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Deconstructing the DSM-5 - By Jason H. King
Assessment and diagnosis of neurodevelopmental disorders
The chapter on neuro- developmental disorders in the fifth edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-5) includes the most substantial changes in the entire manual. Many of the disorders previously found in the “Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence” chapter in the DSM-IV-TR have been relocated or reconceptualized in the DSM-5, or removed altogether.
Specifically, pica, rumination disorder, and feeding and eating disorder of infancy or early childhood (avoidant/ restrictive food intake disorder) are
now included in a chapter titled
“Feeding and Eating Disorders” in
the DSM-5. Encopresis and enuresis
have been moved to a chapter titled “Elimination Disorders” (this title was used as a grouping in the DSM-IV-
TR). Oppositional defiant disorder and conduct disorder are now located in the DSM-5 chapter on disruptive, impulse- control and conduct disorders (they were previously grouped together as disruptive behavior disorders in the DSM-IV-TR). Separation anxiety disorder and selective mutism are now located in the “Anxiety Disorders” chapter, while reactive attachment disorder of infancy or early childhood is now found in the chapter on trauma- and stressor-related disorders.
The neurodevelopmental disorders are reorganized in the DSM-5 based on shared symptoms, shared genetic and environmental risk factors, and shared neural substrates. They are also reorganized to stimulate new clinical perspectives and cross-cutting factor research, to align with developmental and life-span considerations, and to harmonize with the International Classification of Diseases (ICD).
One of the most important additions in this DSM-5 chapter is that “the
neurodevelopmental disorders may include the specifier ‘associated with a known medical or genetic condition or environmental factor.’ This specifier gives clinicians an opportunity to document factors that may have played a role in the etiology of the disorder, as well as those that might affect the clinical course. Examples include genetic disorders, such as fragile X syndrome, tuberous sclerosis, and Rett syndrome; medical conditions such as epilepsy; and environmental factors, including very low birth weight and fetal alcohol exposure” (pages 32-33).
intellectual disability (intellectual developmental disorder)
This is the new name for what the DSM-IV-TR referred to as “mental retardation.” Intellectual disability is the term preferred by the American Association on Intellectual and Developmental Disabilities, and it parallels with the ICD’s use of the title intellectual developmental disorder.
As the DSM-5 explains further, “a federal statute in the United States (Public Law 111-256, Rosa’s Law) replaces the term mental retardation
with intellectual disability, and research journals use the term intellectual disability. Thus, intellectual disability is the term in common use by medical, educational and other professions and by the lay public and advocacy groups.”
The DSM-5 also changes the previous requirement that IQ score solely determines the severity rating for this disorder. This is because IQ measures are less valid in the lower end of the IQ range and “problems in adaptation are more likely to improve with remedial efforts than is the cognitive IQ, which tends to remain a more stable attribute” (DSM-IV- TR, page 42). Counselors now determine severity rating (mild, moderate, severe
or profound) by using both clinical evaluation and individualized, culturally
appropriate, psychometrically sound measures to assess the individual’s conceptual functioning (academic skills), social functioning (social judgment) and practical functioning (self-management of behavior) as listed in the DSM-5 Table 1 Severity Levels for Intellectual Disability (Intellectual Developmental Disorder). The DSM-IV-TR diagnosis “mental retardation, severity unspecified” now becomes “unspecified intellectual disability (intellectual developmental disorder)” in the DSM-5.
Global developmental delay
This new DSM-5 disorder is reserved for individuals under the age of 5 who are unable to complete systematic assessments of intellectual functioning. It requires reassessment after a period of time; therefore, no formal criteria are provided.
Language disorder
This DSM-5 disorder combines
the DSM-IV-TR’s expressive language disorder and mixed receptive-expressive language disorder and features completely reconceptualized criteria.
Speech sound disorder
This is the new name for the DSM-IV-TR’s phonological disorder. Counselors are encouraged to read the diagnostic criteria, which are completely reconceptualized.
Childhood-onset fluency disorder (stuttering)
Changes to this diagnosis in the DSM- 5 include:
n Expanding the DSM-IV-TR title (“stuttering”) to provide a more objective description
n Adding “... of consonants as well as vowels” to Criterion A2
n Removing Criterion A3 (“interjections”)
12 | ct.counseling.org | December 2014