LOS ANGELES – Psychiatrists need to find a better diagnostic home for children who have explosive outbursts, according to Dr. Gabrielle A. Carlson.
They happen in children with all kinds of psychiatric diagnoses, but no good diagnostic description captures the pervasiveness of the problem, said Dr. Carlson, director of child and adolescent psychiatry at Stony Brook (N.Y.) University.
In some places, explosive outbursts earn children diagnoses of bipolar disorder, though they might otherwise lack classic symptoms.
And although some explosive children meet the criteria for temper dysregulation disorder with dysphoria (TDD), a diagnosis being considered for the DSM-5 ("New Pediatric Diagnoses Proposed for DSM-5," Clinical Psychiatry News, December 2010, p. 1), TDD would exclude children with many common psychiatric problems, including autism, depression, and posttraumatic stress disorder, Dr. Carlson said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.
Children with these common diagnoses can have rages, too. "What about those kids?" she asked.
Intermittent explosive disorder isn’t a good fit, either, because it requires the absence of other psychiatric disorders, she said.
Modifying the Problem
Finding a diagnostic home for kids with explosive anger is more than an academic concern.
It matters because "explosive outbursts are the most serious, compelling problem we have in child psychiatry," often the reason why children are institutionalized, Dr. Carlson said.
"Until we’ve got a good label for [the problem], we are not going to have the [Food and Drug Administration] going after the indication; we are not going to have grants from the [National Institute of Mental Health] studying it," she said.
Dr. Carlson said she believes the solution is including a "with explosive outbursts" modifier in the DSM-5 to add to comorbid conditions such as attention-deficit/hyperactivity disorder. But the idea is not likely to make it into the upcoming version of the diagnostic manual. Dr. Carlson said she has been told by those involved in the revision that such a modifier would likely go unused by clinicians.
She proposed the idea to Dr. David Shaffer, the Columbia University professor of child psychiatry who serves as head of the DSM-5 childhood disruptive disorder work group.
In an interview, Dr. Shaffer confirmed that Dr. Carlson had, indeed, proposed the idea in an e-mail. In general, modifiers "come to be seen as subsidiary or a consequence to the parent diagnosis," he said in response to Dr. Carlson. "You then get into the whole causality ... debate which is a guaranteed way to undermine a diagnostic system. While we can usually agree on what we see, it is hard for us to agree on cause," he wrote. The modifier also would "end up littering the system with a host of specifiers," he added.
Complexity is "one of the factors that has been shown to reduce the reliability of a classification system. One of the goals for ... DSM-5 is to reduce the number of codes available," explained Dr. Shaffer, who also serves as chief of the division of psychiatry at Columbia University, New York. Meanwhile, in one of her responses, Dr. Carlson countered that "with explosives outbursts" wouldn’t be a new code, simply a modifier for existing conditions.
A Robust Effect for Stimulants
Though explosive outbursts occur in many disorders, they are most common in severe ADHD, oppositional-defiant disorder, and learning and language disorders, Dr. Carlson said. A thorough diagnostic work-up is needed to pinpoint their underlying cause so treatment can be provided. Behavior modification can help when the cause is ADHD; cognitive-behavioral therapy, when it’s depression. Social skills and language training help in autism.
Drugs have their place, too, but the target of drug therapy shifts to the outbursts themselves if treatment of their underlying cause fails. Lithium and divalproex have modest effect sizes for aggression in children, in the 0.3 range; effect sizes hover around 0.5 for alpha-agonists and 0.7 for atypical antipsychotics, Dr. Carlson said. Stimulants have the largest effect sizes, about 0.8, perhaps because ADHD is common in children with explosive outbursts, she said.
Dr. Carlson said she is concerned that the ADHD connection will be masked by a diagnosis of TDD, should TDD make it into DSM-5. "You’re going to forget these explosive kids [often] have ADHD, and will not use ADHD medication. That’s too bad; the effect size is 0.8," she said.
With drug treatment, "you need to keep the person on it for a while. You’re going to get some improvement, but it isn’t going to clean up nicely. It’s probably a good thing to warn people we can’t always do that," she noted.