DSM-5 Changes: Implications for Child Serious Emotional Disturbance

DSM-5 CHANGES:

IMPLICATIONS FOR CHILD

SERIOUS EMOTIONAL

DISTURBANCE

DISCLAIMER

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Substance Abuse and Mental Health Services Administration

Center for Behavioral Health Statistics and Quality

Rockville, Maryland 20857

June 2016

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DSM-5 CHANGES:

IMPLICATIONS FOR CHILD

SERIOUS EMOTIONAL

DISTURBANCE

Contract No. HHSS283201000003C

RTI Project No. 0212800.001.108.008.008

RTI Authors:

Heather Ringeisen

Cecilia Casanueva

Leyla Stambaugh

SAMHSA Authors:

Jonaki Bose

Sarra Hedden

RTI Project Director:

David Hunter

SAMHSA Project Officer:

Peter Tice

For questions about this report, please e-mail [email protected].

Prepared for Substance Abuse and Mental Health Services Administration,

Rockville, Maryland

Prepared by RTI International, Research Triangle Park, North Carolina

June 2016

Recommended Citation: Center for Behavioral Health Statistics and Quality.

(2016). 2014 National Survey on Drug Use and Health: DSM-5 Changes:

Implications for Child Serious Emotional Disturbance (unpublished internal

documentation). Substance Abuse and Mental Health Services

Administration, Rockville, MD.

Acknowledgments

This publication was developed for the Substance Abuse and Mental Health Services

Administration (SAMHSA), Center for Behavioral Health Statistics and Quality (CBHSQ), by

RTI International, a trade name of Research Triangle Institute, Research Triangle Park, North

Carolina, under Contract No. HHSS283201000003C. Contributors to this report include Lisa

Colpe and Peggy Barker. At RTI, Michelle Back edited and Roxanne Snaauw formatted the

report.

iii

Table of Contents

Chapter Page

1. Introduction ......................................................................................................................... 1

1.1 Definition of SED ................................................................................................... 1

1.2 Published SED Estimates ........................................................................................ 2

2. DSM-IV to DSM-5 Changes: Overview ............................................................................. 5

2.1 Elimination of the Multi-Axial System and GAF Score ......................................... 5

2.2 Disorder Reclassification ........................................................................................ 5

3. DSM-5 Child Mental Disorder Classification .................................................................... 9

3.1 New Childhood Mental Disorders Added to the DSM-5 ........................................ 9

3.1.1 Social (Pragmatic) Communication Disorder (SCD, under

Neurodevelopmental Disorders) ................................................................. 9

3.1.2 Disruptive Mood Dysregulation Disorder (or DMDD) (under

Depressive Disorders) ............................................................................... 11

3.2 Age-Related Diagnostic Criteria Changes to Mental Disorders in the DSM-5 .... 16

3.2.1 Attention-Deficit/Hyperactivity Disorder (ADHD, under

Neurodevelopmental Disorders ................................................................ 16

3.2.2 Post-traumatic Stress Disorder (PTSD, under Trauma- and

Stressor-Related Disorders) ...................................................................... 20

3.3 Changes to Other Mental Disorders with Minor to No Implication for SED

Prevalence Estimates ............................................................................................ 24

3.3.1 Major Depressive Episode/Disorder (under Depressive Disorders) ......... 24

3.3.2 Persistent Depressive Disorder (formerly Dysthymic Disorder,

under Depressive Disorders) ..................................................................... 25

3.3.3 Manic Episode and Bipolar I Disorder (under Bipolar and Related

Disorders) .................................................................................................. 26

3.3.4 Generalized Anxiety Disorder (under Anxiety Disorders) ....................... 34

3.3.5 Panic Disorder and Agoraphobia (under Anxiety Disorders) ................... 35

3.3.6 Separation Anxiety Disorder (under Anxiety Disorders) ......................... 39

3.3.7 Social Anxiety Disorder (formerly Social Phobia [Social Anxiety

Disorder], under Anxiety Disorders) ........................................................ 40

3.3.8 Conduct Disorder (under Disruptive, Impulse-Control, and

Conduct Disorders) ................................................................................... 42

3.3.9 Oppositional Defiant Disorder (under Disruptive, Impulse-Control,

and Conduct Disorders) ............................................................................ 45

3.3.10 Eating Disorders (under Feeding and Eating Disorders) .......................... 47

3.3.11 Body Dysmorphic Disorder (under Obsessive-compulsive and

Related Disorders) .................................................................................... 52

4. Instrumentation ................................................................................................................. 55

5. Summary and Conclusions ............................................................................................... 59

References ..................................................................................................................................... 61

List of Tables

Table Page

1. DSM-IV Childhood Mental Disorders Assessed in Leading Studies with Published

Estimates of SED ................................................................................................................ 3

2. Past 12-month Prevalence of Mental Disorders Based upon the NCS-A, NHANES

Special Study, and GSMS, by Functional Impairment and Child Age ............................... 4

3. Disorder Classes Presented by the DSM-IV and DSM-5, as Ordered in DSM-IV ............ 6

4. Disorder Classification in the DSM-IV and DSM-5 for Disorders Usually First

Diagnosed in Infancy, Childhood, or Adolescence ............................................................ 7

5. DSM-IV Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS)

to DSM-5 Social (Pragmatic) Communication Disorder (SCD) Comparison .................. 10

6. DSM-IV Bipolar Disorder-Manic Episode and Oppositional Defiant Disorder to

DSM-5 Disruptive Mood Dysregulation Disorder (or DMDD) Comparison ................... 12

7. DSM-IV to DSM-5 Attention-Deficit/Hyperactivity Disorder Comparison .................... 17

8. DSM-IV to DSM-5 Post-traumatic Stress Disorder Comparison Children 6 Years

and Younger ...................................................................................................................... 21

9. DSM-IV to DSM-5 Major Depressive Episode/Disorder Comparison ............................ 25

10. DSM-IV to DSM-5 Dysthymic Disorder/Persistent Depressive Disorder

Comparison ....................................................................................................................... 26

11. DSM-IV to DSM-5 Manic Episode Criteria Comparison ................................................ 28

12. DSM-IV to DSM-5 Bipolar I Disorder Comparison ........................................................ 29

13. DSM-IV to DSM-5 Generalized Anxiety Disorder Comparison ..................................... 34

14. Panic Disorder and Agoraphobia Criteria Changes from DSM-IV to DSM-5 ................. 36

15. DSM-IV to DSM-5 Separation Anxiety Disorder Comparison ........................................ 39

16. DSM-IV to DSM-5 Social Phobia/Social Anxiety Disorder Comparison ........................ 41

17. DSM-IV to DSM-5 Conduct Disorder Comparison ......................................................... 43

18. DSM-IV to DSM-5 Oppositional Defiant Disorder Comparison ..................................... 46

19. DSM-IV to DSM-5 Anorexia Nervosa Comparison ........................................................ 48

20. DSM-IV to DSM-5 Bulimia Nervosa Comparison .......................................................... 49

21. DSM-IV to DSM-5 Binge Eating Disorder Comparison .................................................. 50

22. DSM-IV to DSM-5 Avoidant/Restrictive Food Intake Disorder Comparison ................. 52

23.

SM-IV to DSM-5 Body Dysmorphic Disorder Comparison ......................................... 54

24. Summary of Diagnostic Instruments Used to Assess Child Mental Disorders ................ 55

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1. Introduction

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the manual used by

clinicians and researchers to diagnose and classify mental disorders (including substance use

disorders [SUDs]). The DSM specifically classifies child disorders by symptoms, duration, and

functional impact across home, school, and other community settings. The American Psychiatric

Association (APA) published the DSM-5 in 2013, culminating a 14-year revision process. This

latest revision takes a new approach to defining the criteria for mental disorders—a lifespan

perspective. This perspective is very relevant to diagnosing childhood mental disorders. The

perspective recognizes the importance of age and development in the onset, manifestation, and

treatment of mental disorders. The purpose of this report is to describe the differences between

the DSM-IV and DSM-5 diagnostic criteria that could affect national estimates of childhood

serious emotional disturbance (SED). The report also provides a description of DSM-5 updates

that have been made (or are being made) to existing diagnostic instruments and screeners of

childhood emotional and behavioral health.

1.1 Definition of SED

The DSM has never offered a definition of SED. This term has been defined historically

by the Substance Abuse and Mental Health Services Administration (SAMHSA) and released as

a Federal Register notice. The SAMHSA definition was crafted in order to inform state block

grant allocations for community mental health services provided to children with an SED and

adults with a serious mental illness (SMI). The Federal Register definition is intended to identify

and estimate the size of the group of children with SED within the general population of each

state. An accurate and up-to-date estimate of childhood SED is critical for SAMHSA to plan

future block grant allocations and financial supports to states serving children with SED.

The Federal Register notice defines the terms "children with a serious emotional

disturbance" and "adults with a serious mental illness" (SAMHSA, 1993, p. 29422). Pub. L. 102-

321 defines children with an SED to be people "from birth up to age 18 who currently or at any

time during the past year have had a diagnosable mental, behavioral, or emotional disorder of

sufficient duration to meet diagnostic criteria specified within the Diagnostic and Statistical

Manual of Mental Disorders, Third Edition, Revised (DSM-III-R; American Psychiatric

Association, 1987) that resulted in functional impairment, which substantially interferes with or

limits the child's role or functioning in family, school, or community activities" (SAMHSA,

1993, p. 29425).

The 1992 and 1993 Federal Register notices also offer several notes that are helpful in

considering the age, symptom duration, and diagnostic exclusions related to the definition of

childhood SED:

• Age: "Although the definition of SED in children is restricted to persons up to age 18, it

is recognized that some states extend this age range to persons less than age 22. To

accommodate this variability, states using an extended age range for children's services

should provide separate estimates for persons below age 18 and persons aged 18 to 22

within block grant applications" (SAMHSA, 1993, p. 29425).

• Duration: "The reference year…refers to a continuous 12-month period because this is a

frequently used interval in epidemiological research and because it relates to commonly

used [state] planning cycles" (SAMHSA, 1993, p. 29425).

• Diagnostic exclusions: "These disorders include any mental disorders listed in the DSM-

III-R…with the exception of DSM-III-R "V" codes, substance use and developmental

disorders, which are excluded unless they co-occur with another diagnosable serious

emotional disturbance" (SAMHSA, 1993, p. 29425).

A November 6, 1992, Federal Register notice requests public comments to a preliminary

definition of childhood SED (SAMHSA, 1992). The May 20, 1993, Federal Register describes

responses to public comments received in response to the 1992 notice. Public comments to the

proposed SED definition primarily focused on the impairment criteria, with support for

considering a broad definition of impairment and also concerns that including less impairing

disorders would dilute resources for those with the most severely debilitating conditions. A

smaller set of comments focused on the inclusion or exclusion of certain disorders such as

substance abuse, developmental disorders, and attention deficit disorder.

The 1993 Federal Register offers clarification on final decisions about disorders to be

included and excluded in the SED definition. Public comments included concerns about whether

attention-deficit disorder (ADD) should be included for two main reasons: (1) parental concerns

about the negative stigma associated with labelling ADD as a "serious emotional disturbance"

and (2) treatment providers/educators noting difficulties making definitive ADD diagnoses.

Ultimately, ADD was included in the definition of SED because "a significant group of children

with functional impairments associated with this disorder might otherwise be excluded from

service" (p. 29423). SUDs were excluded based upon the rationale that the federal government

administered a separate state block grant intended to fund substance abuse treatment and

prevention services. Developmental disorders (mental retardation, autism, pervasive

developmental disorders) were also excluded. The rationale described for this decision was as

follows: "while comments received cited the frequent involvement of mental health practitioners

in treatment planning and service delivery for these individuals (particularly autistic children),

separate Federal block grant funds and processes for needs assessment cover these population

groups" (SAMHSA, 1993, p. 29424). Finally, DSM-III "V" codes were excluded because "they

represent conditions that may be a focus of treatment but are not attributed to a mental disorder"

(p. 29424).

In summary, DSM mental disorder classifications are relevant to SED as they form the

basis for an essential part of the SED criteria—the presence of a DSM-based mental disorder.

Changes in the number of mental disorders (as defined by the DSM) that fall under the

operationalized definition of SED, and breadth of the diagnostic criteria for existing DSM-based

mental disorders might impact the prevalence rates of SED. The current operationalized

definition of SED may need to be updated to ensure consistent and precise measurement of the

prevalence of SED within epidemiological studies at the national level.

1.2 Published SED Estimates

Three large-scale epidemiological studies have provided estimates of SED based upon

the administration of child and adolescent diagnostic interviews. These studies include a

supplemental study to the National Health and Nutrition Examination Survey (NHANES;

Merikangas et al., 2010), the National Comorbidity Survey Adolescent Cohort (NCS-A; Kessler

et al., 2012), and the Great Smoky Mountain Study (GSMS; Costello, Mustillo, Erkanli, Keeler,

& Angold, 2003). These three studies assess slightly different age groups, use different

diagnostic instruments, and include the assessment of slightly different childhood mental

disorders (see Table 1). The disorders assessed in these studies reflect diagnostic categories to be

considered when estimating the prevalence of SED.

Table 1. DSM-IV Childhood Mental Disorders Assessed in Leading Studies with Published

Estimates of SED

Disorder

Category

NCS-A (13–17 years)

Composite International

Diagnostic Interview

(CIDI)

NHANES (8–15 years)

Diagnostic Interview

Schedule for Children

(DISC)

GSMS (9–16 years)

Child and Adolescent

Psychiatric Assessment

(CAPA)

Mood

Disorder

Major depression

Dysthymia

Bipolar disorder

Major depression

Dysthymia

Major depression

Dysthymia

Bipolar disorder

Mania

Depression NOS

Anxiety

Disorders

Generalized anxiety disorder

Panic disorder

Agoraphobia

Specific phobia

Separation anxiety disorder

Posttraumatic stress disorder

Social phobia

Generalized anxiety disorder

Panic disorder

Generalized anxiety disorder

Panic disorder

Agoraphobia

Simple phobia

Separation anxiety disorder

Posttraumatic stress disorder

Obsessive compulsive

disorder

Behavior

Disorders

ADHD

Conduct disorder

Oppositional defiant disorder

ADHD

Conduct disorder

ADHD

Conduct disorder

Oppositional defiant disorder

Substance

Disorders

Alcohol abuse

Drug abuse

Alcohol abuse

Drug abuse

Other Eating disorders Eating disorder Eating disorders

Trichotillomania

Enuresis

Encopresis

Psychosis

ADHD = attention-deficit/hyperactivity disorder; NOS = not otherwise specified.

Each study defines SED to include any assessed DSM-IV Axis I disorder. The R.C.

Kessler et al. (2012) and Costello et al. (2003) publications include substance disorders within

the SED estimates, while the Federal Register definition of SED excludes substance abuse.

"Serious functional impairment" is defined differently in each study based upon how the study's

diagnostic interview measured impairment. One study, (Costello et al., 2003), defined SED using

the Child and Adolescent Psychiatric Assessment (CAPA) as any Axis I disorder with

"significant functional impairment." CAPA-based definitions of SED include a child who

(1) meets diagnostic criteria for at least one of the assessed Axis I disorders by parent or child

report, and (2) has a report of any partial or severe impairment rating by parent or child report

(personal communication with G. Keeler, October 2012). R.C. Kessler et al. (2012) defined the

serious impairment criteria for SED as a Children's Global Assessment Scale (CGAS) score of

50 or less (having moderate functional impairment in most areas of living or severe impairment

in at least one area). Moderate impairment was defined as one or more Axis I disorders plus a

CGAS score of 51 to 60 (variable functioning with sporadic difficulties in several but not all

areas of living). Meanwhile, Merikangas and colleagues (2010) operationalized four levels of

impairment for each disorder assessed: level A, intermediate or severe rating on ≥ one question;

level B, intermediate or severe rating on ≥ two questions (level A and B are not mutually

exclusive); level C, severe rating on ≥ one question; and level D (severe impairment), included

meeting criteria for either level B or C. Impairment items assessed impairment in six domains,

including interference with the respondent's own life, family life, social life, peers, teachers, and

school performance. "Any DSM-IV Disorder with Severe Impairment," or SED, was defined as a

case with level D impairment.

These definitions of SED result in prevalence estimates that range from 6.8 to 11.5

percent depending on the study and age of children included (see Table 2). The following

sections of this report describe how recent updates to the DSM may or may not result in likely

changes to these prevalence estimates of SED. This report does not summarize DSM-IV to

DSM-5 changes to SUDs since they are excluded from the Federal Register definition of SED.

Another SAMSHA report Impact of the DSM-IV to DSM-5 Conversion on the National Survey

on Drug Use and Health and the Mental Health Surveillance Study includes a detailed

description of changes from DSM-IV to DSM-5 for SUDs among youths aged 12 to 17 years

(Center for Behavioral Health Statistics and Quality, in review).

Table 2. Past 12-month Prevalence of Mental Disorders Based upon the NCS-A, NHANES

Special Study, and GSMS, by Functional Impairment and Child Age

Prevalence Estimate (%, SE)

NCS-A (13-17 years)

Past 12 Months

NHANES Special

Study (12-15

years)

Past 12 Months

NHANES Special

Study (8-11 years)

Past 12 Months

GSMS (9-16

years)

Past 3 Months

Any DSM-IV

Disorder

42.6 (1.2) 13.4 (1.2) 12.8 (1.3) 13.3

SED (and

associated

definition)

8.0 (1.3)

Moderate impairment

rating in most areas of

living or severe in 1

area

11.5 (1.3)

Level A or B:

Intermediate

impairment rating on

2 of 6 items or at

least 1 severe rating

11.0 (1.1)

Level A or B:

Intermediate

impairment rating on

2 of 6 items or at

least 1 severe rating

6.8

Any Axis I plus

"significant

functional

impairment"

Disorder with

moderate or

severe

impairment in

any area of living

17.8 (n/a)

Moderate impairment

was defined as variable

functioning, with

sporadic difficulties in

several, but not all

areas of living.

Not provided Not provided Not provided

2. DSM-IV to DSM-5 Changes: Overview

The American Psychiatric Association (APA) published the DSM-5 in 2013. This latest

revision takes a lifespan perspective recognizing the importance of age and development on the

onset, manifestation, and treatment of mental disorders. Other changes in the Diagnostic and

Statistical Manual of Mental Disorders, 5th ed. (DSM-5) include eliminating the multi-axial

system; removing the Global Assessment of Functioning (GAF score); reorganizing the

classification of the disorders; and changing how disorders that result from a general medical

condition are conceptualized. Many of these general changes from Diagnostic and Statistical

Manual of Mental Disorders, 4th ed. (DSM-IV) to DSM-5 are summarized in the report Impact

of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health. This report

will supplement that information by providing details specifically about changes to disorders of

childhood and their implications for generating estimates of child serious emotional disturbance

(SED).

2.1 Elimination of the Multi-Axial System and GAF Score

One of the key changes from DSM-IV to DSM-5 is the elimination of the multi-axial

system. DSM-IV approached psychiatric assessment and organization of biopsychosocial

information using a multi-axial formulation (American Psychiatric Association, 2013b). There

were five different axes. Axis I consisted of mental health and substance use disorders (SUDs);

Axis II was reserved for personality disorders and mental retardation; Axis III was used for

coding general medical conditions; Axis IV was to note psychosocial and environmental

problems (e.g., housing, employment); and Axis V was an assessment of overall functioning

known as the GAF. The GAF scale was dropped from the DSM-5 because of its conceptual lack

of clarity (i.e., including symptoms, suicide risk, and disabilities in the descriptors) and

questionable psychometric properties (American Psychiatric Association, 2013b).

Although the impact of removing the overall multi-axial structure in DSM-5 is unknown,

there is concern among clinicians that eliminating the structured approach for gathering and

organizing clinical assessment data will hinder clinical practice (Frances, 2010). However, the

direct impact on the prevalence rates of childhood mental disorders is likely to be negligible as it

will not affect the characteristics of diagnoses.

2.2 Disorder Reclassification

DSM-IV and DSM-5 categorize disorders into "classes" with the intent of grouping

similar disorders (particularly those that are suspected to share etiological mechanisms or have

similar symptoms) to help clinician and researchers use of the manual. From DSM-IV to DSM-5,

there has been a reclassification of many disorders that reflects a better understanding of the

classifications of disorders from emerging research or clinical knowledge. Table 3 lists the

disorder classes included in DSM-IV and DSM-5. In DSM-5, six classes were added and four

were removed. As a result of these changes in the overall classification system, numerous

individual disorders were reclassified from one class to another (e.g., from "mood disorders" to

"bipolar and related disorders" or "depressive disorders"). The reclassification of disorder classes

will not have a direct effect on any SED estimation; however, it does warrant consideration when

documenting disorders that may have changed classes.

Table 3. Disorder Classes Presented by the DSM-IV and DSM-5, as Ordered in DSM-IV

DSM-IV DSM-5

1. Disorders usually first diagnosed in infancy,

childhood, or adolescence

Dropped

2. Delirium, Dementia, and Amnestic and other

cognitive disorders

17. Neurocognitive Disorders

3. Mental Disorders due to a general medical

condition

Dropped

4. Substance-related disorders 16. Substance-Related and Addictive Disorders

5. Schizophrenia and other psychotic disorders 2. Schizophrenia Spectrum and Other Psychotic

Disorders

6. Mood Disorders 3. Bipolar and Related Disorders

4. Depressive Disorders

7. Anxiety Disorders 5. Anxiety Disorders

8. Somatoform Disorders 9. Somatic Symptom and Related Disorders

9. Factitious Disorders Dropped

10. Dissociative Disorders 8. Dissociative Disorders

11. Sexual and Gender Identity Disorders 13. Sexual Dysfunctions

14. Gender Dysphoria

19. Paraphilic Disorders

12. Eating Disorders 10. Feeding and Eating Disorders

13. Sleep Disorders 12. Sleep-Wake Disorders

14. Impulse-Control Disorders not elsewhere

classified

15. Disruptive, Impulse-Control, and Conduct Disorders

15. Adjustment Disorders Dropped

16. Personality Disorders 18. Personality Disorders

N/A 1. Neurodevelopmental Disorders

N/A 6. Obsessive-Compulsive and Related Disorders

N/A 7. Trauma- and Stressor-Related Disorders

N/A 11. Elimination Disorders

N/A 20. Other Mental Disorders

N/A 21. Medication-Induced Movement Disorders and Other

Adverse Effects of Medication

A notation of "dropped" does not imply that the specific disorders were removed; rather the overall classification

is not included in DSM-5. Disorders in those classes were mainly recategorized.

Of particular note for childhood mental disorders, the DSM-5 eliminated a class of

"disorders usually first diagnosed in infancy, childhood, or adolescence." Those disorders are

now placed within other classes. See Table 4 for a summary the new DSM-5 disorder classes for

those disorders formally classified as "disorders usually first diagnosed in infancy, childhood, or

adolescence."

Table 4. Disorder Classification in the DSM-IV and DSM-5 for Disorders Usually First

Diagnosed in Infancy, Childhood, or Adolescence

Disorder Types (version) DSM-IV Disorder Class DSM-5 Disorder Class

Mental Retardation (DSM-IV)

Intellectual Disabilities (DSM-5)

Disorders usually first diagnosed in

infancy, childhood, or adolescence

Neurodevelopmental Disorders

Learning Disorders Disorders usually first diagnosed in

infancy, childhood, or adolescence

Neurodevelopmental Disorders

Motor Skills Disorder Disorders usually first diagnosed in

infancy, childhood, or adolescence

Neurodevelopmental Disorders

Communication Disorders Disorders usually first diagnosed in

infancy, childhood, or adolescence

Neurodevelopmental Disorders

Pervasive Developmental Disorders

(DSM-IV)

Autism Spectrum Disorder (DSM-

Disorders usually first diagnosed in

infancy, childhood, or adolescence

Neurodevelopmental Disorders

Attention-Deficit/Hyperactivity

Disorder

Disorders usually first diagnosed in

infancy

Neurodevelopmental Disorders

Conduct Disorder Disorders usually first diagnosed in

infancy

Disruptive, Impulse-Control, and

Conduct Disorders

Oppositional Defiant Disorder Disorders usually first diagnosed in

infancy

Disruptive, Impulse-Control, and

Conduct Disorders

Feeding and Eating Disorders of

Infancy or Early Childhood

Disorders usually first diagnosed in

infancy

Feeding and Eating Disorders

Tic Disorders Disorders usually first diagnosed in

infancy

Neurodevelopmental Disorders

Elimination Disorders Disorders usually first diagnosed in

infancy

Elimination Disorders

Separation Anxiety Disorder Disorders usually first diagnosed in

infancy

Anxiety Disorders

Selective Mutism Disorders usually first diagnosed in

infancy

Anxiety Disorders

Reactive Attachment Disorder Disorders usually first diagnosed in

infancy

Trauma- and Stressor-Related

Disorders

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3. DSM-5 Child Mental Disorder

Classification

The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) includes

changes to some key disorders of childhood. Two new childhood mental disorders were added in

the DSM-5: social communication disorder (or SCD) and disruptive mood dysregulation disorder

(or DMDD). There were age-related diagnostic criteria changes for two other mental disorder

categories particularly relevant to the definition of serious emotional disturbance (SED):

attention-deficit/hyperactivity disorder (ADHD) and post-traumatic stress disorder (PTSD). An

ADHD diagnosis now requires symptoms to be present prior to the age of 12 (rather than 7, the

age of onset from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. [DSM-

IV]). PTSD includes a new subtype specifically for children younger than 6 years of age.

Sections 3.1 and 3.2 provide detailed descriptions of these disorders as well as summaries

of the research that has been conducted around their impact on the prevalence of childhood

mental disorders. Other disorders did not have specific DSM-5 changes related to childhood, but

these changes would be relevant to both adults and children (e.g., major depressive disorder

[MDD], generalized anxiety disorder [GAD]). Section 3.3 provides a brief overview of DSM-5

changes to these remaining disorders. In the report sections that follow we reference prevalence

rates found in studies of community samples using the DSM-5. For some disorders, we also

reference prevalence rates in clinical samples where direct comparisons were performed between

DSM-IV and DSM-5 ratings. The prevalence rates from clinical samples are relevant to this

report in demonstrating the magnitude of change that might be expected in prevalence rates from

DSM-IV to DSM-5.

3.1 New Childhood Mental Disorders Added to the DSM-5

3.1.1 Social (Pragmatic) Communication Disorder (SCD, under Neurodevelopmental

Disorders)

Description. The DSM-5 communication disorders include a new condition for persistent

difficulties in the social uses of verbal and nonverbal communication: social (pragmatic)

communication disorder or SCD. SCD is characterized by a primary difficulty with pragmatics—

the social use of language or communication—resulting in functional limitations in effective

communication, social participation, development of social relationships, and academic

achievement (see Table 5 for a description of DSM-5 SCD diagnostic criteria). Symptoms of SCD

include difficulties in the acquisition and use of spoken language and inappropriate responses in

conversation. Although diagnosis is rare for children younger than 4 years old, symptoms must be

present in early childhood even if not recognized until later. Individuals with SCD have never had

effective social communication. This new disorder cannot be diagnosed if social communication

deficits are part of the two main characteristics of the new autism spectrum disorder (ASD). ASD

is characterized by (1) deficits in social communication and social interaction and (2) restricted

repetitive behaviors, interests, and activities (RRBs). Because both components are required for an

ASD diagnosis, SCD is diagnosed if no RRBs are present or there is no past history of RRBs. As

described by the American Psychiatric Association (APA), the symptoms of some patients

diagnosed with DSM-IV pervasive developmental disorder not otherwise specified (PDD-NOS)

may meet the DSM-5 criteria for SCD (American Psychiatric Association, 2013c).

Table 5. DSM-IV Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) to

DSM-5 Social (Pragmatic) Communication Disorder (SCD) Comparison

DSM-IV DSM-5

Disorder Class: Pervasive Developmental

Disorders

Disorder Class: Neurodevelopmental Disorders

Severe and pervasive impairment in the

development of reciprocal social interaction or

verbal and nonverbal communication skills, or

when stereotyped behavior, interests, and

activities are present but are not met for a

specific pervasive developmental disorder.

This category includes "atypical autism" (late

age of onset, atypical symptomatology).

A. Persistent difficulties in the social use of verbal and

nonverbal communication as manifested by all of the

following:

1. Deficits in using communication for social purposes

2. Impairment of the ability to change communication to

match context

3. Difficulties for following rules for conversation

(taking turns, use of verbal/nonverbal signs to regulate

interaction)

4. Difficulties understanding what is not explicitly stated

B. The deficits result in functional limitations in effective

communication, social participation, social relationships,

and academic achievement.

C. The onset of the symptoms is in the early development

period, but may not fully manifest until social

communication demands exceed limited capabilities.

D. The symptoms are not attributable to another medical or

neurological condition or to low abilities in the domains

of word structure and grammar, and are not better

explained by autism spectrum disorder, intellectual

disability, or developmental delay.

Estimated Prevalence. Although a few studies have reported empirical support for a

conceptualization of SCD distinguishable from ASD (Gibson, Adams, Lockton, & Green, 2013)

and ADHD (St Pourcain et al., 2011), there is one practitioner review publication describing

concern that the inclusion/exclusion criteria and differential diagnosis with ASD, ADHD, social

anxiety disorders, intellectual disabilities, and developmental delays, may mean that very few

individuals will meet diagnostic criteria for SCD (Norbury, 2014).

No study was found on the general population's prevalence of SCD. In one study that

analyzed three datasets (1) data from the Simons Simplex Collection, a genetic consortium study

focusing on families having just one child with an ASD; (2) the Collaborative Programs of

Excellence in Autism, a multicenter study of ASD; and (3) the University of Michigan Autism

and Communication Disorders Center data bank that included a total of 4,453 children with

DSM-IV clinical PDD diagnoses and 690 with non-PDD diagnoses (e.g., language disorder), the

proposed ASD DSM-5 criteria identified 91 percent of children with clinical DSM-IV PDD

diagnoses (Huerta, Bishop, Duncan, Hus, & Lord, 2012). In this samples of children with DSM-

IV diagnosis for PPD (86.6 percent of the pooled sample) and non-PPD (13.4 percent of the

pooled sample), only 75 of 5,143 (1.5 percent) met social communication criteria for ASD, but

did not meet threshold criteria for RRBs. This study concluded that few children with ASD are

likely to be misclassified as having SCD or will be reclassified as SCD under the DSM-5 (Huerta

et al., 2012). In contrast, a second study based on the multisite field trial of the DSM-IV of adults

and children (mean age 9 years old), of which 657 had a clinical diagnosis of PDD and 276 had a

diagnosis other than PDD (mental retardation, language disorders, childhood schizophrenia),

almost 40 percent of cases with a clinical diagnosis of PDD and 71.7 percent of those with PDD-

NOS did not met revised DSM-5 diagnostic criteria for ASD, concluding that proposed DSM-5

criteria could substantially alter the composition and estimate of the autism spectrum

(McPartland, Reichow, & Volkmar, 2012). In the DSM-5 field trials in the United States and

Canada based on child clinical populations (general child psychiatry outpatient services), one of

the sites (Baystate Medical Center, Springfield, MA) found the DSM-IV and DSM-5 prevalence

of ASD was almost the same (23 percent and 24 percent), but a second site (Stanford University

Hospital, Palo Alto, CA) found the prevalence of ASD decreased from 26 percent to 19 percent.

A review of the data (no tables provided in the publication) showed that the decrease at Stanford

was offset by movement into the new SCD diagnosis (Regier et al., 2013).

Overall, these studies suggest that between 1.5 percent to 40 percent or more of children

who would have been classified as PDD before, will not meet diagnostic criteria of ASD under

the DSM-5 and some of them would likely be reclassified as SCD and be included in the SED

estimate, if SCD is part of the SED definition (McPartland, Reichow, & Volkmar, 2012).

should be noted that there is concern in the field that SCD could be over diagnosed by speech-

language pathologists. If SCD is treated as a residual category (like the previous PDD-NOS) for

communication disorders diagnosed by speech-language pathologists, children who should be

diagnosed as ASD would be classified as SCD since identifying ASD may prove challenging for

speech-language pathologists (Norbury, 2014).

Implications for Estimate of SED. As SCD would be under the purview of speech-

language pathology, the inclusion/exclusion of SCD on the Federal Register definition of SED

needs to be determined. If SCD is included in the definition of SED, some increase can be

expected in the estimate of SED from the reclassification of children previously classified as

PDD and PDD-NOS to SCD. An additional increase in the SED estimate can be expected from

the diagnoses of SCD by speech-language pathologists if they are not obtaining differential

diagnosis from other professionals.

3.1.2 Disruptive Mood Dysregulation Disorder (or DMDD) (under Depressive Disorders)

Description. DMDD is a new addition to DSM-5 that aims to combine bipolar disorder

that first appears in childhood with oppositional behaviors (Axelson, 2013). DMDD is

characterized by severe and recurrent temper outbursts that are grossly out of proportion in

intensity or duration to the situation. These occur, on average, three or more times each week for

1 year or more (see Table 6 for a description of DSM-5 DMDD diagnostic criteria). The key

feature of DMDD is chronic irritability that is present in between episodes of anger or temper

tantrums. A diagnosis requires symptoms to be present in at least two settings (at home, at

school, or with peers) for 12 or more months, and symptoms must be severe in at least one of

these settings. Onset of DMDD must occur before age 10, and a child must be at least 6 years old

to receive a diagnosis of DMDD. The main driver behind the conceptualization of DMDD was

concern that diagnosis of bipolar disorder was being applied inconsistently across clinicians

because of the disagreement about how to classify irritability in the DSM-IV. In addition,

chronic childhood irritability has not been shown to predict later onset of bipolar disorder,

suggesting that irritability may be best contained within a separate mood dysregulation category

(Leigh, Smith, Milavic, & Stringaris, 2012).

Table 6. DSM-IV Bipolar Disorder-Manic Episode and Oppositional Defiant Disorder to DSM-5

Disruptive Mood Dysregulation Disorder (or DMDD) Comparison

DSM-IV Criteria DSM-5

Disorder Class: Mood Disorders

Manic Episode

Disorder Class: Attention-Deficit

and Disruptive Behavior Disorders

Oppositional Defiant Disorder

Disorder Class: Depressive

Disorders

Disruptive Mood

Dysregulation Disorder

A. A distinct period of abnormally and

persistently elevated, expansive, or

irritable mood, lasting at least 1 week

(or any duration if hospitalization is

necessary).

A. A pattern of negativistic, hostile,

and defiant behavior lasting at

least 6 months, during which

four (or more) of the following

are present

1. Often loses temper

2. Often argues with adults

3. Often actively defies or

refuses to comply with

adults' requests or rules

4. Often deliberately annoys

people

5. Often blames others for his

or her mistakes

6. Is often touchy or easily

annoyed by others

7. Is often angry or resentful

8. Is often spiteful or vindictive

A. Severe recurrent temper

outbursts manifested

verbally (e.g., verbal rages)

and or behaviorally (e.g.,

physical aggression) that

are grossly out of

proportion in intensity or

duration to the situation or

provocation

B. During the period of mood

disturbance, three (or more) of the

following symptoms have persisted

(four if the mood is only irritable) and

have been present to a significant

degree:

1. Inflated self-esteem or grandiosity

2. Decreased need for sleep (e.g.,

feels rested after only 3 hours of

sleep)

3. More talkative than usual or

pressure to keep talking

4. Flight of ideas or subjective

experience that thoughts are racing

5. Distractibility (i.e., attention too

easily drawn to unimportant or

irrelevant external stimuli)

6. Increase in goal-directed activity

(either socially, at work or school,

or sexually) or psychomotor

agitation

7. Excessive involvement in

pleasurable activities that have a

high potential for painful

consequences (e.g., engaging in

unrestrained buying sprees, sexual

indiscretions, or foolish business

investments)

B. The temper outbursts are

inconsistent with

developmental level

(continued)

Table 6. DSM-IV Bipolar Disorder-Manic Episode and Oppositional Defiant Disorder to DSM-5

Disruptive Mood Dysregulation Disorder (or DMDD) Comparison (continued)

DSM-IV Criteria DSM-5

Disorder Class: Mood Disorders

Manic Episode

Disorder Class: Attention-Deficit

and Disruptive Behavior Disorders

Oppositional Defiant Disorder

Disorder Class: Depressive

Disorders

Disruptive Mood

Dysregulation Disorder

C. The temper outbursts

occur, on average, three or

more times per week.

D. The mood between temper

outbursts is persistently

irritable or angry most of

the day, nearly every day,

and it is observable by

others

E. Criteria A-D have been

present for 12 or more

months. Throughout that

time, the individual has not

had a period lasting 3 or

more consecutive months

without all of the

symptoms in criteria A-D.

D. The mood disturbance is sufficiently

severe to cause marked impairment in

occupational functioning or in usual

social activities or relationships with

others, or to necessitate

hospitalization to prevent harm to self

or others, or there are psychotic

features.

B. The disturbance in behavior

causes clinically significant

impairment in social, academic,

or occupational functioning

F. Criteria A-D are present in

at least two of three

settings

(home/school/peers) and

are severe in at least one

setting

D. Criteria are not met for conduct

disorder, and if the individual is

age 18 years or older, criteria are

not met for Antisocial

Personality Disorder.

G. The diagnosis should not

be made for the first time

before age 6 or after 18

H. The age oat onset of

criteria A-E is before 10

years

(continued)

Table 6. DSM-IV Bipolar Disorder-Manic Episode and Oppositional Defiant Disorder to DSM-5

Disruptive Mood Dysregulation Disorder (or DMDD) Comparison (continued)

DSM-IV Criteria DSM-5

I. There has never been a

distinct period lasting more

than 1 day during which

the full symptom criteria,

except duration, for a

manic or hypomanic

episode have been met.

Note: Developmentally

appropriate mood elevation,

such as occurs in the context of

a highly positive event or its

anticipation, should not be

considered as a symptom of

mania or hypomania.

Disorder Class: Mood Disorders

Manic Episode

Disorder Class: Attention-Deficit

and Disruptive Behavior Disorders

Oppositional Defiant Disorder

Disorder Class: Depressive

Disorders

Disruptive Mood

Dysregulation Disorder

J. The behaviors do not occur

exclusively during an

episode of major

depressive disorder and are

not better explained by

another mental disorder

(e.g., autism spectrum

disorder, PTSD, separation

anxiety disorder).

C. The behaviors do not occur

exclusively during the course of

a Psychotic or Mood Disorder

Note: This diagnosis cannot

coexist with oppositional

defiant disorder, intermittent

explosive disorder, or bipolar

disorder, thought it can coexist

with others, including major

depressive disorder, ADHD,

conduct disorder, and

substance use disorders

(SUDs). Individuals whose

symptoms meet criteria for

both DMDD and oppositional

defiant disorder (ODD) should

only be given the diagnosis of

DMDD. If an individual has

ever experienced a manic or

hypomanic episode, the

diagnosis o DMDD should not

be assigned.

(continued)

Table 6. DSM-IV Bipolar Disorder-Manic Episode and Oppositional Defiant Disorder to DSM-5

Disruptive Mood Dysregulation Disorder (or DMDD) Comparison (continued)

DSM-IV Criteria DSM-5

E. The symptoms are not due to the

direct physiological effects of a

substance (e.g., a drug of abuse, a

medication, or other treatment) or a

general medical condition (e.g.,

hyperthyroidism).

Note: Manic-like episodes that are clearly

caused by somatic antidepressant

treatment (e.g., medication,

electroconvulsive therapy, light therapy)

should not count toward a diagnosis of

bipolar I disorder.

K. The symptoms are not

attributable to the

physiological effects of a

substance or to another

medical or neurological

condition

Estimated Prevalence. A study combining data from three community surveys: (1) a

representative sample of 918 preschoolers (aged 2-5) attending a large primary care pediatric

clinic in central North Carolina; (2) a representative sample of 1,420 children aged 9, 11, and 13

years in 11 predominantly rural counties of North Carolina; and (3) representative study of 920

children aged 9 to 17 years from four rural counties in North Carolina, found that prevalence of

DMDD ranges from less than 1 percent to 3.3 percent depending on child age. DMDD is most

prevalent among young children (aged 2 to 5) whose parents report high rates of temper tantrums

and irritable moods (Copeland, Angold, Costello, & Egger, 2013). However, according to

DSM-5, DMDD cannot be diagnosed in children under 6 years old; therefore, the real DSM-5

prevalence in the population will be closer to 1 percent. In the DSM-5 field trials in the United

States and Canada based on child clinical populations (general child psychiatry outpatient

services), estimates for DSM-IV were considered "not applicable because the diagnosis is new to

DSM-5," and the DSM-5 prevalence was 5 percent for Baystate Medical Center, 8 percent for

Columbia, and 15 percent for Colorado (Regier et al., 2013). Importantly, estimates for ODD in

Columbia decreased from 22 percent using DSM-IV to 17 percent using DSM-5, but no

additional analyses were reported to determine if children with ODD under the DSM-IV were

reclassified as DMDD under DSM-5 (Regier et al., 2013).

Implications for Estimate of SED. The comorbidity of DMDD with other disorders is

extremely high as described in the DSM-5, indicating that the prevalence increase in the SED

estimates, if DMDD is included, will not increase as "it is rare to find individuals whose

symptoms meet criteria for DMDD alone" (American Psychiatric Association, 2013b, p. 160).

However, if children have symptoms that meet criteria for ODD or intermittent explosive

disorders and DMDD, only DMDD should be assigned. Thus with this new diagnosis, children

will be reclassified. When all symptom, severity, and frequency criteria are applied, DMDD is

only present in roughly 1 percent of school-aged children (Copeland et al., 2013). DMDD should

include many of the children who would have been diagnosed with bipolar disorder using the

DSM-IV. Because these children would receive the new diagnosis of DMDD instead of ODD or

bipolar disorder, the addition of DMDD to the DSM-5 should not affect prevalence estimates of

SED.

3.2 Age-Related Diagnostic Criteria Changes to Mental Disorders in the

DSM-5

3.2.1 Attention-Deficit/Hyperactivity Disorder (ADHD, under Neurodevelopmental

Disorders)

Description. ADHD is a chronic neurodevelopmental disorder according to DSM-5 that

is characterized by a persistent and pervasive pattern of inattention and/or hyperactivity-

impulsivity that interferes with functioning or development. ADHD was placed in the

neurodevelopmental disorders chapter to reflect brain developmental correlates with ADHD and

the DSM-5 decision to eliminate the DSM-IV chapter that includes all diagnoses usually first

made in infancy, childhood, or adolescence. The diagnostic criteria for ADHD in DSM-5 are

similar to those in DSM-IV. The same 18 symptoms noted in the DSM-IV are used, and continue

to be divided into two symptom domains (inattention and hyperactivity/impulsivity), of which at

least six symptoms in one domain are required for diagnosis. The majority of ADHD criteria

changes were geared toward improving detection of ADHD among adults. However, one change

may have relevance to the estimation of SED: the onset criterion has been changed from

"symptoms that caused impairment were present before age 7 years" to "several inattentive or

hyperactive-impulsive symptoms were present prior to age 12." Table 7 shows a comparison

between DSM-IV and DSM-5 diagnostic criteria for ADHD.

Estimated Prevalence. In the DSM-5 field trials in the United States and Canada based on

child clinical populations (general child psychiatry outpatient services), using DSM-IV, ADHD

prevalence at Baystate Medical Center was 59 percent and at Columbia it was 55 percent.

Applying the DSM-5 criteria, the prevalence of ADHD was 69 percent at Baystate and 58

percent at Columbia, representing a 10 percent and 3 percent absolute difference, respectively

(Regier et al., 2013). In a birth cohort study of 2,232 British children who were prospectively

evaluated at ages 7 and 12 years for ADHD, the outcome of extending the age-of-onset criterion

to age 12 resulted in the increase in ADHD prevalence by age 12 years by only 0.1 percent

(Polanczyk et al., 2010). This negligible increase is in line with previous findings indicating that

95 percent of adults with a diagnosis of ADHD recall their symptoms starting before age 12 (R.

C. Kessler et al., 2005).

Implications for Estimate of SED. Some increase can be expected in the SED estimate

based on expanding ADHD criteria in the DSM-5 and more cases might be diagnosed. Based on

studies from community samples comparing DSM-IV and DSM-5 criteria, ADHD is expected to

have a modest increase (under 10 percent absolute difference).

Table 7. DSM-IV to DSM-5 Attention-Deficit/Hyperactivity Disorder Comparison

DSM-IV DSM-5

Disorder Class: Disorders Usually Diagnosed in

Infancy, Childhood, and Adolescence

Disorder Class: Neurodevelopmental Disorders

A. Either (1) or (2): A. A persistent pattern of inattention and/or

hyperactivity-impulsivity that interferes with

functioning or development, as characterized by

(1) and/or (2):

1. Six (or more) of the following symptoms of

inattention have persisted for at least 6 months to a

degree that is maladaptive and inconsistent with

developmental level:

1. Inattention: Six (or more) of the following

symptoms have persisted for at least 6 months to a

degree that is inconsistent with developmental level

and that negatively impacts directly on social and

academic/occupational activities:

Note: The symptoms are not solely a manifestation of

oppositional behavior, defiance, hostility, or failure to

understand tasks or instructions. For older adolescents

and adults (age 17 or older), at least five symptoms are

required.

Inattention

a. often fails to give close attention to details or makes

careless mistakes in schoolwork, work, or other

activities

a. Often fails to give close attention to details or

makes careless mistakes in schoolwork, at work, or

during other activities (e.g., overlooks or misses

details, work is inaccurate).

b. often has difficulty sustaining attention in tasks or

play activity

b. Often has difficulty sustaining attention in tasks or

play activities (e.g., has difficulty remaining

focused during lectures, conversations, or lengthy

reading).

c. often does not seem to listen when spoken to

directly

c. Often does not seem to listen when spoken to

directly (e.g., mind seems elsewhere, even in the

absence of any obvious distraction).

d. often does not follow through on instructions and

fails to finish schoolwork, chores or duties in the

workplace (not due to oppositional behavior or

failure to understand instructions)

d. Often does not follow through on instructions and

fails to finish schoolwork, chores, or duties in the

workplace (e.g., starts tasks but quickly loses focus

and is easily sidetracked).

e. often has difficulty organizing tasks and activities e. Often has difficulty organizing tasks and activities

(e.g., difficulty managing sequential tasks; difficulty

keeping materials and belongings in order; messy,

disorganized work; has poor time management; fails

to meet deadlines).

f. often avoids, dislikes, or is reluctant to engage in

tasks that require sustained mental effort (such as

schoolwork or homework)

f. Often avoids, dislikes, or is reluctant to engage in

tasks that require sustained mental effort (e.g.,

schoolwork or homework; for older adolescents and

adults, preparing reports, completing forms,

reviewing lengthy papers).

(continued)

Table 7. DSM-IV to DSM-5 Attention-Deficit/Hyperactivity Disorder Comparison (continued)

DSM-IV DSM-5

Disorder Class: Disorders Usually Diagnosed in

Infancy, Childhood, and Adolescence

Disorder Class: Neurodevelopmental Disorders

g. often loses things necessary for tasks or activities

(e.g., toys, school assignments, pencils, books or

tools)

g. Often loses things necessary for tasks or activities

(e.g., school materials, pencils, books, tools, wallets,

keys, paperwork, eyeglasses, mobile telephones).

h. is often easily distracted by extraneous stimuli h. Is often easily distracted by extraneous stimuli (for

older adolescents and adults, may include unrelated

thoughts).

i. is often forgetful in daily activities i. Is often forgetful in daily activities (e.g., doing

chores, running errands; for older adolescents and

adults, returning calls, paying bills, keeping

appointments).

2. Six (or more) of the following symptoms of

hyperactivity-impulsivity have persisted for at least

6 months to a degree that is maladaptive and

inconsistent with developmental level:

2. Hyperactivity and impulsivity: Six (or more) of the

following symptoms have persisted for at least 6

months to a degree that is inconsistent with

developmental level and that negatively impacts

directly on social and academic/occupational

activities:

Note: The symptoms are not solely a manifestation of

oppositional behavior, defiance, hostility, or a failure to

understand tasks or instructions. For older adolescents

and adults (age 17 or older), at least five symptoms are

required.

Hyperactivity

a. Often fidgets with hands or feet or squirms in seat a. Often fidgets with or taps hands or feet or squirms

in seat.

b. Often leaves seat in classroom or in other situations

in which remaining seated is expected

b. Often leaves seat in situations when remaining

seated is expected (e.g., leaves his or her place in

the classroom, in the office or other workplace, or in

other situations that require remaining in place).

c. Often runs about or climbs excessively in situations

in which it is inappropriate (in adolescents or adults,

may be limited to subjective feelings of

restlessness)

c. Often runs about or climbs in situations where it is

inappropriate. (Note: In adolescents or adults, may

be limited to feeling restless).

d. Often has difficulty playing or engaging in leisure

activities quietly

d. Often unable to play or take part in leisure activities

quietly.

e. Is often "on the go" or often acts as if "driven by a

motor"

e. Is often "on the go" acting as if "driven by a motor"

(e.g., is unable to be or uncomfortable being still for

extended time, as in restaurants, meetings; may be

experienced by others as being restless or difficult

to keep up with).

f. Often talks excessively f. Often talks excessively.

Impulsivity

g. Often blurts out answers before questions have been

completed

g. Often blurts out an answer before a question has

been completed (e.g., completes people's sentences;

cannot wait for turn in conversation).

h. Often has difficulty awaiting turn h. Often has trouble waiting his/her turn (e.g., while

waiting in line).

(continued)

Table 7. DSM-IV to DSM-5 Attention-Deficit/Hyperactivity Disorder Comparison (continued)

DSM-IV DSM-5

Disorder Class: Disorders Usually Diagnosed in

Infancy, Childhood, and Adolescence

Disorder Class: Neurodevelopmental Disorders

i. Often interrupts or intrudes on others (e.g., butts

into conversations or games)

i. Often interrupts or intrudes on others (e.g., butts

into conversations, games, or activities; may start

using other people's things without asking or

receiving permission; for adolescents and adults,

may intrude into or take over what others are

doing).

B. Some hyperactive-impulsive or inattentive

symptoms must have been present before age 7

years.

B. Several inattentive or hyperactive-impulsive

symptoms were present before age 12 years.

C. Some impairment from the symptoms is present in

at least two settings (e.g., at school [or work] and at

home).

C. Several inattentive or hyperactive-impulsive

symptoms are present in two or more settings, (e.g.,

at home, school or work; with friends or relatives; in

other activities).

D. There must be clear evidence of clinically

significant impairment in social, academic or

occupational functioning.

D. There is clear evidence that the symptoms interfere

with, or reduce the quality of, social, school, or

work functioning.

E. The symptoms do not occur exclusively during the

course of a pervasive developmental disorder,

schizophrenia, or other psychotic disorders and is

not better accounted for by another mental disorder

(e.g., mood disorder, anxiety disorder, dissociative

disorder, or a personality disorder).

E. The symptoms do not occur exclusively during the

course of schizophrenia or another psychotic

disorder and are not better explained by another

mental disorder (e.g., mood disorder, anxiety

disorder, dissociative disorder, personality disorder,

substance intoxication or withdrawal).

Code based on type:

314.01 Attention-Deficit/Hyperactivity Disorder,

Combined Type: if both Criteria A1 and A2 are met

for the past 6 months

314.00 Attention-Deficit/Hyperactivity Disorder,

Predominantly Inattentive Type: if Criterion A1 is

met but Criterion A2 is not met for the past 6

months

314.01 Attention-Deficit/Hyperactivity Disorder,

Predominantly Hyperactive-Impulsive Type: if

Criterion A2 is met but Criterion A1 is not met for

the past 6 months

Coding note: For individuals (especially adolescents

and adults) who currently have symptoms that no

longer meet full criteria, "In Partial Remission" should

be specified.

Specify whether:

Combined presentation: If enough symptoms of

both criteria inattention and hyperactivity-

impulsivity were present for the past 6 months

Predominantly inattentive presentation: If enough

symptoms of inattention, but not hyperactivity-

impulsivity, were present for the past 6 months

Predominantly hyperactive-impulsive presentation:

If enough symptoms of hyperactivity-impulsivity

but not inattention were present for the past 6

months.

Specify if:

In partial remission: When full criteria were

previously met, fewer than the full criteria have

been met for the past 6 months, and the symptoms

still results in impairment in social, academic, or

occupational functioning.

Table 7. DSM-IV to DSM-5 Attention-Deficit/Hyperactivity Disorder Comparison (continued)

DSM-IV DSM-5

Specify current severity:

Mild: Few, if any, symptoms in excess of those

required to make the diagnosis are present, and

symptoms result in no more than minor impairments

in social or occupational functioning.

Moderate: Symptoms or functional impairment

between "mild" and "severe" are present.

Severe: Many symptoms in excess of those required

to make the diagnosis, or several symptoms that are

particularly severe, are present, or the symptoms

result in marked impairment in social or

occupational functioning.

3.2.2 Post-traumatic Stress Disorder (PTSD, under Trauma- and Stressor-Related

Disorders)

Description. DSM-5 criteria for PTSD differ significantly from those in DSM-IV for

children and adolescents. The arousal cluster will now include irritability or angry outbursts and

reckless behaviors. PTSD in the DSM-5 is more developmentally sensitive in that diagnostic

thresholds have been lowered for children and adolescents.

Separate criteria have been added for children aged 6 years or younger. These criteria

have been designed to be more developmentally appropriate for young children by including

caregiver-child–related losses as a main source of trauma and focus on behaviorally expressed

PTSD symptoms. According to the DSM-5, PTSD can develop at any age after 1 year of age.

Clinical re-experiencing can vary according to developmental stage, with young children having

frightening dreams not specific to the trauma. Young children are more likely to express

symptoms through play, and they may lack fearful reactions at the time of exposure or during re-

experiencing phenomena. It is also noted that parents may report a wide range of emotional or

behavioral changes, including a focus on imagined interventions in their play. The preschool

subtype excludes symptoms such as negative self-beliefs and blame, which are dependent on the

ability to verbalize cognitive constructs and complex emotional states. The developmental

preschool PTSD subtype lowers the Cluster C threshold from three to one symptom.

The new criteria were based on Scheeringa and colleagues' proposed alternative

algorithm, which was derived from studies performed in young children using modified DSM-IV

PTSD criteria (Scheeringa, Zeanah, & Cohen, 2011). These studies showed that children's loss of

a parent/caregiver through death, abandonment, foster care placement, and other main caregiver-

related events can be experienced as traumatic events. Given young children's need for a

parent/child relationship to feel safe, caregiver loss may be perceived as a serious threat to a

child's own safety and psychological/physical survival, which is part of the criteria defining a

traumatic event. The relevance of caregiver loss as a source of trauma also applies among older

children, since the loss of parents/caregivers is more associated with trauma than high-magnitude

events, like a motor vehicle crash. One report of children in foster care found that the most

common trauma identified by children aged 6 to12 to their therapists was ''placement in foster

care" (Scheeringa et al., 2011). Table 8 shows a comparison between DSM-IV and DSM-5

diagnostic criteria for PTSD.

Estimated Prevalence. Rates of PTSD in preschool children diagnosed with DSM-IV

criteria have been lower than in other age groups. This was in part related to DSM-IV language

stipulating that a child must have an intense response to the event—intense fear, helplessness, or

horror—that in children could be expressed by disorganized or agitated behavior. This language

has been deleted from the DSM-5, because the criterion proved to have no utility in predicting

the onset of PTSD and because the diagnostic criteria were not developmentally informed

(American Psychiatric Association, 2013d). With DSM-IV criteria, even in severely traumatized

young children, the frequencies of PTSD ranged only between 13 percent and 20 percent. With

the new algorithm proposed for DSM-5, 44 percent to 69 percent of children in the same studies

would be diagnosed with PTSD (Scheeringa et al., 2011).

Based on a total of 1,073 parents of children attending a large pediatric clinic that

completed the Child Behavior Checklist Age 1.5-5 Years and a new interviewer-based

psychiatric diagnostic measure (the Preschool Age Psychiatric Assessment), 0.1 percent of 2 to 5

year olds in one study qualified for PTSD under DSM-IV and 0.6 percent qualified with the new

algorithm proposed for DSM-5 (Egger et al., 2006). In other community studies of children 1 to

6 years old recruited after mixed-traumatic events, the estimate for PTSD was 0 to 1.7 percent

using DSM-IV criteria and 10 percent to 26 percent with the proposed DSM-5 algorithm

(Scheeringa et al., 2011).

Table 8. DSM-IV to DSM-5 Post-traumatic Stress Disorder Comparison Children 6 Years and

Younger

DSM-IV: PTSD DSM-5: PTSD

Disorder Class: Anxiety Disorders Disorder Class: Trauma- and Stressor-Related Disorders

A. The person has been exposed to a traumatic

event in which both of the following were

present:

1. The person experienced, witnessed or was

confronted with an event or events that

involved actual or threatened death or

serious injury, or a threat to the physical

integrity of self or others.

2. The person's response involved intense fear,

helplessness, or horror.

Note: In children, this may be expressed instead

by disorganized or agitated behavior.

A. Exposure to actual or threatened death, serious injury, or

sexual violence in one or more of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to

others, especially primary caregivers.

3. Learning that the traumatic event(s) occurred to a

parent or caregiving figure.

Note: Witnessing does not include events that are

witnessed only in electronic media, television, movies,

or pictures.

(continued)

Table 8. DSM-IV to DSM-5 Post-traumatic Stress Disorder Comparison Children 6 Years and

Younger (continued)

DSM-IV: PTSD DSM-5: PTSD

Disorder Class: Anxiety Disorders Disorder Class: Trauma- and Stressor-Related Disorders

B. The traumatic event is persistently re-

experienced in one or more of the following

ways.

1. Recurrent and intrusive distressing

recollections of the event, including images

thoughts or perceptions. Note: In young

children, repetitive play may occur in which

themes or aspects of the trauma expressed.

2. Recurrent distressing dreams of the event.

Note: In children, there may be frightening

dreams without recognizable content.

3. Acting or feeling as if the traumatic event

were recurring (includes a sense of reliving

the experience, illusions, hallucinations, and

dissociative flashback episodes, including

those that occur on awakening or when

intoxicated). Note: In young children,

trauma-specific reenactment may occur.

4. Intense psychological distress at exposure to

the internal or external cues that symbolize

or resemble an aspect of the traumatic

event.

5. Physiological reactivity on exposure to

internal or external cues that symbolize or

resemble an aspect of the traumatic event.

B. Presence of one or more of the following intrusion

symptoms associated with the traumatic event(s),

beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing

memories of the traumatic event(s).

Note: Spontaneous and intrusive memories may not

necessarily appear distressing and may be expressed as

play reenactment.

2. Recurrent distressing dreams in which the content

and/or effect of the dream are related to the traumatic

event(s).

3. Dissociative reactions (e.g., flashbacks) in which the

child feels or acts as if the traumatic event(s) were

recurring. (Such reactions may occur on a

continuum, with the most extreme expression being a

complete loss of awareness of present surroundings.)

Such trauma reenactment may occur in play.

4. Intense or prolonged psychological distress at

exposure to internal or external cues that symbolize

or resemble an aspect of the traumatic event(s).

5. Marked psychological reactions to reminders of the

traumatic event(s).

C. Persistent avoidance of stimuli associated with

the trauma and the numbing of general

responsiveness (not present before trauma), as

indicated by three or more of the following:

1. Efforts to avoid thoughts, feelings, or

conversations associated with the trauma.

2. Efforts to avoid the activities, places, or

people that arouse recollections of the

trauma.

3. Inability to recall important aspect of the

trauma.

4. Markedly diminished interest or

participation in significant activities.

5. Feelings of detachment or estrangement

from others.

6. Restricted range of affect (e.g., unable to

have loving feelings).

7. Sense of a foreshortened future (e.g., does

not expect to have a career, marriage,

children, or a normal life span).

C. One or more of the following symptoms, representing

either persistent avoidance of stimuli associated with the

traumatic event(s), or negative alterations in cognitions

and mood associated with the traumatic event, must be

present, beginning after the traumatic event(s) or

worsening after the event.

Persistent avoidance of stimuli

1. Avoidance of or efforts to avoid places or physical

reminders that arouse recollections of the traumatic

event(s).

2. Avoidance of or efforts to avoid people,

conversations, or interpersonal situations that arouse

recollections of the traumatic event(s).

Negative alterations in cognitions

3. Substantially increased frequency of negative

emotional states (e.g., fear, guilt, sadness, shame,

confusion).

4. Markedly diminished interest or participation in

significant activities, including constriction play

5. Social withdrawn behavior

6. Persistent reduction in expression of positive

emotions.

(continued)

Table 8. DSM-IV to DSM-5 Post-traumatic Stress Disorder Comparison Children 6 Years and

Younger (continued)

DSM-IV: PTSD DSM-5: PTSD

Disorder Class: Anxiety Disorders Disorder Class: Trauma- and Stressor-Related Disorders

D. Persistent symptoms of increased arousal (not

present before the trauma), as indicated by two

or more of the following:

1. Difficulty falling or staying asleep

2. Irritability or outbursts of anger

3. Difficulty concentrating

4. Hyper vigilance

5. Exaggerated startle response

D. Alterations in arousal and reactivity associated with the

traumatic event(s), beginning or worsening after the

traumatic event(s) occurred, as evidence by two (or

more) of the following:

5. Sleep disturbance (e.g., difficulty falling or staying

asleep or restless sleep).

1. Irritable behavior and angry outbursts (with little or

no provocation) typically expressed as verbal or

physical aggression toward people or objects

(including extreme temper tantrums).

4. Problems with concentration.

2. Hyper-vigilance.

3. Exaggerated startle response.

E. Duration of the disturbance (symptoms in

criteria B, C, and D) is more than 1 month.

E. Duration of the disturbance is more than 1 month.

F. The disturbance causes clinically significant

distress or impairment in social, occupational,

or other important areas of functioning.

F. The disturbance causes clinically significant distress or

impairment in relationships with parents, sibling, peers,

or other caregivers or with school behavior.

Specify if: Acute: if duration of symptoms is less

than 3 months.

Specify if: Chronic: if duration of symptoms is 3

months or more.

DROPPED

Specify whether:

With dissociative symptoms: The individual's symptoms

meet the criteria for post-traumatic stress disorder, and in

addition, in response to the stressor, the individual

experiences persistent or recurrent symptoms of either of the

following:

1. Depersonalization: Persistent or recurrent

experiences of feeling detached from, and as if one

were an outside observer of, one's mental processes

or body (e.g., feeling as though one were in a dream;

feeling a sense of unreality of self or body or of time

moving slowly).

2. Derealization: Persistent or recurrent experiences of

unreality of surroundings (e.g., the world around the

individual is experienced as unreal, dreamlike,

distant, or distorted).

Note: To use this subtype, the dissociative symptoms must

not be attributable to the physiological effects of a substance

(e.g., blackouts) or another medical condition (e.g., complex

partial seizures).

Specify if: With delayed onset: If onset of

symptoms is at least 6 months after the stressor.

Specify if: With delayed expression: If the full diagnostic

criteria are not met until at least 6 months after the event

(although the onset and expression of some symptoms may

be immediate).

A study based on a representative population sample of 1,420 children aged 9 to 13 at

baseline and followed annually through age 16 (Great Smoky Mountains Study) found that less

than 0.5 percent met the criteria for full-blown DSM-IV PTSD (lifetime prevalence was 0.1

percent, while the 3-month prevalence was 0.03 percent) (Copeland, Keeler, Angold, & Costello,

2007). Other studies with clinical populations of school-age children exposed to traumatic events

have shown between 4 percent and 52 percent estimates of DSM-IV PTSD, but there is no

equivalent work using these studies to estimate PTSD based on DSM-5 proposed criteria as it

was done for younger children (Scheeringa et al., 2011). It is unknown how the changes

proposed by Scheeringa et al. (2011) on PTSD criteria for school children will impact the

estimate, since some changes will improve applicability, while others may limit it.

Implications for Estimate of SED. Some increase can be expected in the SED estimate

from the inclusion of PTSD criteria in the DSM-5, particularly for younger children.

3.3 Changes to Other Mental Disorders with Minor to No Implication for

SED Prevalence Estimates

Several minor changes have been made to other mental disorders sometimes assessed in

psychiatric epidemiological studies of children and adolescents. These changes are summarized

below, but are largely expected to have little to no impact on SED estimates either because of

minimal DSM-5 changes or their very low base rate in children and adolescents.

3.3.1 Major Depressive Episode/Disorder (under Depressive Disorders)

A major depressive episode (MDE) is characterized by the combination of depressed

mood or loss of interest or pleasure lasting for most of the day, nearly every day for 2 weeks or

more (American Psychiatric Association, 2013b). The primary symptom (depressed mood or loss

of interest/pleasure) must be accompanied by four or more additional symptoms and must cause

clinically significant distress or impairment. The primary difference between MDE and MDD is

that MDD includes all of the criteria for MDE as well as MDE exclusionary criteria for mania

and hypomania.

Changes in the MDE/MDD criteria from DSM-IV to DSM-5 have been minimal. There

have been some changes in the way that "mixed states" are described for diagnostic coding

(mixed states now fall under the specifier "with mixed features"). In addition, the examples

provided to describe a depressed mood have been expanded in DSM-5 from "e.g., feels sad or

empty" (American Psychiatric Association, 1994, p. 327) to "e.g., feels sad, empty, hopeless"

(American Psychiatric Association, 2013b, p. 160). This change in wording has not received

much attention (Uher, Payne, Pavlova, & Perlis, 2013). However, the wording change has the

possibility of increasing the prevalence of MDE/MDD if survey respondents and clinicians were

not already equating feeling hopeless with feeling sad, empty, or depressed.

The more substantive change is that the formal bereavement exclusion for MDE/MDD in

DSM-IV has been removed from DSM-5. The bereavement exclusion criterion has been a

longstanding feature of MDE/MDD, designed to allow clinicians to distinguish between normal

grieving and a mental illness (Fox & Jones, 2013). It has been replaced with text noting that

MDE/MDD should not be confused with normal and appropriate grief but that the presence of

bereavement is not prohibitive of an MDE/MDD diagnosis. All MDE/MDD changes are

expected to have minimal impact on the estimation of SED in children and adolescents. Table 9

shows a comparison between DSM-IV and DSM-5 diagnostic criteria for MDE/MDD.

Table 9. DSM-IV to DSM-5 Major Depressive Episode/Disorder Comparison

Criteria

DSM-IV DSM-5

Class: Mood Disorders



Class: Depressive Disorders



Five or more of the following A Criteria (at least one includes A1 or A2)

 

A1 Depressed mood—indicated by subjective report or observation by others (in

children and adolescents, can be irritable mood).

 

A2 Loss of interest or pleasure in almost all activities—indicated by subjective

report or observation by others.

 

A3 Significant (more than 5 percent in a month) unintentional weight loss/gain or

decrease/increase in appetite (in children, failure to make expected weight gains).

 

A4 Sleep disturbance (insomnia or hypersomnia).

 

A5 Psychomotor changes (agitation or retardation) severe enough to be observable

by others.

 

A6 Tiredness, fatigue, or low energy, or decreased efficiency with which routine

tasks are completed.

 

A7 A sense of worthlessness or excessive, inappropriate, or delusional guilt (not

merely self-reproach or guilt about being sick).

 

A8 Impaired ability to think, concentrate, or make decisions—indicated by

subjective report or observation by others.

 

A9 Recurrent thoughts of death (not just fear of dying), suicidal ideation, or

suicide attempts.

 

The symptoms cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

 

The symptoms are not due to the direct physiological effects of a substance (e.g., drug

abuse, a prescribed medication's side effects) or a medical condition (e.g.,

hypothyroidism).

 

The symptoms do not meet criteria for a mixed episode



There has never been a manic episode or hypomanic episode.

 

MDE is not better explained by schizophrenia spectrum or other psychotic disorders.

 

The symptoms are not better accounted for by bereavement (i.e., after the loss of a

loved one, the symptoms persist for longer than 2 months or are characterized by

marked functional impairment, morbid preoccupation with worthlessness, suicidal

ideation, psychotic symptoms, or psychomotor retardation).



The symptom must either be new or must have clearly worsened compared with the person's pre-episode status and

must persist most of the day, daily, for at least 2 weeks in a row. Exclude symptoms that are clearly due to a

general medical condition, mood-incongruent delusions, or mood-incongruent hallucinations.

Symptom must persist most of the day, daily, for at least 2 weeks in a row, excluding A3 and A9.

A mixed episode is characterized by the symptoms of both a major depressive episode and a manic episode

occurring almost daily for at least a 1-week period. This exclusion does not include episodes that are substance

induced (e.g., caffeine) or the side effects of a medication.

This differentiation requires clinical judgment based on cultural norms and the individual's history.

3.3.2 Persistent Depressive Disorder (formerly Dysthymic Disorder, under Depressive

Disorders)

Dysthymic disorder is a disorder characterized by a persistently depressed mood that

occurs most of the day, for more days than not, for a period of at least 2 years. In children and

adolescents, mood can be irritable and duration must be at least 1 year (American Psychiatric

Association, 2013b). In the DSM-5 it has been re-named persistent depressive disorder. This

name change reflects the consolidation of DSM-IV chronic MDD and dysthymic disorder.

Previously, in DSM-IV, a diagnosis of dysthymic disorder was contraindicated if the patient met

criteria for MDD in the first 2 years after the symptoms arose. In DSM-5 this exclusion has been

removed. This change should have no impact on the estimation of SED because most if not all

adolescents with chronic major depression would be classified as having MDE/MDD, and

therefore would be counted as having SED already. Table 10 shows a comparison between

DSM-IV and DSM-5 diagnostic criteria for dysthymic disorder/persistent depressive disorder.

Table 10. DSM-IV to DSM-5 Dysthymic Disorder/Persistent Depressive Disorder Comparison

DSM-IV DSM-5

Name: Dysthymic Disorder Name: Persistent Depressive Disorder

Class: Mood Disorders Class: Depressive Disorders

Depressed mood for most of the day, for more days

than not, as indicated by subjective account or

observation by others, for at least 2 years.

Same

Note: In children and adolescents, mood can be

irritable and duration must be at least a year.

Presence while depressed of two or more of the

following:

• Poor appetite or overeating

• Insomnia or hypersomnia

• Low energy or fatigue

• Low self-esteem

• Poor concentration or difficulty making

decisions

• Feelings of hopelessness

Same

During the 2 year period of the disturbance, the person

has never been without symptoms from the above two

criteria for more than 2 months at a time.

Same

The disturbance is not better accounted for by MDD or

MDD in partial remission.

Criteria for MDD may be continuously present for 2

years, in which case patients should be given comorbid

diagnoses of persistent depressive disorder and MDD.

There has never been a manic episode, a mixed

episode, or a hypomanic episode and the criteria for

cyclothymia have never been met.

Same

The disturbance does not occur exclusively during the

course of a chronic psychotic disorder.

The symptoms are not better explained by a psychotic

disorder.

The disturbance is not due to the direct physiological

effects of a substance (e.g., a drug of abuse or a

medication) or a general medical condition.

Same

The symptoms cause clinically significant distress or

impairment in important areas of functioning.

Same

3.3.3 Manic Episode and Bipolar I Disorder (under Bipolar and Related Disorders)

Bipolar I disorder, at one time referred to as manic-depressive disorder, is defined by the

occurrence of at least one manic episode, which is a period of abnormally and persistently

elevated, expansive, or irritable mood that is accompanied by increased energy or activity, which

results in clinically significant impairment in functioning or the need for hospitalization

(American Psychiatric Association, 2013b). The prevalence rate of child/adolescent mania and/or

bipolar disorder is extremely rare. In the DSM-5 field trials in the United States and Canada

based on child clinical populations (general child psychiatry outpatient services), the combined

bipolar I and II prevalence was 6 percent using DSM-IV and 5 percent using DSM-5. Bipolar I

disorders are characterized by one or more manic episodes or mixed episodes and one or more

MDEs; bipolar II disorders are characterized by one or more MDEs and at least one hypomanic

episode (Regier et al., 2013).

The diagnostic criteria for manic episodes have undergone several changes between

DSM-IV and DSM-5. Criterion A now requires that mood changes are accompanied by

abnormally and persistently goal-directed behavior or energy. Second, wording has been added

to clarify that (1) symptoms must represent a noticeable change from usual behavior, and

(2) these changes have to be present most of the day, nearly every day during the minimum 1-

week duration.

Exclusion criteria for manic episodes have also changed, mania that emerges after

antidepressant treatment can be classified as bipolar I disorder diagnosis in the DSM-5, whereas

this was a substance-induced manic disorder in DSM-IV. The criteria for bipolar I disorder have

also undergone a slight change. However, in DSM-5, these subtypes were converted to specifiers

instead (i.e., specify most recent episode type according to its features).

In addition to the changes in manic episode criteria, there have been changes to the

overall diagnostic criteria for bipolar I disorder. In DSM-IV, bipolar I disorder was diagnosed by

"type," which was characterized by the nature of the most recent episode (bipolar I disorder,

single manic episode; bipolar I disorder, most recent episode hypomanic; bipolar I disorder, most

recent episode manic; bipolar I disorder, most recent episode mixed; bipolar I disorder, most

recent episode depressed; and bipolar I disorder, most recent episode unspecified). Each of these

"types" had slightly varying criteria. In DSM-5, the diagnostic description has been simplified

and these "types" have been relegated to the role of specifiers. Diagnostic procedure indicates

that clinicians should first provide the bipolar I diagnosis then specify the characteristics of the

most recent episode, in addition to several other specifiers. Although important to understanding

the general change in diagnostic approach, these changes are geared toward communicating a

more streamlined diagnostic description rather than reflecting a change in the diagnostic criteria

and will not have an impact on SED prevalence estimates. Table 11 shows a comparison between

DSM-IV and DSM-5 diagnostic criteria for manic episode, and Table 12 shows a comparison

between DSM-IV and DSM-5 diagnostic criteria for bipolar I.

Table 11. DSM-IV to DSM-5 Manic Episode Criteria Comparison

DSM-IV Criteria DSM-5 Criteria

Name: Bipolar I Disorder Single Manic Episode Name: Bipolar I Disorder Manic Episode

Class: Bipolar Disorders Class: Bipolar and Related Disorders

A. A distinct period of abnormally and persistently

elevated, expansive, or irritable mood, lasting at

least 1 week (or any duration if hospitalization is

necessary).

A. A distinct period of abnormally and persistently

elevated, expansive, or irritable mood and

abnormally and persistently goal-directed behavior

or energy, lasting at least 1 week and present most of

the day, nearly every day (or any duration if

hospitalization is necessary).

B. During the period of mood disturbance, three (or

more) of the following symptoms have persisted

(four if the mood is only irritable) and have been

present to a significant degree:

B. During the period of mood disturbance and

increased energy or activity, three (or more) of the

following symptoms have persisted (four if the

mood is only irritable) are present to a significant

degree and represent a noticeable change from usual

behavior:

1. Inflated self-esteem or grandiosity 1. Same

2. Decreased need for sleep (e.g., feels rested after

only 3 hours of sleep)

2. Same

3. More talkative than usual or pressure to keep

talking

3. Same

4. Flight of ideas or subjective experience that

thoughts are racing

4. Same

5. Distractibility (i.e., attention too easily drawn to

unimportant or irrelevant external stimuli)

5. Distractibility (i.e., attention too easily drawn to

unimportant or irrelevant external stimuli), as

reported or observed.

6. Increase in goal-directed activity (either

socially, at work or school, or sexually) or

psychomotor agitation

6. Same

7. Excessive involvement in pleasurable activities

that have a high potential for painful

consequences (e.g., engaging in unrestrained

buying sprees, sexual indiscretions, or foolish

business investments)

7. Excessive involvement in activities that have a

high potential for painful consequences (e.g.,

engaging in unrestrained buying sprees, sexual

indiscretions, or foolish business investments).

C. The symptoms do not meet criteria for a mixed

episode.

Dropped

D. The mood disturbance is sufficiently severe to

cause marked impairment in occupational

functioning or in usual social activities or

relationships with others, or to necessitate

hospitalization to prevent harm to self or others, or

there are psychotic features.

C. The mood disturbance is sufficiently severe to cause

marked impairment in social or occupational

functioning or to necessitate hospitalization to

prevent harm to self or others, or there are psychotic

features.

E. The symptoms are not due to the direct

physiological effects of a substance (e.g., a drug of

abuse, a medication, or other treatment) or a general

medical condition (e.g., hyperthyroidism).

D. The episode is not attributable to the direct

physiological effects of a substance (e.g., a drug of

abuse, a medication, or other treatment) or another

medical condition.

Note: Manic-like episodes that are clearly caused by

somatic antidepressant treatment (e.g., medication,

electroconvulsive therapy, light therapy) should not

count toward a diagnosis of bipolar I disorder.

Note: A full manic episode that emerges during

antidepressant treatment (e.g., medication,

electroconvulsive therapy) but persists at fully

syndromal level beyond the physiological effect of that

treatment is sufficient evidence for a manic episode and

therefore a bipolar I diagnosis.

Table 12. DSM-IV to DSM-5 Bipolar I Disorder Comparison

DSM-IV

Disorder DSM-IV Criteria

DSM-5

Disorder DSM-5 Criteria

Disorder

Class

Mood Disorders Disorder

Class

Bipolar and Related Disorders

Bipolar

Disorder

DSM-IV specified 6 "types" of bipolar I

disorder:

• Bipolar I disorder, single manic

episode

• Bipolar I disorder, most recent

episode hypomanic

• Bipolar I disorder, most recent

episode manic

• Bipolar I disorder, most recent

episode mixed

• Bipolar I disorder, most recent

episode depressed

• Bipolar I disorder, most recent

episode unspecified

Bipolar I

Disorder

A. Criteria have been met for at

least one manic episode

(Table 11). The manic episode

may have been preceded by and

may be followed by hypomanic

or major depressive episodes

(see Table 9).

B. The occurrence of the manic and

major depressive episode(s) is

not better explained by

schizoaffective disorder,

schizophreniform disorder,

delusional disorder, or other

specified or unspecified

schizophrenia spectrum and

other psychotic disorder.

Note: Major depressive episodes are

common in bipolar I disorder but are

not required for the diagnosis of

bipolar I disorder.

Note: Hypomanic episodes are

common in bipolar I disorder but are

not required for the diagnosis of

bipolar I disorder.

Specify:

With anxious distress

With mixed features

With rapid cycling

With melancholic features

With atypical features

With mood-congruent psychotic

features

With mood-incongruent

psychotic features

With catatonia

With peripartum onset

With seasonal pattern

Specify: Remission status if full

criteria are not currently met for a

manic, hypomanic, or major

depressive episode.

(continued)

Table 12. DSM-IV to DSM-5 Bipolar I Disorder Comparison (continued)

DSM-IV

Disorder DSM-IV Criteria

DSM-5

Disorder DSM-5 Criteria

Disorder

Class

Mood Disorders Disorder

Class

Bipolar and Related Disorders

Bipolar I

Disorder,

Single Manic

Episode

A. Presence of only one manic episode

(see Table 11) and no past major

depressive episodes (see Table 9).

Note: Recurrence is defined as either a

change in polarity from depression or an

interval of at least 2 months without

manic symptoms.

B. The manic episode is not better

accounted for by schizoaffective

disorder and is not superimposed on

schizophrenia, schizophreniform

disorder, delusional disorder, or

psychotic disorder not otherwise

specified.

Specify if:

Mixed: if symptoms meet criteria for

a mixed episode

Specify (for current or most recent

episode):

Severity/psychotic/remission

specifiers

With catatonic features

With postpartum onset

Bipolar I episode "types" dropped

from criteria tables, but diagnostic

procedure still includes noting most

recent episode type.

Bipolar I

Disorder,

Most Recent

Episode

Hypomanic

A. Currently (or most recently) in a

hypomanic episode.

B. There has previously been at least one

manic episode or mixed episode.

C. The mood symptoms cause clinically

significant distress or impairment in

social, occupational, or other

important areas of functioning.

D. The mood episodes in Criteria A and

B are not better accounted for by

schizoaffective disorder and are not

superimposed on schizophrenia,

schizophreniform disorder, delusional

disorder, or psychotic disorder not

otherwise specified.

Specify:

Longitudinal course specifiers (with

and without interepisode recovery)

With seasonal pattern (applies only to

the pattern of major depressive

episodes)

With rapid cycling

Bipolar I episode "types" dropped

from criteria tables, but diagnostic

procedure still includes noting most

recent episode type.

(continued)

Table 12. DSM-IV to DSM-5 Bipolar I Disorder Comparison (continued)

DSM-IV

Disorder DSM-IV Criteria

DSM-5

Disorder DSM-5 Criteria

Disorder

Class

Mood Disorders Disorder

Class

Bipolar and Related Disorders

Bipolar I

Disorder,

Most Recent

Episode

Manic

A. Currently (or most recently) in a

manic episode.

B. There has previously been at least one

major depressive episode, manic

episode, or mixed episode.

C. The mood episodes in Criteria A and

B are not better accounted for by

schizoaffective disorder and are not

superimposed on schizophrenia,

schizophreniform disorder, delusional

disorder, or psychotic disorder not

otherwise specified.

Specify (for current or most recent

episode):

Severity/psychotic/remission

specifiers

With catatonic features

With postpartum onset

Specify:

Longitudinal course specifiers (with

and without interepisode recovery)

With seasonal pattern (applies only to

the pattern of major depressive

episodes)

With rapid cycling

Bipolar I episode "types" dropped

from criteria tables, but diagnostic

procedure still includes noting most

recent episode type.

(continued)

Table 12. DSM-IV to DSM-5 Bipolar I Disorder Comparison (continued)

DSM-IV

Disorder DSM-IV Criteria

DSM-5

Disorder DSM-5 Criteria

Bipolar I

Disorder,

Most Recent

Episode

Mixed

A. Currently (or most recently) in a

mixed episode.

B. There has previously been at least one

major depressive episode, manic

episode, or mixed episode.

C. The mood episodes in Criteria A and

B are not better accounted for by

schizoaffective disorder and are not

superimposed on schizophrenia,

schizophreniform disorder, delusional

disorder, or psychotic disorder not

otherwise specified.

Specify (for current or most recent

episode):

Severity/psychotic/remission

specifiers

With catatonic features

With postpartum onset

Specify:

Longitudinal course specifiers (with

and without interepisode recovery)

With seasonal pattern (applies only to

the pattern of major depressive

episodes)

With rapid cycling

Bipolar I episode "types" dropped

from criteria tables, but diagnostic

procedure still includes noting most

recent episode type.

(continued)

Table 12. DSM-IV to DSM-5 Bipolar I Disorder Comparison (continued)

DSM-IV

Disorder DSM-IV Criteria

DSM-5

Disorder DSM-5 Criteria

Disorder

Class

Mood Disorders Disorder

Class

Bipolar and Related Disorders

Bipolar I

Disorder,

Most Recent

Episode

Depressed

A. Currently (or most recently) in a

major depressive episode.

Bipolar I episode "types" dropped

from criteria tables, but diagnostic

procedure still includes noting most

recent episode type.

B. There has previously been at least one

manic episode or mixed episode.

C. The mood episodes in Criteria A and

B are not better accounted for by

schizoaffective disorder and are not

superimposed on schizophrenia,

schizophreniform disorder, delusional

disorder, or psychotic disorder not

otherwise specified.

Specify (for current or most recent

episode):

Severity/psychotic/remission

specifiers

Chronic

With catatonic features

With melancholic features

With atypical features

With postpartum onset

Specify:

Longitudinal course specifiers (with

and without interepisode recovery)

With seasonal pattern (applies only to

the pattern of major depressive

episodes)

With rapid cycling

Bipolar I

Disorder,

Most Recent

Episode

Unspecified

A. Criteria, except for duration, are

currently (or most recently) met for a

manic, a hypomanic, a mixed, or a

major depressive episode.

B. There has previously been at least one

manic episode or mixed episode.

C. The mood symptoms cause clinically

significant distress or impairment in

social, occupational, or other

important areas of functioning.

D. The mood symptoms in Criteria A

and B are not better accounted for by

schizoaffective disorder and are not

superimposed on schizophrenia,

schizophreniform disorder, delusional

disorder, or psychotic disorder not

otherwise specified.

(continued)

Table 12. DSM-IV to DSM-5 Bipolar I Disorder Comparison (continued)

DSM-IV

Disorder DSM-IV Criteria

DSM-5

Disorder DSM-5 Criteria

Disorder

Class

Mood Disorders Disorder

Class

Bipolar and Related Disorders

E. The mood symptoms in Criteria A

and B are not due to the direct

physiological effects of a substance

(e.g., a drug of abuse, a medication,

or other treatment) or a general

medical condition (e.g.,

hyperthyroidism).

Specify:

Longitudinal course specifiers (with

and without interepisode recovery)

With seasonal pattern (applies only to

the pattern of major depressive

episodes)

With rapid cycling

Dropped

3.3.4 Generalized Anxiety Disorder (under Anxiety Disorders)

Generalized anxiety disorder (GAD) is an anxiety disorder characterized by excessive

anxiety and worry that is not focused on a single trigger (e.g., fear of social situations, fear of

having a panic attack, or fear of a specific event/situation). There have been very few changes

made to GAD criteria in DSM-5. The DSM-IV criteria for GAD included that the anxiety and

worry does not occur exclusively during PTSD, a mood disorder, a psychotic disorder, or PDD.

In DSM-5, this has been replaced with text indicating that "the disturbance is not better

explained by another mental disorder." This will have no impact on any estimate of SED

prevalence. Table 13 shows a comparison between DSM-IV and DSM-5 diagnostic criteria for

generalized anxiety disorder.

Table 13. DSM-IV to DSM-5 Generalized Anxiety Disorder Comparison

DSM-IV DSM-5

Disorder Class: Anxiety Disorders SAME

A. Excessive anxiety and worry (apprehensive expectation),

occurring more days than not for at least 6 months,

about a number of events or activities (such as work or

school performance).

SAME

B. The person finds it difficult to control the worry. SAME

(continued)

Table 13. DSM-IV to DSM-5 Generalized Anxiety Disorder Comparison (continued)

DSM-IV DSM-5

Disorder Class: Anxiety Disorders SAME

C. The anxiety and worry are associated with three or more

of the following six symptoms (with at least some

symptoms present for more days than not for the past 6

months).

Note: Only one item is required in children

1. Restlessness or feeling keyed up or on edge

2. Being easily fatigued

3. Difficulty concentrating or mind going blank

4. Irritability

5. Muscle tension

6. Sleep disturbance (difficulty falling or staying

asleep, or restless unsatisfying sleep)

SAME

Note: Only one item is required in children

1. Restlessness or feeling keyed up or on edge

2. Being easily fatigued

3. Difficulty concentrating or mind going

blank

4. Irritability

5. Muscle tension

6. Sleep disturbance (difficulty falling or

staying asleep, or restless unsatisfying

sleep)

D. The focus of the anxiety and worry is not confined to

features of an Axis I disorder (e.g., the anxiety or worry

is not about having a panic attack [as in panic disorder],

being embarrassed in public [as in social phobia], being

contaminated [as in obsessive-compulsive disorder]

being away from home or close relatives [as in

separation anxiety disorder], gaining weight [as in

anorexia nervosa], or having a serious illness [as in

hypochondriasis]), and the anxiety and worry do not

occur exclusively during post-traumatic stress disorder.

F. The disturbance is not better explained by

another mental disorder (e.g., anxiety or worry

about having panic attacks in panic disorder,

negative evaluation in social anxiety disorder

[social phobia], contamination or other

obsessions in obsessive-compulsive disorder,

separation from attachment figures in

separation anxiety disorder, reminders of

traumatic events in post-traumatic stress

disorder, gaining weight in anorexia nervosa,

physical complaints in somatic symptom

disorder, perceived appearance flaws in body

dysmorphic disorder, having a serious illness in

illness anxiety disorder, or the content of

delusional beliefs in schizophrenia or delusional

disorder).

E. The anxiety, worry, or physical symptoms cause

clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

SAME (part D)

F. The disturbance is not due to the direct physiological

effects of a substance (e.g., a drug of abuse, a

medication) or a general medical condition (e.g.,

hyperthyroidism) and does not occur exclusively during

a mood disorder, a psychotic disorder, or a pervasive

developmental disorder.

E. The disturbance is not attributable to the

physiological effects of a substance (e.g., a drug

of abuse, a medication) or another medical

condition (e.g., hyperthyroidism).

3.3.5 Panic Disorder and Agoraphobia (under Anxiety Disorders)

Panic disorder is an anxiety disorder characterized by panic attack(s) and the ongoing

concern about experiencing additional panic attacks (American Psychiatric Association, 2013b).

A panic attack is an abrupt, but quickly peaking, surge of intense fear or discomfort,

accompanied by a series of physical symptoms. In DSM-IV, panic disorder and agoraphobia

were conceptually linked. Agoraphobia is an anxiety disorder characterized by an intense fear or

anxiety triggered by the real or anticipated exposure to a number of situations (i.e., using public

transportation, being in open spaces), which causes clinically significant distress or impairment.

The diagnoses in DSM-IV included panic disorder with agoraphobia, panic disorder without

agoraphobia, and agoraphobia without history of panic disorder. In DSM-5, however, panic

disorder and agoraphobia have been separated and individuals meeting criteria for both disorders

are considered to have comorbid mental disorders. Examining the comparison of panic disorder

criteria specifically (Table 14), with the exception of the disaggregation of agoraphobia, the

criteria are similar between DSM-IV and DSM-5. There are minor wording changes to the

description of panic attacks that may have slight implications to the prevalence of panic disorder

under DSM-5. Under DSM-IV, the specification was made that panic attacks were discrete

periods of intense fear or discomfort that peaked within 10 minutes. In DSM-5, panic attacks are

described as an abrupt surge of intense fear or intense discomfort that peak within a few minutes.

The wording changes reflect two conceptual issues. First, the change in wording from a discrete

event to an abrupt surge broadens criteria based on evidence that panic attacks do not necessarily

arise "out of the blue" but can arise during periods of anxiety or other distress and that it is the

sudden increase in fear/discomfort that is the hallmark of a panic attack. In addition, they have

removed the 10-minute criterion, in favor of the less precise but implicitly shorter descriptive of

"within minutes" (American Psychiatric Association, 2013b, p. 214). This was only a change in

classification and is expected to have no impact on overarching prevalence estimates of SED.

Table 14 shows a comparison between DSM-IV and DSM-5 diagnostic criteria for panic

disorder and agoraphobia.

Table 14. Panic Disorder and Agoraphobia Criteria Changes from DSM-IV to DSM-5

DSM-IV Disorder DSM-IV Criteria

DSM-5

Disorder DSM-5 Criteria

Diagnostic Class:

Anxiety Disorders

SAME

Panic Attack

A discrete period of intense fear or

discomfort, in which four or more of the

following symptoms developed abruptly

and reached a peak within 10 minutes

• Palpitations, pounding heart, or

accelerated heart rate

• Sweating

• Trembling or shaking

• Sensations of shortness of breath or

smothering

• Feeling of choking

• Chest pain or discomfort

• Nausea or abdominal distress

• Feeling dizzy, unsteady,

lightheaded, or faint

• Derealization (feelings of unreality)

or depersonalization (being

detached from oneself)

• Fear of losing control or "going

crazy"

• Fear of dying

• Paresthesias (numbness or tingling

sensation)

• Chills or hot flushes.

Panic

Attack

An abrupt surge of

intense fear or intense

discomfort that reaches a

peak within minutes and

during which time four or

more of the following

symptoms occur.

• List is unchanged,

except that "hot

flushes" has been

modified to "heat

sensations" and

there has been a

reordering of

symptoms.

(continued)

Table 14. Panic Disorder and Agoraphobia Criteria Changes from DSM-IV to DSM-5 (continued)

DSM-IV Disorder DSM-IV Criteria

DSM-5

Disorder DSM-5 Criteria

Diagnostic Class:

Anxiety Disorders

SAME

Agoraphobia

Anxiety about being in places or situations

from which escape might be difficult (or

embarrassing) or in which help may not be

available in the event of having an

unexpected or situationally predisposed

panic attack or panic-like symptoms.

Agoraphobic fears typically involve

characteristic clusters of situations that

include being outside the home alone;

being in a crowd or standing in a line;

being on a bridge; and traveling in a bus,

train, or automobile.

Agoraphobia A marked fear or anxiety

about two (or more) of

the following five

situations:

• Using public

transportation

• Being in open

spaces

• Being in enclosed

spaces (e.g., shops,

theaters, cinemas)

• Standing in line or

being in a crowd

• Being outside the

home alone.

The situations are avoided (e.g., travel is

restricted) or else are endured with marked

distress or with anxiety about having a

panic attack or panic-like symptoms, or

require the presence of a companion.

SAME

N/A The agoraphobic

situations almost always

provoke fear or anxiety.

N/A The fear or anxiety is out

of proportion to the actual

danger posed by the

agoraphobic situations

and to the sociocultural

context.

N/A

The fear, anxiety, or

avoidance is persistent,

typically lasting 6 months

or more.

N/A The fear, anxiety, or

avoidance causes

clinically significant

distress or impairment in

important areas of

functioning.

The anxiety or phobic avoidance is not

better accounted for by another mental

disorder.

SAME

(continued)

Table 14. Panic Disorder and Agoraphobia Criteria Changes from DSM-IV to DSM-5 (continued)

DSM-IV Disorder DSM-IV Criteria

DSM-5

Disorder DSM-5 Criteria

Diagnostic Class:

Anxiety Disorders

SAME

Agoraphobia without

history of Panic

Disorder

The presence of agoraphobia related to

fear of developing panic-like symptoms.

The individual fears or

avoids these situations

because of thoughts that

escape might be difficult

or help might not be

available in the event of

developing panic-like

symptoms or other

incapacitating or

embarrassing symptoms.

Criteria for panic disorder have never

been met.

DROPPED

The disturbance not due to the direct

physiological effects of a substance (e.g.,

a drug of abuse or a medication) or a

general medical condition

DROPPED

If an associated general medical condition

is present, the fear described in Criterion

A is clearly in excess of that usually

associated with the condition.

SAME

Panic Disorder,

with/without

Agoraphobia

Both:

• Recurrent and unexpected panic

attacks (see below)

• ≥ 1 attack has been followed by 1

month or more of 1 or more of the

following

Persistent concern about additional

attacks

Worry about the implications of the attack

or its consequences

A significant change in behavior related

to the attacks

Panic

Disorder

Both:

• Recurrent and

unexpected panic

attacks (see

below)

• ≥ 1 attack has

been followed by

1 month or more

of 1 or both of the

following

Persistent concern about

additional attacks or

their consequences

A significant

maladaptive change in

behavior related to the

attacks

The panic attacks are not due to the direct

physiological effects of a substance (e.g.,

a drug of abuse or a medication) or a

general medical condition

SAME

The panic attacks are not better accounted

for by another mental disorder.

SAME

• Without agoraphobia: Absence of

agoraphobia (see below)

DROPPED

• With agoraphobia: Presence of

agoraphobia

DROPPED

Not a codable disorder, considered a feature of the specific disorder in which the panic attack/agoraphobia occurs.

3.3.6 Separation Anxiety Disorder (under Anxiety Disorders)

Separation anxiety disorder (SAD) is a psychological condition in which an individual

experiences excessive anxiety, fear, or distress regarding separation from home or from people to

whom the individual has a strong emotional attachment (e.g., a parent, grandparents, or siblings;

Table 15). SAD is the inappropriate and excessive display of fear and distress when faced with

situations of separation from the home or from a specific attachment figure. The anxiety that is

expressed is categorized as being atypical of the expected developmental level and age. The

severity of the symptoms ranges from anticipatory uneasiness to full-blown anxiety about

separation. SAD may cause significant negative effects within a child's everyday life, as well.

These effects can be seen in areas of social and emotional functioning, family life, physical

health, and within the academic context. The duration of this problem must persist for at least 4

weeks and must present itself before a person is 18 years of age to be diagnosed as SAD

(American Psychiatric Association, 2013b).

Table 15. DSM-IV to DSM-5 Separation Anxiety Disorder Comparison

DSM-IV DSM-5

Disorder Class: Disorders Usually Diagnosed in Infancy,

Childhood, and Adolescence

Disorder Class: Anxiety Disorders

A. Developmentally inappropriate and excessive anxiety

concerning separation from home or from those to

whom the individual is attached, as evidenced by three

or more of the following:

A. Developmentally inappropriate and excessive

fear or anxiety concerning separation from those

to whom the individual is attached, as evidenced

by at least three of the following:

1. Recurrent excessive distress when separation from

home or major attachment figures occurs or is

anticipated

1. Recurrent excessive distress when

anticipating or experiencing separation from

home or from major attachment figures.

2. Persistent and excessive worry about losing, or

about possible harm befalling, major attachment

figures

2. Persistent and excessive worry about losing

major attachment figures or about possible

harm to them, such as illness, injury,

disasters, or death.

3. Persistent and excessive worry that an untoward

event will lead to separation from a major

attachment figure (e.g., getting lost or being

kidnapped)

3. Persistent and excessive worry about

experiencing an untoward event (e.g., getting

lost, being kidnapped, having an accident,

becoming ill) that causes separation from a

major attachment figure.

4. Persistent reluctance or refusal to go to school or

elsewhere because of fear of separation

4. Persistent reluctance or refusal to go out,

away from home, to school, to work, or

elsewhere because of fear of separation.

5. Persistently and excessively fearful or reluctant to

be alone or without major attachment figures at

home or without significant adults in other settings

5. Persistent and excessive fear of or reluctance

about being alone or without major

attachment figures at home or in other

settings.

6. Persistent reluctance or refusal to go to sleep

without being near a major attachment figure or to

sleep away from home

6. Persistent reluctance or refusal to sleep away

from home or to go to sleep without being

near a major attachment figure.

7. Repeated nightmares involving the theme of

separation

7. SAME

8. Repeated complaints of physical symptoms (such as

headaches, stomachaches, nausea, or vomiting)

when separation from major attachment figures

occurs or is anticipated

8. SAME

(continued)

Table 15. DSM-IV to DSM-5 Separation Anxiety Disorder Comparison (continued)

DSM-IV DSM-5

Disorder Class: Disorders Usually Diagnosed in Infancy,

Childhood, and Adolescence

Disorder Class: Anxiety Disorders

B. The duration of the disturbance is at least 4 weeks. B. The fear, anxiety, or avoidance is persistent,

lasting at least 4 weeks in children and

adolescents and typically 6 months or more in

adults.

C. The onset is before age 18 years. DROPPED

D. The disturbance causes clinically significant distress or

impairment in social, academic (occupational), or other

important areas of functioning.

SAME (now part C)

E. The disturbance does not occur exclusively during the

course of a pervasive developmental disorder,

schizophrenia, or other psychotic disorder and, in

adolescents and adults, is not better accounted for by

panic disorder with agoraphobia.

D. The disturbance is not better explained by

another mental disorder, such as refusing to leave

home because of excessive resistance to change

in autism spectrum disorder; delusions or

hallucinations concerning separation in psychotic

disorders; refusal to go outside without a trusted

companion in agoraphobia; worries about ill

health or other harm befalling significant others

in generalized anxiety disorder; or concerns

about having an illness in illness anxiety

disorder.

Specify if:

Early Onset: if onset occurs before age 6 years

DROPPED

The primary change from DSM-IV to DSM-5 has been the reclassification of SAD from

the disorders usually diagnosed in infancy, childhood, and adolescence section to anxiety

disorders. Criteria changes from DSM-IV to DSM-5 are largely wording changes rather than

major conceptual differences. The largest differences are related to broadening the criteria to

better align with the presentation of SAD among adults; consequently, this should have minimal

impact on childhood estimates.

3.3.7 Social Anxiety Disorder (formerly Social Phobia [Social Anxiety Disorder], under

Anxiety Disorders)

Social anxiety disorder is an anxiety disorder characterized by fear of social situations

wherein the individual may be exposed to scrutiny by others (American Psychiatric Association,

2013b). In children, the anxiety must occur in peer settings and not just during interactions with

adults. In addition, for children, the fear or anxiety may be expressed by crying, tantrums,

freezing, clinging, shrinking, or failing to speak in social situations.

Diagnostic criteria for social phobia have undergone several minor wording changes from

DSM-IV to DSM-5 (Table 16). One additional change is anticipated to have a broader impact on

estimates of social phobia. In DSM-IV, criteria for social phobia required that an individual

"recognizes that the fear is excessive or unreasonable." In DSM-5 this has been changed to note

that "the fear or anxiety is out of proportion to the actual threat posed by the social situation and

to the sociocultural context." This means that the patient does not need to recognize that their

fear is unreasonable, so long as the clinician can determine that the fear is unreasonable.

Table 16. DSM-IV to DSM-5 Social Phobia/Social Anxiety Disorder Comparison

DSM-IV DSM-5

Disorder Class: Anxiety Disorders SAME

A. A marked and persistent fear of one or more social or

performance situations in which the person is exposed to

unfamiliar people or to possible scrutiny by others. The

individual fears that he or she will act in a way (or show

anxiety symptoms) that will be humiliating or

embarrassing.

Note: In children, there must be evidence of the capacity for

age-appropriate social relationships with familiar people

and the anxiety must occur in peer settings, not just in

interactions with adults.

A. Marked fear or anxiety about one or more

social situations in which the individual is

exposed to possible scrutiny by others.

Examples include social interactions (e.g.,

having a conversation, meeting unfamiliar

people), being observed (e.g., eating or

drinking), and performing in front of others

(e.g., giving a speech).

Note: In children, the anxiety must occur in peer

settings and not just during interactions with

adults.

The individual fears that he or she will act in a way

or show anxiety symptoms that will be

negatively evaluated (i.e., will be humiliating or

embarrassing; will lead to rejection or offend

others).

B. Exposure to the feared social situation almost invariably

provokes anxiety, which may take the form of a

situationally bound or situationally predisposed panic

attack.

Note: In children, the anxiety may be expressed by crying,

tantrums, freezing, clinging, shrinking, or failing to speak

in social situations.

C. The social situations almost always provoke

fear or anxiety.

Note: In children, the fear or anxiety may be

expressed by crying, tantrums, freezing,

clinging, shrinking, or failing to speak in social

situations.

C. The person recognizes that the fear is excessive or

unreasonable.

Note: In children, this feature may be absent.

B. The fear or anxiety is out of proportion to the

actual threat posed by the social situation and to

the sociocultural context.

D. The feared social or performance situations are avoided

or else are endured with intense anxiety or distress.

D. The social situations are avoided or endured

with intense fear or anxiety.

E. The avoidance, anxious anticipation, or distress in the

feared social or performance situation(s) interferes

significantly with the person's normal routine,

occupational (academic) functioning, or social activities

or relationships, or there is marked distress about having

the phobia.

G. The fear, anxiety, or avoidance causes clinically

significant distress or impairment in social,

occupational, or other important areas of

functioning.

F. In individuals under age 18 years, the duration is at least

6 months.

F. The fear, anxiety, or avoidance is persistent,

typically lasting for 6 months or more.

G. The fear or avoidance is not due to the direct

physiological effects of a substance (e.g., a drug of abuse,

a medication) or a general medical condition and is not

better accounted for by another mental disorder (e.g.,

panic disorder with or without agoraphobia, separation

anxiety disorder, body dysmorphic disorder, a pervasive

developmental disorder, or schizoid personality disorder).

H. The fear, anxiety, or avoidance is not

attributable to the physiological effects of a

substance (e.g., a drug of abuse, a medication)

or another medical condition.

I. The fear, anxiety, or avoidance is not better

explained by the symptoms of another mental

disorder, such as panic disorder, body

dysmorphic disorder, or autism spectrum

disorder.

H. If a general medical condition or another mental disorder

is present, the fear in Criterion A is unrelated to it (e.g.,

the fear is not of stuttering, trembling in Parkinson's

disease, or exhibiting abnormal eating behavior in

anorexia nervosa or bulimia nervosa).

J. If another medical condition (e.g., Parkinson's

disease, obesity, disfigurement from burns or

injury) is present, the fear, anxiety, or

avoidance is clearly unrelated or is excessive.

(continued)

Table 16. DSM-IV to DSM-5 Social Phobia/Social Anxiety Disorder Comparison (continued)

DSM-IV DSM-5

Disorder Class: Anxiety Disorders SAME

Specify if: Generalized: if the fears include most social

situations (also consider the additional diagnosis of avoidant

personality disorder)

Specify if: Performance only: if the fear is restricted

to speaking or performing in public.

For the new social anxiety disorder, which replaces social phobia, the "generalized" (if

the fears include most social situations) specifier has been deleted and replaced with a

"performance only" specifier (if the fear is restricted to speaking or performing in public). The

rationale is that the DSM-IV generalized specifier was difficult to operationalize. The DSM-5

describes that individuals who fear only performance situations (i.e., speaking or performing in

front of an audience) appear to represent a distinct subset of social anxiety disorder in terms of

etiology, age at onset, physiological response, and treatment response.

Epidemiological work in the U.S. population using data from the National Comorbidity

Survey-Adolescent Supplement found that only 0.7 percent of adolescents meeting criteria for

social anxiety disorder could be classified as having the performance-only social anxiety disorder

(Burstein et al., 2011). Subsequent work based on a clinical sample in Boston of 204 youth

seeking treatment for anxiety disorders at a university-affiliated center, found that no children

endorsed discrete fear in performance situations only in the absence of fear in other social

situations (Kerns, Comer, Pincus, & Hofmann, 2013). No impact in the prevalence of SED is

expected from the new social anxiety disorder specifier when applied to youth.

3.3.8 Conduct Disorder (under Disruptive, Impulse-Control, and Conduct Disorders)

Conduct disorder (CD) is usually first diagnosed in childhood and was categorized in

DSM-IV under the category of the same name. Conduct disorder is characterized by a repetitive

and persistent pattern of behavior that violates either the rights of others or major age appropriate

societal norms or rules. People with CD often show aggression to people and animals,

destruction of property, deceitfulness or theft, and/or serious violations of rules. At least 3

symptoms out of 15 must be present in the past 12 months with 1 symptom having been present

in the past 6 months. To be diagnosed with CD, the symptoms must cause significant impairment

in social, academic, or occupational functioning. The disorder is typically diagnosed prior to

adulthood (American Psychiatric Association, 2013a).

The main change to the diagnostic criteria for CD is the addition of a subtype grouping

around callous and unemotional traits. The callous–lack-of-empathy trait is defined as a

disregard and lack of concern about the feelings of others and more concerned about the effects

of his or her actions on himself/herself than their effects on others even when they may result in

substantial harm to others (American Psychiatric Association, 2013a). The purpose of this

change was to better account for heterogeneity within CD. As such, this change is not expected

to impact prevalence estimates of CD. In the DSM-5 field trials in the United States and Canada

based on child clinical populations (general child psychiatry outpatient services), CD prevalence

was the same (8 percent) using DSM-IV and DSM-5. The estimated prevalence using DSM-5 for

the new callous/unemotional specifier for CD was 5 percent (Regier et al., 2013). Table 17

shows a comparison between DSM-IV and DSM-5 diagnostic criteria for CD.

Table 17. DSM-IV to DSM-5 Conduct Disorder Comparison

DSM-IV: Conduct Disorder DSM-5: Conduct Disorder

Disorder Class: Attention deficit and

disruptive behavior disorders

Disorder Class: Disruptive, Impulse-Control, and Conduct

Disorders

A. A repetitive and persistent pattern of

behavior in which the basic rights of others

or major age-appropriate societal norms or

rules are violated, as manifested by the

presence of three (or more) of the

following criteria in the past 12 months,

with at least one criterion present in the

past 6 months:

A. A repetitive and persistent pattern of behavior in which the

basic rights of others or major age-appropriate societal

norms or rules are violated, as manifested by the presence

of three (or more) of the following 15 criteria in the past 12

months from any of the categories below, with at least one

criterion present in the past 6 months:

Aggression to people and animals

1. often bullies, threatens, or intimidates

others

2. often initiates physical fights

3. has used a weapon that can cause

serious physical harm to others (e.g., a

bat, brick, broken bottle, knife, gun)

4. has been physically cruel to people

5. has been physically cruel to animals

6. has stolen while confronting a victim

(e.g., mugging, purse snatching,

extortion, armed robbery)

7. has forced someone into sexual activity

Aggression to people and animals

1. SAME

2. SAME

3. SAME

4. SAME

5. SAME

6. SAME

7. SAME

Destruction of property

8 has deliberately engaged in fire setting

with the intention of causing serious

damage

9. has deliberately destroyed others'

property (other than by fire setting)

Destruction of property

8. SAME

9. SAME

Deceitfulness or theft

10. has broken into someone else's house,

building, or car

11. often lies to obtain goods or favors or

to avoid obligations (i.e., "cons" others)

12. has stolen items of nontrivial value

without confronting a victim (e.g.,

shoplifting, but without breaking and

entering; forgery)

Deceitfulness or theft

10. SAME

11. SAME

12. SAME

Serious violations of rules

13. often stays out at night despite parental

prohibitions, beginning before age 13

years

14. has run away from home overnight at

least twice while living in parental or

parental surrogate home (or once

without returning for a lengthy period)

15. is often truant from school, beginning

before age 13 years

Serious violations of rules

13. SAME

14. SAME

15. SAME

(continued)

Table 17. DSM-IV to DSM-5 Conduct Disorder Comparison (continued)

DSM-IV: Conduct Disorder DSM-5: Conduct Disorder

Disorder Class: Attention deficit and disruptive

behavior disorders

Disorder Class: Disruptive, Impulse-Control, and Conduct

Disorders

B. The disturbance in behavior causes clinically

significant impairment in social, academic,

or occupational functioning.

B. SAME

C. If the individual is age 18 years or older,

criteria are not met for Antisocial

Personality Disorder.

C. SAME

Code based on age at onset:

312.81 Conduct Disorder, Childhood-Onset

Type: onset of at least one criterion

characteristic of Conduct Disorder prior to

age 10 years

312.82 Conduct Disorder, Adolescent-Onset

Type: absence of any criteria characteristic

of Conduct Disorder prior to age 10 years

312.89 Conduct Disorder, Unspecified

Onset: age at onset is not known

Specify whether:

312.81 (F91.1) Conduct Disorder, Childhood-Onset Type:

Individuals show at least one symptom characteristic of

conduct disorder prior to age 10 years

312.82 (F91.2) Conduct Disorder, Adolescent-Onset Type:

Individuals show now symptom characteristic of conduct

disorder prior to age 10 years

312.89 (F91.9) Conduct Disorder, Unspecified Onset:

Criteria for a diagnosis or conduct disorder are met, but

there is not enough information available to determine

whether the onset of the first symptom was before or after

age 10 years.

N/A Specify if:

With limited prosocial emotions: To qualify for this

specifier, an individual must have displayed at least two of

the following characteristics persistently over at least 12

months and in multiple relationships and setting. These

characteristics reflect the individual's typical pattern of

interpersonal and emotional functioning over this period

and not just occasional occurrences in some situations.

Thus, to assess the criteria for the specifier, multiple

information sources are necessary. In addition to the

individual's self-report, it is necessary to consider reports

by others who have known the individual for extended

periods of time (e.g., parents, teachers, coworkers,

extended family members, peers).

Lack of remorse or guilt: Does not feel bad or guilty when

he/she does something wrong (excluding remorse when

expressed only when caught and/or facing punishment).

The individual shows a general lack of concern about the

negative consequences of his or her actions. For example,

the individual is not remorseful after hurting someone or

does not care about the consequences of breaking rules.

Callous—lack of empathy: Disregards and is unconcerned

about the feelings of others. The individual is described as

cold and uncaring. The person appears more concerned

about the effects of his or her actions on himself or herself,

rather than their effects on others, even when they result in

substantial harm to others.

(continued)

Table 17. DSM-IV to DSM-5 Conduct Disorder Comparison (continued)

DSM-IV: Conduct Disorder DSM-5: Conduct Disorder

Disorder Class: Attention deficit and

disruptive behavior disorders

Disorder Class: Disruptive, Impulse-Control, and Conduct

Disorders

Unconcerned about performance: Does not show concern

about poor/problematic performance at school, work, or in

other important activities. The individual does not put forth

the effort necessary to perform well, even when

expectations are clear, and typically blames others for his or

her poor performance.

Shallow or deficient affect: Does not express feelings or

show emotions to others, except in ways that seem shallow,

insincere, or superficial (e.g., actions contradict the emotion

displayed; can turn emotions "on" or "off" quickly) or when

emotional expressions are used for gain (e.g., emotions

displayed to manipulate or intimidate others).

Specify severity:

Mild: few if any conduct problems in

excess of those required to make the

diagnosis and conduct problems cause only

minor harm to others

Moderate: number of conduct problems

and effect on others intermediate between

"mild" and "severe"

Severe: many conduct problems in excess

of those required to make the diagnosis or

conduct problems cause considerable harm

to others

Specify current severity:

Mild: Few if any conduct problems in excess of those

required to make the diagnosis are present, and conduct

problems cause relatively minor harm to others (e.g., lying,

truancy, staying out after dark without permission, other

rule breaking).

Moderate: The number of conduct problems and the effect

on others are intermediate between those specified in "mild"

and those in "severe" (e.g., stealing without confronting a

victim, vandalism).

Severe: Many conduct problems in excess of those required

to make the diagnosis are present, or conduct problems

cause considerable harm to others (e.g., forced sex, physical

cruelty, use of a weapon, stealing while confronting a

victim, breaking and entering).

3.3.9 Oppositional Defiant Disorder (under Disruptive, Impulse-Control, and Conduct

Disorders)

Oppositional defiant disorder's (ODD) is characterized by a frequent and persistent

pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness that may

significantly impair social functioning (American Psychiatric Association, 2013b). ODD is

primarily viewed as a younger-child version of CD and it emerges mostly during the preschool

years (before 5 years old), where symptoms of aggression and defiance are present but the acts

committed by the child are less severe. Most research on changes to the categorization of ODD

in DSM-5 have focused on understanding the underlying dimensions of ODD, towards the goal

of being better able to predict different outcomes in later childhood (which children with ODD

develop CD, which children develop other mental disorders, which children become

nonsymptomatic) (Barry et al, 2013; Krieger et al., 2013). As such, there is no expectation that

children previously diagnosed with something else will necessarily move into the ODD category

in the DSM-5. However, some children previously diagnosed with ODD using DSM-IV criteria

may move into the DMDD category under DSM-5 if their symptoms include chronic irritability

along with anger and severe tantrums.

As described in the DSM-5 manual (American Psychiatric Association, 2013b, p, 64),

cases with DMDD and ADHD should be diagnosed separately. In the DSM-5 field trials in the

United States and Canada based on child clinical populations (general child psychiatry outpatient

services), estimates for ODD were described for one of the sites (Columbia/Cornell Medical

Centers-New York) as decreasing from 22 percent using DSM-IV to 17 percent using DSM-5

(Regier et al., 2013).Thus, the prevalence of ODD may decrease very slightly when DSM-5

criteria are applied, but given that DMDD only occurs in 1 percent of the school-age population,

this effect is expected to be minimal. In terms of SED, DSM-5 recategorization of irritability

from ODD to DMDD is expected to result in no difference in the SED prevalence estimate.

Table 18 shows a comparison between DSM-IV and DSM-5 oppositional defiant disorder.

Table 18. DSM-IV to DSM-5 Oppositional Defiant Disorder Comparison

DSM-IV: Oppositional Defiant Disorder DSM-5: Oppositional Defiant Disorder

Disorder Class: Attention Deficit and Disruptive

Behavior Disorders

Disorder Class: Disruptive, Impulse-Control, and Conduct

Disorders

A. A pattern of negativistic; hostile, and defiant

behavior lasting at least 6 months, during which

four (or more of the following are present:

1. Often loses temper

2. Often argues with adults

3. Often actively defies or refuses to comply with

adults requests or rules

4. Often deliberately annoys people

5. Often blames others for his or her mistakes or

misbehavior

6. Is often touchy or easily annoyed by others

7. Is often angry and resentful

8. Is often vindictive

Note: Consider a criterion met only if the behavior

occurs more frequently that is typically observed in

individuals of comparable age and developmental

level.

A. A pattern of angry/irritable mood, argumentative/

defiant behavior, or vindictiveness lasting at least 6

months as evidenced by at least four symptoms of the

following categories, and exhibited during interaction

with at least one individual who is not a sibling:

Angry/Irritable Mood

1. Often loses temper

2. Is often touchy or easily annoyed

3. Is often angry and resentful

Argumentative/Defiant Behavior

4. Often argues with authority figures or, for children

and adolescents, with adults

5. Often actively defies or refuses to comply with

requests from authority figures or with rules

6. Often deliberately annoys others

7. Often blames others for his or her mistakes or

misbehavior

Vindictiveness

8. Has been spiteful or vindictive at least twice within

the past 6 months.

Note: The persistence and frequency of these behaviors

should be used to distinguish a behavior that is within

normal limits from a behavior that is symptomatic. For

children younger than 5 years, the behavior should occur

on most days for a period of at least 6 months unless

otherwise noted (Criterion AB). For individuals 5 years or

older, the behavior should occur at least once per week for

at least 6 months. Unless otherwise noted (Criterion AB).

While these frequency criteria provide guidance on a

minimal level of frequency to define symptoms, other

factors should also be considered, such as whether the

frequency and intensity of the behaviors are outside a

range that is normative for the individual's developmental

level, gender, and culture.

(continued)

Table 18. DSM-IV to DSM-5 Oppositional Defiant Disorder Comparison (continued)

DSM-IV: Oppositional Defiant Disorder DSM-5: Oppositional Defiant Disorder

Disorder Class: Attention Deficit and Disruptive

Behavior Disorders

Disorder Class: Disruptive, Impulse-Control, and Conduct

Disorders

B. The disturbance in behavior causes clinically

significant impairment in social, academic, or

occupational functioning,

B. The disturbance in behavior is associated with distress

in the individual or others in his or her immediate

social context (e.g., family, peer group, work

colleagues) or it impacts negatively on social,

educational, occupational, or other important areas of

functioning,

C. The behavior does not occur exclusively during

the course of a Psychiatric or Mood Disorder.

C. The behavior does not occur exclusively during the

course of a psychotic, substance use, depressive, or

bipolar disorder. Also the criteria are not met for

disruptive mood dysregulation disorder.

D. Criteria are not met for Conduct Disorder, and, if

the individual is age 18 or older, criteria are not

met for Antisocial Personality Disorder

Dropped

Specify current severity:

Mild: Symptoms are confined to only one setting (e.g.,

at home, at school, at work, with peers).

Moderate: Some symptoms are present in at least two

settings

Severe: Some symptoms are present in three or more

settings.

3.3.10 Eating Disorders (under Feeding and Eating Disorders)

Anorexia Nervosa. Anorexia nervosa is an eating disorder characterized by an intense

fear of gaining weight and the refusal to maintain a minimally normal body weight. Individuals

with anorexia also exhibit a misperception of body shape and/or size. There have been several

DSM-5 criteria changes. In DSM-IV, a diagnosis of anorexia nervosa was excluded if the patient

maintained bodyweight at or above the 85th percentile for his or her height/age. In DSM-5 this

criterion is similar, but adds sex, developmental norms, and physical health and uses body mass

index data. The DSM-5 adds "persistent behavior that interferes with weight gain" as an added

way to meet a criterion. The DSM-5 does not include criteria on menstruating females' absence

of three consecutive menses, as the DSM-IV does. The restrictive type and binge-eating/purging

types differ in that DSM-IV specifies "during the current episode" and DSM-5 specifies "during

the past 3 months." The DSM-5 adds criteria for partial and full remission, while the DSM-IV

does not include this information. Data from a U.S. sample of 215 youth 8 to 21 years enrolled as

new patients with eating disorders in six clinics showed an increase from 30 percent to 40

percent in anorexia nervosa when comparing DSM-IV and DSM-5 criteria (Ornstein et al.,

2013). Table 19 shows a comparison between DSM-IV and DSM-5 for anorexia nervosa.

Bulimia Nervosa. Bulimia nervosa is an eating disorder characterized by binge eating

followed by inappropriate compensatory behaviors designed to prevent weight gain. In addition,

the self-evaluation of individuals with bulimia nervosa is excessively influenced by weight and

body shape. The major change in criteria for diagnosis of bulimia nervosa is reducing the binge

frequency threshold from twice per week in DSM-IV to once per week in DSM-5. The other

differences include the DSM-IV differentiating between purging and nonpurging type (the

DSM-5 does not) and the DSM-5 specifying criteria for partial remission, full remission, and

severity, while the DSM-IV does not. DSM-IV to DSM-5 criteria changes may increase the

prevalence rate. Data from an Australian cohort study of 2,822 adolescents and young adults

(57.0 percent female) whose parents were recruited from antenatal clinics at a single hospital and

followed through age 20, indicate that rates of bulimia nervosa are higher when applying the

DSM-5 criteria versus the DSM–IV (Allen, Byrne, Oddy, & Crosby, 2013). Similarly, data from

a U.S. sample of 215 youth 8 to 21 years enrolled as new patients with eating disorders in six

clinics showed an increase in bulimia nervosa from 7.3 percent to 11.8 percent when comparing

DSM-IV and DSM-5 criteria (Ornstein et al., 2013). Table 20 shows a comparison between

DSM-IV and DSM-5 for bulimia nervosa.

Table 19. DSM-IV to DSM-5 Anorexia Nervosa Comparison

DSM-IV DSM-5

Disorder Class: Eating Disorders Disorder Class: Feeding and Eating Disorders

A. Refusal to maintain bodyweight at or above

minimally normal weight for height/age (less

than 85th percentile).

A. Restriction of energy intake relative to requirements,

leading to a significant low body weight in the context of

the age, sex, developmental trajectory, and physical health

(less than minimally normal/expected

B. Intense fear of gaining weight or becoming

obese, even though underweight.

B. Intense fear of gaining weight or becoming fat or

persistent behavior that interferes with weight gain.

C. Disturbed by one's body weight or shape, self-

worth influenced by body weight or shape, or

persistent lack of recognition of seriousness of

low bodyweight.

SAME

D. In menstruating females, absence of at least 3

consecutive non-synthetically induced

menstrual cycles.

DROPPED

Specify type:

Restricting type: During the current episode, has

not regularly engaged in binge-eating or purging.

Specified whether:

Restricting type: During the last 3 months…SAME.

Binge-eating/purging type: During the current

episode, has regularly engaged in binge-eating or

purging.

Binge-eating/purging type: During the last 3

months…SAME.

Partial remission: After full criteria met, low bodyweight has

not been met for sustained period, BUT at least one of the

following two criteria still met:

Intense fear of gaining weight/becoming obese or

behavior that interferes with weight gain

Disturbed by weight and shape.

Full remission: After full criteria met, none of the criteria met

for sustained period of time.

Severity is based on body mass index (BMI) derived from World Health Organization categories for thinness in

adults; corresponding percentiles should be used for children and adolescents: Mild: BMI greater than or equal to

17 kg/m

, Moderate: BMI 16-16.99 kg/m

, Severe: BMI 15-15.99 kg/m

, Extreme: BMI less than 15 kg/m

Purging is self-induced vomiting or misuse of laxatives, diuretics, or enemas.

Table 20. DSM-IV to DSM-5 Bulimia Nervosa Comparison

DSM-IV DSM-5

Disorder Class: Eating Disorders Disorder Class: Feeding and Eating Disorders

A. Recurrent episodes of binge eating, as characterized

by both:

1. Eating, within any 2-hour period, an amount of

food that is definitively larger than what most

individuals would eat in a similar period of time

under similar circumstances.

2. A feeling that one cannot stop eating or control

what or how much one is eating.

SAME

B. Recurrent inappropriate compensatory behaviors in

order to prevent weight gain such as self-induced

vomiting; misuse of laxatives, diuretics, or other

medications; fasting or excessive exercise.

SAME

C. The binge eating and inappropriate compensatory

behaviors occur, on average, at least twice a week for

3 months.

C. The binge eating and inappropriate compensatory

behaviors occur, on average, at least once a week

for 3 months.

D. Self-evaluation is unjustifiability influenced by body

shape and weight.

SAME

E. The disturbance does not occur exclusively during

episodes of anorexia nervosa.

SAME

Specify type:

Purging type: During the current episode, the person

has regularly engaged in self-induced vomiting or the

misuse of laxatives, diuretics, or enemas.

Nonpurging Type: During the current episode, the

person has used inappropriate compensatory

behaviors, such as fasting or excessive exercise, but

has not regularly engaged in self-induced vomiting or

the misuse of laxatives, diuretics, or enemas.

Not a criterion.

Not a criterion. Specify if:

Partial remission: After full criteria were previously

met, some but not all of the criteria have been met

for a sustained period of time.

Full remission: After full criteria were previously

met, none of the criteria have been met for a

sustained period of time.

Not a criterion. Current severity

Mild: An average of 1-3 episodes of inappropriate

compensatory behaviors per week.

Moderate: An average of 4-7 episodes of

inappropriate compensatory behaviors per week.

Severe: An average of 8-13 episodes of

inappropriate compensatory behaviors per week.

Extreme: An average of 14 or more episodes of

inappropriate compensatory behaviors per week.

The level of severity may be increased to reflect other symptoms and the degree of functional disability.

Binge Eating Disorder. Binge eating disorder had been included in DSM-IV as a "criteria

set provided for further study," and has been included in DSM-5 as a disorder. This disorder is

characterized by binge or out of control eating accompanied by significant distress about eating.

Binge eating disorder is differentiated from bulimia nervosa in that there are no inappropriate

compensatory behaviors (e.g., purging or excessive exercise) seen in binge eating disorder. As

noted previously, this disorder was added into DSM-5 because a significant subset of people

presenting with an eating disorder had exhibited binge eating behaviors that were not

accompanied by any behaviors intended to compensate for the binge eating (Call, Walsh, &

Attia, 2013; Crow et al., 2012; Striegel-Moore & Franko, 2008). Changes between the criteria

enumerated in DSM-IV and those in DSM-5 are minimal. The only change, which represents a

less stringent requirement in DSM-5, reduces the minimum frequency/duration of the binge

eating behavior to at least once a week for 3 months (it had been at least 2 days a week for 6

months). Table 21 shows a comparison between DSM-IV and DSM-5 for binge eating disorder.

Table 21. DSM-IV to DSM-5 Binge Eating Disorder Comparison

DSM-IV DSM-5

Disorder Class: Criteria Sets and Axes Provided for Further

Study

Disorder Class: Feeding and Eating Disorders

A. Recurrent episodes of binge eating. An episode of binge

eating is characterized by both of the following:

1. Eating, in a discrete period of time (e.g., within any

2-hour period), an amount of food that is definitely

larger than most people would eat in a similar period

of time under similar circumstances

2. A sense of lack of control over eating during the

episode (e.g., a feeling that one cannot stop eating or

control what or how much one is eating)

SAME

B. The binge-eating episodes are associated with three (or

more) of the following:

1. Eating much more rapidly than normal

2. Eating until feeling uncomfortably full

3. Eating large amounts of food when not feeling

physically hungry

4. Eating alone because of feeling embarrassed by how

much one is eating

5. Feeling disgusted with oneself, depressed, or very

guilty after overeating

SAME

C. Marked distress regarding binge eating is present. SAME

D. The binge eating occurs, on average, at least 2 days a

week for 6 months.

Note: The method of determining frequency differs from

that used for bulimia nervosa; future research should

address whether the preferred method of setting a frequency

threshold is counting the number of days on which binges

occur or counting the number of episodes of binge eating.

D. The binge eating occurs, on average, at least

once a week for 3 months.

E. The binge eating is not associated with the regular use

of inappropriate compensatory behaviors (e.g., purging,

fasting, excessive exercise) and does not occur

exclusively during the course of anorexia nervosa or

bulimia nervosa.

SAME

(continued)

Table 21. DSM-IV to DSM-5 Binge-Eating Disorder Comparison (continued)

DSM-IV DSM-5

Disorder Class: Criteria Sets and Axes Provided for Further

Study

Disorder Class: Feeding and Eating Disorders

Specify if:

In partial remission: After full criteria for

binge-eating disorder were previously met,

binge eating occurs at an average frequency of

less than one episode per week for a sustained

period of time.

In full remission: After full criteria for binge-

eating disorder were previously met, none of

the criteria have been met for a sustained

period of time.

Specify current severity:

Severity is also noted in the diagnosis, from

mild to extreme:

Mild: 1-3 binge-eating episodes per week

Moderate: 4-7 binge-eating episodes per

week

Severe: 8-13 binge-eating episodes per

week

Extreme: 14 or more binge-eating episodes

per week

Avoidant/Restrictive Food Intake Disorder. DSM-IV feeding disorder of infancy or early

childhood has been renamed avoidant/restrictive food intake disorder, and the criteria have been

significantly expanded. The DSM-IV disorder was rarely used, and limited information is

available on its course and outcome or the characteristics of children with this disorder. A large

number of children and adolescents substantially restrict their food intake and experience

significant associated physiological or psychosocial problems but do not meet criteria for any

DSM-IV eating disorder. Avoidant/restrictive food intake disorder is a broad category intended

to capture this range of presentations. In the DSM-5 field trials in the United States and Canada

based on child clinical populations (general child psychiatry outpatient services),

avoidant/restrictive food intake disorder prevalence was described for one site

(Columbia/Cornell Medical Centers-New York) and it was 11 percent using DSM-5 (not

applicable for DSM-IV) (Regier et al., 2013). Table 22 shows a comparison between DSM-IV

and DSM-5 for avoidant/restrictive food intake disorder.

Table 22. DSM-IV to DSM-5 Avoidant/Restrictive Food Intake Disorder Comparison

DSM-IV DSM-5

Name: Feeding Disorder of Infancy or Early

Childhood

Name: Avoidant/Restrictive Food Intake Disorder

Disorder Class: Feeding and Eating Disorders of

Infancy or Early Childhood

Disorder Class: Feeding and Eating Disorders

A. Feeding disturbance as manifested by

persistent failure to eat adequately with

significant failure to gain weight or

significant loss of weight over at least 1

month.

A. An eating or feeding disturbance (e.g., apparent lack of

interest in eating or food; avoidance based on the sensory

characteristics of food; concern about aversive

consequences of eating) as manifested by persistent

failure to meet appropriate nutritional and/or energy needs

associated with one (or more) of the following:

1. Significant weight loss (or failure to achieve expected

weight gain or faltering growth in children)

2. Significant nutritional deficiency.

3. Dependence on enteral feeding or oral nutritional

supplements.

4. Marked interference with psychosocial functioning.

B. The disturbance is not due to an associated

gastrointestinal or other general medical

condition (e.g., esophageal reflux).

D. The eating disturbance is not attributable to a concurrent

medical condition or not better explained by another

mental disorder. When the eating disturbance occurs in

the context of another mental disorder, the severity of the

eating disturbance exceeds that routinely associated with

the condition or disorder and warrants additional clinical

attention.

C. The disturbance is not better accounted for

by another mental disorder (e.g., Rumination

Disorder) or by lack of available food.

B. The disturbance is not better explained by lack of

available food or by an associated culturally sanctioned

practice.

-- C. The eating disturbance does not occur exclusively during

the course of anorexia nervosa or bulimia nervosa, and

there is no evidence of a disturbance in the way in which

one's body weight or shape is experienced.

D. The onset is before age 6 years. DROPPED

D. The eating disturbance is not attributable to a concurrent

medical condition on not better explained by another

mental disorder. When the eating disturbance the eating

disturbance occurs in the context of another condition or

disorder, the severity of the eating disturbance exceeds

that routinely associated with the condition or disorder

and warrants additional clinical attention.

Specify if: In remission: After full criteria for

avoidance/restrictive food intake disorder were previously

met, the criteria have not been met for a sustained period of

time.

3.3.11 Body Dysmorphic Disorder (under Obsessive-compulsive and Related Disorders)

Body dysmorphic disorder (BDD) is a mental illness characterized by an excessive

preoccupation with a perceived physical defect or flaw that causes significant distress or

functional impairment. There have been several important changes in BDD criteria from

DSM-IV to DSM-5. First, BDD has been reclassified from somatoform disorders in DSM-IV to

obsessive-compulsive and related disorders under DSM-5. Second, DSM-5 BDD has an added

diagnostic criterion indicating that the patient must have had repetitive behaviors or mental acts

that were in response to preoccupations with perceived defects or flaws in physical appearance.

Third, a "with muscle dysmorphia" specifier has been added to reflect a growing literature on the

diagnostic validity and clinical utility of making this distinction in individuals with BDD.

Finally, the delusional variant of BDD (which identifies individuals who are completely

convinced that their perceived defects or flaws are truly abnormal in appearance) is no longer

coded as both a delusional disorder (somatic type) and BDD. Under DSM-5, this presentation is

designated only as BDD with the "absent insight/delusional beliefs" specifier and not as a

delusional disorder.

Under DSM-IV criteria, BDD was a fairly common disorder affecting approximately 2.4

percent of the general population at any time (point prevalence) as estimated by a random sample

telephone survey conducted in 2004 among 2,513 adults residing in the United States (Keel,

Brown, Holm-Denoma, & Bodell, 2011). As a comparison, this is similar to point prevalence

estimates of DSM-IV defined GAD. Estimates under DSM-5 criteria are not currently available

for children or adults. However, criteria-induced changes in the estimates are likely to be minor.

Over 90 percent of people with BDD report repetitive behaviors or mental acts in response to

their preoccupation with a perceived physical deficit (Able, Johnston, Adler, & Swindle, 2007),

and this was the only restrictive change to diagnostic criteria. BDD affects both males and

females and has been identified in children as young as age 5 and as old as age 80 (Able et al.,

2007). Moreover, patients with BDD report that unwanted, anxiety provoking obsessions related

to BDD cause significant distress (e.g., avoidance of social situations due to anxiety of being

ridiculed) and the repetitive behaviors are time consuming, functionally impairing (e.g., being

late for work due to compulsive compensatory behavior), and can be dangerous (e.g., skin

picking leading to infection). Suicidal thoughts is a significant concern among people with BDD;

suicidal ideation is as high as 80 percent in this population and one in four make a suicide

attempt (Able et al., 2007). There are very few prospective studies of BDD, but retrospective

studies suggest a mean onset of BDD around age 16 and indicate a chronic course with a low

probability of remission without treatment (Able et al., 2007). Since approximately 75 percent of

those with BDD meeting criteria for MDD as well, even if BDD was not assessed in a clinical

instrument, the majority of the cases with BDD would be classified as having SED due to co-

morbidity. Table 23 shows a comparison between DSM-IV and DSM-5 for body dysmorphic

disorder.

Table 23. DSM-IV to DSM-5 Body Dysmorphic Disorder Comparison

DSM-IV DSM-5

Disorder Class: Somatoform Disorders Disorder Class: Obsessive-Compulsive and Related

Disorders

A. Preoccupation with an imagined defect in

appearance. If a slight physical anomaly is

present, the person's concern is markedly

excessive.

A. Preoccupation with one or more perceived defects or

flaws in physical appearance that are not observable or

appear slight to others.

B. At some point during the course of the disorder, the

individual has performed repetitive behaviors (e.g.,

mirror checking, excessive grooming, skin picking,

reassurance seeking) or mental acts (e.g., comparing his

or her appearance with that of others) in response to the

appearance concerns.

B. The preoccupation causes clinically significant

distress or impairment in social, occupational,

or other important areas of functioning.

C. The preoccupation causes clinically significant distress or

impairment in social, occupational or other areas of

functioning.

C. The preoccupation is not better accounted for by

another mental disorder (e.g., dissatisfaction

with body shape and size in anorexia nervosa).

D. The appearance preoccupation is not better explained by

concerns with body fat or weight in an individual whose

symptoms meet diagnostic criteria for an eating disorder.

Specify if:

With muscle dysmorphia: The individual is preoccupied

with the idea that his or her body build is too small or

insufficiently muscular. This specifier is used even if the

individual is preoccupied with other body areas, which is

often the case.

Specify if:

Indicate degree of insight regarding body dysmorphic

disorder beliefs (e.g., "I look ugly" or "I look

deformed").

With good or fair insight: The individual recognizes

that the body dysmorphic disorder beliefs are

definitely or probably not true or that they may or

may not be true.

With poor insight: The individual thinks that the

body dysmorphic beliefs are probably true.

With absent insight/delusional beliefs: The individual

is completely convinced that the body dysmorphic

beliefs are true.

4. Instrumentation

The purpose of this section is to describe current plans to integrate the Diagnostic and

Statistical Manual of Mental Disorders, 5th ed. (DSM-5) changes into the leading diagnostic

instruments for assessing childhood mental disorders. Instrument developers provided

information about plans to update diagnostic interviews. Table 24 describes the major diagnostic

instruments, including both structured and semistructured interviews. Table 24 also describes the

diagnostic coverage for each instrument. The final column provides an update on the status of

each instrument's DSM-5 compatibility.

Table 24. Summary of Diagnostic Instruments Used to Assess Child Mental Disorders

Instrument

Age

Range Rater Mode

Diagnostic

Criteria

Diagnostic

Coverage

Administered

By DSM-5 Update

K-SADS 6-18

years

Child

Parent

In person

Phone

DSM-IV Affective, anxiety,

behavioral, eating,

psychotic,

substance abuse

Clinician Interview is DSM-5

compatible.

Computer version

under construction.

DISC-IV 6-17

years

Child

Parent

In person DSM-IV

ICD-10

Anxiety, mood,

schizophrenia,

behavior, substance

use, miscellaneous

disorders (30

disorders total)

Trained lay

interviewer

Not DSM-5

compatible.

Will possibly

update in the future.

CAPA 9-18

years

Child

Parent

In person

Phone

DSM-IV Anxiety, mood,

behavioral,

substance, and

antisocial

personality

Trained lay

interviewer (at

least bachelor

degree)

Scoring algorithms

will be updated.

NCS-A

CIDI

13-17

years

Child

Parent

In person

Phone

DSM-IV Mood, anxiety,

disruptive behavior,

substance use,

eating,

neurasthenia, and

suicidality (19

total)

Trained lay

interviewer

No plans to update.

PAPA 2-5

Years

Parent In person

Phone

DSM-IV Mood, anxiety,

disruptive

behaviors,

psychosis,

attachment,

enuresis, encopresis

Trained lay

interviewer

Scoring algorithms

will be updated.

YAPA 19-21

years

Self In person DSM-IV Mood, anxiety,

behavior disorders,

personality

disorders,

substance abuse,

risk factors, living

situations,

relationships

Trained lay

interviewer

Unknown

CAPA = Child and Adolescent Psychiatric Assessment; DISC-IV = Diagnostic Interview Schedule for Children, Version 4; DSM-IV =

Diagnostic and Statistical Manual of Mental Disorders, 4th ed.; ICD-10 = International Classification of Disease, revision 10; K-SADS =

Kiddie-Schedule for Affective Disorders and Schizophrenia; NCS-A-CIDI = National Comorbidity Survey Replication Adolescent Supplement-

Composite International Diagnostic Interview; PAPA = Preschool Age Psychiatric Assessment; YAPA = Young Adult Psychiatric Assessment

In addition to their measurement of disorders and symptoms, these diagnostic interviews

also measure functional impairment. Each instrument measures functional impairment slightly

differently.

• The version of the Composite International Diagnostic Interview (CIDI) used in the

National Comorbidity Survey (NCS) for adults and adolescents includes an expanded

version of the Sheehan Disability Scale after each diagnostic module to assess overall

level of impairment associated with a disorder.

• The Child and Adolescent Psychiatric Assessment (CAPA), Preschool Age Psychiatric

Assessment (PAPA) and Young Adult Psychiatric Assessment (YAPA) interviews

incorporate some assessment of impairment within the diagnostic algorithms to establish

the presence of an Axis I disorder. For example, problems in school, arguments with

peers and family members, and legal actions are all assessed at the beginning of the

CAPA/PAPA/YAPA instruments prior to the diagnosis-specific modules on attention-

deficit/hyperactivity disorder (ADHD), depression, anxiety, oppositional defiant disorder

(ODD), and conduct disorder (CD). The CAPA/PAPA/YAPA instruments close with a

separate "incapacities" module that assesses impairment for all endorsed symptoms.

Interviewers are asked to review all problems or symptoms that emerged during the

interview. Then, taking these one at a time, they must determine whether symptoms in

that area caused incapacity. The interviewer is asked to distinguish two levels of

disturbance or impaired functioning—partial and severe. "Partial incapacity" refers to a

notable reduction of function in a particular area. If a person is still able to do things, but

does them less well or more slowly, then it is coded as a partial incapacity. "Severe

incapacity" refers to a complete, or almost complete, inability to function in a particular

area. If neither of these applies, the interviewer codes "absent."

• The Diagnostic Interview Schedule for Children (DISC) incorporates a series of

impairment questions at the end of each diagnostic section, which are only asked if a

"clinically significant" number of symptoms have already been endorsed, usually half or

more of those required for the diagnosis. These questions are uniform across all

diagnoses. They inquire as to whether the symptoms present during the last year have

resulted in any degree of impairment in six different social domains. Each set of

questions has a two-part structure, the first determining whether impairment is present

and the second measuring severity or frequency. The DISC assesses three levels of

impairment severity. The Clinical Report produced by the C-DISC generates a tally of the

degree of impairment. The separate SAS algorithms can also be used to generate

diagnoses with varying degrees of diagnosis-specific impairment.

• The Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS) determines

severity of a disorder using the Child Global Assessment of Functioning (C-GAF)

(Shaffer et al. 1983), which is administered as the sixth and final module of the

instrument. Severe impairment is indicated by a C-GAF score of 50 or less when a

diagnosis of an Axis I mental disorder is present. Moderate severity is indicated by a C-

GAF score in the range of 51-70 along with presence of an Axis 1 disorder. Mild severity

is indicated by a C-GAF score greater than 70 in the presence of an Axis 1 disorder.

One goal of the project is to develop a model that can predict SED using a mental health

screener and other predictor variables. One possible screener is the Strengths and Difficulties

Questionnaire (SDQ), which has been the subject of one validation study comparing parent SDQ

ratings with clinician ratings using the K-SADS (Kessler, Gruber, & Sampson, 2006), as well as

the Centers for Disease Control and Prevention's (CDC's) SDQ validation study, which

compared the SDQ with the CAPA/PAPA. These studies found that the SDQ had some limited

ability to predict presence of a disorder, depending on reporter (parent versus child) and severity

of disorder. For the purpose of this report, it should be noted that screeners are not directly tied to

DSM symptom classifications. Accordingly, the developers of the SDQ have confirmed that they

do not consider the SDQ to be a diagnostic instrument and therefore do not anticipate any

adaptations based on DSM-5 changes.

Finally, with increasing evidence about the comparable validity and reliability between

telephone and face-to-face administration of mental health interviews, psychiatric researchers

have been conducting clinical interviews over the telephone for the past 20 years (Aneshensel,

Frerichs, Clark, & Yokopenic, 1982; Reich & Earls, 1990; Rohde, Lewinsohn, & Seeley, 1997;

Sobin et al., 1993). In fact, telephone administration has become widely accepted as a way to

conduct clinical appraisals of both adults and adolescents (Kessler et al., 2009). However, most

of the research conducted with telephone administrations of diagnostic mental health interviews

has been done with adults. The only adolescent instrument to be directly compared by telephone

and face-to-face administration was the CIDI in an appraisal study performed by Kessler et al.

(2009). The CAPA and PAPA instruments have only been used in a limited fashion by

telephone, and no formal studies have compared CAPA or PAPA diagnostic outcomes (or for

many of the other diagnostic tools) when gathered in person versus by telephone. Duke

University investigators estimated that approximately 112 CAPA interviews were completed

over the telephone with 15- and 16-year-old adolescents in the Great Smoky Mountain Study

(GSMS). Among these 112 telephone CAPA interviews, the Duke investigators reported no

adverse events (e.g., reports to the Institutional Review Board for suspected child abuse or child

suicidal or homicidal ideation). The published literature does indicate that reliability, validity,

and epidemiological studies have been conducted by telephone with adolescents and children as

young as 12 years of age (Merikangas, Avenevoli, Costello, Koretz, & Kessler, 2009; Reich &

Earls, 1990; Rohde et al., 1997; Sobin, Weissman, Goldstein, & Adams, 1993). However, no

methodological work has been done to evaluate the specific impact of a change in the mode of

administration (from face to face to telephone) on the CAPA or PAPA outcomes.

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5. Summary and Conclusions

Changes included in the fifth edition of the Diagnostic and Statistical Manual of Mental

Disorders (DSM-5) raise issues relevant to the definition of childhood serious emotional

disturbance (SED). Within the original Federal Register definition, SED was defined as

including "any diagnosable mental, behavioral, or emotional disorder of sufficient duration to

meet diagnostic criteria specified within the Diagnostic and Statistical Manual of Mental

Disorders, Third Edition, Revised (DSM-III-R)." Diagnostic "V" codes and Axis II disorders

(personality disorders and mental retardation) as well as substance use disorders (SUDs),

pervasive developmental disorder (PDD), and autism were all specifically excluded. The Federal

considered in operational definitions of SED. With the release of the DSM-5, three specific

issues could be considered:

1. Due to the DSM-5 removal of the Axis system, the operational definition of SED may

now need to explicitly state which DSM-5 mental disorders are excluded from the

SED definition of "any DSM-5 mental disorder."

2. A decision will need to be made about which disorders within the new DSM-5

neurodevelopmental disorders class should be included versus excluded within the

definition of SED. Many, but not all, disorders within the neurodevelopmental

disorders were previously excluded from the 1993 definition.

3. A decision will need to be made as to whether one of the new DSM-5 childhood

disorders, social communication disorder (SCD), should be included as meeting

criteria for SED. If SCD is considered a "developmental disorder," it might be

excluded based upon the 1993 SED definition.

DSM-5 changes also will impact the diagnostic instruments used to assess the presence of

a mental disorder in childhood. Only one diagnostic interview for children and adolescents, the

Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS), has already been

updated to explicitly use DSM-5 diagnostic criteria. The scoring algorithms associated with the

Child and Adolescent Psychiatric Assessment (CAPA) and Preschool Age Psychiatric

Assessment (PAPA) will be updated to accommodate new DSM-5 diagnostic changes. This is

possible within the CAPA and PAPA interviews as they are symptom and functioning based and

not structured in diagnostic-specific modules like the other diagnostic interviews. CAPA and

PAPA scoring algorithms use questions embedded in the entire instrument to indicate the

presence of particular mental disorders. The Diagnostic Interview Schedule for Children (DISC)

will possibly be updated in the future, but the developers did not articulate a specific plan to do

so. Particularly in the near future, the release of the DSM-5 will narrow the number of diagnostic

measures to be considered for use in children's mental health surveillance efforts.

Research examining the impact of DSM-5 changes suggests that there may be a slight

increase in the overarching prevalence of diagnosed mental disorders among children and

adolescents. The potential for this slight increase stems mainly from the changed criteria for

attention-deficit/hyperactivity disorder (ADHD)—the new impulsivity criteria and lower

percentage of criteria needed for the diagnosis. A much smaller increase may be due to the

lowered age of onset for post-traumatic stress disorder (PTSD). Epidemiological studies,

including an assessment of eating disorders among adolescents, may also see an increase in

eating disorder-specific prevalence estimates. Most DSM-5 changes for children reclassified

disorders from one category to another. These changes would have no overarching impact on an

estimate of "any mental disorder." For instance, the prevalence of ODD is expected to decrease

using DSM-5 as some cases will now be diagnosed under the new disruptive mood dysregulation

disorder (DMDD).

The definition of SED includes the presence of both a childhood mental disorder and

functional impairment. If the additional cases identified with updated DSM-5 criteria are not

accompanied by functional impairments that substantially interfere with a child's ability to

function at home, school, or in the community, an SED prevalence estimate would not be

significantly impacted. DSM-5 field trials examined impact on prevalence estimates without

consideration of functioning. Additional research will be necessary to determine the full impact

of DSM-5 changes specifically on estimates of the prevalence of SED among children and

adolescents.

References

Aneshensel, C. S., Frerichs, R. R., Clark, V. A., & Yokopenic, P. A. (1982).Measuring

depression in the community: A comparison of telephone and personal interviews. Public

Opinion Quarterly, 46(1), 110-121.

Able, S. L., Johnston, J. A., Adler, L. A., & Swindle, R. W. (2007). Functional and psychosocial

impairment in adults with undiagnosed ADHD. Psychological Medicine, 37(01), 97-107. doi:

doi:10.1017/S0033291706008713

Allen, K. L., Byrne, S. M., Oddy, W. H., & Crosby, R. D. (2013). DSM-IV-TR and DSM-5

eating disorders in adolescents: Prevalence, stability, and psychosocial correlates in a population-

based sample of male and female adolescents. Journal of Abnormal Psychology, 122(3), 720-

732. doi: 10.1037/a0034004

American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental

Disorders, 3rd revised edition. Arlington, VA: Author.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental

disorders, 4th edition. Arlington, VA: Author.

American Psychiatric Association. (2013a). Conduct Disorder. Retrieved April 28, 2014, from

http://www.dsm5.org/Documents/Conduct%20Disorder%20Factsheet%20Rev%209%206%2013

.pdf

American Psychiatric Association. (2013b). Diagnosis and statistical manual of mental

disorders, 5th edition. Arlington, VA: Author.

American Psychiatric Association. (2013c). Highlight of changes from DSM-IV-TR to DSM 5.

Retrieved April 28, 2014, from http://www.dsm5.org/Documents/changes%20from%20dsm-iv-

tr%20to%20dsm-5.pdf

American Psychiatric Association. (2013d). Posttraumatic stress disorder. Retrieved April 28,

2014, from http://www.dsm5.org/Documents/PTSD%20Fact%20Sheet.pdf

Axelson, D. (2013). Taking disruptive mood dysregulation disorder out for a test drive.

American Journal of Psychiatry, 170(2), 136-139. doi: 10.1176/appi.ajp.2012.12111434

Barry, T. D., Marcus, D. K., Barry, C. T., & Coccaro, E. F. (2013). The latent structure of

oppositional defiant disorder in children and adults. Journal of Psychiatric Research, 47(12),

1932-1939. doi:10.1016/j.jpsychires.2013.08.016

Burstein, M., He, J. P., Kattan, G., Albano, A. M., Avenevoli, S., & Merikangas, K. R. (2011).

Social phobia and subtypes in the National Comorbidity Survey-Adolescent Supplement:

Prevalence, correlates, and comorbidity. Journal of the American Academy of Child and

Adolescent Psychiatry, 50(9), 870-880. doi: 10.1016/j.jaac.2011.06.005

Call, C., Walsh, B. T., & Attia, E. (2013). From DSM-IV to DSM-5: changes to eating disorder

diagnoses. Current Opinion in Psychiatry, 26(6), 532-536. doi:

10.1097/YCO.0b013e328365a321

Center for Behavioral Health Statistics and Quality. (in review). Impact of the DSM-IV to DSM-

5 Conversion on the National Survey On Drug Use and Health and the Mental Health

Surveillance Study. Substance Abuse and Mental Health Services Administration, Rockville,

Copeland, W. E., Angold, A., Costello, E. J., & Egger, H. (2013). Prevalence, comorbidity, and

correlates of DSM-5 proposed disruptive mood dysregulation disorder. American Journal of

Psychiatry, 170(2), 173-179. doi: 10.1176/appi.ajp.2012.12010132

Copeland, W. E., Keeler, G., Angold, A., & Costello, E. J. (2007). Traumatic events and

posttraumatic stress in childhood. Archives of General Psychiatry, 64(5), 577-584. doi:

10.1001/archpsyc.64.5.577

Costello, E. M., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and

Development of Psychiatric Disorders in Childhood and Adolescence. Archives of General

Psychiatry, 60(8), 837-844.

Crow, S. J., Swanson, S. A., Peterson, C. B., Crosby, R. D., Wonderlich, S. A., & Mitchell, J. E.

(2012). Latent class analysis of eating disorders: Relationship to mortality. Journal of Abnormal

Psychology, 121(1), 225-231. doi: 10.1037/a0024455

Egger, H. L., Erkanli, A., Keeler, G., Potts, E., Walter, B. K., & Angold, A. (2006). Test-retest

reliability of the Preschool Age Psychiatric Assessment (PAPA). Journal of the American

Academy of Child and Adolescent Psychiatry, 45(5), 538-549. doi:

10.1097/01.chi.0000205705.71194.b8

Fox, J., & Jones, K. D. (2013). DSM-5 and bereavement: The loss of normal grief? Journal of

Counseling and Development, 91(1), 113-119. doi: DOI 10.1002/j.1556-6676.2013.00079.x

Frances, A. (2010). Opening Pandora's box: The 19 worst suggestions for DSM-5. Psychiatric

Times, 27(9).

Gibson, J., Adams, C., Lockton, E., & Green, J. (2013). Social communication disorder outside

autism? A diagnostic classification approach to delineating pragmatic language impairment, high

functioning autism and specific language impairment. Journal of Child Psychology and

Psychiatry, 54(11), 1186-1197. doi: 10.1111/jcpp.12079

Huerta, M., Bishop, S. L., Duncan, A., Hus, V., & Lord, C. (2012). Application of DSM-5

Criteria for Autism Spectrum Disorder to Three Samples of Children With DSM-IV Diagnoses

of Pervasive Developmental Disorders. American Journal of Psychiatry, 169(10), 1056-1064.

doi: 10.1176/appi.ajp.2012.12020276

Keel, P. K., Brown, T. A., Holm-Denoma, J., & Bodell, L. P. (2011). Comparison of DSM-IV

versus proposed DSM-5 diagnostic criteria for eating disorders: Reduction of eating disorder not

otherwise specified and validity. International Journal of Eating Disorders, 44(6), 553-560. doi:

10.1002/eat.20892

Kerns, C. E., Comer, J. S., Pincus, D. B., & Hofmann, S. G. (2013). Evaluation of the proposed

social anxiety disorder specifier change for DSM-5 in a treatment seeking sample of anxious

youth. Depression and Anxiety, 30(8), 709-715. doi: 10.1002/da.22067

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005).

Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national

comorbidity survey replication. Archives of General Psychiatry, 62(7), 768-768.

Kessler, R. C., Gruber, M., & Sampson, N. (2006, December 21). Validation studies of mental

health indices in the National Health Interview Survey (presented to the Centers for Disease

Control and Prevention). Retrieved from http://www.hcp.med.harvard.edu/ncs/scales.php

Kessler, R. C., Avenevoli, S., Green, J., Gruber, M. J., Guyer, M., He, Y., Jin, R., Kaufman, J.,

Sampson, N. A., & Zaslavsky, A. M. (2009, April). National Comorbidity Survey Replication

Adolescent Supplement (NCS-A): III. Concordance of DSM-IV/CIDI diagnoses with clinical

reassessments. Journal of the American Academy of Child & Adolescent Psychiatry, 48, 386-

399. doi: 10.1097/CHI.0b013e31819a1cbc

Kessler, R. C., Avenevoli, S., Costello, J., Green, J. G., Gruber, M. J., McLaughlin, K. A., . . .

Merikangas, K. R. (2012). Severity of 12-month DSM-IV disorders in the National Comorbidity

Survey Replication Adolescent Supplement. Archives of General Psychiatry, 69, 381-389.

Krieger, F. V., Polanczyk, G. V., Goodman, R., Rohde, L. A., Graeff-Martins, A. S., Salum, G., .

. . Stringaris, A. (2013). Dimensions of oppositionalay in a Brazilian community sample: Testing

the DSM-5 proposal and etiological links. Journal of the American Academy of Child and

Adolescent Psychiatry, 52(4), 389-400. doi: 10.1016/j.jaac.2013.01.004

Leigh, E., Smith, P., Milavic, G., & Stringaris, A. (2012). Mood regulation in youth: research

findings and clinical approaches to irritability and short-lived episodes of mania-like symptoms.

Current Opinion in Psychiatry, 25(4), 271-276. doi: 10.1097/YCO.0b013e3283534982

McPartland, J. C., Reichow, B., & Volkmar, F. R. (2012). Sensitivity and specificity of proposed

DSM-5 diagnostic criteria for autism spectrum disorder. Journal of the American Academy of

Child and Adolescent Psychiatry, 51(4), 368-383. doi: 10.1016/j.jaac.2012.01.007

Merikangas, K. R., Avenevoli, S., Costello, E. J., Koretz, D., & Kessler, R. C. (2009). National

Comorbidity Survey Replication Adolescent Supplement (NCS-A): I. Background and

Measures. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 367-369.

Merikangas, K. R., He, J. P., Brody, D., Fisher, P. W., Bourdon, K., & Koretz, D. S. (2010).

Prevalence and treatment of mental disorders among U.S. children in the 2001-2004 NHANES.

Pediatrics, 125, 75-81.

Norbury, C. F. (2014). Practitioner review: Social (pragmatic) communication disorder

conceptualization, evidence and clinical implications. Journal of Child Psychology and

Psychiatry, 55(3), 204-216.

Ornstein, R. M., Rosen, D. S., Mammel, K. A., Callahan, S. T., Forman, S., Jay, M. S., . . .

Walsh, B. T. (2013). Distribution of eating disorders in children and adolescents using the

proposed DSM-5 criteria for feeding and eating disorders. Journal of Adolescent Health, 53(2),

303-305. doi: 10.1016/j.jadohealth.2013.03.025

Polanczyk, G., Caspi, A., Houts, R., Kollins, S. H., Rohde, L. A., & Moffitt, T. E. (2010).

Implications of extending the ADHD age-of-onset criterion to age 12: Results from a

prospectively studied birth cohort. Journal of the American Academy of Child and Adolescent

Psychiatry, 49(3), 210-216. doi: 10.1016/j.jaac.2009.12.014

Regier, D. A., Narrow, W. E., Clarke, D. E., Kraemer, H. C., Kuramoto, S. J., Kuhl, E. A., &

Kupfer, D. J. (2013). DSM-5 field trials in the United States and Canada, Part II: Test-Retest

Reliability of Selected Categorical Diagnoses. American Journal of Psychiatry, 170(1), 59-70.

doi: 10.1176/appi.ajp.2012.12070999

Reich, W., & Earls, F. (1990). Interviewing adolescents by telephone: Is it a useful

methodological strategy? Comprehensive Psychiatry, 31, 211-215.

Rohde, P., Lewinsohn, P. M., & Seeley, J. R. (1997). Comparability of telephone and face-to-

face interviews in assessing axis I and axis II disorders. American Journal of Psychiatry, 154,

1593-1598.

Scheeringa, M. S., Zeanah, C. H., & Cohen, J. A. (2011). PTSD in children and adolescents:

Toward an empirically based algorithm. Depression and Anxiety, 28(9), 770-782. doi:

10.1002/da.20736

Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P., Bird, H., & Aluwahlia, S. (1983).

A children's global assessment scale (CGAS). Archives of General Psychiatry, 40(11), 1228-

1231.

Sobin, E., Weissman, M. M., Goldstein, R. B., & Adams, P. (1993). Diagnostic interviewing for

family studies: Comparing telephone and face-to-face methods for the diagnosis of lifetime

psychiatric disorders. Psychiatric Genetics, 3, 227-233. doi: 10.1097/00041444-199324000-

00005

St Pourcain, B., Mandy, W. P., Heron, J., Golding, J., Smith, G. D., & Skuse, D. H. (2011).

Links between co-occurring social-communication and hyperactive-inattentive trait trajectories.

Journal of the American Academy of Child and Adolescent Psychiatry, 50(9), 892-902. doi:

10.1016/j.jaac.2011.05.015

Striegel-Moore, R. H., & Franko, D. L. (2008). Should binge eating disorder be included in the

DSM-V? A critical review of the state of the evidence. Annual Review of Clinical Psychology, 4,

305-324. doi: 10.1146/annurev.clinpsy.4.022007.141149

Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

(1992, November 6). Community Mental Health Services Block Grant. Federal Register, 57 FR

53118

Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

(1993, May 20). Defining serious emotional disturbance in children: Final notice. Federal

Uher, R., Payne, J. L., Pavlova, B., & Perlis, R. H. (2013). Major Depressive Disorder in DSM-

5: Implications for Clinical Practice and Research of Changes from DSM-IV. Depression and

Anxiety. doi: 10.1002/da.22217

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