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The first of several surprises: DSM-5 includes only Axis I Disorders. Axes II, III, IV and V are eliminated and replaced by a developmental conceptualization and organization throughout the manual. The diagnostic chapters begin with disorders common in childhood and end with disorders frequently presenting in later life. This new developmental conceptualization incorporates research on the influences of culture and gender, and on genetic and neurodevlopmental differences. DSM-5’s primary goals are to support more accurate and consistent diagnoses based on new research that shows how similarities between disorders inform better treatment.

Another surprise, and most controversial, is the new diagnostic name, Autism Spectrum Disorder (ASD). The new ASD diagnosis underlines the continuity within the DSM-IV Autism, Asperger’s Disorder, Child Disintegrative Disorder, and Pervasive Developmental Disorder Not Otherwise Specified. However, many clinicians voice concern that lumping these disorders may decrease access to care and public understanding. They emphasize that these limitations may lead to greater stigma and less individualized treatment for children, especially those now diagnosed with Asperger’s Disorder.

A third surprise, Disruptive Mood Dysregulation Disorder (DMDD), a new Depressive Disorder, describes children up to age 18 years with “persistent irritability and extreme behavioral dyscontrol”. This common presentation of chronic irritability and severe behavioral dysregulation in children is often comorbid with various psychiatric diagnoses including Attention-Deficit/Hyperactivity Disorder, Posttraumatic Stress Disorder, Depressive Disorder and Bipolar Disorder. DMDD addresses concerns about potential over-diagnosis of Bipolar disorders, especially in young children.

DSM-5’s new organization includes three sections that facilitate clinical decision-making and research:
• Section 1 introduces the DSM-5 and how to use the new manual.
• Section 2 sequences diagnostic chapters developmentally by age. It also groups similar disorders in new chapters, and similar chapters adjacent to each other.
• Section 3 features conditions that require additional research.

Section 1
DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, provides an overview of the newly conceptualized developmental frame, based on new science that informs both the organization of the chapters and the diagnostic criteria. Research shaping the new organization integrates the following:
• Influence of culture and gender
• Influence of genetic and neurodevelopmental research
• Symptoms occurring across multiple disorders

DSM-5, in addition, focuses on increasing the congruency between the DSM-5 and the proposed International Classification of Disorders, Eleventh Edition (ICD-11) by the World Health Organization (WHO).

Section 2
DSM-5 diagnostic chapters are organized to reflect differences across the lifespan. Neurodevelopmental Disorders are listed first to support early identification and intervention. Chapters below describe changes most helpful in understanding children’s developmental processes:

Neurodevelopmental Disorders (frequently presenting together)
• Intellectual Disability (Intellectual Developmental Disorder)
• Communication Disorders
• Autistic Spectrum Disorder
• Attention-Deficit/Hyperactivity Disorder
• Specific Learning Disorder
• Motor Disorders

Depressive Disorders
• Disruptive Mood Regulation Disorder (new)
• Bereavement (now included to increase appropriate treatment of chronic symptoms)

Trauma and Stressor-Related Disorders (features separate Posttraumatic Stress Disorder criteria for children 6 years and younger)

Section 3
DSM-5 supports further diagnostic exploration of conditions that require additional research. It also includes cultural formulations and a glossary.

Summary
DSM-5 integrates new research to advance developmentally informed early identification, age-specific diagnoses and more targeted treatment for children. It also fosters ongoing integrated research to increase understanding of developmental processes and lead to earlier, more accurate and consistent diagnoses and intervention.

For further information, go to: www.dsm5.org

Submitted by California Center National Advisory Council Member:

Jean Thomas, M.D.
Integrated Therapy Services for Children and Families (ITS)
Clinical Professor, Psychiatry and Behavioral Sciences
George Washington University
Children’s National Medical Center

This is a time of promise for all of us who work with infants, children and families, as the fields of early intervention (EI) and infant mental health (IMH) have burgeoned over the past several decades. As a clinical psychologist and infant mental health specialist, I feel lucky to work in a wide range of settings with a wide range of individuals. On any given day, you might find me:

Attending a transitional IEP meeting at a school or district office
Conducting a preschool, day care or home based observation
Consulting with regional center staff regarding a referral or children in my caseload
Attending a multidisciplinary team meeting
Training clinicians at a public or private agency serving young children
Working with parents and families in my office or in the field

I find the field of infant mental health invigorating, as it involves complexity and requires clinical thinking across developmental domains and across disciplines. The ability to properly treat each infant and toddler, dyad and family requires assessment and treatment models as complex the work we do: it involves multi-dimensional thinking and practice. Multi-dimensional thinking is by nature transdisciplinary. My own pathway to transdisciplinary practice was through the DIR® certificate program of the Interdisciplinary Council on Development and Learning (ICDL). Founded by Stanley Greenspan, M.D. and Serena Wieder, Ph.D., the groundbreaking work of the DIR® Institute brought the wisdom of infant mental health (harnessing growth through relationships) to all aspects of development while training professionals in allied fields (occupational therapy, speech therapy, physical therapy, education, pediatrics, etc.). The training focus involved looking at many aspects (dimensions) of development and how each caregiver and child’s individual differences impact development and social emotional milestones. By working in small groups during our summer institutes, and through regular reflective supervision, practitioners from different disciplines learned a common language, and way to codify how a child’s individual differences impact the growing relationships and their acquisition of social emotional milestones (described as Axis V of the DC:0-3R).

In practical terms, DIR® training provides important tools for understanding how to support caregivers and help the relationship with their children blossom. A large part of this understanding comes from the knowledge base in the fields of speech and language therapy and occupational therapy. With non verbal communication between parent and infant forming the earliest foundation of joint attention, speech and language therapists help us understand, assess and grow the quality of non-verbal communication in dyads and families. Similarly, when joint attention is not coming online, occupational therapists teach us how subtle differences in sensory processing and integration, vision, and the range of praxis (including the ideation, planning, sequencing, executing and adaptation of motor movements) can impact the critical journey of connection and relatedness.

In summary, development itself is complex, involving interconnected neurological processes influenced by personal biology, relationships, experience and the environment.

As a practitioner working with young children and families, understanding how to support relationships in the context of individual differences creates the dimensional framework necessary to work flexibly with families and support social emotional development. Please check out what is happening on a national level to bring much needed multi-dimensional thinking into our homes, clinics and schools.

For more information visit www.Profectum.org

Mona M. Delahooke, Ph.D.
Licensed Clinical Psychologist
DIR® Certificate: ICDL and Profectum Foundation
Profectum Foundation: Senior Faculty Member
Profectum Mental Health Working Group Co-Chair
www.monadelahooke.com

DSM-5: A Concise Review of the Changes with a Special Focus on Young Children

Meeting the Complexity of Supporting Infants, Toddlers, and Families