Changes coming in diagnosis of autism, dozens of other mental health conditions

Just like their peers nationwide, the pediatric psychiatrists at Akron Children’s Hospital are watching closely to see how the changes to the Diagnostic and Statistical Manual for Mental Disorders, or DSM-5, will play out.

Will the changes to DSM-5 – the official guide for classifying and diagnosing mental health conditions – help more kids qualify for services? Or will they have the opposite effect? Will the changes be better – or worse – for insurance coverage?

And how will patients themselves feel about such changes?

Some of the changes include the retiring of familiar diagnoses, such as Asperger’s syndrome and the introduction of new conditions, such as hoarding disorder and disruptive mood dysregulation disorder, a diagnosis for kids ages 6 to 18 who have intense temper outbursts three or more times a week.

Several  doctors involved in Akron Children’s pediatric psychiatry fellowship program took the time last week to talk about the DSM-5 after a staff meeting.

Dr. Sumru Bilge-Johnson said the retiring of the diagnosis known as Asperger’s syndrome puts the emphasis on autism as a spectrum disorder.

“It’s just a matter of how kids fit on the spectrum,” the pediatric psychiatrist said.

Dr. Diane Langkamp, a developmental-behavioral pediatrician, said there’s concern that the new guidelines may now exclude children on the end of the spectrum with less severe symptoms.

“Will there be fewer children diagnosed? Probably,” said Dr. Langkamp. “The concern is that those children will be denied insurance coverage for services such as speech therapy or they may no longer qualify for special assistance in school.”

Dr. Laura Markley, a pediatric psychiatrist who is also board certified in pediatrics and general psychology, doesn’t think the term Asperger’s syndrome will go away entirely just because it’s gone from the DSM-5.

“It implies a `higher functioning’ [on the autism spectrum] so I think people already diagnosed with it will hold onto it,” said Dr. Markley.

She noted that some patients still refer to ADD (attention deficit disorder) and it has long been replaced by ADHD (attention deficit hyperactivity disorder) as an official diagnosis.

Proponents of including the diagnosis disruptive mood dysregulation disorder hope it will offer an alternative to the diagnosis of pediatric bipolar disorder.

“This gets to the difficulty of our jobs in diagnosing mental illnesses in children,” said Dr. Stephen Cosby, director of pediatric psychiatry at Akron Children’s. “In many cases, the classifications come from the adult world and children often don’t fully fit. Most of us are not eager to put a bipolar diagnosis on a child because what may look like that at age 8 or 9 may look very different when the child is in his late teens or 20s.”

After more than a decade of discussion and often heated debated, the American Psychiatric Association’s Board of Trustees voted last week to adopt the new clinical guidelines. The changes, the first major ones since 1994, could affect millions of adults and children and the healthcare dollars that follow them.

“DSM-5 is a huge shake-up,” said Dr. John Bober.

The process to update and refine this book highlights the difficult task of diagnosing and treating children and teens with cognitive and mental health disorders.

“Your brain is not fully mature until well into your 20s,” said Dr. Markley. “You’ve got genetics at play but then children are also shaped by family dynamics and many other environmental factors.”

Pediatric psychiatry is full of nuance, subtle differences, and difficult decisions when it comes to diagnosing children and teens.

“Unlike our peers in other branches of medicine, we don’t have lab tests to make things clear and simple,” said Dr. Bober.

Online and print versions of the new DSM-5 guidebook are coming in May 2013.

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