AACP Newsletter, Volume 14,
Number 1, Winter 2000
President's Column: Kids Who Do Bad Things and DSM V
What is lost in our DSM nosological system is what most of us grew up with as medical students: a clear tie between a criteria-defined syndrome and an illness entity that has a defined etiology, pathogenesis and course. Our current understanding of some of the illnesses we treat enables us to apply this same medical logic as we describe the neurochemistry and neuroanatomy of psychiatric diseases, and literally to see an illness manifest in or fabulous imaging methodologies. Yet many of the syndromes in child and adolescent psychiatry, as well as some adult syndromes, still fail to meet some of the most fundamental criteria for a medical diagnosis. Conduct Disorder and Oppositional Defiant Disorder are two such syndromes with which we in adolescent psychiatry struggle daily. Both have clear criteria and are very commonly seen in the practice of public child and adolescent psychiatry. But are they real?
I have advocated that we at least delete Conduct Disorder from the DSM V, and have led a successful campaign in the American Society for Adolescent Psychiatry in support of that proposition. I am seeking support within the AACP as well. Conduct Disorder is an example of a heterogeneous syndrome that has no bottom line criteria to serve as a marker for the disorder, and is simply a list of socially obnoxious and dangerous behaviors. What do we know when we make a diagnosis of Conduct Disorder? Only that a teenager has disorderly conduct; that they have "bad behavior." There is no presumption made that with this diagnosis there will be any treatment afforded which will alter the behavior. In fact, the presumption is that if the disorder starts early, it has a poor prognosis. And if it starts in adolescence, kids might grow out of it. Clearly our funders have sensed that paying for treatment is of dubious value. Kids with any Disruptive Behavior Disorder are seen as not fit for the mental health system and should be the charges of Juvenile Justice. Sadly, ADHD and sometimes even Bipolar II Disorder suffer guilt by association. When reviewing the criteria for Antisocial Personality Disorder one has a similar disquiet as with Conduct Disorder. The criteria are clear enough, but what do we have? We presume that we are dealing with a cold sociopath when we are dealing with someone with Antisocial Personality Disorder and often we are, but what medically might be lurking behind the behavioral criteria we are given in the DSM IV definitions?
In the case of Conduct Disorder we see a phenomenal amount of co-morbidity. It is the co-morbidity we can often treat if it is a more medically understandable syndrome such as an anxiety or affective disorder. We can treat traumatized and insecurely attached children and children with behavior problems as part of an adjustment disorder if we have become skilled in applying various forms of psychotherapeutic interventions. Many seem to treat these kids successfully even though our researchers haven't zeroed in on such syndromes as yet to give us the benefits of a large body of evidence. When the co-morbid condition is less amenable to treatment, such as Fetal Alcohol Syndrome, or Traumatic Brain Injury with personality change, such etiological knowledge is critically important for how we manage such individuals and the mobilization of a humane response to their tragedy. Could it be that the disorderly conduct, which we have segmented off as a separate syndrome, is actually part of the so-called "co-morbid illness"? What do we know of the manifestations of stress in children and adolescents? Certainly we understand that "acting out" or behavioral expression is the currency of communication for children and adolescents.
In looking at our future editions of the DSM, we might need to make some adjustments to allow for behavioral expression of syndromes that are currently defined for adults. We have some excellent research by those who have looked at trauma in children that could be supportive of some expansion of the PTSD criteria to include more behavioral symptoms for those who have suffered chronic abuse. Those of us who are getting the feel for how affective disorders manifest in kids know that behavior is central to understanding these illnesses in kids. Many of us feel that there is a grossly inadequate treatment of attachment disorders in the DSM IV and that small children who have been deprived of essential attachment opportunities continue to show problems based on their developmental stage throughout their childhood and into adulthood. Might we finally begin to make sense of our Axis II diagnoses and see them as personality residue of flawed developmental processes? Might such a conceptual leap enable us to be more focused in our research on personality disorders? To eliminate Conduct Disorder from the DSM would force us to look at the inclusion of behavioral criteria as an option for many other syndromes. This would alter the assumptions we make about the incidence of our syndromes based on the research using the current criteria. To move in this direction turns over the apple cart of our much praised non-etiologically based diagnostic system. Tinkering with Conduct Disorder would demand a re-looking at all our diagnoses, and folding in some etiological presumptions. Perhaps we have matured sufficiently as a field to make such a leap. It would be a move fraught with controversy and demanding of some courage. But to not take such action excludes child and adolescent psychiatrists, our experience with psychological development, and many of our patients from the mainstream of psychiatric medicine.
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