There is a new childhood mental disorder being proposed for DSM-V: temper dysregulation disorder with dysphoria (TDD). When I first read its criteria, my thoughts were: “Finally, it’s about time people are acknowledging not all children’s irritability is bad behavior.” Quite honestly, if this disorder had been around in DSM-IV in 1994, I would’ve been a surefire candidate for a diagnosis, except for the fact that autism should be ruled out first – but then again, I’m not sure autism would’ve been the first thing a shrink thought of when seeing me if TDD had been on the books.
Then, I started wondering about the background to this diagnosis: is this perhaps some kind of euphemism for “pediatric bipolar”? For people not familiar with “pediatric bipolar”, it is a highly controversial condition populated almost exclusively by Joseph Biederman and his associates at Harvard, and almost exclusively diagnosed in American children. This diagnosis presumes the idea that bipolar disorder can have onset, and in that case of course should be treated, in childhood rather than not until adolescence or adulthood. Note that “early-onset” bipolar disorder has pretty different symptoms from classic manic depression in adults: depressed and irritable moods and brief rages are much more prevalent than classic mania. Nonetheless, this disorder is treated with the same pharmaceuticals as adult bipolar disorder, ie. a combination of mood stabilizers, antidepressants and atypical antipsychotics, usually in pretty high doses. I am not aware of any research indicating that “pediatric bipolar” children actually do grow up to be adult bipolar sufferers, even though this is presumed by the Biederman fan club. In fact, my inclination is that “pediatric bipolar” has not been around long enough to tell whether these children actually do develop adult bipolar, but that the assumption that they do, is quite possibly going to cloud further research.
Now TDD turns out to be an attempt at damage control from “pediatric bipolar” indeed. It is presumed to be a brain-based mood disorder, but it is not necessarily thought of as lifelong. Now that is somewhat of a positive thing, in the sense that not every child who receives this diagnosis at age six, will be on Zyprexa for the rest of their life. However, I did not see a single acknowledgement that TDD could possibly not only not be lifelong, but could also be quite different from bipolar, and, for this reason, require different treatment. I am not a big fan of the classic forms of behavior modification for children with disruptive behavior disorders with an obvious mood component, but that is not the same as saying pharmaceutical treatment is best. Has any research been done on psychological interventions for children with disruptive behavior disorders comorbid with mood disorders, and their effectiveness in treating both? I do not know, but if it is, this should be acknowledged when thinking out treatment options for TDD.
Of course, I have presumed here that TDD is real, and that it will be diagnosed in children who are actually mentally ill, rather than opening up a new can of worms of mostly minority children labeled with fake mental illness to conceal the way society fails them. This is, of course, rather naive of me: every new childhood mental disorder has had its “epidemic”. First we had ADHD, then autism, then “pediatric bipolar”. Now TDD seems milder than “pediatric bipolar”, but that effect will largely be annihilated when it in fact opens up the floodgates to diagnosis of children who would never have been diagnosed with “pediatric bipolar” even in Biederman’s wildest dreams. There is, after all, a lot more overlap with normality for TDD than for bipolar: if a child doesn’t meet crieria for a depressive and a (hypo)manic episode, they simply cannot be diagnosed with bipolar disorder unless we amend its criteria. On the other hand, losing your temper quite frequently and being angry or sad most of the time for over a year, is enough to be diagnosed with TDD. When I looked at the criteria, they sounded a lot more stringent than I would have expected for a presumed “epidemic”, but then again I never understood how ADHD could be an “epidemic” with its DSM-IV criteria, and I suspect many children who actually do not meet the criteria, have been diagnosed nonetheless. There is no reason to assume this will not happen with TDD, either.
Then there is the problem with the presumption of TDD just being a non-lifelong form of “early-onset bipolar”. Given that its symptoms are quite different from those of bipolar, what will happen to a child diagnosed with TDD who obviously does not have bipolar, but who still has symptoms after a certain age? In the criteria, onset is said to be before age ten, but the assumption that this means a child cannot still have symptoms at age eleven, sounds a little strange to me: isn’t onset something different from duration? ADHD currently has to set on before age seven (they are expanding that, too, unfortunately), but that doesn’t mean that an eight-year-old child cannot be diagnosed with ADHD. Then again, since they are professionals suggesting that the onset criterion means eleven-year-old potential TDD cases are left in a mysterious psychiatric limbo, it is a possibility that this is indeed going to happen. Will, in that case, these eleven-year-olds be diagnosed with “pediatric bipolar” after all, despite its different symptom presentation?
And what happens to children who on the surface would meet TDD criteria, but who really have something else? I said right at the beginning of this post that I would’ve been a surefire candidate for a diagnosis if this had been around in 1994, yet I am autistic. Children who experienced trauma may also meet TDD criteria, but that quite emphatically does not mean they have a brain-based mood disorder requiring pharmaceutical treatment. I do not trust psychiatrists to rule out every single disorder or condition they have to rule out before making a TDD diagnosis. This will likely open up the doors to yet more inappropriate treatment. This is not merely a matter of drugs being potentially harmful (I hereby predict the next childhood epidemic: type 2 diabetes!), but also the fact that children will miss out on psychological treatment or counseling that would help them. As I said, I do hope some focus will be given to psychological interventions for TDD, if it genuinely makes it into the DSM-V, but I am skeptical given its brain-based hypothesis. This means that many children who actually have social or psychological problems, but who exhibit the behavioral characteristics of TDD, will once again not be served adequately.
Really good consideration of this new “disorder.” I agree with a lot of this.
I, too, would have likely been diagnosed with this as a child had such a diagnostic category existed. (As it was I was informally diagnosed with being an overemotional, hysterical female and a bad child. Even though I was 7 when the DSM IV came out, there was considerable lag time in getting me recognized as being on the spectrum.) And I’m really not sure what to think about this diagnosis. My main objection is that it doesn’t consider WHY a child might be acting this way. And I’m not convinced that the educational system is going to respond to this new diagnosis as meaning something other than Badly Behaved Child Who Needs Punishment. I’m not sure it’s necessarily defined as anything more nuanced than that, which is really unfortunate. This puts an official medical label to being unusually prone to “tantrums,” but doesn’t consider how a child’s environment might be altered and adapted to be less provocative. Like you, I fear medications will be the first resort, when in fact there are many different reasons why a child might act this way, including being the victim of abuse.
If childhood diagnosis of bipolar is a problem, it’s a problem because of medications. I have to look up Biederman–I didn’t realize that one person in particular is largely to blame. Grr. I’ve seen reports of at least one case of a toddler diagnosed with Bipolar Disorder at the age of 3, who then died due to overdose of an antipsychotic. I’m not terribly optimistic that the new DSM will due much to prevent overmedication and tradegies like this.
I am a retired psychologist. I have bipolar II, late onset (38), though I had bipolar characteristics showing up in my late teens.
From 1970 through 1974 I worked in outpatient developmental disabilities settings. We often saw children who behaved like those now “honored” with childhood bipolar diagnoses. We never saw them as bipolar, though we saw they were labile, with a tendency to react negatively to new or challenging situations. The physicians on our team sometimes tried lithium or Tegretol. It either didn’t do much or didn’t help at all.
After 13 years in research, during which my own bipolar condition manifested itself, I began working as a clinical psychologist in a large state psychiatric hospital. We had both developmental disablities and a child psychiatry unit. In my service on those units, I did many evaluations, and in my 18 years at that hospital , I diagnosed a few teens as bipolar, and just two pre-teens. Many other labile, impulsive, negative-affect pre-teens were clearly not bipolar, and when mood stabilizers were tried with them, the results were mediocre or zero.
During the same time period, I was facilitator on a weekly basis for support groups for people who were often depressed or manic depressive. When they related their childhood, there was no indication that they had been “bipolar” as children. Usually their childhood was fairly ordinary, as was mine.
In my opinion, the so-called childhood bipolar patients are not bipolar at all. They certainly have serious temperament, impulse, and mood problems, but they need a lot more behavioral assistance, and somewhat less medication. The two pre-teen bipolar patients I tested and diagnosed had clear bipolar mood swings, clear bipolar type sleep changes, and both had intervals where their behavior was fairly normal, as is typical with adult bipolars. The diagnostic criteria used to diagnose “bipolarity” in many children are not derived from our understanding of adolescent and adult bipolar conditions, and these children do not act bipolar.
Because of the length of my career, I saw a few troubled, labile, moody children mature to adulthood. Though they would have qualified for “childhood bipolar” disorder as children, they did not show bipolarity as teens or young adults. (However, it was not unusual for children with autism to develop some bipolarity as adults.)
A lot of fame and financial gain has gone along with the craze of calling many children bipolar. And in watching “Frontline” interview some of the childhood bipolar crusaders, I was MOST struck by their ignorance of behavior interventions. We were using such interventions with success back in the early ’70s, but for insurance reasons, they have not been sufficiently available.
Finally, regarding the “brain scan” approaches to childhood “bipolar” diagnosis, there is nothing wrong with their raw data. Some kids have small amygdalas. But to even suggest that this is a basis for diagnosis or treatment in a clinical way is to fail to understand limitations of physiological psychology that were drummed into our heads when I was a graduate student.
Gary, I agree with you that moody, temperamental, impulsive children are n ot bipolar. That was oen of the points I wanted to make in this post: even if TDD is real, it is not a non-lifelong form of bipolar, since its symptoms do not conform to classic bipolar. Nonetheless, its proposed pharmaceutical treatment is very similar to that for adult bipolar. This, however, does not seem to necessarily follow out of some idea about similarity between TDD and bipolar, since I see psychiatric drugs being studied and eventually approved for a wide range of disorders with very little in common. To use an example, antipsychotics will of course first be approved for schizophrenia, usually followed by acute mania and then standard therapy for bipolar. After this path has been walked, antipsychotics may be studied and approved for vastly different disorders which may or may not have some overlap with disorders a drug has already been appoved for. For instance, I find it rather intriguing to see that, as soon as an atypical antipsychotic has gained FDA approval for irritability associated with autism, a study will pop out investigaitng its effects on autism core symptoms, despite the fact that I can see absolutely no logical reason why an antipsychotic would ease social or communicative impairments (there is a tiny bit of logic behind its use for repetitive behavior).
I’ve only worked with a few children and young adults at the most severely impaired end of the autism spectrum. What I saw over the years at the hospital was that antipsychotics seldom had a discernible effect on the behavior of our “autistic” patients. The same was usually true for mood stabilizers and antidepressants. Fortunately the physicians managing medication were not inclined to “see things” and prolong use of a medication beyond the point where it was clear it had only non-specific and side effects.
I recall only one possible exception, perhaps not applicable to autism, because it was with a young woman who had contracted disintegrative disorder at about age 2. She had some speech and language, but was quite avoidant socially. She was put on Prozac and Risperdal, and she improved markedly, later being able to return to live with her parents. However, there was another intervention done at the same time as the start of the medications. I had assigned an attractive female psychology intern to work with the patient, and the intern found a number of ways they could spend time together, including learning simple piano pieces. My opinion is that both the meds and the relationship intervention were crucial, but I can’t prove it one way or another. There are indications that SSRIs can decrease avoidant behavior in some people, but I don’t know about autism spectrum disorders. I recall hearing recently that a study did not show general usefulness for SSRIs with autism spectrum disorder.
I am a counselor at a school for children and adolescents with a wide variety of disorders, but primarily who qualify for special education under the emotional disturbance handicapping condition. Most of our students have an official bipolar diagnosis yet few actually present with typical bipolar symptoms. Most of them have abnormal mood at times with frequent and severe rages and temper tantrums. Most of these children are prescribed a concotion of antipsychotics, some SSRI’s and ADHD meds. Based on my training I was always taught that typical ADHD meds such as stimulants are not usually given to people with bipolar because it can induce or increase mania. Yet this doesnt ever seem to happen with our kids leading me to believe their symptoms arent true mania that one would see in adults. Like Gary I have Bipolar II that started presenting in my late teens, takes a very classic course and is treated with mood stabilizers quite successfully. I never displayed any of the symptoms I see in our “bipolar kids”. I suppose I am in support of a change of diagnosis but I agree that every one might jump on the TDD bandwagon and it could spiral out of control.
I think the bipolar discussion with children is very interesting. My 8 year old son has an IEP for “emotional.” He used to qulifify for speech too. My son is currently on zoloft and risperidone and it doesn’t seem to be helping. When he first went on the medication it helped his anxiety disorder. He is also diagnosed ADHD with Oppositional Defiant Disorder. He has such mood swings and is usually very angry and negative. My husband has come across more research and books with bipolar in children and wants to have my son tested. My son hasn’t started ridilin yet, we picked up the presciption the other day. I also want to rule out celiac disease. He gets OTC multivitamins and omega 3; no food colorings esp. reds and yellows, and we eat an all natural diet with no to hardly any preservatives or additives. Our son has a very hard time falling a sleep, but when he does he is out. He is no exhibits anxiety, counseling has seemed to help, but then I am also not sure how much is the medication at work because our son is now the life of the party (at soccer and cub scouts). My husband would describe him is manic. Sometime he will do something mean and asked why, he will respond that he just felt like it or his brain told him to. So many professionals have diagnosed our son with different labels and as parents we just want answers and to pin point what it really is to help him. When teachers fill out the ADHD/ADD form, he scores zeros on everything expept for focus, he will get a 1 or 2. If he was truly ADHD it should exhibit itself at school unless it is being supressed by anxiett, zoloft or risperidone. When he gets home he is a different kid then at school, he is all over the place, energetic, gets bored easily and seems pent up–the same goes for at soccer or cub scouts. Our son has been defiant since he was 3, along with anxiety. At the age of 4 different psychs/counselors diagonosed- ADHD, mood disorder, oppositional defiant disorder, anxiety, speech therapy. We are trying to figure out if they are all intertwined, some disorders share similar traits….I just don’t want a depressed little boy that can’t even wnjoy Disney World, thinks that everything is “stupid” and can’t focus. You have a great blog that helps to ponder different ideas.
Wow I’m not sure about anything, my son is 9 he is on zoloft and resperdone last March he woke up one day and started confessions about anything and everything at first we thought it was church related..It wasn’t then he started getting aggitated and his mind kept telling him to say or things he obsessed about several things he was an honor roll student in the third grade, it’s like the filter left his brain after several weeks of everyone turning us away he finally became very agressive and suicuidal…. He has been diagnosed with OCD and a mood disorder at first they said PANDAS we’ve been to Riley Hospital and had extensive blood work done and an MRI although some blood work showed some elevated levels that could link us to PANDAS I really believe that’s not it, which anyways you wouldn’t change your course of action anyway. The thing is the meds aren’t working anymore he’s extremely aggitated alot hyper always has been but always remorseful if he says or has a terrible rage which he does 4 or 5 days a week. He controls it pretty well at school focus and distraction sometimes get the better of him but still almost all A’s no problems other than the need to speak often. He’s fearless and when he gets something in his mind he won’t let it go. He’s very competetive and plays several sports but the meds are effecting his endurance? We are at a loss and not sure what to try ?? I would love to talk with parents or doctors we are tired and sad for him he dosen’t like the way he feels at all..
This sounds like a rather intelligent and fast-thinking child who gathers reinforcement from others for his thoughts and behaviors. Unless he is manic (very unlikely), medication is not going to do much. He needs a psychiatrist or psychologist skilled in helping him (and his family) to seek gratification for “normal” interesting behavior, not for rage episodes or quirky thoughts like “confessions.” You will have to learn to sidestep (not the same as completely ignoring) his quirky or overly emotional behaviors, and try to steer toward and reinforce behaviors that are normal for an intelligent child.
This will not be easy, and it will go faster if you can find a behaviorally oriented professional to help. Again, you cannot focus only on medications, because he will stop acting odd only when he finds it more satisfactory to act mostly normal.
According to APA website, the folks who bring us the DSM, children who have been in the 10 year criteria study that were diagnosed with TDD ended up being depressive individuals in adulthood and responded best to antidepressant medications. The children diagnosed with early onset Bipolar, especially if classic “mania” was documented tended to be Bipolar into adult hood.
I think they’re bending their data. I have facilitated several bipolar/depressive support groups over a period of 15 years, and I never met a participant who reported bipolar characteristics as a child. I worked at med school pediatric/developmental/psychiatric programs in 1970-72, and served on the child psychiatry unit in a high throughput state hospital in the 90s. In those periods, I encountered only three (3) bipolar children, not young, but 11-13 in age. I once heard of a bipolar type 1 boy, 7 years old, from a person I trusted.
On the other hand, back in the 70s, we were seeing TDD kids all the time. They showed a weak response to the mood stabilizers we had at the time, but our behavior modification programs helped if parent saw it through. At the state hospital facility, if there *were* bipolar kids who responded to mood stabilizers, we certainly would have seen them. I also worked on the adolescent unit at the same hospital, and occasionally an unquestionably bipolar patient would show up.
Again I say, the childhood bipolar disorder diagnosis was created by people who did not know what they were doing. It served their ends, but has exposed many kids to drugs they didn’t need , while depriving them of behavioral services that would have helped. The DSM diagnosis changes are very welcome, and I hope insurance companies pay attention.