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

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.

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