that her 3-year-old child had autism, one parent said, “Well, I finally know what’s wrong. I always suspected it and now I know. I suppose we can finally move forward.” Diagnostic labels can also facilitate communication between caregivers of children with similar disorders in order to share information and gain social support.
Finally, diagnostic classification can facilitate scientific discovery. Researchers who conduct studies on the causes and treatment of autism can compare the results of their investigations with the findings of others. Indeed, many studies are conducted by teams of researchers across multiple locations. As long as researchers use the same diagnostic criteria and procedures to classify children, results can be combined to generate a more thorough understanding of the disorder.
Potential Drawbacks
The DSM-5 classification system also has some inherent disadvantages and risks (Hyman, 2011; Rutter, 2011). One drawback of the DSM-5 approach is that it often gains parsimony at the expense of detailed information. Although a diagnostic label can convey considerable information to others, it cannot possibly provide the same amount of information as a thorough description of the individual. As we have seen, children assigned the same diagnosis can display different patterns of behavior and levels of impairment. We must not overlook the unique strengths and weaknesses of each child.
A second criticism of the DSM-5 diagnostic system is that it does not adequately reflect the individual’s environmental context. Mental health professionals seek to understand children’s problems in the context of their developmental level and surroundings. Many problematic behaviors exhibited by children and adolescents can be seen as attempts to adapt to stressful environments at specific points in time. For example, some physically abused children attempt to cope with their maltreatment by becoming defensive and mistrusting others. Although these coping strategies can psychologically protect them when they were experiencing abuse, they may interfere with the development of interpersonal relationships later in life (Cicchetti & Doyle, 2016).
A third drawback of the DSM-5 lies in its focus on individuals. DSM-5 conceptualizes psychopathology as something that exists within the person. However, childhood disorders are often relational in nature. For example, youths with oppositional defiant disorder show patterns of noncompliant and defiant behavior toward others, especially adults in positions of authority. Considerable research indicates that the quality of parent–child interactions plays an important role in the development of oppositional defiant disorder. Furthermore, treatment for this disorder relies heavily on parental involvement. However, in the DSM-5 system, oppositional defiant disorder is diagnosed in the child. The DSM-5 approach to diagnosis can overlook the role caregivers, other family members, and peers play in the development and maintenance of children’s problems.
A fourth limitation of the DSM-5 system is that distinctions between normality and abnormality are sometimes arbitrary. In the categorical approach used by DSM-5, individuals either have a disorder or they do not. For example, to be diagnosed with ADHD, a child needs to show at least six symptoms of inattention or hyperactivity–impulsivity. If the child displays only five of the required six symptoms, he would not qualify for the ADHD diagnosis. Although this lack of diagnosis might seem like a good thing, it could mean that he does not receive the treatment or support services that he needs.
A final criticism of the DSM-5 is that sometimes boundaries between diagnostic categories are unclear. Categorical classification systems, like DSM-5, work best when all members of a diagnostic group are homogeneous, when there are clear boundaries between two different diagnoses, and when diagnostic categories are mutually exclusive. Unfortunately, these conditions are not always met. When two disorders include the same signs or symptoms, children can be diagnosed with both disorders, causing an artificial co-occurrence of the two conditions. For example, bipolar disorder is a serious emotional disorder seen in approximately 1% to 2% of youth. Some studies indicate that as many as 80% of youths with bipolar disorder also meet diagnostic criteria for ADHD. In most cases, children with bipolar disorder clearly show symptoms of ADHD, even when they are not having mood problems. In some instances, however, the high co-occurrence of bipolar disorder and ADHD is caused by the same signs and symptoms included in the diagnostic criteria for both disorders: an increase in activity, short attention span, distractibility, talkativeness, and impulsive behavior. Some children with bipolar disorder may be incorrectly diagnosed with ADHD also because of this overlap in signs and symptoms (Youngstrom, Arnold, & Frazier, 2010).
Research Domain Criteria
The National Institute of Mental Health (NIMH) is attempting to move beyond the current DSM-5 system of classifying mental disorders based on descriptions of signs and symptoms (Insel & Lieberman, 2013). NIMH has launched the Research Domain Criteria (RDoC) initiative to identify the genetic and biological causes of each disorder. The RDoC are based on the assumption that mental disorders are “biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior” (Insel & Lieberman, 2013). The goal of this initiative is to use genetic and biomedical research to identify the underlying causes of these disorders in order to provide more effective treatments. Specifically, research targets several levels of analysis: genes, molecules, cells, neural circuits, physiology, and behavior.
Critics of DSM-5 argue that instead of being a “bible” of mental disorders, it functions more like a dictionary—providing mere definitions in terms of observable signs and self-reported symptoms. Instead, advocates of the RDoC initiative argue that a new system is needed that addresses the underlying genetic and neurological causes for each disorder (Reed, Robles, & Dominguez-Martinez, 2018).
The DSM-5 and RDoC initiative reflect different approaches to conceptualizing mental disorders (Lilienfeld & Treadway, 2016). Time will tell if classification based on underlying genetic risk and neural circuitry increases diagnostic validity and leads to more effective treatment than one based on description. In the meantime, psychologists should not forget the rich information that is gained from approaching childhood disorders from both biological and psychosocial perspectives in the context of youths’ development and surroundings. Recent advances in mental health research indicate that psychological, familial, and sociocultural influences are at least as important in explaining the cause and maintenance of childhood disorders as the genetic and biological factors emphasized by these other diagnostic systems (Cicchetti, 2016a, 2016b). Furthermore, most evidence-based treatments for these disorders operate at these “higher” levels by improving the psychological, familial, and sociocultural functioning of children and families (Christophersen & Vanscoyoc, 2013). We must not neglect these psychosocial interventions for helping at-risk youths while simultaneously looking to the future.
Review
A DSM-5 diagnosis is parsimonious, it allows professionals to communicate clearly with each other, and it can be helpful in predicting outcomes and planning treatment. A diagnosis can also help children gain access to educational or psychological services, help caregivers understand their child’s behavior, and facilitate research.
A DSM-5 diagnosis may not provide a detailed description of the child’s strengths and functioning, may not reflect the child’s developmental or environmental context, and may focus too much on the child rather than on important people in his or her life.
Whereas a DSM-5 diagnosis is based largely on the signs and symptoms of each disorder, the proposed RDoC initiative classifies children based on underlying biological causes.
How Do Social–Cultural Factors Affect Our Understanding of Mental Health?
Culture, Race, and Ethnicity
As we have seen, children’s
