DSM 5 Changes in Common Pediatric Mental Health Issues

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General Information

Published  5/2013.

Lack of physiologic understanding/ categories are artificial.

DSM 1952/ DSM II 1968/ DSM III 1980/ DSM IV 1994/ DSM IV-TR 2000  (text revision)

American Psychiatric Association

Gold standard for the description of mental illness

Insurers and service providers use it to determine eligibility for services

Last update about 20 years ago.

Goal: improve accuracy of diagnosis

Risk: misdiagnosis/ over diagnosis/ medicalization of normal behavior

Changes: 

  • single axis not multi-axis format
  • Simplify use by clinician
  • Age/ gender/ culture are now considered factors when making a diagnosis
  • Just starting the science of psychiatry (3 sections: introduction/ outline of categorical diagnosis/ conditions that require further research)
  • “Unclear what we know and what we do not know”

 

Notable Changes            

Neurocognitive Disorders: Major neurocognitive disorder (dementia): memory impairment is not essential/ ex. frontotemporal dementia has personality changes early and memory changes later.

Mild neurocognitive disorder: mild cognitive decline beyond normal forgetfulness of aging. 1-2 SD below norm on NC testing.

Intellectual Disabilities:  

  • MR is removed
  • Based on cognitive and adaptive function
  • Mild/ moderate/ severe/ profound are eliminated
  • Specifiers are now used
  • Severity is determined by adaptive functioning not IQ score

 

Autism Spectrum Disorder:     

  • Replaces PDD: AD/ AS/ CDD/ Rett’s syndrome/ PDD(NOS)
  • autistic disorder/ PDD(NOS)/ AS are joined
  • Specifiers: language delay or intellectual disability
  • Primary focus is on strengths and weaknesses
  • Mild/ moderate/ severe are eliminated
  • Defined in terms of level of support required
  • New specifier: ASD is associated with a known medical/ genetic/ environmental factor. (ex: FAS/ Fragile X syndrome/ epilepsy)
  • Benefits: improve diagnosis in girls
  • Unsolved: minority access to services delays diagnosis
  • Dual diagnosis of ADHD and ASD now allowed
  • 2 domains:         
    • deficits in social communication and social interaction
    • RR (restricted repetitive) behaviors, interests and activities

 

Social Communication Disorder               

  • new diagnostic category/ outside of ASD
  • Lack RR behaviors
  • Children with severe ADHD and social skill deficits
  • Allows a new group of patients

 

Somatic Symptom Disorders  

  • Somatoform diagnosis is eliminated: this focused on medically unexplained symptoms.
  • Somatic symptom disorder: medically unexplained is not central to this diagnosis. (lowers the risk of alienating patients by imaginary context)
  • Focus on symptoms lasting longer than 6 months that are associated with disproportionate thoughts, feelings and behaviors such as extreme anxiety.

 

ADHD

  • Reverse of most psychiatric conditions that are defined in adults and modified for use in children.
  • Limits social, academic or occupational functioning
  • At least six symptoms from either or both of two symptom domains: inattention and hyperactivity/ impulsivity.  Over 17 years need only five symptoms.
  • Inattention:  Careless mistakes/ difficulty with sustained attention/ not listen/ not follow instructions/ difficulty organizing/ poor sustained tasks/ loses things/ easily distracted/ forgetful.
  • Hyperactivity and Impulsivity:  Not due to oppositional behavior/ defiance/ hostility or lack of understanding instructions.  Fidgets, squirms or taps/ leaves seat/ runs and climbs when not appropriate/ lack of quiet play/ unable sit still/ talks excessively/ blurts out answers/ difficulty waiting turn/ interrupts or intrudes.
  • Several symptoms must be seen in each setting rather than more than one setting involved as the past criteria.
  • Levels: mild (few symptoms and minor impairment)/ moderate (between mild and severe)/ severe (many symptoms and marked impairment in social or occupational functioning)
  • Age of onset increased to 12 years from age 7 years since some issues with inattention do not manifest until a child is older.
  • 314.00 Predominantly inattentive
  • 314.01 Combined
  • 314.01 Predominantly hyperactive/ impulsive

 

Communication Disorders

  • language disorder: previously called expressive and mixed receptive-expressive language disorders.
  • Speech sound disorder: previously called phonological disorder.
  • Childhood-onset fluency disorder: previously called stuttering

 

Specific Learning Disorder    

  • Includes reading disorder/ mathematics disorder/ disorder of written expression/ learning disorder (NOS).
  • Coded specifiers for the deficit types

Resource: http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf

Joseph Barber, MD