Developmental Psychopathology: DSM-5 Update Supplement - Chapter 06 Study Notes

Developmental Psychopathology: DSM-5 Update Supplement

Chapter Overview

  • Focus: Infancy Through Preschool

  • Key Disorders Studied:

    • Insecure Attachment

    • Oppositional-Defiant Disorder (ODD)

    • Enuresis

Attachment Disorders

  • Attaches to new category: Trauma- and Stressor-Related Disorders in DSM-5.

    • Includes disorders that require exposure to trauma/stress as diagnostic criteria.

  • Formerly classified as Reactive Attachment Disorder (RAD) has two new distinct diagnostic entities:

    • One characterized by internalizing symptoms and social withdrawal.

    • The other characterized by externalizing symptoms and social disinhibition.

DSM-5 Criteria for Reactive Attachment Disorder (RAD) (Table 6.1)

  • Criterion A: Inhibited, emotionally withdrawn behavior towards caregivers:

    1. Rarely seeks comfort when distressed.

    2. Rarely responds to comfort from caregivers.

  • Criterion B: Social and emotional disturbances characterized by at least two:

    1. Minimal social/emotional responsiveness to others.

    2. Limited positive affect.

    3. Unexplained irritability, sadness, or fearfulness during interactions.

  • Criterion C: Evidence of extreme insufficient care:

    1. Persistent social neglect or deprivation of emotional needs.

    2. Repeated changes of primary caregivers limiting attachment opportunities.

    3. Rearing in settings that limit the formation of attachments, e.g., high child-to-caregiver ratios.

  • Criterion D: Care responsible for behaviors in Criterion A; disturbances began following inadequate care.

  • Criterion E: Criteria not met for autism spectrum disorder (ASD).

  • Criterion F: Disturbance evident before age 5.

  • Criterion G: Developmental age of at least 9 months.

    • Specify if persistent: lasting more than 12 months.

    • Specify severity: severe if exhibiting all symptoms at high levels.

Explanation of Reactive Attachment Disorder

  • The diagnosis for RAD focuses on interactions with caregivers.

  • Key features:

    • Absence of attachment behaviors like seeking comfort.

    • Overall lack of social and emotional responsiveness, with pervasive negative emotions.

  • Diagnosis rooted in severe inadequate caregiving environments:

    • Emotional neglect, frequent changes in caregivers, or rearing in deprived institutions.

Disinhibited Social Engagement Disorder (DSED)

  • New OCD-like, derived from RAD disinhibited type.

  • DSM-5 Criteria for DSED (Table 6.2)

    • Criterion A: Engaging with unfamiliar adults via at least two of:

    1. Reduced or absent caution in interaction with unfamiliar adults.

    2. Overly familiar behavior disregarding social boundaries.

    3. Absent checking back with caregivers after venturing away.

    4. Willingness to go with unfamiliar adults with minimal hesitation.

    • Criterion B: Behaviors not limited to impulsivity.

    • Criterion C: Insufficient care matching RAD criteria.

    • Criterion D: Care responsible for behaviors in Criterion A.

    • Criterion E: Developmental age of at least 9 months.

    • Specify if persistent: lasting more than 12 months.

    • Specify severity: severe if all symptoms manifest at high levels.

Differential Diagnosis for RAD

  • Distinguishing features from:

    • Autism Spectrum Disorder (ASD): Children with RAD have a history of severe social neglect and lack selective attachments, unlike those with ASD showing restricted interests or repetitive behaviors.

    • Intellectual Developmental Disorder (IDD): RAD lacks selective attachments seen even in severely cognitively impaired children.

    • Childhood Depression: While depressed affect may occur in RAD, failure to seek comfort is a distinguishing factor.

Oppositional-Defiant Disorder (ODD)

  • Children often experience rebellious phases, especially around ages 2-4 and adolescence.

  • Research indicates the emergence of externalizing problems as early as 3-4 years.

  • Importance of recognizing age-specific behavioral presentations.

  • Need for research on ODD across genders:

    • Existing studies show aggression tied more to males through physical means; females may display aggression differently and underdiagnosed.

    • Cultural factors can deeply influence expressions and perceptions of ODD.

Controversies and Areas for Further Research

  • Understanding ODD's varied manifestations dependent on age and cultural context is crucial.

  • Different expectations based on culture and generational changes complicate diagnosis.

Enuresis

  • Reclassified under Elimination Disorders in the DSM-5.

  • Defined as persistent inability to control urination inconsistent with developmental age.

  • Types of Enuresis:

    • Nocturnal (nighttime only)

    • Diurnal (daytime only)

    • Combination of both.

  • Nocturnal enuresis is more prevalent in boys, commonly occurring in the first third of the night.

  • Diurnal enuresis can lead to social embarrassment among peers.

DSM-5 Criteria for Enuresis (Table 6.4)

  • Criterion A: Repeated voiding of urine, involuntary or intentional.

  • Criterion B: Clinically significant frequency (twice a week for 3 months) or distress in functioning.

  • Criterion C: Chronological age of at least 5 years.

  • Criterion D: Not due to a medical condition or substance effects.

    • Specify type: Nocturnal only, Diurnal only, or both.

Potential Implications of the New DSM-5 Criteria

  • Notable changes have been in the reclassification and clarity between attachment disorders focused on caregiving histories.

  • Distinction between two forms of RAD (internalizing vs externalizing) may aid in diagnostics and treatment tailored to behaviors caused by poor caregiving environments.