Warning label on new diagnosis
I SAW 5-year-old Alex with his parents in my pediatric practice (details have been changed to protect privacy) for “explosive behavior and irritability.’’
One morning Alex’s father, Ben, called to Alex upstairs and asked if his younger sister could have some of his pancakes. There was a misunderstanding; Ben thought he said “yes’’ but Alex insisted he had said “maybe.’’ Alex came into the kitchen and found his sister eating his pancakes. He immediately began to scream, and threw her plate on the floor.
He hit his mother, Carla, who, overwhelmed with rage herself, grabbed him and carried him up the stairs to his room. There he attempted to kick the door down. After about 45 minutes, both Alex and Carla collapsed in tears of exhaustion and frustration. This type of scene occurred in their home several times a day.
I met with Ben and Carla alone, and they described Alex as a challenging baby from the start. Carla cried as she spoke of her own abusive father and her difficulty managing her anger. She decided to address these issues in her own therapy. Ben told of stresses in their marriage that they felt had resulted from having such a difficult child. Over time, as these issues were brought to light, Ben and Carla felt better equipped to help Alex contain and manage his frustration. Though the problems are far from resolved, a more positive pattern of interaction was set in place, and Alex’s development is on a healthier track.
I thought of this family while reading about the controversy swirling around the proposed new diagnosis in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: temper dysregulation disorder with dysphoria (negative, unhappy mood). An 11-page justification for the addition of the new diagnosis, written by the Child and Adolescent Disorders Work Group, begins with reference to a 40-fold increase in the diagnosis of pediatric bipolar disorder since the mid-1990s. That statistic is, in my opinion, justification enough.
A new diagnosis could be a first step off of the path child psychiatry is now on. Use of antipsychotics, powerful drugs with serious side effects, for 2- to 5-year-olds has doubled in the past several years. While medication can be an important part of treatment for older children, a different way to think about “explosive’’ behavior that does not necessarily involve medication is urgently needed.
Problems with the new diagnosis abound. There is no guarantee that clinicians will be any less likely to prescribe antipsychotics for this disorder than for bipolar disorder. Though the intention is to view this disorder as biologically based, the authors of the justification report acknowledge that evidence for the biological basis of any psychiatric disorder is “very preliminary.’’ Insurance companies may not cover treatments other than medication.
Allen Frances, chair of the DSM-IV Task Force and a harsh critic of DSM-V, refers to the diagnosis as “a misguided medicalization of temper outbursts.’’
He worries that the diagnosis would be very common in the general population and promote a large expansion in the use of antipsychotic medication. I agree that this is a risk. Aggression and temper tantrums are a healthy normal part of development. It would be wrong to label children exhibiting these behaviors with a disorder.
But families like Alex’s are suffering. It is important to find a way within the DSM system to describe their experience without use of the bipolar label. The criteria for the diagnosis must clearly reflect the intensity, frequency, and disruptive nature of the problem.
I hope that this new diagnosis will open up discussion about the meaning of these children’s behavior. Use of the word “dysregulation’’ is an important first step. Extensive research at the interface of developmental psychology and neuroscience has demonstrated that young children learn to regulate emotions in the setting of relationships with their caregivers.
A child may be born with a genetic vulnerability for emotional dysregulation. Responsive parenting, however, may alter the actual expression of these genes, and even change the chemistry and structure of the brain.
Emotional “dysregulation’’ is an accurate description of Alex’s behavior. DSM-V is primarily a descriptive document that does not address cause. However, if clinicians treating this new disorder think about emotional regulation as a quality that is learned in relationships, it may open up a path to considering meaningful alternative interventions.
Dr. Claudia M. Gold is a pediatrician in Great Barrington.