DSM-5: Why (and What) Parents Should Know About It

Tuesday, May 21st, 2013

As a parent, you may be wondering why such a fuss is being made about the release of the DSM-5 (the 5th edition of the Diagnostic and Statistical Manual of the American Psychiatric Association). Here is a brief overview of why it may be (0r become) relevant to you – and why it’s important to learn about the issues that are being debated.

Many Kids Will Experience A Mental Disorder

The primary reason parents need to know about DSM-5 is that many psychiatric disorders that originate in childhood are not uncommon. Consider some rough numbers:

• Around 1 in 50 kids are being diagnosed with Autism Spectrum Disorder
• Around 1 in 10 kids are being diagnosed with Attention Deficit Hyperactivity Disorder
• Around 1 in 10 kids are being diagnosed with Conduct Disorder
• Around 1 in 10 kids are being diagnosed  with an Anxiety Disorder
• Around 1 in 10 kids are being diagnosed with a Mood Disorder
• Around 1 in 2 teens have reported meeting diagnostic criteria for at least 1 disorder in their lifetime

Having a good look at these numbers means that lots of parents will be faced at some point in time with the possibility of having their child evaluated for a disorder – and will need to consider treatment options. That’s where the DSM-5 comes in.

DSM-5 Is The Primary Guide For Clinical Diagnosis

The DSM-5 is the handbook used by a broad range of health care professionals who evaluate individuals (youth and adults) for potential psychiatric disorders. It’s an authoritative guide that reflects a consensus statement on the best way to categorize disorders along with the specific symptoms and rules to be used to make a diagnosis. The intention is to make it reflect current clinical thinking that is supported by research. It is not perfect, it reflects a particular point of view by those charged with generating the guidelines, and there is much debate (and criticism) of the diagnostic approach taken by the DSM-5.

All that said, the fact remains that the DSM-5 will be used if you bring your child to a health care professional for evaluation. The clinician will consider lots of information during this process – the DSM-5 does not dictate what information they use and how they get it. It’s intended to serve as a guide to the endpoint of making (or not making) a diagnosis. And it serves as the template for a health care provider to request reimbursement from insurance companies to support treatment.

Why All The Controversy Now?

The DSM-5 is a revision of the prior version which was released in 2000. As such, it includes a number of changes – some of which are minor, some of which are major. Beyond the more general discussions about what’s “normal” and what isn’t, the key things that parents need to know are the practical implications of the changes. As a parent, you should be aware of the changes to disorders that are especially relevant for youth. Here’s a brief overview:

Autism Spectrum Disorder: Major changes have occurred. In the prior version, a spectrum of disorders were available to clinicians, reflecting important variations in symptom profile. Four disorders were listed: Autistic Disorder, Asperger’s Disorder, Childhood Disintegration Disorder, and Pervasive Developmental Disorder Not Otherwise Specified. The key change is that there is now just one diagnosis made of Autism Spectrum Disorder (ASD) – and the other diagnostic categories will no longer be used. Proponents of this change suggest that it is more accurate by defining the core features of ASD that were common to all of the disorders in the spectrum and allowing for differences in severity level under one diagnostic umbrella. Critics suggest that a number of youth who require diagnosis and treatment will not be diagnosed – and that the reliance on severity levels may make it harder for kids with more mild symptoms to receive treatments they need. There’s no answer to these issues yet – they will unfold over time as data are collected. But if your child is evaluated for ASD, it’s in your best interests to be up on the debates and have informed discussions with your clinician in order to make sure you are advocating for the best care for your child.

Attention Deficit Hyperactivity Disorder (ADHD): Minor changes have occurred. In the past, there had to be evidence that a child showed symptoms of ADHD before age 7. That has been extended to age 12 in the DSM-5. There is also more attention to making diagnoses in adults more manageable. All of these changes mean that if you have an older child who has never been diagnosed with ADHD, they might now be evaluated differently. It’s also important to know what isn’t in the DSM-5 – a lower limit on age. That is, there are no guidelines in terms of how young a child may be when making a diagnosis. This is relevant as there have been (controversial) suggestions that kids as young as 4 years of age could be diagnosed (and many in fact have). Know that DSM-5 does not offer guidance here and you will need to make up your own mind if this makes sense for your child –  hopefully with the appropriate guidance of a well-trained clinician. Overall, the worry here is that kids of all ages may be overdiagnosed.

Conduct Disorder (CD): Minor changes have occurred. Conduct disorder represents a persistent pattern of rule breaking behavior and behavior that violates the rights of others. It can be diagnosed in young children as well as teens. The primary change has been to incorporate symptoms indicating a callous and unemotional interpersonal style. The thinking here is kids with this profile may be especially prone to experience problems in the future – and require more intensive management and treatment. Be aware that these symptoms will receive more attention now in the diagnostic process.

Disruptive Mood Dysregulation Disorder (DMDD): This diagnosis reflects a major change – it is a new diagnostic category. The idea was to provide a diagnostic option for kids who show persistent irritability and extreme emotional and behavioral outbursts. The rationale for developing the DMDD criteria was to make sure kids who show these symptoms do not get mislabeled as having pediatric bipolar disorder – but still may qualify for treatment. The controversy is that many feel that there is not sufficient evidence to support this new diagnosis – and in the worst case scenario kids who do not have psychiatric problems will be diagnosed with a disorder and get treatment that they don’t need.

Over the next few days, I will publish blog posts that consider each of these four disorders in greater detail, and provide some guidance for parents to help sort through these complex issues. There are no straightforward answers to be found – rather parents need to know about DSM-5 so they can be prepared to navigate the best decisions for their child.

Is ADHD On The Rise – Or Just Overdiagnosed?

Monday, April 1st, 2013

The latest numbers on the rate of ADHD are extraordinary. The New York Times has reported data collected from the Centers for Disease Control and Prevention which suggest that 11% of youth (between 4 and 17 years of age) have been diagnosed with ADHD at some point in their lifetime. 

This is troubling – primarily because the data come from phone surveys of parents. This means that parents are receiving this diagnosis at unprecedented rates – not that kids are being properly diagnosed with ADHD at higher rates than before. It is too easy for kids to get labeled ADHD and not go through the comprehensive screening that should take place as administered by a multidisciplinary team of professionals.

It’s becoming clear that ADHD is being used as a label to try to provide a quick handle on behavior that may – or even may not – be somewhat troublesome. ADHD involves much more than not sitting still and not paying attention. All kids exhibit “ADHD” like behaviors now and then. It’s a difficult condition to diagnose because it is based on increased frequencies of a number of behaviors across a number of contexts (home and school) for a sustained period of time which cause impairment for the child. Without a detailed diagnostic process, it can be too easy to misread normative behaviors as symptoms of ADHD.

Part of the increase comes from diagnoses of older kids including those in high school. Diagnostic criteria are beginning to reflect the thinking that symptoms can develop later in childhood and even in the teen years (and not just the early years). That said, it can also become another convenient label for a kid who is not doing well in school. At the other end of the spectrum, diagnosing preschoolers can raise related issues in terms of figuring out which kids are really showing early signs and which kids are just being kids.

There are a number of problems with overdiagnosis. Kids typically get treated with drugs that are not appropriate for them. They get labeled rather than receive the kind of attention that they deserve (for example, to improve their engagement in the classroom). And some kids get diagnosed simply because they are in very large classrooms which promote inattention and not sitting still.

The less obvious issue is that the cursory diagnosing that may be going on is also a disservice to kids who do suffer from ADHD. They should be getting full assessments and comprehensive treatment plans that find optimal combinations of psychosocial intervention and, when necessary, well monitored use of drug therapy. Tossing around labels and drugs as a diagnostic and treatment strategy is not going to give them the help they need, especially since we know that ADHD can persist into adulthood and cause much in the way of academic and social impairment.

The bottom line? If you are a parent, and you (or someone else) suspects that your child might have ADHD, try to seek out an assessment from a multidisciplinary team that has the requisite experience to know how to sort out normative behaviors and issues from clinically meaningful ADHD. You might need to network with other parents, your pediatrician, and educators to locate a provider. But it will be worth your time and effort to make sure your child isn’t misdiagnosed as having ADHD – or not given the proper assessment and treatment plan if they do show the clinically meaningful symptoms of ADHD.

ADHD image via Shutterstock.com

Do Kids With ADHD Become Adults With ADHD?

Wednesday, March 27th, 2013

A new study suggests that a significant number do – almost 30%. 

This report is noteworthy for two reasons:

• It is based on a large database of kids (5,718) seen originally at the Mayo Clinic (in Minnesota)
• It utilized a 29-year follow-up

Other significant findings include increased rates of one (or more) other psychiatric disorders, and a greater risk for suicide.

There’s one other number that makes this study especially important – the base rate of ADHD in the childhood sample was about 6%, which is in line with population estimates. This suggests that ADHD was not being over-diagnosed. Or put another way, the kids that were diagnosed with ADHD in all probability had pretty severe symptoms.

So this study – while not breaking new ground – provides further evidence that ADHD in childhood can lead to lifelong impairment. As such, it certainly suggests the importance of intervention in childhood when the level of symptoms and impairment warrants it. But it’s important to remember that this does not necessarily mean getting medication (though that helps some kids) – psychosocial interventions can be quite powerful as well.

Perhaps future reports on this sample will offer more insight into the factors that promote – or inhibit – the continuity of ADHD from childhood through adulthood.

ADHD via Shutterstock.com

Childhood Psychiatric Disorders: Will Genetic Engineering Ever Be A Solution?

Wednesday, February 27th, 2013

Following a stimulating Intelligence Squared debate, we’ve been discussing genetic engineering (think of it as directly changing DNA) here at Parents.com – both in terms of using it to create a “Super Baby” and to prevent disease. As a follow-up, let’s consider the likelihood of genetic engineering being a factor in the future for a number of childhood psychiatric disorders – or more to the point, the challenges that lay ahead. 

Autism Spectrum Disorder (ASD)

There would be hope that genetic engineering would be feasible in the future, as ASD is believed to be highly genetic in origin. However, the genetic basis for ASD is not clear. In fact, there may be a range of genetic etiologies. For example, some cases may be due to a rare genetic mutation – but there could be a number of mutations that can lead to ASD (not just one identified disease gene) making the idea of genetic engineering more challenging. The majority of ASD cases may reflect a complex mix of genetic and environmental influences – and the latest statistical modeling suggests that the genetic contribution to ASD may not be as strong as previously thought (and that the role of the environment may be more pronounced). For those situations, the idea of using genetic engineering is even more murky, because there may be many genes involved and they probably interact with a variety of environmental factors. All of this is not to say that genetics won’t lead to possible biological therapeutics – rather it’s to point out that the lure of genetic engineering as a solution may not be the avenue that will be pursued.

ADHD

The best evidence to date suggests that ADHD is due to a mix of genetic factors along with the influence of a number of environmental factors. As discussed above, this makes the pure application of genetic engineering difficult to imagine. There may a large number of genes involved, each of which may only have a small effect on the likelihood of developing ADHD – which, simply put, would make it very difficult to know what genes to target. Again, it’s tough to predict where genetic research will go, but while it may certainly lead to improved treatments over time for ADHD, it’s tough to see the role of genetic engineering.

Depression

You’re starting to see a pattern here. Like ADHD, depression is also thought to be influenced by many genes as well as the environment. As discussed above, this constellation of risk factors does not suggest that genetic engineering will be a factor any time soon.

Conduct Disorder (CD)

This is the same deal as the case for ADHD and depression – and it may be that the environment plays an even stronger role in the etiology of CD.

Conclusion

The idea of genetic engineering is provocative. But the reality may be far in the future for most childhood psychiatric disorders – and in many cases it may not be the way in which genetic research gets translated into prevention and intervention.

Molecular Biology Test via Shutterstock.com

ADHD: 2012 In A Snapshot

Sunday, December 30th, 2012

Two themes stand out for me this year with respect to research on ADHD: 

Diagnosis: We continued to observe a potential paradox – ADHD may be overdiagnosed, yet many kids do not receive proper diagnosis and care. Here’s why. The overdiagnosis aspect comes about because kids are given a label of ADHD without going through a rigorous interdisciplinary evaluation. And that’s where some kids slip through the cracks – some kids with severe symptoms do not get evaluated properly and struggle for years without appropriate intervention. So even though studies suggest that the rate of ADHD is very high (like some of the data reported by the Centers for Disease Control and Prevention), that does not translate into saying that all kids who may suffer from high levels of severity and impairment are getting the clinical services they need.

Treatment: The debate about using medications to treat ADHD got more extreme this year. A controversial opinion piece by a leading developmental researcher essentially negated the role of biology as a root cause of ADHD. On the other side of the issue, there were suggestions that kids as young as 4 years of age should start receiving medications to control their symptoms – and there were reports that in some (economically disadvantaged) areas of the country doctors are giving kids ADHD medication (without assessment and diagnosis) to try to improve their behavior and performance in school. Lost in the debate is the very real need for behavioral treatments that focus on parental strategies to help kids with ADHD function better both at home and in school. My viewpoint on all this continues to be that behavioral approaches should be tried first and should always be in place – and that once those effects are established clinicians and parents can have a more meaningful dialogue about the possible additional advantages of medication.

Time For Review via Shutterstock.com