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.