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 dis-
order (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 dis-
orders 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).1The unexpected tri-
pling 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.2–5The youn-
gest 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 com-
panies introduced new and expensive on-patent drugs
that provided the incentive and resources for an
aggressive marketing campaign to psychiatrists, pedia-
tricians, 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 unre-
plicated findings of just 1 (albeit very influential) research
group suggesting that kids present a developmentally dif-
ferent 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
2011.6These 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
The introduction of Asperger’s by DSM-IV was
expected to result in a 3- to 4-fold increase rates of
autism. Severe classic autism had an unmistakable pre-
sentation 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 child-
hood mental disorder. It is introducing a new and
untested diagnosis, Disruptive Mood Dysregulation Dis-
order (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
†Department of Special Needs Education and Child Care, Faculty of Behavioural
and Social Sciences, University of Groningen, Groningen, The Netherlands.
Received March 2013; accepted March 2013.
Disclosure: A. Frances was chair of the DSM-IV taskforce. L. Batstra declares no
conflicts of interest.
Address for reprints: Laura Batstra, PhD, Department of Special Needs Education
and Child Care, Faculty of Behavioural and Social Sciences, University of Groningen,
Grote Rozenstraat 38, 9712 TJ Groningen, The Netherlands; e-mail: email@example.com.
Copyright ? 2013 Lippincott Williams & Wilkins
Vol. 34, No. 4, May 2013
www.jdbp.org | 291
childhood bipolar disorder by substituting for it a more Download full-text
benign mental disorder that lacks the implication of nec-
essary medication use and a lifetime course. But the
method of combating loose diagnosis of childhood bipolar
disorder should have been direct—a black box warning in
DSM-5 against childhood exceptions and conferences
sponsored by the pertinent professional associations to
counter drug company marketing. Instead, DMDD offers
yet another new target for inflation in childhood diagnosis
and off-label prescriptions of inappropriate medication.
Three lessons of the recent past are clear. First, the
diagnosis of mental disorder in children and teenagers
should be performed with much greater caution, conser-
vatism, and respect for the uncertainty caused by
developmental and contextual factors. Second, drug
company marketing should have much less influence over
physician prescribing and parent and teacher perceptions.
And finally, the provision of school services should be
based on education need, not clinical diagnosis.
Stepped diagnosis that begins with watchful waiting is
a way of restraining overdiagnosis in children, without
risking undertreatment of those who really need it. Before
a diagnostic label is applied, there is a period of observation,
normalization, and simple parent, teacher, and child train-
ing. “Stepping up” to a psychiatric diagnosis and treatment
occurs only after previous steps have proven insufficient.
Formalizing the prediagnostic steps7gives children time to
overcome “growing pains” and mild psychiatric problems.
It may spare many of them an unnecessary medical di-
agnosis and treatment and save resources for the more se-
verely ill who really need them. It is time to reevaluate the
loose application of mental disorder labels to children and
the excessive use of medication that has been encouraged
by aggressive drug company marketing.
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Why So Many Epidemics of Childhood Mental Disorder?
Journal of Developmental & Behavioral Pediatrics