Major Changes From DSM-IV-TR to DSM-5

The DSM-5 has significant changes to the nomenclature, categorization, and diagnostic criteria of neurodevelopmental disorders. Most of the disorders included in this chapter were previously located in the eliminated Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence chapter of the DSM-IV-TR. The consolidation of the five pervasive developmental disorders (i.e., autistic disorder, Asperger’s disorder, childhood disintegrative disorder, Rett syndrome, PDD-NOS) into the umbrella category autism spectrum disorder (ASD) received criticism and praise. With awareness of the impact of changes to the autism nomenclature, the Neurodevelopmental Disorders Work Group took great effort to improve the diagnostic process and, specifically, to reduce incidence of the overused PDD-NOS category (APA, 2013; Mandy, Charman, & Skuse 2012).

There has been concern and controversy that heightened levels of diagnostic specificity in the criteria for ASD would leave many individuals in need of treatment undiagnosed. Researchers investigated applicability of the revamped criteria and found conflicting results as to the exclusion of individuals previously diagnosable under the DSM-IV-TR. Proponents of the change lauded the heightened specificity of the ASD diagnosis (Kurita, 2011; Lauritsen, 2013; Mandy, Charman, Gilmour, & Skuse, 2011; Mandy et al., 2012; Mazefsky, McPartland, Gastgeb, & Minshew, 2013; McGuiness & Johnson, 2013; Wilson et al., 2013), whereas critics asserted the stringent specificity led to unnecessary exclusion (Barton, Robins, Jashar, Brennan, & Fein, 2013; Frazier et al., 2012; Gibbs, Aldridge, Chandler, Witzlsperger, & Smith, 2012; Mayes, Black, & Tierney, 2013; McPartland, Reichaw, & Volkmar, 2012; Tsai, 2012; Weitlauf, Gotham, Vehorn, & Warren, 2013). In a response to the critics, the Neurodevelopment Disorders Work Group clarified that, under the auspices of the DSM-5, individuals previously diagnosed in any of the DSM-IV-TR pervasive developmental disorder categories would receive a diagnosis of ASD (APA, 2013; Wakefield, 2013).

Intellectual disability (intellectual developmental disorder) replaces mental retardation in the DSM-5 as this reflects common professional usage. Public Law 111–256, Rosa’s Law, is a 2010 federal statute that legally replaces the term mental retardation with intellectual disability. Regardless of nomenclature, limitations in pervasive intellectual functioning qualify intellectual disability (intellectual developmental disorder) as a mental disorder in the DSM-5. Diagnosis is now rendered by level of functioning as opposed to a specific standardized IQ (APA, 2013; Wakefield, 2013).

Specific learning disorder combines the separate diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder NOS. Coded specifiers are included for each type. The APA (2013) emphasized that specific learning disorders are highly comorbid with each other (see also Wakefield, 2013).

There are substantial changes to the classification of ADHD. Age of onset has been changed from before 7 years of age to before 12 years of age, and ADHD is now diagnosable in adults. Additional modifications include strengthening the cross-situational requirement; eliminating the subtypes; adding specifiers, including examples to facilitate diagnosis; and allowing for concomitant diagnosis of ADHD and ASD. Consistent with the DSM-IV-TR, the same 18 symptoms are used within the domains of inattention and hyperactivity/impulsivity (APA, 2013).

Communication disorders now include language disorder, previously expressive and mixed receptive-expressive language disorder; speech sound disorder, previously phonological disorder; and childhood onset fluency disorder, previously stuttering. The biggest modification to the communication disorders is the addition of social (pragmatic) communication disorder, which focuses on verbal and nonverbal social deficiencies in communication and represents an important differential category for ASD. The key difference between social (pragmatic) communication disorder and ASD is the mandatory absence of repeated restrictive behaviors, interests, and activities in diagnosing the former (APA, 2013).

Implications for Counselors

Counselors working across settings should be comfortable with the revised nomenclature for neurodevelopmental disorders. By definition, symptoms of neurodevelopmental disorders begin in childhood and affect functioning in home and school settings (Addington & Rapoport, 2012). This underscores the importance of assessment and clinical intervention for clients and their families.

It is imperative for counselors to have strong knowledge of diagnostic criteria and differential diagnoses for neurodevelopmental disorders; this is especially relevant because of the controversy surrounding the changes to ASD, the frequency of ADHD diagnoses, and the impact of each of the developmental disorders. Several important areas for counselors to focus on are identifiying signs and symptoms indicative of need for assessment referral, providing appropriate clinical treatment services, facilitating client and family education, and working with clients previously diagnosed with a different condition in the DSM-IV-TR (e.g., Asperger’s disorder, PDD-NOS).

The APA (2013) clarified that the new category of social (pragmatic) communication disorder could more accurately explicate the symptoms and etiology of individuals previously diagnosed with PDD-NOS. The research supports this diagnosis in appropriate identification of this population, which enables provision of a strength-based treatment approach (Lai, Lombardo, Chakrabarti, & Baron-Cohen, 2013; McGuiness & Johnson, 2013).

ASD is lifelong, with adult rates of diagnosis increasing, so clinical interventions and adjunctive support should be emphasized for children, youth, and adults. It is advantageous for counselors to use a spectrum approach depending on each client’s level of ability; clinical interventions can then be tailored to specific client needs. The ASD diagnosis is retained, even if the criteria are not currently met, to reflect successful behavioral interventions or environmental changes; this allows for continued treatment services for clients (Greaves-Lord et al., 2013; Kurita, 2011; Mandy et al., 2012).

For ADHD and learning disorders, counselors should achieve a level of comfort with the diagnostic changes and coding. Research-informed practice allows counselors to advocate for clients and implement targeted interventions in their clinical settings. ADHD responds well to structured treatment approaches, including behavioral therapy and CBT (Ghanizadeh, 2013).