DSM-IV

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR) (American Psychiatric Association [APA], 2000) is used for clinical, research, and educational purposes. The focus of the manual is on diagnostic codes that are used in medical record keeping and communication of information to governmental agencies, private insurers, and the World Health Organization (APA, 2000). The relative infancy of this classification system warrants skepticism, yet empirical support for diagnostic reliability and validity has evolved significantly since its inception.

The first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) (1952) was [Page 176]recognized as the manual of mental health categorization. It was developed as a variant of the “Mental Disorders” section of the sixth edition of the World Health Organization's (WHO, 1949) International Classification of Diseases (ICD). DSM-I included one child mental health category (adjustment reactions of childhood and adolescence) as developmental differences between psychopathology in adults and children went unrecognized within the nomenclature. The psychoanalytic term of “reaction” (changes in personality related to psychological, social, and biological factors) found extensively within DSM-I was largely excluded from the second edition (DSM-II) (APA, 1968). However, few changes were made to improve the specificity of diagnostic definitions as narrative descriptions of symptoms remained. The third edition (DSM-III, APA, 1980) paralleled advancements made within the ninth edition of ICD (WHO, 1975), which emphasized diagnostic clarity and improved clinical utility. Specifically, diagnostic criteria were made more explicit, a multiaxial assessment system was included, and greater neutrality in etiological explanations of disorders was evident. The five Axes included in a multiaxial diagnosis are:

• 1.
  Axis I: Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention
• 2.
  Axis II: Personality Disorders and Mental Retardation
• 3.
  Axis III: General Medical Conditions
• 4.
  Axis IV: Psychosocial and Environmental Problems
• 5.
  Axis V: Global Assessment of Functioning

This system helps to capture the complexity of mental health conditions and the diversity of contexts and issues surrounding individuals presenting with the same diagnoses (APA, 2000).

Revisions and corrections to the major changes made within DSM-III resulted in the publication of DSM-III-R (APA, 1987). Because of the extensive research that was generated by the diagnostic criteria used in DSM-III and DSM-III-R, the fourth edition (DSM-IV) (APA, 1994) underwent significant research development, specifically for the childhood categories. A three-stage evidence-based process involving thorough literature reviews, reanalyses of extant data sets, and comprehensive field trials was completed. DSM-IV includes 10 categories specific to children called Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence with criteria available for more than 40 mental health diagnoses. Consistent with the purpose of serving as an educational tool, changes within the text sections of DSM-IV were made to reflect new information available since the early 1990s. This resulted in the publication of DSM-IV-TR (APA, 2000). No substantive changes in diagnostic criteria were made nor are they anticipated until DSM-V, which is scheduled to be published sometime after 2010.

DSM-IV-TR facilitates communication and consultation across multiple settings. Mental health professionals in clinical settings use the manual for diagnostic decision making within a comprehensive evaluation to guide treatment planning and development, to communicate service need to third-party payers like insurance companies, and to improve communication with others who may work with the client such as physicians and teachers. Within school settings, the use of the DSM-IV-TR is limited and used in combination with educational categories derived from the Individuals With Disabilities Education Act (IDEA). Eligibility for special educational programming is based on the presence of a special educational classification from IDEA such as “Other Health Impairment” or “Learning Disabilities.” For these two examples, one might find comparable symptom profiles within DSM-IV-TR under categories termed “Attention Deficit Hyperactivity Disorder” and “Reading Disorder,” respectively. The lack of overlapping classifications and incompatible terminology creates difficulties in communication between professionals in the school and community settings that are not easily resolved. School personnel often consult this manual to improve understanding of children's social–emotional behavior in an effort to ultimately create learning environments that meet the child's mental health and academic needs.

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