As I observed yesterday, the move by the American Psychiatric Association to expand diagnoses of childhood "disorders," driven by institutional power and Big Pharma profit-taking, is attracting notice. CanWest health reporter Sharon Kirkey's second article on the psychiatrization of our children appears today.
Under the relaxed criteria set out in the fourth edition of the APA's Diagnostic and Statistical Manual, it seems that too many kids were being misdiagnosed with various "disorders." The chair of the committee that drafted that edition, Dr. Allen Frances, ruefully notes now that diagnoses of bipolar disorder alone increased forty-fold in the US after the release of DSM-IV in 1994. Children no longer had to act manic to be bipolar, and persistent irritability could be taken as a form of clinical depression, and expensive drugs dispensed.
Well, what to do, what to do. Rather than pull back and stop this institutionalized child abuse, the APA is now proposing to create a Big New Disease: "Temper Dysregulation Disorder with Dysphoria." That would provide a "diagnostic home" for all the kids misdiagnosed with bipolar disorder--and likely a raft of new patients as well.
Here are the criteria for "TDD":
A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.
1. The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.
2. The reaction is grossly out of proportion in intensity or duration to the situation or provocation.
3. The responses are inconsistent with developmental level.
B. Frequency: The temper outbursts occur, on average, three or more times per week.
C. Mood between temper outbursts:
1. Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).
2. The negative mood is observable by others (e.g., parents, teachers, peers).
D. Duration: Criteria A-C have been present for at least 12 months. Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.
E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be severe in at least in one setting.
Additional criteria are set out to distinguish this new "disorder" from others already in the book.
Pay close attention to these criteria, particularly if you have children in school. Meltdowns may now be recorded by the school nurse as possible "TDD." The medical-institutional gaze will now fall upon your child. And it doesn't matter if this happens during a few difficult weeks. Note criterion D: your kid can be without the symptoms for up to three months at a time.
The dangers here are so obvious that they shouldn't have to be explained. But articulate critics are already emerging. As Kirkey reports:
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."
And Dr. Frances explains the problems in some depth, calling "TDD" a "makeshift proposal, with considerable risks."
The definition was created largely ad hoc with no systematic testing (outside...one research program) of the performance characteristics of the items to determine how they would play if in wide general use. It is loosely written and in fact contains no exclusion for use in adults (which I assume is an oversight).
Why is such a makeshift solution being given any serious consideration? The work group freely admits that the scientific rationale is completely inadequate. Their proposal rests exclusively on two real and pressing clinical needs: 1) to reduce the over diagnosis and over treatment of bipolar disorder; and, 2) to do something to help the considerable suffering that these temper outbursts cause the children themselves, their parents and teachers, and society at large.[emphasis added]
The solution to "over diagnosis," in other words, is--to invent another diagnosis. But as Frances notes:
The biggest problem with the proposal is that it is not nearly restrictive enough. While trying to rescue kids who are now misdiagnosed as bipolar, it will undoubtedly open the door to the misdiagnosis of normal kids who happen to be temperamental or in difficult family circumstances.
--
First off, there is enormous variability in what are considered appropriate expressions of temper across kids, across developmental periods, across families, and across subcultures. The definition of "severe" will likely vary greatly depending on the tolerance of the clinician, family, school, and peer group. The "stressors" that trigger the episodes may be minimal in some cases, remarkably provoking of readily understandable temper reactions in others. Family fights that are based in interpersonal problems will be translated into individual psychopathology. Finally, in the heat of battle, it will be forgotten that kids often do outgrow a developmentally or situationally triggered temperamental period in their lives.
--
[I]n the real world many diagnoses are made by primary care clinicians who have limited expertise in psychiatry, little time with each patient, are dealing with harried family members who want a quick solution to a pressing problem, and are influenced by drug company salespeople. My experience tells me that this makeshift diagnosis may well become very popular and will spread to normal kids who would do a lot better without treatment.
--
Which brings us to the risks of treatment for this prematurely concocted diagnosis. Unfortunately, it is inevitable that this will often consist of atypical antipsychotic drugs because these are heavily marketed and may be helpful in reducing some forms of explosive temper outbursts....Their use in kids who are having disturbing (but essentially "normal") developmental or situational storms or are irritable for other reasons (e.g. substance use, ADD) would be disastrous-but it will happen and probably often. [emphases added]
Let's be clear: there are some children who, as Dr. Frances notes, are quite literally out of control, causing suffering to themselves and others. I have received one email describing such a case, and Kirkey provides another example in her article today.
But like the old adage about hard cases making bad law, extreme disturbance is here giving rise to a set of criteria that can fit a whole lot of ordinary people, and they will inevitably be applied by unqualified school officials and health care professionals. Worse, they just dope the kids up these days, treating symptoms rather than causes.
I'm not one of those who thinks, like R.D. Laing did back in the '60's, that schizophrenia is a grand adventure: I don't believe that there's no such thing as mental illness. But that word "illness" needs to be severely circumscribed, not expanded, and talk-therapy administered in preference to routinely prescribing Ritalin and other chemicals, which are too often used to drug our kids into obedient passivity.
We should be also aware that much of what is considered "illness" is culturally constructed. As proof, homosexuality was considered a mental illness by the APA until it was deleted from the DSM in 1973--not that long ago, historically speaking.
Big Pharma and the medical-institutional gaze are a lethal combination. It would appear that they, not the children, are the ones genuinely out of control.
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