Changes in the DSM-5: what social workers need to know
By Cynthia Franklin
Social workers that provide therapeutic and other services to children and adolescents can expect to find some major changes in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: in their placement within the DSM-5, the conceptualization of the disorders, the criteria for the disorders, the elimination of disorders, and the inclusion of some new diagnoses.
Where to find diagnoses: The separate chapter on disorders usually found in childhood and adolescents (that was in the DSM IV) no longer exists. Instead, the DSM-5 provides a life span development approach to diagnosis meaning that disorders for children and adolescents are scattered throughout the manual. Chapters and groupings of mental disorders have also been organized differently. The diagnosis of ADHD, for example, has been moved to the new chapter, Neurodevelopmental Disorders and has added symptom criteria for ages 17 and older. In the same chapter you will also find specific learning disorders, Autism Spectrum Disorder, motor disorders, Tourette disorder, and Intellectual Disability (Intellectual Developmental Disorder), which replaces the term ‘mental retardation’ that was in the DSM IV. The diagnosis for Reactive Attachment Disorder now exists within a new chapter on Trauma and Stress Related Disorders. Post-traumatic Stress Disorder is further covered in this chapter (instead of the Anxiety Disorders chapter as it was in DSM IV) and has new criteria for children under the age of six.
Changes in criteria: Symptoms and specifiers have changed for several disorders. Criteria for Intellectual Disability, for example, has changed to dis-include the establishing of severity levels through cutting points that were shown for IQ test scores — emphasizing instead that considerable clinical judgment is needed in interpreting those tests and in accurately making the diagnosis. In order to determine the levels of severity (mild, moderate, severe, and profound) that are associated with Intellectual Development Disorder, practitioners are directed to assess a client’s functioning across conceptual, social, and practical domains of functioning. The childhood diagnosis of Conduct Disorder (now found in the Disruptive, Impulse Control and Conduct Disorders chapter) has added the specifier “with limited prosocial emotions”: to demonstrate lack of empathy, guilt, and shallow affect that may show considerable aggression, thrill seeking, and callous behavior.
New diagnoses: Disruptive Mood Dysregulation Disorder is perhaps one of the most debated disorders that was added to the DSM-5 and was included to try and decrease the numbers of children and adolescents being diagnosed with Bi-polar disorders. It was also a goal of the DSM-5 task force to reduce the numbers of children and adolescents that were being prescribed psychotropic medications. Disruptive Mood Dysregulation Disorder is found in the chapter on Depressive Disorders — while criteria for the Bi-polar I & II disorders are now in a different chapter on Bi-polar and Related Disorders. The core symptoms of Disruptive Mood Dysregulation Disorder is the chronic and persistent irritability that is severe accompanied with temper outbursts that occur 2-3 times a week across different settings. Another disorder that was added to the DSM-5 is the Disinhibited Social Engagement Disorder that describes children who are overly friendly and familiar with strangers. The criteria for this disorder describes a lack of reticence to go with strangers, a lack of social boundaries, and decreased checking in with adults. This new disorder is seen in children and adolescents that have experienced difficult upbringing and that do not have their basic needs met from caretakers.
Elimination of disorders: Removed diagnoses that apply to children include: (1) Feeding Disorder of infancy and early childhood, (2) Rett’s Disorder, (3) Learning Disorder NOS, (4) Childhood Disintegrative Disorder, (5) Asperger’s Disorder, and (6) Pervasive Developmental Disorder NOS. The removal of Asperger’s syndrome was the most controversial. Now children and adolescents receiving this diagnosis are diagnosed along the mild dimension of Autism Spectrum Disorder. Or they may be diagnosed with Social Communication Disorder if a person does not meet the specific criteria for impairments in restrictive and repetitive behavior patterns that are associated with the Autism Spectrum Disorders diagnosis.
How disorders are reported: The DSM-5 does not use the Axis 1-5 structure that was used in the DSM IV for recording diagnoses, but instead encourages a case conceptualization approach that allows practitioners to record multiple mental disorder diagnoses. A primary diagnosis may be indicated, and health conditions may also be included. Conditions that are not mental disorders per se but may be a focus of clinical attention, that were taken from the International Classification of Diseases (ICD-9-Clinical Modification) and the ICD-10, may also be diagnosed. Child maltreatment or neglect problems, economic problems, education problems, and problems related to social environment are examples of diagnosable clinical condition categories. The Global Assessment of Functioning scale that was a part on Axis V of the DSM IV has further been replaced by several cross cutting measures that may be used as screening and assessment tools.
While adapting to the new DSM-5 may be a challenge for many social workers, it is an opportunity to provide clients with a more nuanced approach to their situation – emphasizing more cultural, social, and developmental issues that may be associated with mental disorders. The diagnosis of clinical conditions that are not mental disorders, but are often a focus of clinical attention, also provides social workers with an opportunity to more thoroughly explain the cultural, social, and family circumstances of clients.
Cynthia Franklin, PhD, LCSW is the Stiernberg/Spencer Family Professor in Mental Health and Assistant Dean for Doctoral Education in School of Social Work at the University of Texas at Austin. She is Editor in Chief of the Encyclopedia of Social Work Online.
Learn more about the DSM-5 changes and new developments in social work with the Encyclopedia of Social Work Online, the first continuously updated online collaboration between the National Association of Social Workers (NASW Press) and Oxford University Press (OUP). Building off the classic reference work, a valuable tool for social workers for over 85 years, the online resource of the same name offers the reliability of print with the accessibility of a digital platform. Over 400 overview articles, on key topics ranging from international issues to ethical standards, offer students, scholars, and practitioners a trusted foundation for a lifetime of work and research, with new articles and revisions to existing articles added regularly.