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

Ottawa Citizen - - CANADA -

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.”

ASHLEY FRASER, CANWEST NEWS

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...

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