The New DSM-5: Changes to Childhood Disorders
The DSM-5 no longer has a category of disorders called, “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.” Life-span development guided the organizational structure and classification of disorders in DSM-5. Therefore, the first category of disorders are those that typically onset during childhood. This new category of disorders is called Neurodevelopmental Disorders. Many (if not most) of the disorders that were previously classified as, “Disorders Usually First Diagnosed in Infancy, Childhood, and Adolescence” are now classified as Neurodevelopmental Disorders. However, there are some significant changes.
Perhaps the most significant change is the formation of a single diagnostic category called autism spectrum disorder (ASD). ASD integrates and subsumes Asperger’s, childhood disintegrative disorder, and pervasive developmental disorder NOS. Other important changes include the addition of social communication disorder, a consolidation of learning disorders, and changes to criteria for intellectual disability (previously mental retardation).
Autism Spectrum Disorder (ASD) (replaces the group of disorders called pervasive developmental disorders including autistic disorder, childhood disintegrative disorder, Asperger’s disorder, and pervasive developmental disorder NOS)
Clinicians are likely to welcome this merger and simplification. In fact, a primary reason for this change was that research demonstrated wide variability among clinicians in applying the diagnostic criteria for this group of disorders. Furthermore, the DSM-5 workgroup concluded there was no evidence to support separate diagnoses. The new ASD diagnostic criteria describe two primary sets of symptoms: 1) social communication and social interaction deficit, and 2) restrictive and repetitive behavior patterns. Each of these symptom sets (social and behavioral) will include three severity levels to identify the supportive services that are required. These three severity levels are: 1) requiring support, 2) requiring substantial support, and 3) requiring very substantial support. The DSM-5 describes each of these severity levels, with examples, to aid clinicians in making these determinations.
There is a subset of children who exhibit the social deficits of autism, but not the repetitive or restrictive behavioral patterns that characterize autism. Because these children did not meet both the social and behavioral symptom criteria of autism, they were often diagnosed with pervasive developmental disorder NOS (also called atypical autism). An overall goal of the DSM-5 task force was to reduce the use of NOS diagnoses. A new diagnosis has been added to capture this group of children who have the social, but not the behavioral characteristics of autism. This new diagnosis is called social communication disorder.
Specific Learning Disorder (replaces reading disorder, mathematics disorder, and disorder of written expression)
Three learning disorders (reading, writing, and math) have now been merged into a single disorder called specific learning disorder. The merger of these three disorders highlights that various difficulties in learning and academic achievement tend to occur together. The new diagnostic criteria are more comprehensive. Clinicians can now diagnose deficits in all three areas, with specifiers that identify the relative deficit levels in each of the three areas of learning (reading, writing, and math).
Intellectual Disabilities (replaces mental retardation):
DSM-5 adopted the diagnostic term “intellectual disability” to align with language used by federal legislation, and by professionals who specialize in this disorder. The new criteria no longer require an IQ cut-off score of 70 or below. Instead, IQ scores must be considered alongside an assessment of adaptive functioning. The new diagnostic criteria describe, “deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility.” In addition to emphasizing adaptive functioning, these new criteria reflect DSM-5’s greater attention to socio-cultural symptom presentation across all disorders.
Eliminating the IQ cutoff score has many important implications. First, it has the potential to allow more people to qualify for supportive services. Second, this change is particularly important in forensic work. Previously, someone with an IQ score of 71 could receive the death penalty even though their capacity for judgment was far below adults with normal developmental abilities.
The new criteria also include severity measures for mild, moderate, severe, and profound intellectual disability. From a clinical perspective, these changes allow the clinical team to more easily provide and align support services to match the specific needs of each individual person.
Other changes to childhood disorders
ADHD symptoms are largely unchanged but age of onset has changed from age 7 to 12. Specifiers have replaced sub-types (inattentive, hyperactive, and mixed). Comorbid diagnosis with Autism is now permitted.
Communication disorders have new names: language disorder (combines expressive and mixed receptive-expressive language disorders); speech sound disorder (previously phonological disorder); childhood onset fluency disorder (previously stuttering); and a new disorder has been added called social communication disorder. This addition of this disorder is discussed in the autism section (see above).
Motor disorders are largely unchanged. Stereotypic movement disorder has been more clearly differentiated from the repetitive behavior of autism and obsessive-compulsive disorders.
Oppositional defiant disorder and conduct disorder have been reclassified and moved into a new group of disorders called Disruptive, Impulse-Control, and Conduct Disorders. This category of disorders will be discussed in future newsletters.
Separation anxiety and selective mutism have been reclassified and moved into Anxiety Disorders. However, the new Anxiety Disorder group does not resemble the DSM-IV. It no longer contains obsessive-compulsive disorder or PTSD. These disorders are classified elsewhere and will be discussed in upcoming newsletters.
Pica and rumination disorders have been reclassified and moved into Feeding and Eating Disorders.
Enuresis and Encopresis disorders have been reclassified and moved into a new group of disorders called Elimination Disorders.
Reactive attachment disorder has been reclassified moved into a new group of disorders called Trauma and Stressor-Related Disorders. PTSD and adjustment disorder are also a part of this new group.