Today the American Psychiatric Association released a draft of the major changes that are expected in the new version of the Diagnostic and Statistical Manual of Mental Disorder – 5th Edition (DSM-V). While most people in the field will be underwhelmed by the relatively minor changes, there are a few areas where the DSM-V will likely make some drastic changes. Today most of the news coverage was focused on the proposed changes to the Autism diagnosis, which has raised some heated debate in the autism community. However, there is another major change that has received little, if any, attention: the clarification that a syndrome that in recent years has been labeled childhood bipolar disorder is actually NOT bipolar disorder. Instead, a new disorder category was created: Temper Dysregulation Disorder with Dysphoria (TDD).
Let me start by explaining that the creation of TDD does NOT deny the existence of classic bipolar disorder in childhood. That is, although extremely rare, bipolar disorder can occur in children and adolescents, and it looks very much like adult bipolar. Instead, TDD was created to capture a valid syndrome with characteristics and outcomes that are different than those of bipolar disorder. The available scientific data supports the position that the TDD syndrome is NOT simply the manifestation of bipolar disorder in childhood. This means that thousands of children that have been diagnosed with childhood bipolar disorder may not have bipolar and instead have a completely different syndrome now called Temper Dysregulation Disorder with Dysphoria.
So what is TDD?
Here is the proposed criteria for TDD:
A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.
1. The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.
2. The reaction is grossly out of proportion in intensity or duration to the situation or provocation.
3. The responses are inconsistent with developmental level.
B. Frequency: The temper outbursts occur, on average, three or more times per week.
C. Mood between temper outbursts:
1. Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).
2. The negative mood is observable by others (e.g., parents, teachers, peers).
D. Duration: Criteria A-C have been present for at least 12 months. Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.
E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be severe in at least in one setting.
F. Chronological age is at least 6 years (or equivalent developmental level).
G. The onset is before age 10 years.
H. In the past year, there has never been a distinct period lasting more than one day during which abnormally elevated or expansive mood was present most of the day for most days, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of three of the “B” criteria of mania (i.e., grandiosity or inflated self esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal directed activity, or excessive involvement in activities with a high potential for painful consequences; see pp. XX). Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.
I. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder) and are not better accounted for by another mental disorder (e.g., Pervasive Developmental Disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can co-exist with Oppositional Defiant Disorder, ADHD, Conduct Disorder, and Substance Use Disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.
The syndrome captured by section A-C (frequent and intense temper outbursts, happening several times per week in the context of negative emotionality) is the core of the symptoms that has been incorrectly interpreted as indicative of childhood bipolar disorder. Section H is very interesting. It states that this diagnosis is not appropriate if the person has experienced classic mania (e.g., bnormally elevated or expansive mood), as in such a case the diagnosis of bipolar is likely more accurate.
So why did the DSM-V decide that this syndrome is not simply bipolar disorder of childhood?
1. Lack of continuity to bipolar.
If TDD is simply the expression of bipolar disorder during childhood, then children diagnosed with this condition would eventually develop symptoms of classic bipolar disorder as they reach adulthood. The data do not support this hypothesis. That is, children who display the TDD syndrome in childhood (and are often incorrectly diagnosed as bipolar) are not more likely to develop classic bipolar disorder later in life as their peers (see Brotman et al., 2006; Leibenluft et al, 2006; Stringaris et al, 2009). Instead, these children are more likely to develop depression, not bipolar!
2. Different Biological Markets.
Youth who are diagnosed with classic bipolar differ significantly from those who have a TDD-like syndrome (see Brotman et al, 2010; Guyer et al, 2007; Rich et al, 2008). If TDD is simply bipolar, then the biomarkers of TDD should be similar to those of bipolar, but this is not the case.
3. Different Demographic Factors.
If TDD is simply bipolar, then the gender distribution of TDD should be similar to that of bipolar. This does not appear to be the case. Specifically, there is no gender differences in the rate of classic bipolar; male and females are equally likely to develop the condition. However, the TDD-like syndrome is disproportionately observed in boys rather than girls.
4. A need for a new category that would impact treatment and research.
In theory, the presence of TDD will educate clinicians, researchers, and the public that this syndrome is not simply a version of bipolar disorder. This would facilitate research on the causes, features, and treatments for this condition. This has major implications for treatment. For example, the standard treatment for bipolar disorder does NOT seem to work in children that have the TDD syndrome (Dickstein et al, 2009). By explicitly stating that TDD is not bipolar, researchers would be less likely to approach the search for treatments from a “bipolar framework”, which would potentially facilitate the discovery of more effective interventions.
I am actually glad about this change as it will have a clear impact on clinical practice and research that will most likely benefit the children affected with this condition.
References:
Brotman MA, Schmajuk M, Rich BA, Dickstein DP, Guyer AE, Costello EJ, Egger HL, Angold A, Pine DS, & Leibenluft E (2006). Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biological psychiatry, 60 (9), 991-7 PMID: 17056393
Dickstein DP, Towbin KE, Van Der Veen JW, Rich BA, Brotman MA, Knopf L, Onelio L, Pine DS, Leibenluft E (2009): Randomized double-blind placebo-controlled trial of lithium in youth with severe mood dysregulation. J Child Adolesc Psychopharm 19: 61-73
Guyer AE, McClure EB, Adler AD, Brotman MA, Rich BA, Kimes AS, Pine DS, Ernst M, Leibenluft E (2007): Specificity of face emotion labeling deficits in childhood psychopathology. Journal of Child Psychiatry and Psychology, 48:863-71
Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS (2003): Defining clinical phenotypes of juvenile mania. Am J Psychiatry 160: 430-437
Rich BA, Grimley ME, Schmajuk M, Blair KS, Blair RJR, Leibenluft E (2008): Face emotion labeling deficits in children with bipolar disorder and severe mood dysregulation. Development and Psychopathology 20: 529-546
Stringaris A, Cohen P, Pine DS, Leibenluft E (2009): Adult outcomes of adolescent irritabilty: A 20-year community follow-up. Am J Psychiatry 166: 1048-54
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53 Responses to Childhood Bipolar Disorder is not Bipolar? DSM-V and the new Temper Dysregulation Disorder with Dysphoria
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I would like to response to Kellen Von Houser. I find it unfortunate that somebody in your line of work would automatically assume that these repetative outbursts are a result form abusive homes. Yes, I agree that a lot of emotionally disturbed kids come from abusive situations but not all of these kids do. It is a very lonly and isolating feeling when a parent does everything they can to help their child, including providing a safe environment and they cannot explain these continual outbursts. Assumtions such as yours and Sean’s provide a large amount of disservice not only to parents but to these children as well. All I can say is that unless you are in our shoes, please don’t make such careless assumtions.
Hey guys, i really know how its to have a problem like this. I’ve struggling from this since a few years with the usual ups and downs so i really know its not fun when you have a illness like this. At some forum i found out some visitors were pretty satisfied about a pill they got of the net and i ordered it when i found those pills at – herbalhealingstore dot com -. So you see, those herbals do work, you only have to find the good ones!
My son is now 17 y.o. From day 1 he would not settle. sleep, wear clothing (sensory); I would get punched in the head while we were driving (he in the back carseat); RAGES lasting hours on end (comparable to seizures); massive irritability; negativity; No daycare/babysitter or family member could deal with him; divorced his Father as he had never been diagnosed but now realize the abuse was genetic. Could not go to family functions/parties/picnics without an incident having to leave with him kicking and screaming…
Been hospitalized multiple times; counseling; private school; Clinical trials; Neuropysch studies; EEG’s to pituatary tests….
SO THOSE ABOVE THAT STATE THAT THIS IS AN EXCUSE FOR BAD PARENTING AND MEDICATING TEMPER TANTRUMS–HAVE NO CLUE. I have 2 other children (18 y.o. son-11 y.o. daughter) that excel in school/have friends, etc., THE PARENTS AND FAMILY THAT SUFFER WITH THIS AND THEN HAVE RIDICULE OF THE JUDGEMENTAL THAT ARE IGNORANT OF MENTAL ILLNESS KNOW–We continuously try to educate, explain this illness… Although my son has multiple dx–this fits him to a “T”!
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I read this description of TDD and thought, my god, finally something that explains my son!!!
He is now 14 years-old and chronic irritability seems to describe him well with temper outbursts that are out of proportion to whatever it is that sets him off. Additionally, impulsivity is another hallmark of his behavior — both verbal and through actions, which makes the ADHD diagnosis a tempting one.
He has had behavioral issues since Kindergarten and the problem never seems to go away despite:
– Having had him evaluated and getting on an IEP
– Taking him to various doctors, psychologists and psychiatrists for diagnoses
– Diagnosed with ADHD and currently on Adderall
– Diagnosed by another as not having ADHD, but ODD
– Thinking/theorizing that he’s spoiled and needs more structure/discipline.
Don’t know what to say, other than the fact that Bipolar didn’t really seems to describe him and ADD didn’t either, but it was the closest we could get and gave us something to cling to because you need a label to understand and get your child help.
Hopefully, with this new more accurate diagnosis, we can get our child the help he needs, and hopefully through counseling, diet, or other non-drug therapies.
(And yes, he does crave sugary foods and carbs . . . what’s the supposed connection to that? Our doctor never mentioned or asked about his love of sweets.)
Are there any online support groups for us parents? Would love to connect with someone else who has a kid with TDD. My 13 yo daughter is recently diagnosed, with initial diagnosis as ADHD, ODD and Mood Disorder NOS.
I am reading all your comments and i have to say this is the first sign of hope i have seen for my son in almost 14 years. He has been crying since he was born and raging since he was 6. Yes life is hard but life is life and Kellen not all children that have anger issues come from bad parenting. I think some one needs to look further into the heridity aspects of this issue. because in my family it goes way back generations, girls and boys, and though you can chalk that up to dysfuctional learned behavior, you can also look at DNA, Heridatary issues, Why is a sister i never meet also an acholic, and a brother too. Not because they were raised in the same house as me no they weren’t, it is because it is something in the genes.
I have been struggleing to find help for my son and have changed my parenting, my beliefs and my surroundings to help him, and yet nothing has. I have also tryed controling his diet,(food must have something to do with this) Medication after medication, has not helped, he is alone, angry negitive and sad 99.9 % of the time Diag. adhd, bipolar-diorder and odd and yet nothing helps. For over a year i have been doubting the diag. and was very close to placing him in a school that was equipt to handle this kid of child. Thank you for the new perspective with TDD because this one was not working for me.
So there’s a new diagnosis but how do I treat it? There are dozens of medications that could be useful but the only ones that will get any research are the expensive newer atypicals that will be funded by pharmaceutical companies. Older and possibly safer medications will get little if any evaluation for this new disorder.
For Marti:
I hope this is not too late to respond. Stimulants have a negative affect on my daughter as well, and anitdepressants don’t address the rages. We have found Vyvanse to be effective because it does not have a man-made stimulant in it. Rather, it introduces the chemicals necessary for her brain to make its own stimulant. It is the only ADHD medication that has ever worked for us. Also, the dr recently introduced us to a new med called Intuniv. This seems to be helping her with her rage issues. Not all the way gone, and the hands-on aggression can still appear, but her control and recognition of needing to remove herself from inflamatory situations seems to be improving. Don’t know if you have heard of either, and both are fairly new.
The greater problem is that what works for one kid never seems to work the same for the next one. But hopefully it will be a starting point.
Best of luck to you and your family!
Like many of the commenters here, I too think this new category fits my daughter almost to a T. She’s been having rages lasting up to hours where she screams, throws things, kicks, punches, etc. Also, her mood is generally very negative. She is now 11 but even at about age 5, when some “experts” would say to hold her down to prevent her from hurting herself or others, we basically couldn’t handle her. For quite a while I read all I could about her condition and did consider bipolar or ODD, neither of which seemed to describe her fully. I didn’t really want her on unproven drug treatments. What helped me quite a bit was reading Dr. Ross Greene’s book,”the Explosive Child”. Since I’ve implemented some of his thinking, my daughter is doing much better. In addition, she also is now involved in vigorous physical activity -swimming and soccer, which also has been helpful. I too, have other children, so I know this behavior has been quite unusual. Good luck to all of you.
It’s like you all are speaking to me!!!!
My daughter is 14 and was born highly irritable and difficult to soothe.
Her rages began in 3rd grade, verbal to physical..all geared at me.
In 4th grade she was diagnosed with an anxiety dissorder. But I have
always known it was more than that.
She is on lexapro (antidepressant), lamictal (antipsychotic), valium and rozerem (sleeping med).
The meds work at around 50%.
She is unable to concentrate in school.
She is cute and has a personality, so she fakes her way through the day.
She always says that the medicine does not work. She feels hopeless and exhausted from her life.
Oh, she had a spec scan at amen’s. There is nothing normal about her brain. So for anyone to say this is the result of bad parenting or just high emotions…bs! Come live with in my house or check out her scan.
I have two successful boys in college.
Dr. Nestor, please find some help for these children!!!!
Are you familiar with the work ( and books ) of Ross Greene PhD? He uses the term “explosive children” to describe these kids and I think he has a compassionate and sensible approach to working with these children. Good evidence to support his method, whereas the evidence behind medical therapy is not great.
I want to respond to this:
#21 Kellen Von Houser Says:
March 2nd, 2010 at 3:02 pm
As a family therapist I really have to object to this medicalizing of a child’s emotional problems. We need to stop diagnosing and medicating children and look at their parents and their home lives. This type of behavior is often seen in children who are being abused or experiencing some serious dysfunction at home, i.e. substance abuse, domestic violence, etc.
Medicating these children and sending them back into the home which caused the distress in the first place, without addressing what is happening there, will increase the likelihood of the child suffering further.
________________________________________
While you are correct in saying that children that come from dysfunctional homes will exhibit some of these behaviors you also need to back up and realize that some children have these issues for other reasons–My daughther is 13, she was abused as a baby by bio parents–she came to us(her foster parents) at 21 days old–even then she did not sleep normal, would cry for long periods of time, as hse aged her anger was explosive, she would rage, hit, spit, bite, throw things,break things and cuss–this was at 3 years old–She is now 13 and is still a violent child–she has TBI(Traumatic Brain Injury) didn’t know that for years–She is also dx’ed with Bi-polar(which I now question and wonder if its TDD) and also Pervasive Developmental Disorder –NOS
So, Since you think these parents are so bad–I would love to have my dd come and live with you for a few months and see if your wonderful parenting skills would solve all the issues–I have other children that are just fine, one is married with wonderful children of her own–I am fully aware that this is not normal behavior and knew 13 years ago something was very wrong–We have looked high and low for help–Seems you have all the answers, so if you would like we can make arrangements for my daughter to come live with you, where you can observe her behavior in your environment–You seem to think your life/home is more functional than others so I would love to see the miracle you can work–If you are not open this arrangement would you consider coming and living in my home for a few months so that you can observe our lives and give us your “functional”, “Professional”, “Your know it all” opinion? We will not charge you the outrageous fees you charge only to tell parents its all their fault–we will open our home to you for free all you be required to do is work your miracles–And if this is not an option for you why don’t you get your head out of the books and into the real world and realize that most abusive parents would not be taking their child to therapy in the first place–Abusive parents try to hide from the world to keep from being found out–Also keep in mind that in the most functional of homes, when you bring in dysfuction the entire home will be upset and become somewhat dysfunctional–On the medication topic–If you had a heart problem would you take meds?–If you had disabetes would you take meds?–If you had cancer would you take meds?–Ummmm, I am betting the answer is yes–so, again lets be real and realize that these children need medication to get through their day and survive, don’t get on here and spout off your B.S. about meds–It is painfully obvious you have never really “heard” what these parents are saying about their children and their children are suffering tremendously all because you are looking for a “boogie man” that isn’t there!
Although I don’t doubt that this TDD thing does exist and that there are children like this, who have this, bipolar disorder DOES exist in children under the age of 10. They have true depressive episodes with suicide attempts and true mania that sometimes involves psychosis. Will these children be diagnosed with TDD instead of bipolar? Yes, bipolar is an adult-onset disorder, I’m not arguing against that. But when it comes to the human mind, anything is possible. A diagnosis or presence of any psychological disorder is going to be hard on young children. But for those of them who understand full well what’s happening, that there’s something wrong, a diagnosis that says they’re more or less just more prone to throw fits, that minimizing and brushing aside of symptoms can be devastating. Will these kids who, except for their age, fit better into a diagnosis of bipolar than of this new TDD still be diagnosed with TDD?
.>>Medicating these children and sending them back into the home which caused the distress in the first place, without addressing what is happening there, will increase the likelihood of the child suffering further.<<
I thought we had left this belief behind us years ago. My son , at age five,the youngest of three boys, showed all the distress, fear, anxiety and violent temper described here by other parents.
We used the services of a well experienced counsellor to virtually move in with us for several weeks, only for her to report to her colleagues that she had seen no evidence of anything but a loving, and close knit extended family.
It was only when the decision was made to medicate our son that he found peace within himself, and with others. He is still medicated, with excellent results, but remembers the days pre-medication as being like “lost in space,’ and a horrifying experience.
One of his worst memories is of being told by professionals that it was “OK’ to tell people that he was abused at home, of being disbelieved when he denied this, and not knowing what else to say.
Now THAT was abuse.
Thank you Lorelie for posting your note about the corn syrup and high fructose corn syrup.
My daughter has been suffering with all these symptoms most of her life, and after carefully trying to eliminate these 2 things, (not even cane sugar), she has improved GREATLY. It’s in everything, (including hot dog buns, we found out yesterday), but I am learning to shop carefully.
She is coming of her anti anxiety meds given by a child psychiatrist we saw, to the tune of $300 per hour.
God Bless You!
I’m all for updating the labels and lenses through which we look at kids in distress as new data comes to light. After all, health and healing is the goal isn’t it? And more accurate understanding of etiology, environmental factors, and what is actually happening in the brain will hopefully result in more helpful treatments. In other areas of health, similar symptoms can be caused by different underlying issues, and I’m pretty sure that is what is going on with bipolar and what might be called SMD. Even w/in the group of those who might be called SMD that’s probably the case, so great caution needs to be used in prescribing meds as the front line approach.
Hi! I am a mother of a Five and a half year old son…..who had a speech delay and pickedup speaking after three and a half years of his age (had under gone speech therapy for four months when he was two and half) now he speaks well but we could see the gap of 2 years as per the perfection level……As of now he has a writing delay….doesn’t write on his own……He is very impatient. He was diagnosed mild Autism…..with an IQ level 6 months more than his age and social adjustment six months below his age. He loves to be in the company of children but will not go down in the garden to play with them…..would like to play with them when they are at home….He certainly walks on his toes. He is very rigid in some matters like buying toys….he is fond of cars so he will buy only cars and no other toys…..As to spaek about his intelligence level he has a sharp memory…..but doesn’t remember his study material(may be he doesn’t want to remember because he is very impatient) but is too good to remember colors and names of the cars and who gave him that car, from where he bought that car (even the name of the shop). All his concentration is there with the cars. He doesn’t concentrate on studies well…while teaching he will not even look in the book…even if I try to look into his eyes he starts looking here and there…Sometimes he has really bad temper outbursts….sometimes he is very understanding…One thing that is very peculiar about him is that he loves to rotate at one place all alone and can do so for more than 15 – 20 mins. He loves this solace which is very unusual….He doesn’t want to go out only when we tell him that he can buy a car…….Next year he would be in Grade I but still doesn’t write…..Sometimes in the night he weeps silently like adults….If I use slightly harsh words for him to study he starts crying……
“Lorelie Says:
February 15th, 2010 at 1:13 pm
Hello,
This diagnosis could have been written for my son. He had an extreme inability to control his moods and body. We tried allergy testing which reveled he was allergic to wheat, dairy, and eggs… Corn syrup and HFCS *DO* cause it to happen…. We diligently removed all corn syrup from his diet and it was like a light switch turning off.”
I’m very happy to see that some has brought up the food/gut/brain connection. I’m a Health Counselor and Nutritionist who works with kids with learning and behavioral problems. I can tell you first hand that food allergies and sensitivities are the root cause of these disorders in a majority of kids. It takes time and work to figure this stuff out but in the end it’s worth it. You’re not just treating the symptoms with drugs; you are literally fixing an underlying malfunction that most doctors simply aren’t looking for. Most parents will try this for a few weeks and give up if they see no difference. It’s easier to let their kids pop pills.
Hello,
My daughter started exhibiting symptoms of the bipolar/tdd type at about age 3. The rages were horrible, violent and destructive. They occurred many times a day. In addition, her mood was always very irritable and the smallest things would set her into a rage or a several hour crying fit. It was torture to be around her – she was always on the verge of exploding. On the other hand, she also had the shyness toward strangers that her brother and sister also had. This trait was a blessing in that she could go to day care and school without having the tantrums.
Here’s what I did – and I hope it can be of help to others.
I was highly sceptical of drugs and didn’t want to use them. I read all I could about her condition. (The book I liked best was the “Explosive Child”). Starting at about age 8, I tried to be as loving and patient as I could. I avoided situations that often led to tantrums. I started giving her moderate doses of fish oil (with the thought that her condition was akin to ADHD). And then I started her on as much excersise as she’d do. She takes dance lessons, plays basketball, indoor and outdoor soccer, and most of all, she swims on a very athletic swim team.
The results have been beyond anything I could hope for. She is now funny, loving and often cheerful. She still has her moods and tempers, but more like a normal child of 12.
Hope this might help others facing this problem.
In response to Kellan Von Houser:
I understand you may be a therapist. However, being a mother of three boys (the two oldest being an Aspie, the middle being an Autie, and the youngest one with TDD, ADD, and ODD) I have to disagree with you. These children come from a very loving family and we are a very verbal family never shy about expressing our feelings when we say “I love you” several times a day, showing affection, giving praise, building self-esteem in them, making them feel secure, nurturing…..everything they need to feel they are safe, accepted the way they are and truly needed. The youngest one with TDD is 12 years old. He was hospitalized two times in December because he threatened to kill himself on one occasion and threatened to kill his brother with a butcher knife on the other occasion. He has been seeing a therapist for years because of this condition (probably since he was 5 years old) and is in a STABLE family environment. He has been active in sports (soccer, baseball, football, basketball), the Young Marines, Boy Scouts and was trying to manage his outbursts in public to some degree with some success (but not always). However, he would totally lose it when he got home. It nearly devastated him and about a year ago he became extremely depressed and began to withdraw from all his activities, and his grades at school began dropping. He then entered middle school in the Fall this past year. The transition was too much for him. His pattern of becoming enraged at school increased to the point of his having lunch detention, after school detention, and then to his hospitalization. He becomes enraged and has extreme outbursts when asked to take a bath. He has meltdowns when asked to do simple homework assignments or chores. Sometimes he comes home from school and begins crying for no reason and a complete meltdown will follow. He gets so angry he will rip up clothing and hide it under his bed so I will not find it. He cries and asks what is wrong with him. He cannot control this anger. This diagnosis can co-exist with ODD. He has become defiant, belligerent, irresponsible, disrespectful (not only to his Dad and myself but to the teachers at school and the neighbors). So please don’t refer to these children diagnosed with TDD as having temper tantrums unless you have walked in their shoes. We are now in throws of intensive in-home therapy to reconstruct a discipline system (because our previous system was failing) and to rebuild trust with him. We have also been working on a consequence/reward program with him. The psychiatrist has prescribed meds that now have taken the edge off some of his irrational behavior and relieved some of the depression. He has been making slow progress but he takes two steps forward and one step back. We are doing this in hopes it will work because if it doesn’t he will have to be placed in a Level III residential day treatment program. Please understand I recognize you have made your career as being a therapist but a parent knows what is best for their child with the help of a professional team and that includes a psychiatrist that makes the diagnosis and makes recommendations for medications that will decrease the depression and take the edge off the destructive cycle. The child does not have to come from an abusive home, dysfunctional family, substance abuse, etc. You are entitled to your own opinion.