Human Development and the DSM-5 he Diagnostic and Statistical Manual of Mental Disorders (DSM) provides a common language and standard criteria for psychiatrists, psychologists, and other healthcare providers to classify mental disorders. It is also used by schools and insurance companies to set the criteria for who qualifies for services including everything from government disability benefits to special education. K AThleen STASSen Berger NiNth edition The Developing Person Through Childhood and Adolescence Invitation to The Life Span Invitation to The Life Span Second edition Kathleen Stassen Berger
This edition of the DSM, like many of the editions that came before it, has been hotly debated by everyone from parents of children with disabilities to researchers and politicians. While there are some controversial changes in the new DSM, for the most part it is extremely similar to the editions that have come before. But students of human development will want to be aware of the latest diagnostic categorizations, particularly for disorders like autism spectrum disorder and attention deficit/hyperactivity disorder. Some of the changes to the DSM are too specific and at too high a level to be covered in an introductory human development course; this is an overview and is not meant to be an exhaustive summary of the changes. This table shows a chapter-by-chapter list of the DSM-5 changes in your textbook. oliveromg/shutterstock Kathleen Stassen Berger s Developing Person Through Childhood and Adolescence, 9e Updated for DSM-5 Chapter, pages Description of change Characterization of change Chapter 7, pp. 210 Chapter 11, pp. 338-339 Chapter 11, pp. 339-340 Chapter 11, p. 342 New coverage of Reactive Attachment Disorder. Updated coverage of Attention-Deficit/ Hyperactivity Disorder Coverage of the new Disruptive Mood Dysregulation Disorder Updated coverage of Autism Spectrum Disorder Reactive Attachment Disorder is a highly unusual diagnostic category evident in young children who have never had the chance to form any attachment, even an insecure one. Updated coverage of ADHD as per DSM-5. Thorough overview of this new DSM-5 category. New DSM-5 describes Autism Spectrum Disorder, with Asperger syndrome no longer considered a separate diagnosis. Chapter 14, pp. 422-423 Updated coverage of eating disorders New diagnostic criteria for Anorexia Nervosa and Bulimia Nervosa Chapter 16, p. 486 Updated coverage of Gender Dysphoria DSM-5 now focuses on an individual s dissatisfaction with their current gender, gender incongruence, rather than crossgender identification. 2
wrangler/shutterstock Kathleen Stassen Berger s Invitation to the Life Span, 2e Updated for DSM-5 Chapter, pages Description of change Characterization of change Chapter 4, p. 147 New coverage of Reactive Attachment Disorder Reactive attachment disorder is a highly unusual diagnostic category evident in young children who have never had the chance to form any attachment, even an insecure one. Chapter 7, pp. 272-274 Updated coverage of Attention-Deficit/ Updated coverage of ADHD as per DSM-5. Hyperactivity Disorder Chapter 7, p. 273 New coverage of Disruptive Mood Dysregulation Disorder Thorough overview of this new DSM-5 category. Chapter 7, pp. 275-276 Updated coverage of Autism Spectrum Disorder New DSM-5 describes Autism Spectrum Disorder, with Asperger syndrome no longer considered a separate diagnosis. Chapter 9, pp. 329-330 Updated coverage of eating disorders New diagnostic criteria for Anorexia Nervosa and Bulimia Nervosa Chapter 10, p. 360 Updated coverage of Gender Dysphoria DSM-5 now focuses on an individual s dissatisfaction with their current gender, gender incongruence, rather than crossgender identification. Chapter 11, p. 414 New coverage of Social Anxiety Disorder The DSM-5 has reclassified Social Phobia as Social Anxiety Disorder, primarily to clarify the diagnosis. Chapter 14, pp. 520-521 Updated coverage of the DSM-5 category of major or mild Neurocognitive Introduction of the new term neurocognitive disorder Disorders Epilogue, p. 594 Updated coverage of the DSM-5 s removal of the bereavement exclusion In earlier editions of the DSM, people who had depressive symptoms in the two months after the death of a loved one did not qualify for the diagnosis of depression. The new edition of the DSM has removed the bereavement exclusion. 3
The Role of the DSM in Lifespan Development The Diagnostic and Statistical Manual of Mental Disorders (DSM) provides a common language and standard criteria for classifying mental disorders. Mental disorders occur in infancy through later life. In any given year, about one-quarter of American adults and one in five American children are diagnosed with a mental disorder. These disorders affect many of us our families, our friends, and the adults and children in our neighborhoods. Hopefully learning how these disorders can be more accurately classified will help us better understand ourselves and the people in our communities and help obtain appropriate services for all who need them. In the most recent update to the DSM, categories for some key childhood and adult disorders have been broadened in many cases, allowing opportunities for more support and services. Key diagnostic changes relevant to human development have been made to the following disorders: Autism Spectrum Disorder Attention-Deficit/Hyperactivity Disorder New diagnosis of Disruptive Mood Dysregulation Disorder Changes to eating disorders (Anorexia, Bulimia) and new official diagnosis of Binge-Eating Disorder Dementias now reframed as Major or Mild Neurocognitive Disorders 4 Eleonora_os/Shutterstock
New Childhood Disorder and Diagnosis: Disruptive Mood Dysregulation Disorder Percentage of Office Visits with a Diagnosis of Bipolar Disorder by Children and Adolescents, 1994-2003 PT Images/Shutterstock 0.45 0.4 0.35 0.3 0.25 0.2 0.15 0.1 0.05 0 1994-1995 1996-1997 1998-1999 2000-2001 2002-2003 The rate of children diagnosed with bipolar disorder rose significantly over the past twenty years, leading to a re-examination of the diagnosis. Some children suffer from extremes in mood they tend to have frequent tantrums and periods of depression or anger. Parents, teachers, and healthcare professionals often struggle to understand these children and to know best how to treat them. During the past twenty years, such children have been increasingly diagnosed with bipolar disorder, once thought to be a disease exclusively of adults. Diagnoses of childhood-onset bipolar disorder increased more than 40-fold between 1994 and 2003 (Moreno et al., 2007). It was thought to be a variant of the adolescent- or early-adulthood-onset bipolar disorder (NIMH, 2010). Childhood bipolar disorder became controversial because practitioners and health care providers disagreed about the definition of the diagnosis, the prognosis, and the treatment. There was a sense that children were being misdiagnosed or overdiagnosed. Many researchers and clinicians believed that some children were misdiagnosed with bipolar disorder because they didn t have true episodes of mania and depression (characteristics of adult bipolar disorder), but did have severe mood regulation issues. In part to address this, DSM-5 has established a new diagnosis: Disruptive Mood Dysregulation Disorder. Children qualify for this diagnosis if they are between the ages of 6 and 18, are persistently irritable, and have frequent behavioral outbursts (like temper tantrums) more than three times a week for more than a year. With any new diagnosis come new concerns: Some clinicians and researchers have worried that this new diagnosis may pathologize normative child behavior. They are concerned that it may be difficult to distinguish the typical tantrums of a five year old from the behaviors of a child truly suffering from disruptive mood dysregulation disorder. References: Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. National Trends in the Outpatient Diagnosis and Treatment of Bipolar Disorder in Youth. Arch Gen Psychiatry. 2007;64(9):1032-1039. doi:10.1001/archpsyc.64.9.1032. CDC. (2009). Prevalence of autism spectrum Disorders Autism and Developmental Disabilities Monitoring network, United States, 2006. MMWR Surveillance Summary, 58, 1 14 National Institute of Mental Health (2010). Diagnosis: Pediatric bipolar disorder? Retrieved from http://www.nimh.nih.gov/about/director/2010/diagnosis-pediatric-bipolar-disorder.shtml 5
Autism Spectrum Disorder (ASD) Children Identified with Autism Spectrum Disorder 0.66% 0.90% 1.13% 2007 2008 2009 bikeriderlondon/shutterstock While many researchers and clinicians disagree about the exact rate of the rise in diagnoses of Autism Spectrum Disorder, nearly all agree that the numbers of children carrying this diagnosis have risen in recent years. These numbers are taken from a Centers for Disease Control multi-site study. Children with autism spectrum disorder have difficulty relating to other people. They typically have problems with appropriate communication (often including significant speech delays) and social interactions (sometimes to the extreme of avoiding eye contact and expressions of affection). The other typical signs of autism include unusual, sometimes obsessive play, interests, and activities (often referred to as restricted, repetitive behaviors, or RRBs). Diagnoses of autism and related disorders such as Asperger syndrome, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified) have ballooned over recent decades. The DSM-5 has established new criteria for these disorders and a new label Autism Spectrum Disorder (ASD) meant to reflect the fact that these related disorders are actually a single condition with different levels of severity. In order to be diagnosed with ASD, children need to have problems with social communication, social interaction and demonstrate the kind of repetitive patterns of behavior mentioned previously. Children who do not demonstrate these repetitive patterns of behavior now fall into the diagnostic category of Social (Pragmatic) Communication Disorder. Children with ASD still span a broad spectrum some of these children are of typical intelligence or even gifted and others have significant intellectual impairments. Some will only be able to speak a few words; some may engage in frightening episodes of head-banging or other self-stimulating activities; and others may be indistinguishable in a classroom at first glance, notable only for difficulty in making friends and an unusual obsession with routine. References: Figure from Rice, C. (2009). Prevalence of Autism Spectrum Disorders: Autism and Developmental Disabilities Monitoring Network, United States, 2006. Morbidity and Mortality Weekly Report. Surveillance Summaries. Volume 58, Number SS-10. Centers for Disease Control and Prevention. 6
Attention-Deficit/Hyperactivity Disorder Lifetime prevalence of ADHD Men 12.9 hektor2/shutterstock Women 4.9 10 8.1 8.8 13-14 year olds 15-16 year olds 17-18 year olds A surprising number of adults and children will be diagnosed with ADHD over their lifetime, making it one of the most commonly diagnosed psychiatric disorders in children. Attention-Deficit/Hyperactivity Disorder is the most prevalent mental disorder among American children currently more than 10 percent of children are diagnosed with ADHD. Children with ADHD have trouble with attention or impulse control or both. These children have problems with what clinicians call executive function impulse control, judgment, planning, and working memory as well as problems with sustaining, directing, and selecting the focus of their attention. The DSM-5 did not substantially change the diagnosis of ADHD. There are still two core symptom domains to the diagnosis the inattentive type and the hyperactive-impulsive type. However, the diagnosis has been made more inclusive so that symptoms of adult ADHD are more clearly defined and thus the condition is easier to diagnose. In addition, the age of onset of symptoms has been changed; in earlier editions of the DSM, at least one symptom had to be present before the age of 7; now, several symptoms need to appear before the age of 12. References: Figure from: Merikangas KR, He J, Burstein M, Swanson SA, Avenevoli S, Cui L, Benjet C, Georgiades K, Swendsen J. Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Study-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatriy. 2010 Oct; 49(10): 980-989.] 7
Eating Disorders Lifetime prevalences 0.9% 0.5% 0.5% 0.1% 3.5% 2.0% women men women men women men Anorexia Bulimia Binge Eating Disorder Juice Team/Shutterstock While many of us worry about our weight, only a few suffer from the health and emotional effects of an eating disorder. While many Americans worry about their weight and physical appearance, more than 8 million men and women suffer from a true eating disorder (NIMH, 2008). The DSM-5 has made small alterations to the core diagnostic criteria for two common eating disorders bulimia nervosa and anorexia nervosa and a new category, binge eating, has been established. For the most part, these changes have expanded the number of people who qualify for treatment and services. For bulimia nervosa the minimum frequency of binge eating and inappropriate compensatory behavior has been changed from twice to once weekly. For anorexia nervosa the requirement for amenorrehea (the cessation of a woman s menstrual period) has been eliminated, and the definition of how low one s body weight must be for the diagnosis has been clarified in terms of BMI to a BMI of 17 or less. The new diagnosis of binge-eating disorder is characterized by uncontrolled bingeing at least once a week for at least three months. This disorder is found in children and is more common in adolescents and emerging adults, although it can occur at all times in the lifespan. References: National Institutes of Mental Health (NIMH), 2008. The Numbers Count. Mental disorders in America. National Institutes of Mental Health. Figure from: Hudson JI, Hiripi E, Pope HG, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry. 2007; 61:348-58. 8
Understanding Neurocognitive Disorders 5.3 million 1.5 million 1.3 million 250,000 130,000 30,000 Aletia/Shutterstock Alzheimer disease Vascular dementia Lewy Body dementia Frontotemporal dementia Wernicke- Korsakoff Syndrome Huntington s Disease Dementia While neurocognitive disorders like Alzheimer disease are common among elders, they aren t an inevitable part of aging. Finding the different causes and treatments for these disorders is inspiring research around the world that is changing how we treat and understand these illnesses. Millions of Americans suffer from debilitating mental illnesses that effect their thinking, memory, and other cognitive abilities. When such diseases affect older people they are commonly termed dementia. In younger people effected by such diseases or by traumatic brain injuries, the term neurocognitive disorder has been preferred. In the most recent edition of the DSM, the mild and major cognitive disorders that occur across the lifespan have been combined into one category covering disorders ranging from delirium to Alzheimer disease and from Huntington s disease to Traumatic Brain Injury (TBI). These Neurocognitive Disorders are now broken into major and mild variants making it easier and clearer to define the level of impairment. Major Neurocognitive Disorders involve a significant and progressive decline in cognitive abilities (complex attention, executive function, learning/ memory, language, perceptual-motor, and social cognition). With a Major Neurocognitive Disorder, the individual loses the ability to perform some of the activities of daily living and thus to live independently memory problems, for instance, can be so significant that it is difficult for someone to follow the story line of a novel and impossible to plan a trip to the mall to shop for new shoes. Mild Neurocognitive Disorders may be accepted in some elderly people as a normal part of the aging process; such people may use creative coping strat- Reference: Figure from: Alzheimer s Association, 2013; National Institution on Aging, 2013; The Association for Frontotemporal Degeneration. (2010). Frontotemporal Dementia. Available at http://www.theaftd.org/frontotemporal-degeneration/ftd-overview; Medscape; Sharon, I., Bienenfield, D. (2012). Huntington Disease Dementia. Epidemiology. U.S. National Library of Medicine, National Institute of Neurological Disorders and Stroke (NINDS) (2013) 9
Monkey Business Images/Shutterstock egies, such as stacks of post-it notes and reminders to compensate, but they are nonetheless suffering from steady, progressive declines in cognitive abilities. It is hoped that the new designation of Mild NCDs will help facilitate early intervention and diagnosis of these diseases. Both degrees of the disorder can trigger depression, paranoia, anxiety, and even personality change. Linking the common cognitive diseases of aging with other progressive cognitive impairments may help address some of the stigma and ageism associated with the traditional term dementia. It is hoped that elders, and their care providers, will not accept cognitive losses as an inevitable part of the aging process but will rather understand that there are discrete biological origins for these diseases and possible interventions. Pharmaceutical treatment is available for many of the types of major neurocognitive disorders that affect aging adults. While these drugs show promise in improving symptoms and slowing the progression of the disease, they do not halt or reverse existing brain damage (APA, 2013). The different types of Neurocognitive Disorders differ in their biological origins (some are strongly genetic like Huntington s Disease; others, like Parkinson s disease, may have environmental risk factors) and in their underlying brain pathology. Common types of Neurocognitive Disorder include Alzheimer disease, NCD with Lewy bodies (which may cause up to 30 percent of NCDs in older adults), vascular neurocognitive disorder (cognitive loss caused by a cerebrovascular event such as a stroke, vascular disease), Parkinson s disease, and Huntington s disease. While we will undoubtedly continue to see the term dementia used in everyday conversations and in doctors offices, we should also be prepared to see this new acronym, NCD. Our understanding of the biology behind common dementias continues to expand, and with it a new way of referring to and understanding these disorders emerges, all of which the DSM has tried to reflect. Hopefully this new diagnosis and the attempt to catch NCD early, in the mild stages, will help get elders treatments that will help improve the quality of their lives. 10
New Understanding of Bereavement Dmitry Pistrov/Shutterstock The new edition of the DSM has removed the bereavement exclusion so that people who are mourning and depressed can now qualify for treatment if they so desire. This change also recognizes that researchers and clinicians are thinking about grief in a slightly different way than they used to. There is now a recognition that bereavement typically lasts more than two months more like one or two years for many people and that, for some, it can be a significant stress that triggers an episode of major depression. On the other hand, we also understand that typical grief does not look like major depression: Typical grief does not include feelings of worthlessness, sudden weight loss or gain, or thoughts of suicide. The reason for removing the bereavement exclusion is that if someone is feeling depressed, even if the trigger for that depression is the death of a loved one, they should have access to treatment. 11