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Robin DuFresne, MA, PC, NCC

Allison Arnekrans, MA, PCC, NCC

July 26, 2013

Updating Your Clinical Toolkit: Understanding and Applying DSM-5

Changes with Children & Adolescents

Objectives

Overview of major DSM-IV to 5

changes.

Review current Neurodevelopmental

Disorders in the DSM-5.

Identify and apply changes to the

Disruptive, Impulse-Control, and

Conduct Disorders chapter.

DSM-IV-TR DSM-5 First DSM published in 1952.

◦ It had 106 diagnoses and 130 pages.

DSM-5 will be the first full revision since 1994.

◦ It has over 340 diagnoses and 947 pages.

◦ More developmental and evidence-based approach.

◦ Represents the contributions of more than 1,500 mental health and medical experts over a 14-year process of discussion and collaboration.

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Utilization

You can start using DSM-5 today! ◦ APA encourages utilization by 12/31/13.

Claim: “The new manual represents a step forward in more precisely identifying and diagnosing mental disorders.” ◦ DSM-5 will continue to use statistical

codes in the International Classification of Diseases (ICD).

DSM Code & ICD for most diagnoses (i.e. 313.81 (F91.3).

Changes in Reporting Structure

DSM-5 combines the first three DSM-IV-TR axes into one list that contains: ◦ All Mental Disorders

◦ Personality Disorders

◦ Intellectual Disabilities

◦ Medical Diagnosis

Psychosocial and environmental factors now represented through an expanded selected set of ICD-9-CM: V-codes and from the forthcoming ICD-10-CM: Z-Codes.

GAF is no more. . .

NOS categories replaced with two options:

1.) other specified disorder and 2.) unspecified disorder

Other Noteworthy Changes…

Some different disorders or subtypes share same diagnostic codes.

The diagnostic groups have been deleted or reconfigured. (e.g. PTSD no longer included in Anxiety group;

Disorders of Infancy, Childhood, & Adolescence has been eliminated)

◦ 17 groups in total

Dimensional component. ◦ No more NOS labeling More specificity

through dimensional labeling.

Categories more sensitive to gender and cultural differences.

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Neuro-

Developmental

Disorders

Intellectual Disabilities (319.)

Previously Mental Retardation

Diagnosis based on cognitive capabilities and adaptive functioning: ◦ Adaptive functioning level determines severity Mild (F70), Moderate (F71), Severe (F72), and

Profound (F73)

Intellectual Developmental Disorder is ICD title for disorder

Additional Diagnoses of: ◦ 315.8 (F88) Global Developmental Delay

◦ 319 (F79) Unspecified Intellectual Disability

Communication Disorders

Language Disorder 315.39 (F80.9)

◦ Combination of Expressive and Mixed

Receptive Expressive Disorder

Speech Sound Disorder 315.39 (F80.0)

◦ Phonological Disorder

Childhood-Onset Fluency Disorder

315.35 (F80.81)

◦ Stuttering

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Communication Disorders (continued)

Social (Pragmatic) Communication Disorder 315.39

(F80.89)

◦ New addition in DSM-5

◦ Persistent difficulties in social use of verbal and

nonverbal communication

◦ Cannot be diagnosed when concurrent with

restrictive repetitive behaviors, interests or

activities (See Autism)

◦ Encompasses some symptoms of Pervasive

Developmental Disorder NOS

Unspecified Communication Disorder 307.9 (F80.9)

◦ No changes

Autism Spectrum Disorder (ASD)

299.00 (F84.0)

Combination of Autism, Asperger’s,

Pervasive Developmental Disorder NOS,

and Childhood Disintegrative Disorder.

Two core domains:

◦ Social communication and social interaction

◦ Restricted repetitive behaviors, interests and

activities

Autism Spectrum Disorder (continued)

Specifiers ◦ Associated with known medical or genetic

condition or environmental factor ◦ Associated with another

neurodevelopmental, mental or behavioral disorder

◦ Severity With very substantial support

With substantial support

With support

◦ Accompanied by intellectual impairment

◦ Accompanied by language impairment

◦ Accompanied by catatonia

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Asperger’s Integration into ASD

DSM-IV-TR ◦ Impairment in social interaction ◦ Restricted repetitive and stereotyped patterns

of behavior, interest and activities

◦ No delay in language

◦ No clinically significant delay in cognitive development, age appropriate self-help skills, adaptive behavior and curiosity about the environment

DSM-5 ◦ Autism Spectrum Disorder with no intellectual

impairment, without language impairment, requiring support

Childhood Disintegrative

Disorder into ASD

DSM-IV-TR ◦ Normal development in all areas for at least first

two years of life ◦ Loss of previously acquired skills before the age

of 10 in two areas

◦ Abnormal functioning in two of the three areas of social interaction, communication, or restrictive, repetitive and stereotyped patterns of behavior, interests and activities

DSM-5 ◦ Autism Spectrum Disorder with intellectual

impairment, with or without language impairment, and determine support level.

Pervasive Developmental

Disorder NOS into ASD

DSM-IV-TR

◦ Used when severe and pervasive impairment in development of reciprocal social interaction with either Impairment in verbal or non-verbal communication

OR

Presence of stereotyped behavior, interests and activities

DSM-5

◦ Autism Spectrum Disorder without intellectual disorder, with or without language impairment, and specify support level

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Attention-Deficit/Hyperactivity

Disorder (ADHD) 314.00/.01

Moved to Neurodevelopmental chapter when chapter addressing diagnosis usually first made in infancy, childhood or adolescents was eliminated.

Application across the lifespan

Cross-situational requirement necessities several symptoms in each setting

Onset changed from before 7-years to symptoms were present prior to age 12

Subtypes replaced by presentation specifiers

Can be diagnosed co-morbid with Autism

Addition of symptom threshold for adults

Specific Learning Disorder

Combination of reading disorder, mathematics disorder, disorder of written expression and learning disorder NOS

Specifiers: ◦ 315.00 (F81.0) Impairment in reading

◦ 315.2 (F81.81) Impairment in written expression

◦ 315.1 (F81.2) Impairment in mathematics

◦ Severity (Mild, Moderate, Severe)

Motor Disorders

Developmental Coordination Disorder 315.4 (F82)

Stereotypic Movement Disorder 307.3 (F98.4)

Tourette’s Disorder 307.23 (F95.2)

Tic Disorders ◦ Persistent Motor or Vocal Tic Disorder 307.22

(F95.1)

◦ Provisional Tic Disorder 307.21 (F95.0)

◦ Other Specified Tic Disorder 307.2 (F95.8)

◦ Unspecified Tic Disorder 307.2 (F95.9)

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Other Neurodevelopmental

Disorders

Other Specified Neurodevelopmental

Disorders 315.8 (F88)

Unspecified Neurodevelopmental

Disorder 315.9 (F89)

Disruptive,

Impulse-Control,

and Conduct

Disorders

New Chapter in DSM-5

Brings together disorders that were

previously included in two others chapters.

Disorders all characterized by problems in

emotional and behavioral self-control.

◦ Because of its close association with Conduct

Disorder, Antisocial Personality Disorder has

dual listing in this chapter.

◦ ADHD often co-morbid with the disorders in this

chapter but its listed with Neurodevelopmental

disorders.

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Oppositional Defiant Disorder

313.81 (F91.3) Symptoms now grouped into three types: ◦ Angry/irritable mood ◦ Argumentative/defiant behavior, and

◦ Vindictiveness

Exclusion criterion for Conduct Disorder has been removed.

A note has been added to the criteria to provide guidance on the frequency typically needed for a behavior to be considered symptomatic of the disorder.

Severity Rating has been added.

Oppositional Defiant Disorder

313.81 (F91.3) Specifiers:

◦ MILD: Symptoms are confined to

only one setting (e.g. at home, at

school, at work, with peers.)

◦ MODERATE: Some symptoms are

present in at least 2 settings.

◦ SEVERE: Some symptoms are

present in three or more settings.

Intermittent Explosive Disorder

312.32 (F63.81) Type of aggressive outbursts that should

be considered: ◦ Physical aggression was required in DSM-IV,

whereas verbal aggression and non-destructive/noninjurious physical aggression also meet criteria in DSM-5.

More specific symptomology defining the frequency needed to meet criteria added.

Minimum age of 6-years (or equivalent developmental level) now required.

Relationship of this disorder to other disorders has been clarified.

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Conduct Disorder

Largely unchanged from IV 5

Conduct disorder is characterized by behavior that violates either the rights of others or major societal norms. ◦ Symptoms must be present for at least three

months with one symptom having been present in the past six months.

◦ The symptoms must cause significant impairment in social, academic or occupational functioning.

◦ Typically diagnosed prior to adulthood.

Conduct Disorder Specifiers

◦ Specify whether:

312.81 (F91.1)- Childhood-onset type: at least

one symptom prior to age 10.

312.82 (F91.2)- Adolescent-onset type: no

symptom characteristic of conduct disorder

prior to age 10 years.

312.089 (F91.9)- Unspecified onset: Criteria for

CD are met, but there is not enough

information available to determine whether

onset was before or after age 10.

Conduct Disorder Specifiers

Specify if: ◦ With limited prosocial emotions:

Individual must have displayed at least 2 characteristics over at least 12 months and in multiple relationships/settings. Reflect typical behavior versus occasional functioning.

Lack of remorse or guilt

Callous- lack of empathy

Unconcerned about performance

Shallow or deficient affect

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Conduct Disorder Specifiers

MILD

• Few problems in excess are present.

• Problems cause minor harm.

MODERATE

• Number and effect are intermediate

SEVERE

• Many problems in excess are present.

• Cause considerable harm to others.

Other Disorders

No Significant Changes to:

◦ Pyromania

312.33 (F63.1)

◦ Kleptomania

312.32 (F63.2)

Other Disorders

Previous Disruptive Behavior Disorder

NOS broken down into two disorders…

Other Specified Disruptive,

Impulse-Control, and Conduct

Disorder 312.89 (F91.8)

•Symptoms are present, but not

enough to diagnose.

•Clinician should designate

reason.

Example: Recurrent behavioral

outbursts of insufficient

frequency

Unspecified Disruptive,

Impulse-Control, and

Conduct Disorder 312.0

(F91.9) •Used in situations in which

the clinician chooses NOT to

specify the reason that the

criteria are not met, AND

•includes presentations

where there is insufficient

information to make a more

specific diagnosis.

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Other Important

Changes with

Child and

Adolescent

Disorders

Disruptive Mood Regulation

Disorder From Depressive Disorders Group

Characterized by severe and recurrent temper outbursts that are out of proportion in intensity or duration to the situation. ◦ Occur three or more times each week for one year or

more.

Between outbursts, children with DMDD display a persistently irritable or angry mood, most of the day and nearly every day, observable by parents, teachers, or peers.

A diagnosis requires the above symptoms to be present in at least two settings (at home, at school, or with peers) for 12 or more months, and symptoms must be severe in at least one of these settings. ◦ During this period, the child must not have gone three or

more consecutive months without symptoms.

Understanding the Differences

Mood

DMDD

Severe and recurrent temper

tantrums

Increased frequency and

duration

ODD

Ander-guided disobedience

Hostilely Defiant

behavior

BD

More episodic than DMDD

Severely Irritable

Increasing Severity

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Posttraumatic Stress Disorder

New addition: Separate criteria for

Children ages 6 and younger.

See provided chart for more information.

PRESENTER CONTACT INFORMATION:

ROBIN DUFRESNE- ROBIN.DUFRESNE@ROCKETS.UTOLEDO.EDU

ALLISON ARNEKRANS-

ASANDRO@ROCKETS.UTOLEDO.EDU

Questions??