Why so many epidemics of childhood mental disorder?

Allen Frances, MD,* Laura Batstra, PhD† Since the publication of DSM-IV in 1994, the rates of 3 mental disorders have skyrocketed: attention deficit disorder (ADD) tripled, autism increased by 20-fold, and childhood bipolar disorder by 40-fold. It is no accident that diagnostic inflation has focused on the mental disorders of children and teenagers. These are inherently difficult to diagnose accurately because youngsters have a short track record; are in developmental flux that makes presentations transient and unstable; are sensitive to family, peer, and school stresses; and may be using drugs. If ever diagnosis should be conservative, it should be in kids. Instead, we have experienced an unprecedented diagnostic exuberance encouraged in part by DSM-IV, but mostly stimulated by the powerful external forces of drug company marketing and the close coupling of school services to a diagnosis of mental disorder. ADD is a prime example. The DSM-IV field trial had predicted that the rates of ADD would increase by just 15% in response to a criterion change that made it a bit easier to make the diagnosis in girls (who more often present only with inattentiveness). 1 The unexpected tripling of ADD rates to 10% of all kids has resulted in a jump of medication use to 4%. Some of this explosive growth may have resulted from increased awareness and better case finding, but most certainly, there was also a dramatic overshoot. Four large studies showed that relative age is a significant determinant of attention-deficit hyperactivity disorder (ADHD) diagnosis and treatment.2–5 The youngest children in class are up to 70% more likely than their classmates to receive a diagnosis of ADHD and medication. Being young should not be medicalized inappropriately into mental disorder. Three years after DSM-IV was published, drug companies introduced new and expensive on-patent drugs that provided the incentive and resources for an aggressive marketing campaign to psychiatrists, pediatricians, and family doctors. Simultaneously, successful drug company lobbying gave them unrestricted freedom to advertise directly to consumers. Parents and teachers were inundated with the message that ADD was terribly underdiagnosed and easily treated with a pill. Sales of ADD drugs ballooned to an astounding $7 billion. Childhood bipolar disorder is an even more chilling case. DSM-IV had wisely rejected a proposal that there be a separate and much looser definition of bipolar disorder in children. The argument for inclusion rested on the unreplicated findings of just 1 (albeit very influential) research group suggesting that kids present a developmentally different prodromal form of bipolar disorder characterized by ambient irritability, impulsivity, and temper outbursts, rather than the typical cyclical mood swings of adults. Rejection by DSM-IV did not stop charismatic thought leaders (who were heavily financed by drug companies) from spreading the gospel of childhood bipolar disorder. The 40-fold increase in rates was accompanied by an increase in antipsychotic spending up to $18.2 billion in 2011.6 These drugs frequently cause massive weight gain in children. The overuse of antipsychotics in kids was not deterred by the fact that childhood obesity is an important risk factor for diabetes and heart disease. Drug companies have received billion dollar fines for off-label marketing to kids, but these pale in comparison to the enormous revenues. Of note, the inappropriate use of antipsychotics is most pronounced among children who are economically disadvantaged. The introduction of Asperger’s by DSM-IV was expected to result in a 3to 4-fold increase rates of autism. Severe classic autism had an unmistakable presentation with rates lower than 1 per 2000. Asperger’s blends imperceptibly into normal eccentricity, and the rates of autism are now reported at 1 per 88 in the United States and 1 in 38 in Korea. Theories connecting the increase in prevalence to vaccination have been discredited. Instead, the rates have grown so rapidly because a diagnosis of autism is required to allow a child access to greatly enhanced school services. About half the youngsters who now receive the diagnosis do not really meet the DSM-IV criteria when these are carefully applied. And follow-up studies finding that half the kids no longer meet criteria also confirm that diagnostic inflation is rampant. Eligibility for school services should be decoupled from an unreliable clinical diagnosis and instead be based on educational need. DSM-5 threatens to start a further epidemic of childhood mental disorder. It is introducing a new and untested diagnosis, Disruptive Mood Dysregulation Disorder (DMDD), that has been studied systematically by only 1 research group for just a few years. The motive is praiseworthy—to reduce the harms of overdiagnosis of From the *Department of Psychiatry, Duke University, Durham, NC; †Department of Special Needs Education and Child Care, Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, The Netherlands.