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Wednesday, May 29th, 2013
DSM-5 has raised lots of controversies by making changes to the way some psychiatric disorders are defined. But less controversial is flagging the importance of callous-unemotional traits in childhood as part of the diagnostic approach to Conduct Disorder.
Conduct Disorder refers to a pattern of behavior that consistently violates the rights of others. As kids reach later childhood and their early teens, the types of behaviors include what we would think about as things that would get kids in trouble: destroying property, breaking and entering, fighting, lying, stealing. While some kids may do some of these things now and then, what’s important clinically is when a lot of these behaviors cluster together and occur with some frequency.
There can be many reasons why kids behave this way. It’s clear that kids exhibiting signs of Conduct Disorder require some type of intervention. It’s a pattern of behavior which can be associated with a lot of bad outcomes – dropping out of school, eventual substance abuse, and even jail.
So why are callous-emotional traits relevant, and flagged in DSM-5? The risk for these outcomes may be especially high if a child is showing callous-unemotional traits – such as a lack of empathy, a lack of remorse, and shallow emotions. When tracked over time, youth with these traits are especially likely to show a stable pattern of antisocial behavior over time – from childhood through adulthood. Their actions may be (or become) especially aggressive and violent.
Treating kids with callous-unemotional traits is complicated. A number of behavioral strategies may be considered, as well as some forms of drug treatment (especially if they have symptoms of other disorders, such as ADHD or depression).
DSM-5 has certainly be criticized. There are many hot-button topics raised in the revision. But the inclusion of callous-unemotional traits is an example of how research findings can lead to diagnostic changes that are simply there to signal which kids may be at especially high risk for a number of bad long-term outcomes and hence require some immediate form of intervention. That’s solid information for a clinician to weigh during the evaluation process.
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Friday, May 24th, 2013
The new diagnostic criteria for ADHD in DSM-5 flag issues that deserve attention if you are a parent. These include:
1) Age doesn’t matter as much. In prior versions of the DSM, ADHD was represented as a disorder which starts in childhood – an onset prior to age 7 had to be established to make a diagnosis. This has changed – the age of onset has been extended to before 12 years of age. So parents should be aware that ADHD symptoms may now be detected later in childhood. And parents too may be more likely to be diagnosed themselves, as the new criteria make it easier to recognize ADHD in adults.
2) Age does matter though. While it is legitimate to say that children, teens, and adults all can show symptoms of ADHD, applying the criteria to the different age groups requires much clinical skill. Keep in mind that the proper use of DSM-5 requires this. For example, a clinician must apply the same criteria to a 5-year-old, a 10-year-old, and a 15-year old. The symptoms of ADHD reflect behaviors that can be shown by any child – it’s typically the frequency of these behaviors (they occur much more often as compared to what’s expected developmentally), the pervasiveness of the behaviors (you see them at home and in school), and the consequences of the behaviors (e.g., a kid is having difficulties keeping up with school work, is getting in trouble in school). A clinician needs to have a reference point for each age in their head in order to properly apply the DSM-5 criteria. This means that they should have very solid training in developmental science as part of their overall expertise. This is particularly true given the controversies about diagnosing and treating ADHD in preschoolers.
3) Be careful who applies the criteria. The DSM series (we are now on the 5th edition) is a guidebook for clinicians. It represents current thinking on the most telling signs of a disorder. It does not say anything about how the information should be collected to come to a clinical decision. So, you need to beware of anyone who doesn’t do a full, comprehensive evaluation that includes observations of the child, interviews with the child, much discussion with parents, acquiring lots of information from parents via questionnaires, collecting information from teachers and school personnel, and ideally a range of tests (including neuropsychological exams) that can consider alternative issues (like underlying learning disorders). This kind of evaluation is required to prevent overdiagnosis of ADHD, which may be rampant these days.
4) DSM-5 does not dictate what treatment will work best. DSM-5 is designed to facilitate the diagnostic process. It does not dictate the treatment strategy. A diagnosis of ADHD does not mean that a child necessarily needs Ritalin or other similar medications to control the symptoms. That’s a whole different discussion with a clinician who is trained to consider a range of treatment strategies. It is always wise to consider first behavioral treatments for ADHD and determine, after a sufficient amount of time, how much improvement can be gained by them before thinking about medication. Do not believe a practitioner who only endorses medication after a diagnosis is made.
The bottom line is the the DSM-5 is not intended to be used in a simplistic way to quickly diagnose ADHD and immediately promote medication. It is a tool that helps clinicians come to a determination of where a child is at developmentally with respect to ADHD. This is a complex process that requires lots of clinical insight. Having DSM-5 in hand doesn’t change that.
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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.
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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.
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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.
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