DSM-5 Explanation and assessment in school counseling
Alicia N. Macheda
Seton Hall University
May 29, 2018
A school-wide presentation discussing the utilization of the DSM-5 to diagnose psychological disorders which includes the advantages and disadvantages for school counselors and psychologists. Methods of assessment such as clinical interviews, psychological testing and behavioral assessment are explained. The importance of understanding and considering sociocultural factors during assessment is also explored.
Keywords: DSM-5, reliability, validity, predictable validity, transdiagnostic, syndrome, psychological disorders, clinical syndromes, clinical interview, psychological tests, objective, projective, sociocultural, personality traits, functional analysis, behavioral interview, direct observation,
Hello and welcome to the presentation and explanation of the DSM-5 which is utilized when diagnosing many of our special education students. I am happy to announce that throughout the year I will be giving several of these presentations to share with out the importance and purpose of these diagnostic tools. I plan to provide as much detail as possible, without boring you with too many clinical terms, so that each of you also have an understanding about how this process works. Please be sure to stop and ask any questions as we go through the program.
DSM-5: Advantages and Disadvantages
The Diagnostic and Statistical Manual of Mental Disorders, commonly known as the DSM-5, is the manual widely used by mental health professionals. The original was introduced in 1952 and the DSM-5 edition was published in 2015. DSM-5 classifies various mental disorders allowing mental health professionals to offer diagnoses with a certain set of criteria. “Classification is the core of science” and scientists would not be able to “communicate findings without labeling and organizing” (Nevid, Rathus, & Greene, 2018, p.99). The manual has twenty general categories and each of them range from mild to severe. The clinician uses the manual by utilizing the yes and no questions to make a judgement.
An advantage to using the DSM-5 is that the manual specifies a minimum number of symptoms for particular diagnoses. The diagnosis is given only when the minimum number is present per illness. Another advantage is that the DSM-5 offers reliability and validity with the criteria for assessment. Reliability means that different people can use the assessment to evaluate the same person and get the same diagnosis, while validity is the diagnostic judgment corresponding with the observed behaviors. Due to the predictable validity clinicians have the ability to predict the course a disorder will likely follow and how it is going to respond to the provided treatment. The DMS-5 allows the clinician to match the client’s complaints to standards that would best fit the criteria of the symptoms for best diagnosis. The DSM-5 is similar to the medical models which focus on the individual and not the physical, social or environmental factors. There is categorization of a psychological disorder as the main focus instead of a description of the client’s behavioral strengths and weaknesses. A new model is being explored, called transdiagnostic model that identifies common neurological substrate in the brain.
A disadvantage to the DSM-5 is that it is descriptive of the criteria but not explanatory therefore the clinician has to interpret the meaning of each of the criteria per illness. “Critics challenge the utility of particular symptoms or features associated with a particular syndrome or of specified diagnostic criteria” (Nevid et al., 2018, p.107). There also may be a disadvantage of a stigma of labeling when utilizing the DSM-5 or a prejudice towards mental health issues.
Methods of Assessment
Clinical interviews and other means to assess normal behavior are the method in which clinicians obtain the information needed to use the DMS-5 to make the diagnosis. The collected data is matched with the “presenting problems and associated features to the set diagnostic criteria to form a diagnostic impression” (Nevid et al., 2018 p.99). This represents a way to classify patterns of abnormal behaviors by common features.
Some mental disorders involve emotional stress, such as depression and anxiety which causes significant impairment to the normal daily functions of the sufferer. These can lead to behavioral changes such as substance use/abuse or even suicide attempts. Mental disorder, also known as a psychological disorder, is utilized to “describe clinical syndromes (clusters of symptoms) involving a significant level of disturbance in a person’s cognitive, emotional or behavioral functioning” (Nevid et al., 2018, p.100). The assessment methods must be reliable (meaning a measurable consistency) and valid (the instruments used to measure must measure what they intend to measure.)
The clinical interview is the most widely used assessment method. It is a face to face interview between the clinician and the client. It allows the client to describe their complaints in their own words. It also allows the clinician to not only hear the complaint from the client, but also to observe their non-verbal cues, actions and behaviors. The clinician can observe the clients grooming, attire (for appropriateness) mood and focus. The clinician is able to ask more questions to the client of the presenting problem such as their discomfort, the circumstances surrounding the start of the behavior and any history of the behavior in the past. The clinician can discuss with the client how their everyday functioning is impacted. The clinician is also able to discuss any changes in life, circumstances, social relationships, schooling or employment with the client to determine anything that may have triggered the new behavior. Clinician interviews can be structured, semi structured or unstructured depending on the client being assessed.
A second method of assessment is the utilization of psychological tests. This is a “structured method of assessment used to evaluate reasonably stable traits, such as intelligence and personality. Tests are usually standardized on large numbers of people and provide norms that compare a client’s scores with the average” (Nevid et al., 2018, p. 114). One of these psychological tests is an intelligence test which is often utilized to determine if there is an intellectual disability. This allows the clinician to assess the client’s intellectual strengths and weaknesses as well as be able to diagnose any intellectual disability impairment from other disorders. The IQ score is often utilized to determine the level of intelligence and it is determined by the deviation of the individual’s score from the norms of others. 100 is defined as the mean on the IQ test. There are approximately 5 percent of individuals who score above 130 or below 70 on this test.
Additional psychological tests include objective testing which is when the client “self-reports personality inventories that use items… to measure personality traits such as emotional instability, masculinity/femininity, and introversion” (Nevid et al., 2018, p. 116). These are considered objective because there is a limit on the possible responses the client can provide. The projective test is also utilized however it “offers no clear, specified response options” (Nevid et al., 2018, p. 118). The most familiar of these tests would be the ink blot test where people are provided “ambiguous stimuli” and then asked about it. The clients “impose or project, their own psychological needs, drives and, motives much of which lie in the unconscious, onto their interpretation” of these objects (Nevid et al., 2018, p.118).
Behavioral assessment “treat test results as samples of behavior that occur in specific situations rather than as signs of underlying personality traits” (Nevid et al., 2018, p.121). Essentially the behavioral assessment is trying to determine if the behavior is triggered by an outside environmental or situational issue rather than a behavioral trait within the person. The client would be observed in the particular setting to determine whether or not the behavior is happening solely in that environment and if there is anything that is sparking the behavior to occur. For example, does the client only flip a desk during a change in classroom or classroom time line, or does the client act out aggressively at other times. This is referred to as a functional analysis. This allows the clinician to assess any stimuli that could trigger the behaviors and therefore try to control or eliminate them before a behavior happens.
The clinician may also interview the client further during this type of an assessment, known as a behavioral interview, in order to gather more information about what is happening when the behavior happens. All of this analysis allows the clinician to make an informed decision when comparing the behaviors to the DSM-5 diagnostic material. Many times these types of assessments are completed while the child is in the classroom environment in order to determine what is going on there. This portion of the assessment is called direct observation. An advantage to direct observation is that the clinician is able to make the assessment based on experience (and often input from the classroom staff) without the client self-reporting behaviors. This tends to be a less biased approach as it is not swayed by the way the client is trying to make themselves appear to the clinician, although it could potentially leave the risk of bias by the observer.
Nevid et al., (2018) explain that Cultural-bound syndromes happen in some cultures but rarely occur or do not occur at all in others. Some of these are exaggerated forms of common folk superstitions and their belief patterns. An example of this is in the Japanese culture where many have an excessive fear of embarrassing or offending others. In the USA an example of this would be anorexia nervosa or dissociative identity disorder, which is virtually unheard of in undeveloped countries. It is important for the school counselor to understand that these cultural differences, known as sociocultural factors, can impact a student’s behaviors and could be considered abnormal to those who do not practice the same customs. The counselor would need to ensure the behavior is not something learned and appropriate within the other culture before assessing for a disorder. “The DMS system recognizes that clinician who are unfamiliar with an individual’s cultural background may incorrectly classify the individual’s behavior as abnormal when in fact it falls within the normal spectrum in that individual’s cultural” (Nevid et al., 2018, p. 104). The school counselor will need to determine if the behavior pattern considered abnormal within the school culture is actually abnormal within the cultural that the child comes from and that the behavior is not culturally specific.
Relevance to faculty
It is important for faculty to understand the process of evaluation and how the DSM-5 factors into that because the children that you are all working with daily are impacted by the criteria and diagnosis it supports. Providing faculty the knowledge of the key to assessments allows the faculty to understand what exactly is being looked for when evaluations are done, and it allows faculty to provide insightful information in regards to behaviors and such that are observed in their classrooms. This also allows staff and the clinician to work together to develop an effective evaluation plan to ensure the child is being evaluated in the classroom setting as well as a face to face individual basis.
The DSM-5 is important to clinicians everywhere, not just in the school setting. It allows everyone to be on the same page, so to speak, in regards to diagnostic criteria and making determinations on diagnosis. It provides specific information for each illness and specific criteria that can essentially be checked marked off in order to determine if a client has the pathologies of that diagnosis. The DSM-5 has unified the mental health diagnostic world.
Nevid, J.S., Rathus, S.A. ; Greene, B. (2018). Abnormal Psychology in a Changing World, Tenth Edition. Upper Saddle River, NJ: Pearson.