DSM-V and the Riley Murder Conviction

Carolyn Riley’s act of giving her daughter Rebecca an overdose of prescribed medication may have been the immediate cause of Rebecca’s death, the conclusion reached by the jury that convicted her of murder. Even if, as the prosecutor argued, Carolyn and her husband concocted symptoms of mental illness and the psychiatrist, who diagnosed bipolar disorder, was a gullible enabler, the real guilty party in this story is, in my opinion, our health care system. With our over-reliance on psychoactive medication to fix complex problems, we condone the actions of the psychiatrist. We have failed to create a system that values prevention and meaningful, relationship based intervention. If she didn't have the drugs, Rebecca would not have died.

A recent announcement by The American Psychiatric Association that it intends to include a new diagnosis in its upcoming fifth edition of the Diagnostic and Statistical Manual(DSM-V) has me feeling optimistic. The new condition will be called temper dysregulation with dysphoria(TDD). The hope is that new label will be used instead of the bipolar label, allowing clinicians to describe a serious behavior problem without committing children to a chronic lifelong disorder.

Gabrielle Carson, a child psychiatrist at Stony Brook University offers this perspective on the issue in an NPR piece.. Many of the behaviors associated with what is currently referred to as “bipolar disorder” were previously described as “conduct disorder”, She says, “If you’ve got something that is not a medical problem, insurance is not going to pay for it. Conduct disorder is bad parenting, lousy environment, poor supervision, you’re a bad seed. It ain’t a medical problem. Bipolar they’ll pay for.”

Concerned about the large numbers of children being placed on powerful medications with serious side effects, David Schaffer, a psychiatrist on the DSM-V committee, proposed to create a new diagnosis. The hope is that this new disorder TDD, will be understood as a biologically based disorder that does not necessarily need to be treated with medication.

What if, instead of being prescribed medication to control her young children’s behavior (all three were on psychoactive medication by age 3), Carolyn had received a different type of intervention, one that aimed to repair relationships? For example at the Yale based Minding the Baby program, Carolyn would have been given the opportunity, in the presence of a caring and non judgmental person, to consider experiences from her own troubled past that contributed to her difficult handling her daughter’s challenging behavior. That person would have worked with Carolyn and Rebecca together over time to support Carolyn in her efforts to think about her daughter’s inner world. Such interventions have been demonstrated to have a significant positive impact on a child’s mental health.

There is convincing evidence that psychoactive medication reduces problem behavior. But just as an Escher print offers two completely different ways to look at the same picture, research at the interface of neuroscience, developmental psychology and behavioral genetics offers a different paradigm from that offered by the pharmaceutical industry.

Problem behavior is a symptom. Children with behavior characteristic of bipolar disorder have difficulty with emotional regulation. Young children learn to regulate emotions in relationships. When people who care for a child can think about his experience of the world, when they can help him to contain intense emotions without becoming overwhelmed themselves, that child learns to manage himself in a complex social environment. A child may be born with a genetic vulnerability for difficulty regulating emotions. Responsive parenting, however, may alter the actual expression of these genes, and even change the chemistry and structure of the brain.

As a pediatrician, I understand why we are so quick to turn to drugs. Parents feel overwhelmed. The combination of a temperamentally difficult infant and a parent with few supports who may herself have been abused is particularly challenging. Mental health resources are severely limited. Parents are pressured by teachers, whose classrooms are disrupted by these children. Pediatricians, psychiatrists, parents and teachers are bombarded by intense marketing efforts of the pharmaceutical industry.

Just because a problem is biologically based does not mean drugs are the answer. Relationships, too, can change the brain. I hope we can get health care reform moving again and build a system that values prevention and early intervention. It is too late for Carolyn and Rebecca Riley. But let’s not make the same mistake twice.