DSM, Drugs and Labeling the "Troubled Child"

In this past week's New England Journal of Medicine there is an article with the captivating title Pediatric Mental Health Care Dysfunction. Gabrielle Carlson and her colleagues address the controversy over the new DSM V diagnosis Temper Dysregulation Disorder with dysphoria(TDD). They write: "No existing DSM diagnosis conveys the appropriate severity and complexity of these children's moods and behaviors: the "bipolar disorder" label was meant to provide a home for children who were "diagnostically homeless."

But why, I wonder, do young children need to have any label at all? What is the purpose of such a label? Dan Carlat in his new book Unhinged: The Trouble with Psychiatry has a wonderful chapter about the history of DSM, source of these labels, offering a balanced portrayal of the benefits and limitations of this so called "Bible of Psychiatry."

He writes, "DSM assigns each slice of craziness with a name and a number." When parents are struggling with a troubled child, there may be great comfort in having an answer. They may also have the idea that a label points to the correct treatment. But there are serious downsides to this approach.

Since the mid-1990's when a "small but influential group of child psychiatrists" proposed to label children with severe mood dysregulation as "bipolar" the number of children receiving this diagnosis increased 40 fold. Carlson writes: "These children, some preschoolers, were primarily treated with mood stabilizers and a new generation of antipsychotic drugs. But, as Carlson acknowledges in her article, the evidence for efficacy of the medications used to treat bipolar disorder in childhood, medications with very serious side effects, is "sparse at best." The argument that labelling leads to appropriate treatment falls flat.

Moreover, she offers the alarming research finding that "a recent study of large data bases of privately insured individuals showed that most young children prescribed antipsychotic medications did not receive adjunctive psychosocial treatment."

This past March I had an oped in the Boston Globe addressing the TDD diagnosis entitled Warning Label on a new Diagnosis. I describe what a child with severe explosive behavior looks like, and what "psychosocial treatment" might involve.

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.

In Carlat's discussion of DSM he writes, "The tradition of psychological curiosity has been dying a gradual death, and the DSM is part cause, part consequence of this transformation of our profession. These days psychiatrists are less interested in "why" and more interested in "what."

When young children are labeled with any diagnosis, the "why" is often not explored. Yet it is the "why" that offers the path to effective treatment. As I wrote in my op ed:

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.

Use of psychiatric drugs and not answering the "why" are two significant downsides to labelling to young children with a psychiatric disorder. I propose a third downside, in my opinion perhaps the most compelling reason not to label a young child.

In my blog, I have been writing about the ideas of D.W.Winnicott, pediatrician turned psychoanalyst. Another brilliant contribution was his notion of the "true self." A complex idea beyond the scope of a blog post, I will simplify it by saying that a child develops a healthy sense of self when the people who care for him recognize the meaning of his behavior, rather than substituting their own adult meaning. Parent's who receive a diagnostic label for their child inevitably go through a period of mourning. The child they had is gone and replaced by the child with a "disorder." For a very young child whose development is unfolding, his "true self" might be lost. Given that we know so little about either the diagnosis of bipolar disorder or the new temper dysregulation disorder, I would argue that the comfort of a label is never a valid reason to risk such a loss.