Diagnostic Labels and Kids: A Call for Context
To a great extent, DMDD and PBD are problems created by managed health care systems within the United States, because ongoing care is restricted to a few diagnostic labels resulting in "diagnostic up-coding." Brief consultations and pharmacotherapy are reimbursed in preference to a more time-consuming holistic, biopsychosocial approach that includes the child’s family and all contextual factors.
In contrast, the practice of child psychiatry in Australasia and Europe is less dependent on managed care restrictions and can incorporate the holistic model. PBD is rarely diagnosed in those parts of the world (Child and Adolesc. Mental Health 2009;14:140-7).
While doing research for this piece, I conducted a review of the SMD/TDD/DMDD literature. Forty-seven English-language articles failed to mention attachment and gave minimal attention to trauma, maltreatment, parenting, and family dynamics as etiologic factors. Interestingly, a single German and one French article did focus on those contextual factors.
The DSM itself has come under intense criticism as of late because of its "a-theoretical" symptom checklist approach. This comes at the cost of the core psychiatric skills of taking a thorough history and mental state examination of not only the child, but also the child’s family and environment. One way in which the DSM-5 could improve the focus on contextual factors would be to expand reactive attachment disorder (RAD) or include another proposed diagnosis: that of developmental trauma disorder (DTD). Both RAD and DTD acknowledge that childhood emotional and behavioral problems usually don’t occur in a vacuum. Meanwhile, the emergence of the DMDD diagnosis can be seen as a symptom of a deeper problem in psychiatric nosology.
Like many (48 professional organizations have signed the American Psychological Association’s online petition to the DSM-5 as of this writing), I, as a clinician, am concerned about the overemphasis on often-simplistic labels that pretend to explain all. As I have argued before, we must not lose sight of the traditional child psychiatric skills of synthesizing a thorough family and developmental history with exploration of attachment, family dynamic, trauma/maltreatment, and temperamental factors (J. Trauma Dissociation 2012;13:51-68). Indeed, Dr. Frances was right when he said that inventing a new diagnosis to combat a bad one is not necessarily a good idea.
Dr. Parry is a child and adolescent psychiatrist, and a senior lecturer at Flinders University in South Australia. He has worked in inpatient and outpatient Child and Adolescent Mental Health Services in South Australia, Queensland, and Wales (the United Kingdom). He is a member of "Healthy Skepticism," an organization dedicated to "improving health by reducing harm from misleading drug promotion."
