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How Mental Health Disorders Are Diagnosed

It’s thick. It’s heavy. It’s full of medical jargon. It’s definitely not nightstand material. But for mental health professionals, the Diagnostic and Statistical Manual of Mental Disorders (or DSM), is something like a bible—used by doctors to diagnose everything from autism to depression to sleepwalking. And for patients, a DSM diagnosis means the difference between health insurance coverage for treatment ... and nothing. (If it’s not in the DSM, it’s typically not covered.)

So plenty of people were paying attention when the American Psychiatric Association recently announced that they had approved a new, fifth version of the book, known as the DSM-5, which has been in the making for more than a decade. It didn’t take long for patients, parents, clinicians, and critics jumping in from all sides to offer their take on the changes—particularly the elimination of Asperger’s syndrome and the inclusion of a new pediatric condition called “disruptive mood dysregulation disorder.” But what do the updates mean for parents and kids in the real world? We spoke with several experts about some of the biggest changes in the new DSM, and how they could affect your family.

For Kids Who Have Asperger's Syndrome

What’s changing: In the DSM-IV, Asperger’s syndrome was listed separately from autism. The new version will eliminate Asperger’s in favor of a broader umbrella diagnosis called “autism spectrum disorder,” which will apply to all adults and kids who have some form of autism.

Why it’s changing: “The truth is that many clinicians who work with autistic children have always thought of Asperger’s as part of the spectrum disorder,” says Dr. Ron J. Steingard, senior pediatric psychopharmacologist at the Child Mind Institute. “It was never clear to a lot of people in the field how it was different from high-functioning autism.” In addition, says Goldman, “With the term ‘spectrum,’ there’s now more room for dimensionality. Previously, you either had autism or Asperger’s or PDD-NOS [pervasive development disorder not otherwise specified]—and that was it. Now we can look at the strengths and weaknesses of each individual child and tailor their treatment based on those symptoms.”

What parents need to know: While some critics have expressed concern that children with Asperger’s may not meet the diagnosis criteria under the new “autism spectrum” category, all of the experts we spoke to agreed that is unlikely to happen to most kids.

“I know there have been dire predictions about children losing their diagnoses or not having access to services,” says Steingard. “But for the most part, I don’t think that those predictions will come true, because the diagnostic criteria really haven’t changed. It’s still about a cluster of symptoms that have to do with a child’s social relationships, their understanding of social nuance and cues, their range of interests in the world, etc. The new criteria define a range of people along the spectrum, including Asperger’s individuals.”

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In fact, many parents may find that the insurance coverage for their child’s treatment actually improves, according to Dr. Stuart Goldman, associate professor of psychiatry at Harvard Medical School and senior associate at Children’s Hospital Boston. “Previously, many plans would cover autism but not Asperger’s,” he says. “The change should put more pressure on insurance providers and schools to cover the needs of these children.”


For Kids Who Have Serious Behavior Problems

What’s changing: A new category called “disruptive mood dysregulation disorder” (DMDD) will target children who suffer from massive temper outbursts and severe mood swings.

Why it’s changing: “The addition of DMDD is really an attempt to curb the massive overdiagnosis of bipolar disorder in children,” says Dr. Rebecca Schrag, a psychologist in the pediatrics department at Montefiore Medical Center and assistant professor of pediatrics at the Albert Einstein College of Medicine in New York City. “We realized that there is a group of kids who are diagnosed with pediatric bipolar disorder, but do not grow up to develop bipolar disorder as adults. They’re given really intense medications, like antipsychotics, mood stabilizers or anticonvulsants, when they don’t actually need those drugs.”

What parents need to know: “The big question has been whether children with normal tantrums or outbursts could wind up diagnosed with DMDD, says Steingard. “But we’re not talking about a 2-year-old who has occasional tantrums at bedtime. This is a persistent, severe pattern of aggressive, irritable behavior that’s well beyond what you see in a typical child.” Agrees Goldman, “These are kids who have hour-long temper tantrums at the drop of a hat, regularly, over a long period of time. I don’t think we will see a rash of overdiagnosis.”

And many clinicians, including Goldman, hope that the new category will drastically cut down on the number of pediatric bipolar diagnoses. “In my clinic, I have undiagnosed somewhere between 70 and 80 percent of kids who come in having been told they have bipolar disorder,” he says. The more important question is, he says, what will the standard treatment be for children with DMDD?

“Since professionals and parents often feel desperate when presented with a kid like this, I would imagine most will be put on medication,” says Goldman. “But rather than being treated with mood stabilizers, which we know don’t work in this population and can cause serious side effects, they would probably be treated with drugs like Ritalin or Prozac that could help ease their symptoms.” Steingard also hypothesizes that for some children with DMDD, intensive therapy and behavior modification may be the best course of treatment.

And if your child has already been labeled bipolar, this may also be a time to reconsider the diagnosis, says Schrag. “If you’re not happy with the treatment your child is receiving, and you’re wondering if bipolar disorder is a correct diagnosis, then use this as an opportunity to get a second opinion,” she says.


For Kids or Teenagers Who Binge Eat

What’s changing: For the first time, binge eating disorder (BED) has been recognized as an official diagnosis.

Why it’s changing: BED was previously was listed in the appendix under “eating disorder, not otherwise specified” (ED-NOS), and “that made that category sort of useless,” says Doug Bunnell, Ph.D., a clinical psychologist specializing in eating disorders and vice president of the Renfrew Center Foundation. “People who have BED have different characteristics than those with bulimia, and overweight patients with BED are clearly different than overweight people without BED.” For example, he notes, those with BED are more prone to depression and anxiety.

What parents need to know: Many experts, including Bunnell, believe that BED may be by far the most common eating disorder. Some research has suggested that 20 percent of people using commercial weight loss programs have BED. Still, he notes, “The fear is that we’ve created a whole class of people who have occasional bouts of abnormal eating but otherwise don’t have a disorder. But if you look at the other criteria—the loss of control, the emotional distress—then you realize that it does exclude, say, the teenage boy who polishes off a box of Oreos on occasion, but feels fine otherwise.”

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For those kids who do have BED, the inclusion of the condition in the new DSM is good news. “The lack of an official diagnosis was really demoralizing for people who were struggling with this, but told they didn’t meet the criteria for an eating disorder,” says Bunnell. “Now there’s a whole new class of people that are seen as treatable and can get insurance coverage.” That, in turn, will help improve research into BED, since more patients will have access to treatment.


For Kids Who Are Struggling After a Divorce

What’s (not) changing: Despite years of discussion over whether to include a new category called “parental alienation syndrome” (PAS), which refers to the way that a child's relationship with a parent can be poisoned in the wake of a divorce, it does not appear in the new DSM.

Why it’s (not) changing: “The bottom line is that the data didn’t support PAS as a mental disorder,” says Goldman. “That doesn’t mean that some children in the middle of an ongoing, nasty divorce aren’t suffering, but it’s essentially a parental relationship issue, not a mental health issue.”

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What parents need to know: “The take-home message here is that the exact diagnosis isn’t always the most important thing, as long as your child is getting the treatment that he or she needs,” says Schrag. “If you see that your child is hurting or struggling, if you have a gut feeling that something is off, then the lack of a PAS diagnosis does not mean that he can’t get help.” Goldman agrees: “A clinician can still diagnose a child with something like adjustment disorder, or disruptive behavior disorder, and get them into a category that’s covered by insurance.”


For Kids Who Have ADHD

What’s changing: In order to meet the diagnostic criteria for ADHD, patients previously had to have experienced symptoms before the age of 7. That age cutoff has now been increased to 12.

Why it’s changing: “As we’ve discovered more about the complexity of ADHD, we’ve learned that it can be difficult to recognize the signs in the early years,” says Schrag. “This change reflects a change in our understanding of the condition.”

What parents need to know: The new DSM will open the door for more older children and teenagers to receive help for attention disorder than were previously able. “If you think that your child has been showing symptoms of ADHD, but they’ve never received an official diagnosis or appropriate treatment, this is a good time to go back for a second—or even first—opinion,” says Schrag.

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