Child psychiatric diagnosis on trial

When Carolyn Riley was convicted of killing her 4-year-old daughter Rebecca by overdosing her with psychotropic drugs prescribed for the child, some jurors reportedly felt that the psychiatrist who wrote the prescriptions should also have been on trial.

That will not happen: the doctor was granted immunity when agreeing to testify in the case. But the validity of the condition for which Rebecca was being treated is being questioned by psychiatrists. The American Psychiatric Association (APA) says it needs to be replaced by an entirely new diagnosis, while others argue that this move could create fresh problems.

Rebecca was being treated for juvenile bipolar disorder. The number of children diagnosed with this condition has skyrocketed: in 2003 it was diagnosed in 1 in 100 under-20s who visited US doctors, up from 1 in 4000 in 1995, according to one estimate.

But the day after Carolyn Riley's conviction for second-degree murder last week, the APA released proposals suggesting that a newly defined condition, to be called temper dysregulation disorder with dysphoria(TDD), would better reflect the problems of many children who swing between extreme outbursts of aggression and periods of irritability, anger and sadness, and who are now classed as bipolar.

According to Gabrielle Carlson, a child psychiatrist at Stony Brook University in New York, diagnoses of juvenile bipolar disorder rose partly as a knock-on from previous diagnostic shifts, including a narrowing of "conduct disorder" to focus on children who will go on to develop antisocial personality disorder.

That left psychiatrists searching for a label to guide treatment for children who were prone to severe violent outbursts and persistent mood problems. The answer seemed to come in 1995, when Janet Wozniak of Massachusetts General Hospital in Boston argued that the violent outbursts were equivalent to the manic episodes of adults with bipolar disorder. It has since emerged, however, that these children rarely go on to become bipolar adults.

The big question is what effect a new diagnosis will have on treatment. Rebecca Riley was on an antipsychotic called quetiapine, the anticonvulsant valproate, and clonidine, which was being given as a sedative. The most severe cases of TDD might still be treated with antipsychotics, but probably only as a temporary measure. With bipolar disorder, drugs are often prescribed long-term.

The psychiatrist Allen Frances, who led a 1994 revision of the APA's diagnostic manual, has already accused the association of creating a "new monster". Writing in the professional newspaper Psychiatric Times, Frances argued that TDD "would be very common at every age in the general population and would promote a large expansion in the use of antipsychotic medications".

That criticism is rejected by David Shaffer of Columbia University in New York, who chairs the APA working group that proposed the new TDD definition. He argues that it has been carefully defined to focus on children with especially severe outbursts. "It's not psychiatrising normal temper tantrums," he says.

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