Diagnostic change not enough to help children diagnosed with bipolar disorder

May 19 2010

Shifting children from the controversial diagnosis of bipolar disorder to one that more accurately reflects their symptoms will not by itself decrease the rate of psychopharmacologic treatment and is not enough to help troubled children flourish, according to a commentary in the May 20, 2010 issue of the New England Journal of Medicine by researchers at The Hastings Center, a bioethics research institute, and a physician-researcher at Stony Brook University School of Medicine.

A new diagnostic category for troubled children called Temper Dysregulation Disorder with Dysphoria (TDD), which would to a considerable extent replace the diagnosis of bipolar disorder in children, is one of the most talked-about features of recently released draft revisions to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). The new diagnosis would focus on negative mood and temper outbursts as their own symptoms, rather than as indications of mania or other elevated mood symptoms associated with bipolar disorder.

The proposal of a new category suggests that the dramatic increase in the number of children diagnosed with bipolar disorder is not appropriate. But "will the TDD diagnosis promote the ultimate goal of psychiatric classification: helping troubled children to flourish?" ask Erik Parens, senior research scholar at The Hastings Center; Josephine Johnston, research scholar at The Hastings Center; and Gabrielle A. Carlson, Director of Child and Adolescent Psychiatry at Stony Brook University School of Medicine. The answer is no, "unless we get serious about reforming pediatric mental health care," the authors write in an essay, "Pediatric Mental Health Care Dysfunction Disorder?"

"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," according to the authors. "The dispute has been about whether bipolar disorder is the right diagnostic home."

The TDD label more accurately describes the behavior of most children currently diagnosed as having bipolar disorder, the authors write, and it reflects what is not known, including the outcome of their condition. They add that the new label will assist researchers studying the etiology, treatment, and outcomes of a serious behavioral and mood disturbance.

"But switching from the bipolar label to the TDD label will not decrease the rate of psychopharmacologic treatment," the authors warn. "If applied trivially to any kind of temper tantrum, it will actually increase medication use." Children labeled TDD will probably receive many of the same medications currently prescribed for children labeled bipolar disorder, which are associated with significant side effects.

One thing is widely agreed, according to the commentary: treatment with medications alone is seldom sufficient. Yet a recent study of large private insurance databases found that most children prescribed antipsychotic medications did not receive psychosocial treatment, as well. "Troubled children, regardless of their diagnostic label, deserve better," the authors conclude.

Parens and Johnston led, and Carlson participated in, an interdisciplinary series of workshops at The Hastings Center that looked at controversies in the diagnosis and treatment of mental illness in children. Participants included psychiatrists, pediatricians, educators, bioethicists, parents, and social scientists. The project was funded by the National Institute of Mental Health.

www.thehastingscenter.org.