seen, some youths experience tremendous emotional pain, but they do not show marked impairment in their social or academic functioning. Other youths drop out of school, abuse alcohol and other drugs, and/or engage in criminal behavior but do not report anxiety, depression, or low self-esteem. Although most youths with mental health problems experience both distress and impairment, only one feature is required for most DSM-5 diagnoses.
Limitations
DSM-5 is published by the American Psychiatric Association and reflects a medical approach to identifying mental health problems. According to the DSM-5 definition, mental disorders reside within the individual, just like medical illnesses. For example, if someone is diagnosed with smallpox, we know that the illness is caused by a virus that has infected the person’s body. The virus causes symptoms (e.g., fatigue, fever, rash) that lead to severe impairment and an increased risk of death. Similarly, practitioners who adopt the medical model for mental disorders assume that if a child exhibits behavioral, cognitive, or emotional symptoms, these problems are caused by some underlying dysfunction within the child that causes distress or impairment (Stein et al., 2010c).
There are at least three limitations with the DSM-5 medical conceptualization of mental disorders, especially when it is applied to children and adolescents. First, we often do not know the underlying cause for children’s psychological problems. When physicians first described smallpox in the 15th century, they diagnosed the illness based on its symptoms: small blisters (i.e., pox) on the skin. It was not until many years later that researchers discovered that smallpox is caused by a viral infection, not the blisters themselves. Similarly, when a mental health professional diagnoses a child with ADHD, they are describing the child’s symptoms (i.e., hyperactivity and/or inattention), not the underlying cause of the disorder. Although researchers have identified several risk factors for ADHD, a single underlying cause for the disorder remains elusive (Pliszka, 2016).
Second, many childhood disorders are relational in nature—that is, they occur between people rather than within an individual. Consequently, childhood disorders are best understood in an interpersonal context. For example, young children with oppositional and defiant behavior argue with adults, refuse to comply with requests, and throw tantrums when they do not get their way. Interestingly, their defiant behavior is often directed at some adults (e.g., parents) but not others (e.g., teachers). Therefore, the disorder seems to be dependent on the relationship between the child and specific people; it does not merely reside within the child. Relationships may be especially important to mental disorders in children and adolescents, who are highly dependent on other people for their well-being (Heyman & Slep, 2020).
Third, children’s behavior can only be understood in terms of their social–cultural surroundings. Behaviors that people would consider “dysfunctional” in one context might be adaptive in a different setting. For example, consider a girl named Nia who lives with her parents on a military base in California. Upon hearing that her mother will soon be deployed to a combat area, Nia becomes excessively clingy with both parents, has problems eating and sleeping, and refuses to go to school. According to the harmful dysfunction criteria, Nia would likely be diagnosed with an anxiety disorder because (1) she has problems regulating her emotions and (2) these problems limit her social and academic functioning. However, her anxiety might be justified given her social context—that is, the imminent deployment of her mother. Behavior is best understood in the context of children’s social–cultural surroundings, never in isolation (Achenbach, 2019).
Review
According to DSM-5, a mental disorder reflects a biological, developmental, or psychological dysfunction that causes disability or distress in the individual. This definition borrows from Wakefield’s notion of a harmful dysfunction.
DSM-5 adopts a medical approach to mental disorders.
The medical approach is limited when applied to children and adolescents because (1) we cannot always identify the underlying cause of children’s disorders, (2) many childhood disorders are best understood in an interpersonal context rather than existing only within the child, and (3) children’s behavior is best understood in terms of their social–cultural surroundings.
How Do Psychologists Diagnose Mental Health Problems in Children?
Each DSM-5 disorder is defined by the presence of specific signs and symptoms. A sign is an overt feature of a disorder, whereas a symptom is a subjective experience associated with a disorder. For example, a sign of depression is weight loss or sluggish movement. In contrast, a symptom of depression is a subjective lack of appetite or energy. To be diagnosed with a given disorder, the individual must have the signs and symptoms described in the manual.
To illustrate the diagnostic approach used in DSM-5, consider the diagnostic criteria for a major depressive episode (Figure 1.1). Depression is characterized by a discrete period of time, lasting at least 2 weeks, in which a child or adolescent experiences a marked disturbance in mood. Children with depression typically experience sad, hopeless, or irritable moods most of the day and no longer engage in activities they previously enjoyed, such as spending time with family, playing games with friends, or engaging in hobbies and sports. Children with depression can also show a wide range of other cognitive, emotional, and physical problems. This mood disturbance causes distress or leads to problems at school, at home, or with peers (American Psychiatric Association, 2013).
Figure 1.1 ■ The DSM-5 Diagnostic Approach
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association. All Rights Reserved.
Categorical Classification
DSM-5 uses a hybrid of three different approaches to classification: (1) categorical, (2) prototypical, and (3) dimensional. Categorical classification involves dividing mental disorders into mutually exclusive groups, or categories, based on sets of essential criteria. The categorical approach is the oldest approach to classification and is used predominantly in biology and medicine. For example, in the field of biology, an animal is classified as a mammal if it (a) has vertebrae, (b) has hair, and (c) feeds its young with mother’s milk. An animal that does not possess these essential features is not a mammal. In the field of medicine, a person is diagnosed with diabetes if she has significant problems regulating her blood glucose. A person without significant blood sugar problems is not diagnosed with diabetes. Similarly, each mental disorder is defined by the presence of essential diagnostic criteria listed in DSM-5. A person without those criteria would not be diagnosed with a given disorder (Widiger & Mullins-Sweatt, 2018).
You can see the categorical approach to classification in the diagnostic criteria for a major depressive episode. The episode has three essential features (labeled A, B, and C). All three are required for a diagnosis of major depression.
Prototypical Classification
Prototypical classification is based on the degree to which the individual’s signs and symptoms map onto the ideal picture or prototype of the disorder (Westen, 2012). This approach assumes that individuals with a given disorder may show some variability; not all people with the disorder will manifest it in exactly the same way. For example, if you were asked to generate a mental picture of a bird, you would likely conjure an image of a small,
