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UCLA School Mental Health Project
Center for Mental Health in Schools
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Continuing Education: Unit II

Addressing Barriers to Learning
New Directions for Mental Health in Schools

Section A Continued

(DSM-IV* 1994)

Because the DSM is so widely used throughout the U.S., school professionals need to have some level of awareness of its focus and the categories that are used with respect to children and adolescents. If you are unfamiliar with this classification scheme, you will find a summary description below.

About the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994)

Among the purposes of diagnostic systems such as the DSM are to (1) facilitate communication among professionals and (2) standardize criteria for diagnosis.

Multiaxial Assessment

With the intent of capturing a good deal of the complexity of psychological problems, the DSM focuses simultaneously on several dimensions. This effort is referred to as multiaxial assessment. Simply stated, an axis is a dimension to be considered in assessment. Recent versions of the Diagnostic and Statistical Manual of Mental Disorders developed by the American Psychiatric Association (see DSM-IV, 1994) include a focus on five dimensions -- thus the term multiaxial. The five are:

Axis I Clinical Disorders -- the focus is on assessing symptoms to identify whether criteria are met for assigning one of the psychiatric disorders (or other conditions that may be the focus of clinical attention) identified in the DSM-IV classification scheme.
Axis II Personality Disorders Mental Retardation -- the focus is on facets of an individual's persona or intellectual ability that are likely to be resistant to change.
Axis III General Medical Conditions -- the focus is on any medical conditions that may be contributing to psychological problems or may be a factor in intervention.
Axis IV Psychosocial and Environmental Problems -- the focus is on specific contextual factors that have relevance for conclusions about differential diagnosis, treatment, and prognosis
Axis V Global Assessment of Functioning -- the focus is on how well the individual is presently functioning.

For the four axes (I-IV) that focus on specific areas, the DSM-IV classification scheme provides a range of possible categories and delineates relevant criteria. The categories are:

Axis I

• Disorders usually first diagnosed in infancy, childhood, or adolescence (excluding Mental Retardation, which is diagnosed on Axis II)
• Delirium, dementia, and amnestic and other cognitive disorders
• Mental disorders due to a general medical condition
• Substance-related disorders Schizophrenia and other psychotic disorders
• Mood disorders
• Anxiety disorders
• Somatoform disorders
• Factitious disorders
• Dissociative disorders
• Sexual and gender identity disorders
• Eating disorders
• Sleep disorders
• Impulse-control disorders not elsewhere classified
• Adjustment disorders
• Other condtions that may be a focus of clinical attention

Axis II
• Paranoid personality disorders
• Schizoid personality disorders
• Schizotypal personality disorders
• Antisocial personality disorders
• Borderline personality disorders
• Histrionic personality disorders
• Narcissistic personality disorders
• Avoidant personality disorders
• Dependent personality disorders
• Obsessive-compulsive personality disorders
• Personality disorder not otherwise specified
• Mental retardation

Axis III
•Infectious and parasitic diseases
• Neoplasms
• Endocrine, nutritional, and metabolic diseases and immunity disorders
• Diseases of the blood and blood-forming organs
• Diseases of the nervous system and sense organs
• Diseases of the circulatory system
• Diseases of the respiratory system
• Diseases of the digestive system
• Diseases of the genitourinary system
• Complications of pregnancy, childbirth, and the puerperium
• Diseases of the skin and subcutaneous tissue
• Diseases of the musculoskeletal system and connective tissue
• Congenital anomalies
• Certain conditions originating in the perinatal period
• Symptoms, signs, and ill-defined conditions
• Injury and poisoning

Axis IV
•Problems with primary support group
• Problems related to the social environment
• Educational problems
• Occupational problems
• Housing problems
• Economic problems
• Problems with access to health care services
• Problems related to interaction with the legal system/crime
• Other psychosocial and environmental problems

With respect to Axis V (Global Assessment of Functioning), the point is to clarify the level of coping ability/adaptive functioning. The assessor rates the individual on a scale of 1 to 100.

91-100 = superior functioning, no symptoms
81-90 = good functioning, minimal symptoms
71-80 = a few transient and commonplace symptoms
61-70 = mild symptoms but functioning pretty well
51-60 = moderate symptoms and functional problems
41-50 = serious symptoms and impairment in functioning
31-40 = some impairment in reality testing or major impairment in several functional areas
21-30 = delusions or hallucinations or serious impairment in judgment or inability to function
11-20 = some danger of hurting self or others or occasional failure to maintain hygiene
1-10 = persistent danger of severely hurting self or others or inability to maintain hygiene

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence

The following group of categories is of particular interest to those working with young people:

• Mental Retardation (coded on Axis II)1
mild mental retardation
moderate mental retardation
severe mental retardation
profound mental retardation
mental retardation, severity unspecified

• Learning Disorders1
reading disorder
mathematics disorder
disorder of written expression
learning disorder NOS2

• Motor Skills Disorder
development coordination disorder

• Communication Disorders
expressive language disorder
mixed receptive-expressive
language disorder
phonological disorder
communication disorder NOS

• Pervasive Developmental Ditsorders
autistic disorder
Rett's disorder
childhood disintegrative disorder
Asperger's disorder
pervasive developmental disorder NOS

• Attention-Deficit and Disruptive Behavior Disorders
attention-deficit/hyperactivity disorder
combined type
predominantly inattentive type
hyperactive-impulsive type
attention-deficit hyperactivity disorder NOS
conduct disorder (childhood or adolescent-onset)
oppositional defiant disorder
disruptive behavior disorder

• Feeding and Eating Disorders of Infancy or Early Childhood
rumination disorder
feeding disorder of infancy or early childhood

• Tic Disorders
Tourette's disorder
chronic motor or vocal tic disorder
transient tic disorder
tic disorder NOS

• Elimination Disorders
with constipation and overflow incontinence
without constipation and overflow incontinence
enuresis (not due to a general medical condition) -- nocturnal, diurnal or both

• Other Disorders of Infancy, Childhood, or Adolescence
separation anxiety disorder
selective mutism
reactive attachment disorder of infancy or early childhood (inhibited or disinhibited)
stereotypic movement disorder
disorder of infancy, childhood, or adolescence NOS

1 Diagnoses of mental retardation and learning disorders must be based on use of one or more of the standardized, individually administered intelligence tests. In addition, diagnosis of learning disorders requires use of standardized, individually administered achievement tests in determining the degree of discrepancy between intellectual functioning and achievement.

2 NOS = Not Otherwise Specified -- As indicated in the DSM: "Because of the diversity of clinical presentations, it is impossible for the diagnostic nomenclature to cover every possible situation. For this reason, each diagnostic class has at least one Not Otherwise Specified (NOS) category and some classes have several ......

Other Categories Used in Diagnosing Child and Adolescent Problems

The following are additional categories often used in diagnosing young people:

• Adjustment Disorder *
with depressed mood
with anxiety
with mixed anxiety and depressed mood
with disturbance of conduct
with mixed disturbance of emotions and conduct
Specify if acute/chronic

• Anxiety Disorders
panic disorder without agrophobia
panic disorder with agrophobia
agrophobia without history of panic disorder specific phobia (specified)
social phobia
obsessive-compulsive disorder
posttraumatic stress disorder
acute stress disorder
generalized anxiety disorder
anxiety disorder due to….
(indicated general medical condition)
substance-induced anxiety disorder
anxiety disorder NOS

• Mood Disorders
Depressive Disorders
major depressive disorder
(single episode/recurrent)
dysthmic disorder
depressive disorder

• Bipolar Disorders
bipolar I disorder
bipolar II disorder
cyclothyrnic disorder
bilor disorder NOS
mood disorder due to…
(indicated general medical condition)
substance-induced mood disorder
mood disorder NOS

*The essential feature of such a disorder is described as "the development of clinically significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor or stressors"

Other Conditions That May Be A Focus of Clinical Attention

• Relational Problems
relational problem related to a mental disorder or general medical condition
parent-child relational problem
. . .
sibling relational problem
relational problem NOS

• Problems Related to Abuse or Neglect
physical abuse of child
sexual abuse of child
neglect of child
. . .

• Additional Conditions that May Be a Focus of Clinical Attention
. . .
child or adolescent antisocial behavior
. . .
academic problem

For statistical (and payment) reporting purposes, assessments made using the DSM are assigned codes. For example, each of the categories listed above has a specific code assigned to it. Thus, if a youngster is diagnosed as attention-deficit hyperactivity disorder, combined type, the problem is assigned the code 3 14. 01 - if the diagnosis is conduct disorder, the code is 312.8. a special set of codes, called V codes, are used to identify individuals who have problems that require treatment but do not meet the criteria set for one of the disorders.

A summary diagnosis and coding might look like this:

Axis I Conduct disorder -- adolescent onset (severe) 312.8
Axis 11 No evident disorder V71.09
Axis III No apparent contribution
Axis IV Problems with educational setting 3
Axis V Current functioning GAF = 50

W. Paul Jones has written a useful little book for school staff interested in the DSM. He entitles the work: Deciphering the Diagnostic Codes: A Guidefor School Counselors (1997, Corwin Press). In the work, he states that using the DSM really begins with the General Assessment of Functioning. That is, if the GAF is high, even if there are symptoms there is no disorder to diagnose. Axis IV is used to assess psychosocial facet, Axis III considers medical conditions, Axis II looks at persistent, cross-situational pattems of behavior or conditions that are related to symptoms. Finally, the primary focus of treatment is identified on Axis I.

Some Cautions

(1) Diagnoses must be based onformal criteria andprofessional assessment.

Because so many terms used in formal classification schemes such as the DSM have found their way into everyday language, the words often are used without reference to formal criteria and without use of related professional assessment. For example, it is easy to fall into the trap of referring to common learning problems as learning disabilities, very active children as hyperactive or ADHD, commonplace an) eties as anxiety disorders, and sadness as depression or a mood disorder. Use offormal diagnostic categories requires careful application of designated criteria as operationalized in formal assessments. Such criteria have an inclusionary and exclusionary focus to facilitate differential diagnosis and are concerned with severity, pervasiveness, onset, and duration in determining whether there is a clinically significant impairment. They also stress ways of determining whether symptoms are substance -induced (through use of alcohol and others drugs/medications or as a result of toxin exposure) and what should be considered in determining whether symptoms are the result of a general medical condition.

(2) Diagnoses should not be based on ensuring reimbursementfrom third-party years.

In his book, W. Paul Jones (cited above) recognizes the role that third-party payment for mental health services plays in the overdiagnosis of psychopathology by requiring identification of a disorder for reimbursement. He cautions "when, for example, a parent- child relation problem is identified on Axis I as the primary focus of treatment, there is a high probability that no third-party reimbursement will be available. If the provider can find sufficient evidence to identify another disorder on Axis I, for example, anxiety, and then list the parent-child problem on Axis PV, the probability of eligibility for reimbursement by an insurer increases dramatically. ... until or unless third-party reimbursement becomes available before problems become severe, V codes will probably be reported on Axis I at a lower rate than codes that are eligible for reimbursement."

Two cautions discussed in the DSM-IV also should be noted

(3) DSM diagnostic criteria are only guidelines and not all conditions needing treatment are included.

"The specified diagnostic criteria for each mental disorder are offered as guidelines for making diagnoses ... to enhance agreement among clinicians and investigators. The proper use of these criteria requires specialized clinical training ... [The work reflects a consensus of current formulations of evolving knowledge ... They do not encompass, however, all the conditions for which people may be treated...

(4) Watch out for cultural diversity.

"Diagnostic assessment can be especially challenging when a clinician from one ethnic or cultural group uses the DSM-1V Classification to evaluate an individual from a different ethnic or cultural group. A clinician who is unfamiliar with the nuances of an individual's cultural frame of reference may incorrectly judge as psychopathology those normal variations in behavior, belief, or experience that are particular to the individual's culture."

DSM and the International Classification of Diseases (ICD)

The official diagnostic classification and coding system in use in the U. S. is the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). development is the International Statistical Classification of Diseases and Related Problems, 10th Revision QCD-10) -- developed by the World Health Organization The U.S. Department of Health and Human Services plans to require use of ICD- 10 codes reporting purposes throughout the U.S. (probably around the turn of this century). The notes that to facilitate the transition, "preparation of DSM-IV has been closely coordinated with the preparation of Chapter V, 'Mental and Behavioral Disorders,' of ICD- 10 . . . ." so the respective codes and terms are fully compatible. Appendix H in the DSM-IV provides cross-translation.

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