For many clinicians like myself, families come to us with insurance that they seek to use in addressing psychological issues. As most know, in order to utilize the insurance benefits, a diagnostic code has to be billed that is specifically assigned to the identified patient, who in my case is a child or adolescent. As has been widely documented on MIA and other venues, this presents many challenges/controversies, both of an ethical and etiological origin. The categorical system itself utilized by DSM is fraught with many issues, and recent changes in DSM-5 have not seemed to help matters.
But this article is about a very specific concern, one that is inherent in the categorical, disease-based model, but also one that continues to depict the human person as a set of parts, not a dynamic, holistic being constantly interfacing with his or her environment. This concern was further manifested in the DSM-5 changes, which no longer utilizes a multiaxial system. While information provided by APA cites concerns with the Global Assessment of Functioning (previously Axis V) as one reason for this change, and indicates that medical conditions (previously Axis III) are now subsumed under the single axis system, it negates to mention just why Axis IV was removed. Axis IV was previously designed to code the major psychosocial stressors that an individual faced (e.g., recent divorce, father left home, mother lost a job, etc…) which impacted their functioning. At the very least, despite the justified criticisms of the categorical system, this multiaxial approach allowed those reviewing the report to see how different factors may have coalesced into the problems an individual displayed. Now with DSM-V, this is not even brought to attention unless an individual reads the report thoroughly (assuming the information is included at all), which often does not occur.
But beyond this, there is another specific problem I would like to address with the DSM model, especially as it relates to youth. This is not new to DSM-V, but is now magnified through the single axis system. I will use the diagnosis of Oppositional Defiant Disorder (ODD) to demonstrate this problem, but I could illustrate the same issue with many other diagnoses, such as ADHD, depression, and anxiety disorders. The criteria for ODD focuses on significant difficulties with losing temper, anger, argumentative behavior, defiance, vindictiveness, etc…that either cause significant distress or impairment beyond what is appropriate for development. However, the criteria do not indicate that this has to occur across multiple settings as symptoms “may be confined to only one setting, and this is the most frequently at home.” As DSM notes “behaviors are common among siblings” and “typically more evident in interactions with adults or peers whom the individuals know well.” As stated, “It can be difficult to disentangle the relative contribution of the individual with the disorder to the problematic interactions he or she experiences.” DSM-5 goes on to acknowledge the role that “hostile parenting” plays, and amazingly admits that “it is often impossible to determine if the child’s behavior caused the parents to act in a more hostile manner toward the child, if the parents’ hostility led to the child’s problematic behavior, or if there was some combination of both.”
It only gets more disconcerting from there. As DSM further notes, “whether or not the clinician can separate the relative contribution of potential causal factors should not influence whether or not the diagnosis is made. In the event the child may be living in particularly poor conditions where neglect and mistreatment may occur (e.g., in institutional settings), clinical attention to reducing the contribution of the environment may be helpful.”
Okay, for those of you have read my posts before, you know I strive to be as balanced and reasonable as possible when it comes to understanding various positions. But I have to be honest. This makes me downright angry and uncomfortable, as I had to actually read the paragraph multiple times to make sure it actually said what it did.
Let’s review. First, when a child is diagnosed with ODD using DSM-5, they are diagnosed with a disorder, one that clearly puts the onus on them as a person (now and potentially for a long time), not the environment and people that surround them. However, DSM not only acknowledges (what we all know) that harsh, inconsistent, unstable circumstances can create ODD behaviors (especially if your biologically-driven temperament was challenging to begin with), but that it is often impossible to know just who is the chicken and who is the egg. Most inexplicably, though, DSM goes on to say that even if all these diagnostic and etiological challenges present themselves, it doesn’t matter—diagnose them anyway. Then, after the fact, try and do what you can to reduce environmental factors that may be actually causing the “disorder” in the first place. Huh? As father of six kids, if my 7-year-old was diagnosed with ODD because I verbally and physically abused him, made him stay in the room for an entire night without food because he accidentally broke a bowl during dinner while his fighting and cussing went unaddressed, and rarely showed him any love and nurturing at all except in apologetic circumstances, would this not seem like a terribly confusing and misdirected message?
It provides a chilling flashback of my earliest experience in psychology as a mental health technician before graduate school, admittedly where diagnoses such as ODD were the disorder “du jour.” I was sitting in on a family meeting focused on discussing the needs and progress of a child. The father suddenly looked at us in a condescending, authoritarian way and said, “You just need to fix my child.” I could only think that the degree of naïve insolence he displayed must have been directly correlated with the severity of problems present in the home environment. But in some ways, he was echoing just what DSM is saying—diagnose and treat the child first and foremost, and then go about addressing factors that may actually be causing the problem.
Unfortunately, this story only gets worse as the next DSM pages are turned, and final problem is uncovered. It is when I get to the Differential Diagnosis section of the DSM, and I start to discern other possible reasons that oppositional defiant behaviors may be occurring, which would not warrant a diagnosis of ODD. Here are my options: conduct disorder, ADHD, depressive and bipolar disorders, disruptive mood dysregulation disorder, intermittent explosive disorder, intellectual disability, language disorder, and social anxiety disorder. Something missing? DSM just got done acknowledging that environmental factors, such as harsh parenting, can cause ODD behaviors. But now, when I go to figure out how I am going to code this, nothing is available except another disorder/disability. Again, the inconsistency is glaring. The underlying message seems to be that no matter what is causing the problems, we have to find a disorder for it.
For clinicians such as myself, who utilize insurance benefits for most of our patients, it creates a really unfair ethical dilemma. There is no doubt that many children and families I see with the aforementioned issues are in serious need of intervention, but because no insurance company will pay (which is a subject for another time) for V-codes (such as child physical, psychological, sexual abuse, or child neglect), we and families are put in the wrong position of having to utilize a diagnosed disorder in a child when all involved know that the issue has way more to do with the parents bringing him or her in.
Given all this, I have a genuine request to any APA official involved with subsequent DSM revisions. If the categorical model continues to be utilized (despite obvious concerns), I would like to see the following offered as a diagnostic option for Disruptive, Impulse-Control, and Conduct Disorders (under which ODD is subsumed) in addition to all other diagnostic categories where environmental factors can clearly induce significant impairment or distress (which is about every category). The option would include the following 2 provisions:
- Remove the term “disorder” and replace with “difficulties” or “problems”
- Include the term “due to dysfunctional and/or unstable circumstances”
So, instead of diagnosing ODD (or even Other/Unspecified Disruptive, Impulse-Control, and Conduct Disorder) for a child whose behaviors seems to be a response to a harsh, inconsistent environment, the condition would be labeled something like “Oppositional Defiant Difficulties due to Dysfunctional and/or Unstable Circumstances.” Although I realize that some will critique this for various reasons (including the “mouthful” reason), I believe it is much better option than what currently exists. Furthermore, no one disagrees with this contention. Not the DSM-V committee. Not the clinicians. Not even the family, if they are willing to look in the mirror. When we look at other conditions, we find the same story. Unstable, harsh circumstances (or lack of good sleep and too much screen time) cause ADHD-like behaviors. Serious depressive features can arise from hopeless, abusive, and deprived situations. And so on. Furthermore, this new option would not be unprecedented. DSM-V already has the provision for many diagnoses that includes “Due to Another Medical Condition” or “Substance/Medication-Induced,” so the stretch from documenting a medical or substance cause to a psychosocial one would hardly be a stretch at all.
When it comes to labeling behaviors, why would we settle for anything less than what we know, especially when it is more confusing, pathologizing, and unrepresentative than other options available? Especially when pages next to each other, in the same diagnostic manual, tell such different and contradictory story. No one likes reading a book where the protagonist lacks clear motives and identity, and changes role midstream in a way that renders everything else said or done before as meaningless. So why we would accept the same from a diagnostic manual where real lives are at stake?