DSM-5 & School Psychology
Substance-Related and Addictive Disorders
By Rondy Yu
Volume 44 Issue 5
By Rondy Yu
Substance use disorder (SUD) describes a pattern of repeated drug use to the extent that significant clinical or functional impairment is caused, including physical health problems and failure to meet the major responsibilities of work, school, or home. A diagnosis of SUD can be applied to nine separate classes of drugs: alcohol; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants; tobacco; and other substances (American Psychiatric Association [APA], 2013a). And the cognitive, physical, and social changes experienced by developing adolescents all contribute to a heightened period of risk for substance use (Chung, 2013). According to the 2013 National Survey on Drug Use and Health, an estimated 8.8% of youth between the ages of 12 and 17 used illicit drugs, 11.6% used alcohol, and 5.2% met criteria for an SUD (Center for Behavioral Health Statistics and Quality, 2014). Based on a study with a sample of 4,930 adolescents receiving substance abuse treatment services, the most common substance use problem was cannabis, followed in order by alcohol, polysubstance dependence, and other drug use (Chan, Dennis, & Funk, 2008).
The potential consequences of substance use can be devastating, impacting not only the health and safety of students, but also their social–emotional well-being and learning. As evidenced in the literature, substance use disorders among adolescents frequently occur along with a number of other mental and behavioral challenges. Studies have reported between 55% and 88% of those receiving treatment have a co-occurring psychiatric problem such as conduct disorder, ADHD, depression, and anxiety disorders (Godley et al., 2014). There is also a growing body of literature linking substance use and school performance, much of which supports that school performance decreases as substance use increases (Andrade, 2014).
Changes From Dsm-Iv-Tr and Rationale for the Dsm-5 Changes
Important changes in the diagnosis of SUDs were made in the Diagnostic and Statistical Manual of Mental Disorders—Fifth Edition (DSM-5; APA, 2013a), particularly in the move toward a more dimensional approach that conceptualizes SUD as a single construct. Previously, diagnostic criteria divided substance-related disorders into two groups: substance use disorders (substance dependence and substance abuse) and substance-induced disorders (intoxication, withdrawal, and other substance-induced disorders; APA, 2000). In the DSM-5, substance dependence and substance abuse have been combined into a single disorder, accompanied by criteria for substance-induced disorders. Table 1 outlines the differences between these diagnostic criteria. The decision to combine substance dependence and substance abuse was the result of a number of issues in the DSM-IVTR involving the abuse diagnosis and the stipulated relationship between dependence and abuse. This change was supported by the findings from an examination of 39 item response theory studies, which showed that dependence and abuse criteria (except legal problems) essentially indicate the same underlying problem and are intermixed across levels of severity (Hasin et al., 2013).
Table 1 DSM-IV-Tr and DSM-5 Criteria for Substance Use Disorders Organized by DSM-5 Criteria Groups
SUBSTANCE DEPENDENCE SUBSTANCE ABUSE SUBSTANCE USE
|Impaired Control Criteria|
|Used larger amounts/longer||✓||✓|
|Desire/efforts to control use||✓||✓|
|Large amount of time spent using||✓||✓|
|Craving or strong desire to use||✓|
|Social Impairment Criteria|
|Failure to fulfill major role obligations||✓||✓|
|Social problems from use||✓||✓|
|Given up activities to use||✓||✓|
|Risky use Criteria|
|Use in physically hazardous situations||✓||✓|
|Physical/mental problems from use||✓||✓|
|Criteria dropped from DSM-5|
|Substance-related legal problems||✓|
a Diagnosis requires three or more criteria be met within a 12-month period.
b Diagnosis requires one or more criteria be met within a 12-month period and no dependence diagnosis.
c Diagnosis requires two or more criteria be met within a 12-month period.
Contributing Editors’ Note: This series of articles on DSM-5 reviews changes made to specific diagnostic criteria (including both modified criteria and new disorders), emphasizing changes that may be relevant in the school context. If any Communiqué reader is interested in contributing to this series, please contact Dr. Brock at firstname.lastname@example.org.
As indicated in Table 1, DSM-5 removed the legal problems criterion, which was in part due to low rates of prevalence observed among adults and adolescents, poor discrimination (i.e., this criterion does not clearly separate those with SUD from those with other social or mental health problems), lack of fit with other SUD criteria, challenges applying criteria internationally, and failure to provide any additional information of significant diagnostic value (APA, 2013a; Hasin et al., 2013). The DSM-5 added one new substance disorder criterion, craving, which was considered a possible target for biological treatment and found to fit well with the other SUD criteria (Hasin et al., 2013). Diagnostic threshold was also changed; whereas the DSM-IV-TR only required one symptom to be met for a diagnosis of substance abuse, the DSM-5 requires at least two or three (out of a possible 11) for a mild SUD (APA, 2013b). The number of criteria endorsed is used to describe whether an individual has a mild, moderate, or severe SUD (APA, 2013a).
In addition to the substance-related disorders, gambling disorder was the only behavioral addiction added to the DSM-5 as a nonsubstance-related disorder. This change reflects research findings that recognize pathological gambling to be similar to substance-related disorders in natural history, physiology, clinical expression, tolerance, comorbidity, and response to treatment (Grant, Potenza, Weinstein, & Gorelick, 2010; Rennert et al., 2014). Several other changes were made, such as the addition of diagnostic criteria for cannabis and caffeine withdrawal, and removal of polysubstance dependence and the specifier indicating physiological subtype, which has received significantly less emphasis in the literature reviewing the major DSM-5 changes.
It was anticipated that the major changes to the DSM-5 would improve the reliability of SUD diagnoses. As stated by the APA (2013a), the diagnostic criteria have been strengthened with the increase in the minimum number of symptoms required for a diagnosis of SUD. With regard to its use with adolescents, the removal of the legal problems criterion due to its lack of prevalence and its poor association with the severity of substance use may very well strengthen the validity of SUD diagnoses applied to youth (Kaminer & Winters, 2015). The revisions were also intended to eliminate the confusion with the term dependence, which has been often mistakenly interpreted by clinicians as implying addiction when it is also used to describe the body's natural response to a substance. This problem has allegedly propagated the clinical practice of undertreating pain due to fear of causing patients to develop an addiction to opioids (APA, 2013a; O'Brien, 2011). As the DSM-5 no longer uses the term dependence, it is hoped that the distinction between addiction and physical dependence will be clarified.
Although the DSM-5 may have included positive changes for describing SUDs, a number of concerns have been raised regarding its application with adolescents. One alarming limitation of the DSM-5 is the SUD criteria's lack of developmental considerations, as the differences between adult and adolescent substance users are not addressed (Kaminer & Winters, 2015). The lack of developmentally informed criteria that considers the trajectory of SUDs among youth may negatively impact efforts toward early detection for intervention.
Another potential limitation is the use of the word addiction, which is often negatively perceived and may act as an obstacle to help-seeking behavior in the context of working with youth and their families (Kaminer & Winters, 2015). Knowing this, it will be important for school psychologists to exercise caution when communicating with families, school staff, and students to diminish the stigma and avoid further alienating those that may need support.
The effects of substance use often can be difficult to separate from other mental health challenges and may produce an inaccurate picture of a student's educational needs. A diagnosis of SUD can provide schools with valuable information relevant to the determination of special education eligibility under the category of emotional disturbance (ED). However, the Individuals with Disabilities Education Act (IDEA) does not recognize SUD as a qualifying disability, and solely meeting DSM diagnostic criteria for a substance-related or addictive disorder is not sufficient for a student to meet federal or state criteria for special education services. DSM-5 changes are therefore not expected to impact school psychologists’ assessment findings for the determination of special education eligibility.
While the DSM-5 changes may not impact eligibility determinations, it is still important for school psychologists to be aware of students’ diagnoses and the related symptoms that can impact their functioning in school. Substance use is a widespread issue, and school psychologists are likely to be called on by parents, school staff, and even students to answer questions about substance-related problems. School psychologists may also encounter students who present symptoms of SUDs in the course of their direct work with adolescents across multiple contexts (e.g., during assessment or in counseling), and the ignorance of or failure to identify problematic symptoms that warrant intervention can jeopardize a student's chance of receiving appropriate help. Having knowledge of the diagnostic criteria for SUDs will assist school psychologists to assess for risk across these situations and determine the appropriate type and intensity of intervention required, as well as the most appropriate community-based support service referral.
Rondy Yu, NCSP, is a doctoral student at the University of California, Santa Barbara