that in mind, that other meds not just those can induce suicidal thinking….
Good luck.
I have something of the opposite take on this. I have bipolar disorder and I definitely was mentally ill as a child, but was never properly diagnosed. Had I been properly diagnosed, I think my childhood may have been a lot less miserable.
I realize that there is a massive increase in bipolar disorder diagnoses among children, but it’s not as though all of those children were being diagnosed with nothing before. Children with the same symptoms were being diagnosed with schizophrenia, as hyperkinetic or ADHD. So children were still getting medications, just the wrong medications (and in the case of ADHD, stimulants that could make the situation worse).
Daniel,
Never underestimate the ability of a parent to screw you up either way. My son’s “diagnosis” and the medications introduced new stress into our household, big time. A diagnosis, according to Dr. Geert Hamer, makes healing from the trauma even more difficult because it introduces sadness, fear, etc. into the mix.