rethink this: Why the DSM Still Matters

The all powerful DSM is currently under revision (image courtesy of

Happy Monday Everyone. Today I want to spend a little time on a news item that almost slipped right past me. I’m talking about the American Psychiatric Association’s decision to once again revise the Diagnostic and Statistical Manual (or DSM) – an dictionary/encyclopedia of mental disorders that doctors use to diagnose patients. The APA is working on what will be the 5th edition of the DSM – due for release in May of 2013. The DSM has a number of critics and has drawn plenty of criticism throughout its existence (for more on that you can refer to wikipedia’s page on the DSM here). According to NPR the latest debate concerns how one of the revisions in the DSM will affect children. The 5th edition of the DSM will include a new diagnosis called temper dysregulation disorder – and many hope this label will replace the diagnosis of bipolar disorder in children. In order to understand why this is a big deal, we have to look at how the diagnosis of bipolar disorder came to be associated with children.

It’s only been since the mid-1990s that children began to be diagnosed as bipolar. Behavior that was once labeled “conduct disorder” in young children (or as unmanageable cases of extreme ADHD) – such as extreme mood swings, violent episodes, and destructive behavior – was recast as symptoms of bipolar disorder after a famous paper by Dr. Janet Wozniak. Up until this point psychiatrists hadn’t even considered the possibility that children could exhibit bipolar tendencies. Labeling children as bipolar rather than having conduct disorder opened up several new avenues for parents and their kids. According to child psychiatrist Gabrielle Carlson, before the bipolar label, children diagnosed as having conduct disorder were given very little in terms of treatment options. Moreover, most insurance companies refused to cover any form of treatment for children with conduct disorder – since many thought the diagnosis was the direct consequence of poor parenting rather than a mental disorder or a biological concern. But all that changed once the children diagnosed as having conduct disorder were relabeled as being bipolar, which insurance companies viewed as biological problem and one that could be treated through psychiatric drugs.

One of the downsides of relabeling conduct disorder as bipolar disorder in children is that bipolar disorder is considered a life-long diagnosis. Meaning that once someone is diagnosed as bipolar there is no amount of therapy or psychiatric drugs that can make it go away – they can only help to manage the disorder . . . for the rest of their life. This is especially important in relation to children, whose moods and behavior may change as they mature. Applying a label as harsh and life-defining as bipolar to a child means that the child’s life will forever be altered, and a hasty judgment or a misdiagnosis can have drastic effects. This isn’t the only concern in labeling children as bipolar. Within the psychiatry field, most forms of treatment for bipolar disorder incorporate anti-psychotic medications. Anti-psychotic drugs are also used for children diagnosed as bipolar, yet very little is understood on how these medications affect children’s bodies and brains.

That last part was made abundantly clear in a Frontline special titled “The Medicated Child.” In this special (which you can preview above and view in its entirety on PBS’ site here) producer Marcela Gaviria asks psychiatrists and researchers how they can be sure children diagnosed with bipolar disorder are being properly diagnosed and properly treated. One of the scariest things the program highlights is how so many of the medications given to children diagnosed with bipolar disorder have actually never (!) been tested on children – which is to say that professionals have no idea if the drugs work the same way for children as they do for adults AND equally important they have no idea what dosage should be given to children. This information is crucial whenever administering any drug to a child, but it is especially critical when we’re discussing the use of anti-psychotic drugs in relation to children – in which the associated side effects include Parkinson’s syndrome, seizures, and tardive dyskinesia (or involuntary repetitive movements like tics) just to name a few. The Frontline special is so sad because many of the parents put all their faith in these psychiatrists and trust that what they’re doing is the absolute best for their child. Moreover, class distinctions are represented in the documentary, in which wealthier families can afford to significantly alter their child’s diet (such as consuming only organic produce and products) or incorporate unique forms of therapy, whereas working-class families are shown having to work and care for their child or care for multiple children along with their child diagnosed as bipolar. These parents often seem taxed and exhausted when they appear on camera.

Due to these concerns psychiatrists on the childhood committee for revising the DSM are asking that the new label temper dysregulation disorder be used rather than bipolar disorder for children. These doctors stress that the new label will “be seen as a brain or biological dysfunction, but not as a necessarily lifelong condition like bipolar.” Of course the new disorder may be treated with the same medications, but professionals are hoping that with a brand new label, psychiatrists will focus more on understanding children’s behavior rather than simply applying a label used for adults and mapping it onto children without understanding the nuances of how children’s bodies will be affected by the label and the medications used in treating the disorder.

I want to end this post by clarifying my position on children and medications. I want it to be clear that I am in no way suggesting that children shouldn’t be given psychiatric medications when appropriate and when there is sufficient evidence to suggest that the medication in question does more good than harm to children. To give you a greater sense of where I’m coming from let me share a little on my work history. For almost two years I worked as part of the direct support personnel in a group home that oversaw 5 mentally challenged teenage boys. The youth I worked with were diagnosed with everything from Asperger’s Syndrome to Dandy Walker Syndrome to Fetal Alcohol Syndrome. When on shift I was in charge of administering their medications in the morning and evening, making their meals, cleaning their rooms, and transporting around town and to and from doctors appointments. Working one on one with the boys, and being there for quite some time, I could see the positive effects of their medications, how for some the drugs made it possible for them to attend school and hold down a job. However, I also saw instances in which the side effects of one drug caused depression in one of the charges – which was then “treated” with yet another drug. Some of the boys in my care received up to 5 medications each morning and evening . . . and any amount of tweaking this medication or trying this other medication could cause a flare up in new behaviors or have such serious side effects that a combination of drugs was seen as the only possible solution. Due to my previous work experience, it is alarming to realize how little psychiatrists and professionals in the field know regarding medications’ affects on children and how children’s minds work.

~ by actyourage09 on February 22, 2010.

3 Responses to “rethink this: Why the DSM Still Matters”

  1. I read about this the other day-should have forwarded it to you! The thing that freaks me out about the sudden rush to diagnose kids with Bipolar Disorder is that there are clear and significant discrepancies in how the disorder presents itself in adults compared to in these children who’ve been diagnosed. So the shift in diagnosis back in the ’90s doesn’t even follow logically (esp. without systematic tests or inquiries!). Seems like a hasty grab at treatment options, which may have helped many children. but with the kind of drugs used to treat such a mysterious disorder, no one should be so hasty.

    • I couldn’t agree more! I understand that people want results and that families with children who exhibit violent behavior and (self-)destructive tendencies need support – but hasty decisions are dangerous.

  2. […] rethink this: Why the DSM Still Matters […]

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