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Evidence-Based Practice in School Mental Health: Addressing DSM-5 Disorders in Schools, Second Edition
James C. Raines
EVIDENCE-BASED PRACTICE IN SCHOOL
MENTAL HEALTH
Addressing DSM-5 Disorders in Schools
Second Edition
EDITED BY James C. Raines
OXFORD WORKSHOP SERIES
1
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Library of Congress Cataloging-in-Publication Data
Names: Raines, James C., editor.
Title: Evidence-based practice in school mental health : addressing DSM-5 disorders in schools / Edited by James C. Raines.
Description: Second edition. | New York : Oxford University Press, [2019] | Series: Oxford workshop series: school social work association of America | Includes bibliographical references and index.
Identifiers: LCCN 2018035406 (print) | LCCN 2018042701 (ebook) | ISBN 9780190886585 (updf) | ISBN 9780190886592 (epub) | ISBN 9780190886578 (pbk. : alk. paper)
Subjects: LCSH: School children—Mental health services. | School social work— United States. | Evidence-based social work—United States. | Evidence-based psychiatry—United States. | Students with disabilities—Services for—United States.
Classification: LCC LB3430 (ebook) | LCC LB3430 .R35 2019 (print) | DDC 371.7/13—dc23 LC record available at https://lccn.loc.gov/2018035406
Shantel D. Crosby, Andy J. Frey, Gary Zornes, and Kristian Jones
Self-Harm Disorders 381
James C. Raines and Stephanie Ochocki
Index 433
Preface
There are other books about child and adolescent mental health disorders, so what makes this one both different and necessary? First, this book is edited and authored by social workers. This means that it takes an ecological, strengths-based perspective. That may sound glib, but this type of approach to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is quite rare. Psychiatry has typically focused on what is wrong with people and looked for deficits, dysfunctions, and disabilities to determine an individual diagnosis. An ecological perspective sees each person within an environmental milieu. This book goes even further in exploring not just a person-in-environment framework but also an environment-in-person viewpoint by considering how adverse childhood experiences can affect human development. A strengthsbased perspective does not ignore deficits but seeks to balance them with strengths and resources to aid in recovery.
The authors were recruited by the editor for their expertise on the disorder(s) that they were invited to address. They have published articles, presented at conferences, and, in some cases, have even written books about these conditions. They were also provided with a rough outline of what each chapter should cover so that readers could find similar information about any of the disorders presented in a similar sequence.
First, the authors were asked to determine the prevalence of the disorder in school-age children and adolescents, ages 3–18. Prevalence should not be confused with incidence. Both terms are drawn from the field of epidemiology. Incidence refers to the probability of occurrence of a given condition within a certain timeframe. Prevalence refers to the number of cases within the total population, typically given in terms of percentage. If the chapter deals with a broad range of disorders (e.g., anxiety disorders), authors were asked to focus on those with the highest prevalence for children and youth.
Second, authors were expected to address changes that had been made to the diagnostic category since the publication of the DSM-IV-TR. In some cases, these changes were profound. Both the chapter on specific learning disorder and the chapter on autism spectrum disorder speak to dramatic changes in how the disorders are conceptualized. Some chapters in the old
DSM had been split apart in the newest edition. Thus, bipolar disorders are now separate from the depressive disorders, and obsessive-compulsive disorders (OCDs) are now distinct from the anxiety disorders.
Third, the writers were asked to address differential diagnoses. For new practitioners, this can be the most difficult part of determining which diagnosis to make. Even experienced clinicians need to consider newly defined syndromes, such as whether a child with OCD symptoms actually has a pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDA).
Fourth, the authors were invited to explore how to screen for the disorders as part of a school-wide positive behavior intervention and support system. Thus, each author provides rapid assessment instruments for busy schoolbased clinicians to determine which students require a full assessment. Readers should be warned, however, to use these tools with discretion. All screening instruments are fallible: they will miss some students with a disorder, and they will identify some students without one. Where the information was available, the authors have provided statistics about both sensitivity and specificity. Sensitivity refers to the ability of an instrument to accurately include all potential people who have a specific problem, and specificity refers to an instrument’s ability to accurately exclude all potential people who do not have a specific condition.
Fifth, the authors were asked to identify clinical interventions that could be employed using a multitiered system of supports framework. Tier 1 interventions focus on universal prevention. Tier 2 interventions focus on early intervention, typically in the form of short-term or group interventions for students at risk. Tier 3 interventions focus on tertiary interventions that usually occur in long-term individual counseling or therapy and may require special education and/or community wrap-around services.
Sixth, the authors were expected to address how to collaborate with others in the student’s milieu. Key figures that can ease or exacerbate a mental disorder include teachers, parents or family members, community mental health providers, and even school administrators. The chapter of trauma- and stressrelated disorders, for example, discusses how to train school resource officers to take a trauma-informed approach.
Seventh, the writers were asked to include a case study of a student with the disorder. The cases were meant to illustrate how a child with a particular disorder acted and how he or she might be helped within a school setting.
Preface
This resulted a wide range of cases that readers could study to consider whether similar students could be helped in an analogous way.
Finally, all of the authors provide a contemporary list of web resources about where to find rapid assessment instruments, treatment manuals, or support groups. While these lists are probably just the tip of the iceberg, they are meant to save time for busy professionals who don’t want to depend on Google.
Overall, it is my hope that this book is useful to school-based mental health providers regardless of their academic discipline. If even one child is helped as a result of this book, then it has been worth the time and effort invested.
About the Editor
James C. Raines calls himself an accidental academic with the heart of a practitioner. He has practiced clinical social work in a pediatric psychiatric unit, and in community mental health centers, family service agencies, residential treatment centers, and schools. He has worked in New York, Illinois, and California. He has been President of the Illinois Association of School Social Workers, the Midwest School Social Work Council, and now the School Social Work Association of America. He previously keynoted the International Conference on School Social Work in Auckland, New Zealand, in 2009 and the SSWAA National School Social Work Conference in St. Louis in 2010 and in San Diego in 2017. He was the recipient of the Midwest School Social Work Career Achievement Award in 2012. As a professor of social work, he is the author of three previous books published by Oxford University Press, two dozen articles, and numerous book chapters. He won the Gary Lee Schaffer award for academic contributions to school social work in 2016. Jim was Chair of the Department of Health, Human Services, and Public Policy at California State University Monterey Bay from 2010 to 2016. He is currently a professor of social work, teaching ethics and evidence-based practice with children and adolescents. You can follow his work on www. academia.edu.
About the Contributors
Chris Ahlman, MSW, PhD, is an Adjunct at Capella University. After receiving her MSW from University of Illinois, Chicago, in 1986, she began her school social work career at Rutland School District, contracted out to six school districts (nine schools). She became a member of IASSW and then SSWAA. In 1993, she earned her PhD in social work from the University of Illinois, Chicago, where her dissertation addressed those organizational factors in the school setting that influenced the labeling of students as having behavior disorders. In 1992, she accepted a position at Aurora University, where she became the school social work coordinator until 2004, when she relocated to Lewis-Clark State College in Idaho. She was a founding member of the Idaho school social work organization and remains active there, as well as being on the board of NASW Idaho. She has continued to publish and present on issues related to working with parents and students. Currently, she is teaching part-time for Capella University.
Michelle S. Ballan, PhD, is Professor of Social Welfare and Professor of Family, Population and Preventive Medicine at SUNY Stony Brook Health Sciences Center. Dr. Ballan’s research, teaching, and service are dedicated to individuals with disabilities. She has published more than 40 articles and book chapters and is an investigator on several disability research grants. Dr. Ballan is the recipient of numerous teaching, research, and leadership awards including the 2010 Columbia University Presidential Teaching Award and the 2015 Mid-Career Exemplary Leader Award for the NASW-NYC Chapter. She is a board member for Services for the Underserved and has worked as a practitioner in various community settings including the New Jersey Brain Injury Association and Safeplace.
Jacqueline Corcoran, PhD, LCSW, is Professor at the University of Pennsylvania School of Social Policy and Practice. Dr. Corcoran has been a master’s-level social worker for more than 25 years and has enjoyed 20 years of productive academic scholarship, starting out at the University of Texas at Arlington (4 years), then at Virginia Commonwealth University (17 years),
Shantel D. Crosby, PhD, LCSW, is Assistant Professor in the Kent School of Social Work at the University of Louisville. She received both her BA in Psychology and her MSW from the University of Michigan, and her PhD in Social Work from Wayne State University in Detroit, Michigan. She previously practiced as a community mental health clinician, working with children and families in the metro-Detroit area. Dr. Crosby’s ongoing research interests include well-being and adverse childhood experiences among youth who are court-involved or at risk of court involvement, particularly youth of color. She focuses on trauma and behavioral/emotional health among this population and explores trauma-informed responses to maladaptive youth behaviors. She is also interested in examining other innovative practices and interventions utilized within child-serving systems to improve youth outcomes.
Theresa Early, MSW, PhD, is Associate Professor at the Ohio State University (OSU) School of Social Work. With more than 20 years’ experience in mental health service system research, Dr. Early is the director of international programs at the College of Social Work and is an affiliate of the Center for Latin American Studies at OSU. In 2011–12, she was a Fulbright-Garcia Robles Research Fellow at the National Autonomous University of Mexico in Mexico City. She has published numerous articles and book chapters on social work and mental health. She has served as a consulting editor for Social Work Research, Children & Schools, Journal of the Society for Social Work and Research, and Journal of Social Work Research and Evaluation: An International Publication. Dr. Early is past president of the Group for the Advancement of Doctoral Education in Social Work. She has developed or led educationabroad programs in India, Mexico, Nicaragua, and Australia.
Andy J. Frey, MSW, PhD, is Professor at the University of Louisville, Kent School of Social Work. After completing a BA at Rollins College in Florida, a master’s degree in social work at the University of Michigan, and a PhD at the University of Denver in Colorado, Dr. Frey has worked as a social worker, behavior coach, and consultant in a number of academic settings. Dr. Frey’s
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About the Contributors and now at the University of Pennsylvania. She was the first person in social work to publish a book on evidence-based practice, Evidence-Based Social Work Practice with Families, which she wrote in 2000. She has written 14 textbooks, more than 50 articles, and 40 book chapters in the areas of mental health, evidence-based practice, and systematic reviews.
research and teaching has focused on school-based mental health and social work services, such as the First Step NEXT intervention, home-based approaches, and motivational interviewing within school settings. His work is currently aimed at comparing the effectiveness and impact of interventions for children with disruptive behavior. Over the course of his career, Dr. Frey has received a number of awards, including the Gary Lee Shaffer Award (2010) from the School Social Work Association of America; the Outstanding Scholarship, Research, and Creative Activity in Social Sciences Award (2015) from the University of Louisville; and the school of social work scholar award from the University of Denver (2015).
Stephen Hydon, MSW, EdD, is Clinical Professor at the USC Suzanne Dworak-Peck School of Social Work in Los Angeles. Dr. Hydon was invited to New Orleans several years ago by the US Department of Education to participate in the development of a curriculum to train teachers and mental health professionals working in schools about secondary traumatic stress and educator resilience. This initiative was a result of the Deepwater Horizon Oil Spill and hurricanes Katrina and Rita. Teachers were devastated by these events and needed ways to process the feelings they were experiencing. Since 2010, Dr. Hydon has presented to groups across the country, including those in Flowery Branch, Georgia; Townshend, Vermont; and Joplin, Missouri. He currently teaches in USC’s school social work track for students seeking to receive their Pupil Personnel Services Credentials in school social work and child welfare.
Jennifer C. Hyk, MPP, is a current Social Welfare PhD student and adjunct instructor at SUNY Stony Brook, School of Social Welfare. Her research and services are devoted primarily to poverty and inequality, with a focus on public policy. Jennifer has more than 15 years of experience in various human and social service settings, including work with adults as well as children with disabilities.
Kristian Jones, MEd, is a first-year doctoral student at the Steve Hicks School of Social Work at the University of Texas at Austin. He received his bachelor’s degree in psychology from Albany State University and his master’s in education from Boston University where he studied counseling with a concentration in sport and performance psychology. After spending the past few years as a counselor, he is now interested in researching ways to improve positive youth development, particularly among male adolescents; finding ways to
About the Contributors xv
alleviate and remove mental health stigma; and utilizing early intervention and prevention methods through trauma-informed care to prevent mental health issues and juvenile delinquency. He has presented research at Albany State’s Undergraduate Research Symposium and at the Southern Sociological Society Conference. He was also part of a research team that presented a campus-wide mental health awareness plan at the Dr. Lonnie E. Mitchell HBCU Behavioral Health Policy Academy.
Amy N. Mendenhall, MSW, PhD, is Associate Professor in the School of Social Welfare at the University of Kansas. She joined the KU faculty in 2009 and served as the Director for the School’s Center for Children & Families from 2013 to 2016. Dr. Mendenhall received her MSW and PhD from the College of Social Work at Ohio State University. She also completed a postdoctoral fellowship in the Child & Adolescent Psychiatry Division of the Department of Psychiatry at Ohio State University Medical Center. Her scholarship and research focus on child and adolescent well-being and mental health, specifically service utilization, mental health literacy, and the impact of trauma and mental illness on families. Past research and evaluation projects include studies on strengths case management for youth, the Attachment BioBehavioral Catch-up intervention, Mental Health First Aid, service utilization of children diagnosed with serious emotional disturbance, and rural patientcentered health care. Dr. Mendenhall teaches foundation and clinical social work courses at both the undergraduate and graduate levels.
Stephanie Ochocki, DSW, LICSW has served the students and families of the Anoka-Hennepin School District for over ten years. Ochocki received her master's degree with a school social work specialization from the University of Louisville and began her school social work career in Minnesota’s largest school district as an elementary school social worker serving various buildings. During this time, Ochocki also supported the work of AnokaHennepin colleagues in the role of Lead School Social Worker. Ochocki has been actively involved in the Minnesota School Social Workers Association by serving in a variety of roles, including President, to advocate for the needs of children, families and the school social work profession. Most recently, Ochocki has assumed a new role as the District School Social Worker for Anoka-Hennepin Schools, obtained her Doctorate in Social Work from the University of Tennessee, and enjoys teaching students in the University of Wisconsin-Madison's part-time MSW program.
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About the Contributors
Kirstin R. Painter, PhD, LCSW, is a public health analyst with the Substance Abuse and Mental Health Services Administration (SAMHSA). Prior to joining SAMHSA, she was Senior Director of a community-based evaluation center and taught as an adjunct professor in the School of Social Work at the University of Texas Arlington. Dr. Painter has an extensive administrative and clinical background in community mental health. She was the Director of Child and Adolescent Mental Health Authority Services for nearly 10 years; prior to that, she was a psychiatric social worker at a community psychiatric hospital where she provided case management and child and family therapy. Her area of research is in serious emotional disturbances experienced by children and adolescents. She has published her research in peer-reviewed journals and presented at numerous national and international conferences.
Elizabeth C. Pomeroy, PhD, LCSW, is the Bert Kruger Smith Professor of Aging and Mental Health at the School of Social Work, University of Texas at Austin. She is the Co-Director of the Institute for Collaborative Health Research and Practice. She teaches in the undergraduate and graduate social work programs. Her research has focused on the effectiveness of mental health interventions for adults, children, and families, and she has published numerous articles using experimental and quasi-experimental designs. She has authored more than 100 journal articles and has also conducted numerous presentations and workshops on the DSM-5, grief and loss issues, and social work values and ethics. She is a member of the Academy of Distinguished Professors and a UT Regents’ Outstanding Teaching Professor. She has published four textbooks, including The Clinical Assessment Workbook: Balancing Strengths and Differential Diagnosis-Second Edition (2015).
Maria Scannapieco, MSW, PhD, was recently appointed Distinguished University Professor at the School of Social Work, University of Texas at Arlington for her extensive research in the area of child welfare. She is also the Director of the Center for Child Welfare (since 1996). She has more than 150 publications and presentations in the areas of the impact of child maltreatment, mental health outcomes for youth experiencing trauma, outof-home placement, youth aging out of foster care, Indian Child Welfare, and training and retention of child welfare workers. She has authored three books: Kinship Foster Care: Practice, Policy, & Research (1999, with Rebecca L. Hegar), Understanding Child Maltreatment: An Ecological and Developmental Perspective (2005, with Kelli Connell-Carrick), and Understanding Mental
About the Contributors xvii
Health Problems of Children and Adolescents: A Guide for Social Workers (2015, with Kirstin Painter).
Nikolaus Schuetz is a PhD student at the School of Social Welfare, University of Kansas. His research interests focus on the intersection of physical health and mental health, but he has also conducted research on financial capability, child and adult mental health, and synesthesia. His practice experience includes working as the case manager for an emergency shelter for children and helping families involved with family court in the Kansas City area. After graduating from Beloit College with a degree in psychology, his dedication to helping marginalized and oppressed people took him to rural Kenya, where he served as a Peace Corps volunteer from 2009 to 2011 in the public health arena. He subsequently completed his master’s degree in Social Work at the University of Kansas, where he currently conducts research and teaches. He is also currently serving as a member of Resilience, Inclusion, Support, and Empowerment, a committee that supports students of color at the School of Social Welfare.
Alice Tate Smith, LMSW, is a recent graduate of the University of Texas at Austin. She specializes in working with survivors of abuse and trauma. She currently works as a Family Advocate at the Center for Child Protection and enjoys spending her free time hiking and swimming outdoors.
Pamela Vona, MA, is Program Manager for the Treatment and Services Adaptation Center for Resilience, Hope, and Wellness in Schools, which is part of the National Child Traumatic Stress Network. She is the co-developer of the Trauma Responsive School Implementation Assessment (TRS-IA), an online school self-assessment to support schools adopting trauma-informed practices and policies. She is currently developing the Trauma-Informed Policing in Schools (TIPS) curriculum in collaboration with law enforcement in Southern California. Her research interests include understanding how web-based platforms can be utilized to support training in and implementation of evidence-based trauma interventions in school settings.
Marleen Wong, PhD, is Senior Vice Dean at the USC Suzanne Dvorak Peck School of Social Work and Executive Director of the USC Telehealth Clinic. Formerly, Dr. Wong served as the Los Angeles Unified School District (LAUSD) Director of Mental Health, Crisis Teams and Suicide Prevention Programs. She has been engaged in a 20-year community-based research
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About the Contributors
partnership with RAND Health and the UCLA Partnered Health Research Center and is currently the principal investigator for the SAMHSA-funded Trauma Treatment Adaptation Center for Resilience, Hope, and Wellness in Schools. Identified as one of the “pre-eminent experts in school crisis and disaster recovery” by the White House, she has been invited speaker and subject matter expert in child trauma at several White House summits and at state- and regional-level conferences on mental health and school safety, trauma informed approaches to supporting children in schools, and rethinking discipline.
Gary Zornes, MSSW, a native of Maysville, Kentucky, earned his BA in Child and Family Studies from Berea College in 2012. In 2014, he earned his MSSW from Kent School at the University of Louisville. Since earning his MSSW, his areas of focus have included clinical work and research.
About the Contributors xix
EVIDENCE-BASED
PRACTICE IN SCHOOL MENTAL HEALTH
1
Introduction
James C. Raines
This book is premised on the idea that schools have become the default mental health providers for children and adolescents (Atkins, Hoagwood, Kutash, & Seidman, 2010). The broad audience for this book is school-based mental health providers. The Every Student Succeeds Act (ESSA) defines this group as follows:
The term “school-based mental health services provider” includes a State-licensed or State-certified school counselor, school psychologist, school social worker, or other State licensed or certified mental health professional qualified under State law to provide mental health services to children and adolescents. (Section 4102(6), emphasis added)
It therefore includes school-employed mental health practitioners as well as school-contracted mental health practitioners. This book’s narrow audience is school social workers and clinical social workers working primarily in schools. It is written from a social work perspective for social workers. This book is not aimed at mental health practitioners who are primarily community-based, but they may find it helpful when collaborating with a public school. Some examples from my own career in schools may be helpful. While working in the borough of Brooklyn, New York, I was employed to work in a community-in-schools program which had a contract to provide mental health services to students in grades 6–8 who were labeled with a severe emotional disturbance. I knew all of the special education teachers, the
special education coordinator, and the other mental health professionals in the building. Since my primary caseload and my office were in the school, I was a school-based mental health services provider. After I left that agency, I worked for a child guidance center in the borough of Queens, New York. One day per week, I did mental health consultation at Hillcrest High School, which had 5,000 students and one part-time school social worker. I knew only a few students, the school secretary, school principal, and most of the mental health providers in the building. Since my primary caseload and my office were in the community, I was really a community-based mental health services provider using a clinical, not a systems model. After moving to Chicago, I worked in three suburban school districts as a school-employed social worker. For the first time, I knew all of the students in my school, all of the teachers, and all of the staff. My role was thoroughly integrated into the life of the school. Since my primary caseload and my office were in a school, I was once again a school-based mental health services provider. The term “school-based mental health services provider” is not, however, synonymous with the new term for related services personnel, now called specialized instructional support personnel (SISP). The ESSA defines that group later in the statute as follows:
The term “specialized instructional support personnel” means—
(i) school counselors, school social workers, and school psychologists; and
(ii) other qualified professional personnel, such as school nurses, speech language pathologists, and school librarians, involved in providing assessment, diagnosis, counseling, educational, therapeutic, and other necessary services (including related services as that term is defined in section 602 of the Individuals with Disabilities Education Act) as part of a comprehensive program to meet student needs. (Section 8002(47)(A), emphasis added)
It may help to visually illustrate this complicated relationship using a Venn diagram (Figure 1.1). The advantage I experienced as a school-based mental health provider and as a member of the SISP team was perspective—I knew the rhythms and harmonies of the school and could see systemic issues that needed to be addressed when the beat was disrupted or the music was discordant.
School-based mental health providers:
• Licensed professional counselors
• Licensed clinical psychologists
• Licensed clinical social workers
School counselors, School social workers, School psychologists,
Specialized instructional support personnel (SISP):
• School nurses
•Speech language pathologists
• School librarians
•And others as needed
Figure 1.1 Relationship between school-based mental health providers and specialized instructional support personnel.
This chapter summarizes the need for mental health services in schools, recent changes in the field of mental health diagnosis, and the process of making students eligible for services. It then addresses school-based mental health assessment and levels of available service. It also addresses how to collaborate with others in the school environment who are instrumental in helping youth improve their mental health. It ends with a comparison of evidence-based practice standards under No Child Left Behind Act (NCLBA) and the ESSA.
Prevalence of Youth Mental Health Problems
The prevalence of mental disorders among youth depends, in part, on who you ask and how you ask. According to the latest US government statistics, in 2013, slightly more than 5% of children were reported by their parents as having “serious difficulties with emotions, concentration, behavior, or being able to get along with other people” (Federal Interagency Forum on Child and Family Statistics, 2015, p. 61). That may be an optimistic assessment. Of youth aged 12–17, 11% report having had a major depressive episode in the past year. Despite this discrepancy, there is some good news. Parents reported that increased use of special education resources for emotional and behavioral difficulties has gone up from 5.4% in 2001 to 10% in 2013. Likewise, parental contact with a mental health professional (including clinical social workers) went up from 15% in 2001 to 20.1% in 2013. Still, only 38.1% of youth with a major depressive episode received treatment.
A recent report from US Centers for Disease Control and Prevention (CDC) revealed that 7.5% of American children are on mental health medications (Howie, Pastor, & Lukacs, 2014). The authors note that “over the past 2 decades, the use of medication to treat mental health problems has increased substantially among all school-aged children and in most subgroups of children” (p. 5). Some authors place the prevalence rate for mental disorders for children in the United States as high as 20% (Younger, 2017), while others believe that such numbers are inflated by mis- and overdiagnosis (Merten, Cwik, Margraf, & Schneider, 2017). Probably the best estimate is that 10% of students have a diagnosable mental disorder, but that only 2% are served by schools and even fewer are served by community agencies (Eber, Malloy, Rose, & Flamini, 2014).
Estimates of prevalence rates for mental health problems among children and adolescents are always a little murky (Holbrook, Bitsko, Danielson, & Visser, 2016). Some of the problems are systemic. When the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) (American Psychiatric Association [APA], 2013) lowered its clinical thresholds on a number of disorders, more children were diagnosed with a mental disorder than previously (Mikolajewski, Scheeringa, & Weems, 2017). As implied earlier, data sources and survey techniques make a difference. Using estimates based on insurance claims omits those families who do not have insurance or live in underserved areas. How one phrases the question changes the answer. For example, the Individuals with Disabilities Education Act (IDEA) dropped the term “serious” from emotional disturbance in the 1997 revision to make more children eligible for special education services. Words matter.
Major Changes to the DSM-5
The DSM has been around for more than 65 years. The first edition (1952) mentioned 94 mental disorders, and the second edition (1968) nearly doubled this number to 182. The third edition (1980) jumped to 265 disorders, and the DSM-IV had 340 mental disorders (Pomeroy & Parrish, 2012). While the new DSM-5 is not expected to increase the number of disorders, it is important to note that some disorders have been combined and others have been split. As mentioned earlier, the changes to the DSM-5 have real-life consequences for children and adolescents. While the APA mentioned nine “enhancements” in its introduction to the new manual, this chapter will address the five most important ones for social workers.
The first major change is the dropping of the multiaxial system. DSM-5 combines the first three axes into one list that contains all mental disorders
(including personality disorders and intellectual disability) as well as other medical diagnoses (APA, 2013). Axes IV and V have simply disappeared. This probably follows psychiatrists’ tendency to ignore Axes IV anyway, but this poses a problem for many social workers (Probst, 2014). Axis IV was the only opportunity to discuss psychosocial or environmental factors that caused or contributed to a mental disorder. The new edition does make a slight change in wording to its definition of a mental disorder:
A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. (APA, 2013, p. 20, emphasis added)
The APA (2013) was aware of many of these criticisms so it suggested a potential solution. It recommends that clinicians use “a selected set of the ICDCM V codes and the new Z codes contained in ICD-10-CM” (p. 16). Walsh (2016) has explored how this might work. He notes that four of the Axis IV categories were already represented in the V codes (e.g., academic problem or parent–child problem) and that the number of Z codes has grown from 23 to 118. Some of the categories of Z codes of most interest to social workers engaged with children and adolescents include problems related to family upbringing, child abuse and neglect, educational problems, housing and economic problems, and problems related to the social environment.
The one exception to relegating environmental issues to the Z codes is a new chapter on trauma- and stressor-related disorders in the DSM-5. This chapter includes reactive attachment disorder (newly defined), disinhibited social engagement disorder (new), posttraumatic stress disorder, acute stress disorder, and adjustment disorders. It is within this last diagnostic category that the DSM-5 allows that “individuals from disadvantaged life circumstances experience a high rate of stressors and may be at increased risk for adjustment disorders” (APA, 2013, p. 288).
Axis V was the only place to identify strengths (functioning) of the individual being diagnosed. Without these two axes, the DSM reverts back to a biologically driven, deficit-based model of mental illness. The Society for Humanistic Psychology (Division 32 of the American Psychological Association) wrote an online open letter about similar concerns and garnered more than 15,000 individual signatures and the official support more than 50 professional associations, but not that of the National Association of Social Workers. Here is an excerpt from the petition:
In light of the growing empirical evidence that neurobiology does not fully account for the emergence of mental distress, as well as new longitudinal studies revealing long-term hazards of standard neurobiological (psychotropic) treatment, we believe that these changes pose substantial risks to patients/clients, practitioners, and the mental health professions in general. (Society for Humanistic Psychology, 2011)
The new DSM-5 has replaced the strengths-based global assessment of functioning (GAF) measure with the deficit-based World Health Organization (WHO)’s Disability Assessment Schedule (WHODAS, version 2.0). While this aligns with the International Classification of Functioning, Disability and Health system, it completely eliminates any strengths-based focus in the DSM-5.
The second major change was to harmonize the DSM-5 with the International Classification of Disease (ICD) system, specifically ICD-11. One of the consequences of this decision was to eliminate the DSM-IV chapter that includes all diagnoses usually first made in infancy, childhood, or adolescence. All of the disorders listed therein have been redistributed into other clusters, reflective of a new lifespan approach to mental disorders. For example, attention deficit hyperactivity disorder (ADHD) is now placed with the neurodevelopmental disorders, such as autism spectrum disorder and specific learning disorder. It is significant that this change moves it away from disruptive behavior disorders, which are discussed in a different chapter (Sethi, 2015; Sharma, 2014). After the neurodevelopmental disorders, the DSM-5 is organized by internalizing disorders and externalizing disorders. This reorganization not only makes the diagnoses for children and adolescents more difficult to locate, it also subtly suggests that these disorders will continue into adulthood. Perhaps this is due to the fact that two-thirds of children with a mental disorder do not get the help they need, and the one-third that do
receive help get it through their local school—most likely from a school social worker (Raines, 2008). The assumption, however, that mental disorders are lifelong is a pessimistic prognosis about the possibility for improvement.
The third major change is the elimination of the “not otherwise specified” (NOS) categories. This is accomplished in three ways. First, this reduction is accomplished by combining diagnoses. For example, the new autism spectrum disorder (ASD) now encompasses the previous DSM-IV autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. This change was highly controversial for people who were diagnosed with high functioning autism because they did not wish to be lumped together with people who were lower functioning (Linton, Krcek, Sensui, & Spillers, 2014; McLaughlin & Rafferty, 2014). Likewise, specific learning disorder combines the DSM-IV diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. Second, this reduction is accomplished by creating new diagnoses. For example, the DSM-5 now includes hoarding disorder, excoriation (skin-picking) disorder, disruptive mood dysregulation disorder, and disinhibited social engagement disorder. The increase in child-related disorders, however, has some professionals worried. The Society for Humanistic Psychology (2011) states that it is “gravely concerned about the introduction of disorder categories that risk misuse in particularly vulnerable populations” and explicitly mentions disruptive mood dysregulation disorder for children as a case in point. The final method for reducing NOS diagnoses is to replace them with two options: other specified disorder and unspecified disorder. The first allows a practitioner to specify the reason that the criteria for a disorder are not met; the second allows a practitioner the option to forgo any specificity.
The fourth major change is the addition of dimensional aspects to diagnostic categories. At this point, some history is in order. Some of us have been practicing long enough to remember the DSM-III (1980). That edition of the DSM was predicated on the belief that each mental disorder would ultimately be validated by its separation from other disorders, common clinical course, genetic aggregation in families, and further differentiation by future laboratory tests— which would now include anatomical and functional imaging, molecular genetics, pathophysiological variations, and neuropsychological testing. (Regier, Narrow, Kuhl, & Kupfer, 2009, p. 645)
