Meltdowns or mental illness?
Temper dysregulation disorder is being recommended for inclusion in the next addition of the Diagnostic and Statistical Manual of Mental Disorders, which is undergoing an update. If it is accepted, some experts are worried it could open the door to the di
When Tammy Robinson’s daughter loses it, her tantrums erupt seemingly out of nowhere, it’s like a hurricane.
She shouts obscenities, hurls insults and storms through the house, sometimes ripping and breaking things in her path. Last week, she bolted from the house in her pyjamas and ended up in a tree after her mother wouldn’t allow her to use Facebook.
“When you look in her eyes, it’s like nobody’s there sometimes,” Robinson says. “She doesn’t even have a memory of what happens.”
Her daughter, now 12, has suffered from severe mood swings since she was a toddler. “We’re still dealing with the tantrums of a two-yearold.”
As Robinson read through the proposed criteria for a new childhood mental disorder called temper dysregulation disorder with dysphoria, the similarities were uncanny, she says.
“Severe recurrent temper outbursts” grossly out of proportion to the situation or provocation? Check, Robinson thought. The outbursts manifest “in the form of verbal rages or physical aggression towards people or property,” they’re “inconsistent with developmental level,” and they occur, on average, three or more times per week? Check, check, check. Temper dysregulation disorder is being recommended for inclusion in the next addition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, a massive catalogue of brain dysfunction now undergoing its first major revision in 16 years.
If accepted, TDD could soon become as entrenched in our vernacular as ADD.
The disorder is being proposed as an alternative to the runaway diagnosis of childhood bipolar disorder. The number of children being diagnosed with — and medicated for — bipolar disorder has shot up dramatically in the past decade, despite concerns that many don’t meet the official criteria, but are getting the lifelong label nonetheless because of their explosive temper outbursts.
The idea behind TDD is to create a less-severe diagnostic “home” for these children.
The fear is that TDD could open the door to the diagnosis of any child with a bad temper, that it risks pathologizing a normal part of a child’s development and could lead to wider prescribing of antipsychotics, antidepressants and mood stabilizers to children, including preschoolers barely out of training pants.
“It’s an extremely significant move, and it’s a very alarming one,” says Christopher Lane, author of Shyness: How Normal Behaviour Became a Sickness.
“What it implies is that anyone cycling through emotions that are a part of normal human development could be susceptible to a psychiatric diagnosis that they’re going to be saddled with for the rest of their lives.”
Infants and children have meltdowns, regularly and routinely, Lane says.
“It’s a healthy expression of frustration. It’s a very serious move to contemplate that as a bona fide mental illness, which is what they’re very seriously proposing.”
Dr. Allen Frances, professor emeritus at Duke University’s School of Medicine in Durham, North Carolina, says TDD is a well-meaning attempt to reduce the number of children misdiagnosed with bipolar disorder.
But he worries it could lead to over-diagnosis in the other direction, to kids who would otherwise not be diagnosed or treated at all, and wonders what it could mean for disciplinary problems. For example, could a bully who beats up on other kids claim: “I can’t control myself. I have a mental disorder that made me do it. I’m under a doctor’s care.”
“Whenever you create a new category that has a boundary with normality, you’re definitely going to have a high prevalence,” says Frances, who chaired the task force that created the current edition of the psychiatrists’ bible of mental disorders, known as the DSM-IV.
The diagnosis of bipolar disorder in children in-
‘So they’ve tried to come up with another diagnosis that will somehow let you diagnose unruly children. But maybe they’re unruly, full stop. Maybe the parents … just plop them in front of the computer (or) or let them play video games all day.To give them a psychiatric diagnosis and treat them with antipsychotics is insane.’
EDWARD SHORTER professor of the history of medicine and professor of psychiatry at the University of Toronto’s faculty of medicine
creased after the DSM-IV broadened the definition to include irritability.
In the U.S. alone, the number of outpatient visits by children and teens for bipolar disorder increased 40-fold in the decade after the DSM-IV was published in 1994.
Meanwhile, in Canada, the number of prescriptions filled for powerful antipsychotics for children and teens has more than doubled in recent years. Last year, nearly 1.7 million prescriptions for socalled “atypical” or newer antipsychotics — quetiapine, risperidone, olanzapine and clozapine — were filled for people under the age of 20, compared to about 634,000 in 2005, according to data provided to Canwest News Service from IMS Health Canada.
The drugs, prescribed not just for bipolar, but for symptoms such as aggression, “low frustration tolerance” and mood and anxiety disorders, can cause dramatic weight gain, elevated blood fats and an increased risk of diabetes. None of the drugs has been authorized in Canada for use in children under 18 for any condition.
“The population of children with a diagnosis of bipolar has increased exponentially in the last 10 years and this has turned out to be a colossal embarrassment to the field, because they know that, out there in the real world, there are not all these children who have bipolar disorder,” says Edward Shorter, a professor of the history of medicine and professor of psychiatry at the University of Toronto’s faculty of medicine.
“So they’ve tried to come up with another diagnosis that will somehow let you diagnose unruly children. But maybe they’re unruly, full stop. Maybe the parents haven’t placed limits on them at all, or just plop them in front of the computer all day or let them play video games all day. To give them a psychiatric diagnosis and treat them with antipsychotics is insane.”
But Dr. William Narrow, research director for the task force writing the new edition of the DSM, says TDD isn’t run-of-the-mill tantrums.
“We’re not talking about the temper tantrum of a twoyear-old or a three-year-old who’s not getting his way,” Narrow says. “We’re talking about kids of age six or above who kind of have a hair-trigger, and really quite violent temper tantrums totally out of proportion to any kind of provocation that might have brought them on. Something out of the norm of what you would call a normal temper tantrum. And these are the kids who were receiving a diagnosis of bipolar disorder.”
Some worry that children will merely be shuffled from one diagnostic box to another, or that those diagnosed with TDD will be just as likely as children with bipolar disorder to be put on medication.
TDD could become just a default diagnosis, says Frances, “somewhere to pigeonhole children who don’t fit other criteria.”
Robinson says it takes incredible strength for parents of a child with severe mood dysregulation to keep it together. Her daughter has been diagnosed with non-verbal learning disability, traits of attention-deficit hyperactivity disorder, self-regulation disorder and sensory regulation disorder.
She was once diagnosed with bipolar disorder and put on medications “that made her worse, not better.” And she has been bullied at school.
“Your heart just breaks for her and you want to help her,” says Robinson.
“None of these kids fit perfectly into any one box. They don’t fit the profile for ADHD or bipolar, they don’t fit the profile for anxiety, so they just fall through the cracks. Hopefully something like (temper dysregulation disorder) is going to catch some of these kids.”
Tammy Robinson and Clive Akenhead’s 12-year daughter will run and hide in these trees when she has one of the severe tantrums she’s suffered since she was a toddler. Their daughter’s symptoms match many of the criteria for ‘temper dysregulation...