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Disorders in Disagreement: The New Testament of Psychiatry & the Prognosis of Rights for Children with Neurodevelopmental Disorders

Credit: Na Kim, New York Times, Feb. 10, 2011, http://www.nytimes.com/2010/02/10/opinion/10grinker.html

By Maureen Brocco, Student Writer for The Journal of Gender, Race & Justice

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the “bible” of psychiatry and psychology. This book, published by the American Psychiatric Association (APA), is used by mental health professionals throughout the United States to define, diagnose, and treat mental health conditions. DSM has evolved since its introduction in 1980, and the newest edition, DSM-V, is scheduled for release in May of 2013.

DSM is a powerful book. Mental health practitioners use its criteria to determine which persons are mentally ill and who should be prescribed powerful stimulant or antipsychotic medications. These diagnoses shape how individuals view themselves, how others view them, and how the government classifies certain disabilities. DSM is also used by private insurance companies and government-managed health systems to determine the scope of their coverage. With so much on the line, the mental health community is divided in its opinion over the potential benefits or adverse consequences any revisions to DSM may carry.

On January 20, 2012, an APA news release announced the specifics of its proposal to update the diagnostic criteria for autism. As currently drafted, DSM-V will introduce a new classification, Autism Spectrum Disorder (ASD), which will integrate a number of separately defined disorders from DSM-V’s predecessor, DSM-IV-TR. In the new manual, autism disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified) will become a single broad-spectrum disorder. ASD will require mental health practitioners to apply the same diagnostic criteria on what were previously four distinct disorders, with a scale of impairment ranging from mild to severe.

The APA intends for DSM to create a uniform standard of diagnosis and communication to aid in a patient’s prognosis and treatment planning. The APA claims the reclassification of these four separate childhood disorders into one spectrum will simplify the diagnostic process, since all four of these disorders share certain key characteristics; however, these four disorders do not share all of the same diagnostic criteria. For example, in DSM-IV-TR, the diagnosis for autism required (in simplified terms) three separate criteria: (1) “impaired social interaction;” (2) “impaired communication;” and (3) “restricted repetitive and stereotyped patterns of behavior, interests, and activities;” whereas the diagnosis for Asperger’s disorder only required criteria (1) and (3) from autism, or social impairment and restricted repetitive behavior.

Critics fear that collapsing disorders that commonly manifest in less-severe ways than the DSM-IV-TR version of autism, such as Asperger’s disorder, under a single ASD-umbrella will leave some high-functioning children who would qualify as having Asperger’s disorder as being on the normal spectra of functioning. This could result in children who may need special services in order to learn equally with their developmental peers without assistance. Members of the Asperger’s community could also lose their identity by being denied their classification as unique from the typical human neuropsychological spectra. Others warn that being over-diagnosed and grouped with a formerly separate and typically more impaired cohort, such as autistic persons, may create a self-fulfilling prophecy in which high-functioning children cannot reach their potential due to a low self-image.

On the other hand, integrating Asperger’s disorder into ASD may benefit some children. Each state defines which disorders qualify for special services differently. While some states recognize that children with Asperger’s disorder and children with autism require special services, other states will only provide autistic children with extra help and leave children with Asperger’s disorder unassisted. In states that make this latter distinction, children who would be diagnosed with Asperger’s disorder by DSM-IV-TR may benefit from the broad-ASD definition in DSM-V, since those children would then qualify for special services.

Regardless of where you stand on the issue of ASD, you should be aware of the emerging New Testament. DSM-V will have a profound effect on how doctors, schools, and employers view you. It could change what medications your insurance company will cover, and what services your children will receive at school. It could alter your legal rights, and impose new legal obligations. It might even change how you perceive yourself, and whether society views you as a “normal” person, or one suffering from a disorder.

In addition to changing existing definitions, the new psychiatric bible is slated to introduce new disorders, turning frequent gamblers into persons with a gambling disorder, and some women with premenstrual syndrome (PMS) into women with the new psychiatric condition of premenstrual dysphoric disorder (PMDD).

APA is accepting comments on DSM-V, and may consider revisions based on public feedback. You can review and submit comments on the tentative changes to the manual here.

Links:

DSM-V’s Draft Changes & Feedback Webpage: www.dsm5.org/Pages/Default.aspx

DSM-V’s Proposed Asperger’s Syndrome Collapse: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=97#

DSM-V’s Proposed Autism Spectrum Disorder Definition: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=94