Posts Tagged ‘
DSM 5 ’
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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Friday, April 19th, 2013
As part of Autism Awareness Month, I’ve been reflecting on some of the new things we have learned about Autism Spectrum Disorder (ASD) over the past few years. Four findings stand out for me:
It’s Not Just DNA: The landmark twin study published in 2011 suggests that while genes are important, environmental factors that increase likelihood of ASD are a key etiological influence as well. This finding is a critical one as it is the first twin study to show such a strong environmental effect after controlling for the role of genetics. It gives new impetus to examining a range of environmental influences in addition to searching for genes that increase risk for ASD.
Recovery From ASD Is Possible: While it’s been a controversial topic in the scientific literature, a recent study provides solid evidence that some kids can “outgrow” ASD. What we still don’t know is why that is the case. But this paper does stand out as important documentation that the phenomena of recovery is real.
Psychosocial Interventions Can Change Brain Functioning: While complete recovery from ASD is still rare, the positive effects of early intervention are not. New research published in 2012 provides dramatic evidence that some interventions – such as the Early Start Denver Model – may not just improve behavior, but also “normalize” brain functioning in response to social stimuli. This is a dramatic result because it demonstrates there is ‘plasticity’ in the brain that can be shaped by intensive intervention. It shows that we should give more weight to supporting psychosocial interventions, in part because they can effect biological development.
ASD Is More Common Than Ever: A recent paper reported that 1 in 50 kids have ASD. While it is difficult to generate a premise statistical estimate of the frequency of ASD, it is clear that each new attempt reports that the frequency is higher than previously reported. This trend may, of course, reverse with the publication of the new DSM 5 criteria for ASD. That said, the newest estimates bring attention to how common ASD is in the population – and how many kids need appropriate diagnosis and intervention.
Human Brain Research via Shutterstock.com
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Monday, April 1st, 2013
In 1980, the rate of autism was typically quoted as 4 in 10,000. The most recent rate reported is 1 in 50. While it is difficult to get a precise estimate, it’s abundantly clear that rates of autism have increased dramatically since 1980 – and in fact over the last decade. So what has changed?
There are a number of factors that have brought the startling levels of autism to our attention. These include:
Better Awareness: In 1980, autism was first introduced as a separate diagnostic category in the third addition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Prior to that time, clinicians using the DSM applied other categories such as childhood schizophrenia. Since 1980, there has been extraordinary growth in awareness – both for professionals and parents alike. This is particularly so over the past decade. Advocacy groups have done an admirable job of helping us understand what autism is (and isn’t). Pediatricians now screen for early warning signs – as do parents. These actions have all led to a much greater awareness of the symptoms of autism which undoubtedly translates in more proper diagnoses being made. In addition, the increased awareness has permitted older kids to be diagnosed more properly when the signs earlier in life were not recognized as autism.
Expansion Of The Symptoms: In parallel with efforts to increase awareness, diagnostic changes that recognized autism as a spectrum – now referred to as Autism Spectrum Disorder (ASD) – helped capture the wide range of symptoms that go beyond “classic” autism. Including a much broader representation of social, communicative, and repetitive/stereotyped behaviors certainly helped recognize the disorder in many youth who would not have been diagnosed in past years. Of course, there is debate about how the changes in the upcoming DSM-5 may result in a reduction in the rate of diagnosed ASD in the future. But up until now, recognizing the variation in symptoms that can characterize ASD has certainly been a factor in understanding how common autism really is.
Changes In Etiological Factors: Less understood is the role of new causative factors that increase risk for ASD. Much attention is being given to a large number of potential environmental contributors. There is the suggestion that specific genetic mutations that may be linked to autism – and associated with paternal age – are more common in the population because of average increases in paternal age over the last few decades. Much of this work, though, is work in progress, as it is believed that ASD typically results from the combination of a number of environmental and genetic risk factors. But many researchers operate under the assumption that there are both environmental and genetic risk factors that may be increasing in the population, though they remain elusive.
So, since 1980, what we have learned? We know now that autism is very common, is best thought of as a spectrum that includes substantial variation in how symptoms are expressed, and may be influenced by increasing levels of risk factors that are not well understood at this time. For all these reasons, it is critical that we keep researching the causes of autism, and continue to promote awareness of the early signs and symptoms in order to support early diagnosis and intervention.
Image: Autism Awareness Ribbon via Shutterstock
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Monday, December 31st, 2012
In lieu of a review of the past month, I’d like to pose a question: What will be the big topics on child health and development in the coming year? Kara Corridan and I have taken a stab at predicting what these will be. We selected 6 topics:
The Book That Will Change How Mental Disorders Are Diagnosed: Why you should know what the DSM-5 is and the hot-button issues it is raising
Kids And Play: New data and new thinking which suggests that kids are not getting enough of the right type of play
Pregnancy Health Risks: The emerging, and murky, data on potential prenatal risks and the complex decisions some pregnant women face
Injuries (The Downside Of Physical Activity): The realization that many youth are getting injured – some seriously – at an alarming rate
Post-Traumatic Stress Disorder: The very real consequences to kids when they are exposed to a number of traumas
Obesity: New efforts to combat this epidemic in kids
Click here to read our take on these topics. Since we published this, we have all been affected, in lasting ways, by the Sandy Hook shooting. So in addition to the above, I also anticipate much more debate and discussion about the 4 public health issues raised by that tragedy.
The one thing we know for sure is that 2013 will be a very important year for continuing our collective conversation about child health and development. Wishing you all a peaceful and good New Year.
2013 Calendar via Shutterstock.com
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Sunday, December 30th, 2012
There were three big themes this year in autism research from my vantage point:
The ongoing debate and speculation about the diagnostic changes that have now taken hold in the upcoming DSM-5 was clearly the biggest story of the year. Proponents suggest that the change to a singular diagnostic category (which eliminates Asperger’s Disorder
as a separable diagnosis) will provide clearer criteria and hence more precision. Those who disagree worry that some youth will no longer receive diagnoses – and hence access to services. Another concern is that even if children meet diagnostic criteria, the new severity ratings may prove troublesome when it comes time to receiving coverage for services. The only thing for certain is that it will take some time until we see enough data – and feedback from clinicians and parents – to know how this will all play out.
Causes of Autism
: There were a number of studies which demonstrated the complexity of searching for the causes of autism. Genetic research continued to focus on rare mutations that may help explain a very small number of cases. Included here were studies suggesting potential links between paternal age and risk for spontaneous mutations. While these findings continue to appear in the journals, it is not clear if there are many other genes involved – and if a vast majority of cases of autism are due to many genes acting in combination with environmental effects. To that end, environmental studies pointed to prenatal influences, including use of antidepressants and exposure to the flu
virus. The studies to date are preliminary, require replication and expansion in terms of isolating mechanisms, and again account for small increases in absolute risk (typically a magnitude of 1%). Overall, the pieces of the puzzle continue to be researched, but the puzzle remains elusive.
Early Intervention: While it is known that early intervention yields positive changes in development, new studies suggest that intensive intervention that is especially tailored to promoting reactivity to the social environment may hold considerable promise. One study showing changes in brain activity in response to faces after such intervention (the Early Start Denver Model) was particularly intriguing. While autism remains a mystery, the one thing we know is that early intervention is beneficial – and we can hope that it will become even more powerful in the future.
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