- Email: [email protected]
DSM-5 Criteria for Youth Substance Use Disorders: Lost in Translation?
EDITORIAL DSM-5 Criteria for Youth Substance Use Disorders: Lost in Translation? Yifrah Kaminer,
MD, AND
W
hen faced in a clinical setting with an adolescent suspected of, or known to have, a substance abuse problem, it is important to integrate the assessment process with potential treatment decisions. The initial assessment phase involves efficient identification of substance use and related problems, psychiatric comorbidity, and psychosocial maladjustment.1 This objective can be achieved by conducting a comprehensive assessment of these content domains, including whether the adolescent meets criteria for DSM-5 substance use disorders (SUDs). The end result of this assessment is a designed treatment plan that identifies the adolescent’s clinical needs. Reports on performance of physicians who need to assess adolescent substance abuse have not been encouraging. The reasons for these troubling figures include unfamiliarity with assessment, lack of training to manage positive screening results, the need to triage competing multidimensional problems, lack of treatment resources, and insufficient time.1 The objective of this commentary is to examine the potential merits and limitations of applying the SUD diagnostic criteria in the DSM-5 for adolescents and clinicians on a learning curve for assessing and treating adolescents with SUDs.
DIFFERENCES BETWEEN DSM-IV AND DSM-5 The changes in diagnostic criteria for SUDs present one of the most drastic differences between the DSM-IV and DSM-5 diagnostic formulations of any disorder. The new criteria eliminate the diagnosis of substance abuse and substance dependence. Instead, the DSM-5 relies on a set of 11 criteria to define a single SUD for all substance classes, such as alcohol use disorder. A count of criteria determines the level of SUD (2–3, mild; 4–5, moderate; 6, severe). Thus, a threshold of 2 of 11 criteria suffices to meet a SUD diagnosis. Replacing the DSM-IV distinction between abuse and dependence and combining these constructs into a single criterion set in the DSM-5 has some empirical support.2 For example, factor and latent class analyses of DSM-IV symptoms indicate a single dimension of substance problems.3 Also, the decision to eliminate the “legal problems” symptom in the DSM-5, which in adolescents was poorly associated with drug involvement problem severity and likely confounded by gender and coexisting conduct disorder,3 also has the potential of strengthening the validity of the DSM-5 SUD diagnosis when applied to youth. However, there are considerable conceptual and pragmatic limitations in applying these DSM-5 criteria for youth.
350
www.jaacap.org
Ken C. Winters,
PhD
The DSM-5 workgroup on SUDs changed the title to “substance related and addictive disorders.” The term addiction was derived from the Latin “bound to” or “enslaved by.” It has been associated with continued and compulsive drug use in the presence of negative consequences. In prior DSM systems, this severe end of drug use was accompanied by a less advanced but clinically relevant concept of abuse particularly appropriate for youth. The reframing of SUDs as a severity continuum within a single addiction dimension might be problematic when applied to adolescents. Empirical data indicate that the progression from drug use, which usually begins in adolescence, to a severe end state of addiction represents a heterogeneous clinical continuum. Furthermore, there is emerging evidence that alcohol consumption and use of marijuana by adolescents that might not rise to the level of meeting the DSM-5 criteria for a SUD are associated with substantial neurocognitive damage.3 Therefore, we are particularly concerned that the DSM-5’s lack of a developmental perspective will contribute to many youth not receiving a DSM-5 diagnosis but remaining nonetheless involved with drugs in a harmful or hazardous manner. There is a large body of scientific literature that addresses the differences among patterns, trajectories, and implications for intervention for adolescent and adult drug involvement.4 This body of work, often referred to as a biobehavioral developmental perspective, indicates that adolescents with a SUD, with or without a coexisting mental or behavioral disorder, are not simply “miniature adults.” This perspective supports the notion that drug involvement by youth at the early, pre-addiction stage routinely involves the emergence of significant social and psychological consequences that merit early intervention. By organizing the DSM-5 around an adult concept of addiction, the public health value and significance of early detection and referral to non-intensive treatment are greatly diminished. Those clinicians and clinical researchers working with teenagers and their families are aware how difficult it is to engage with these adolescents and motivate them to come for an assessment and treatment without coercion. Although we appreciate that there is growing acceptance of the concept of addiction in our society, we are concerned that this perception is far from the truth for youth and their families. Families too often might reject the term, which might enable the perception that their child does not have a drug problem. This can needlessly add to the help-seeking barriers that already exist. The purpose of a nosology is to improve communication among all stakeholders, not just the scientific community. JOURNAL
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 54 NUMBER 5 MAY 2015
EDITORIAL
This goal would not be accomplished by further alienating our patients and their families from treatment for fear of stigmatization. Further, the title change has implications for public policy and people for whom health services are made available. For example, more than 40% of college students report heavy drinking. These emerging adults are usually younger than 25 years, and patients in primary care who might manifest drinking-related problems would not react well to screening and brief interventions if labeled as addicts. Perhaps there has been a significant degree of support for the use of the word addiction as a diagnosis for adults, and the introduction of dimensional severity is a thoughtful novelty. Yet we believe there is an almost unanimous lack of support among those in the adolescent drug abuse prevention and treatment community. There are other limitations for the DSM-5 criteria for youth.
THE 2-SYMPTOM THRESHOLD FOR SUD The 2-of-11 threshold for SUD in youth deserves further research. Although we noted earlier that the new criteria might miss youth who are using at harmful levels, there is also the issue that the proposed criteria could mistakenly over-diagnose mild cases that might not rise to a clinicallevel problem. If the 2þ threshold is too liberal, many adolescents might be unnecessarily stigmatized as having a problem. Another limitation is that some of the DSM-5 criteria for SUD have questionable validity when applied to adolescent substance users.
TOLERANCE Tolerance to substances, particularly to alcohol, is a relatively mild symptom, can present without significant harm or distress, and might be normative in adolescent and young adult drinkers,5 when individuals typically escalate their substance use patterns from experimentation to more regular use. Tolerance implicitly references an undefined temporal comparison, which makes it excessively developmentally sensitive such that it is much easier to meet this criterion earlier in the career of the substance user. Also, neurodevelopmental changes during adolescence can contribute to variability of developmental sensitivity to substances among teenagers who are only a few years apart in age.
heavy drug use. Withdrawal reflects severe substance problems and could have prognostic significance only in the few adolescents who report it. Thus, its inclusion in the DSM-5 is important but mainly for adults.
HAZARDOUS USE There is controversy as to whether hazardous use clearly reflects a compulsive pattern of use and is equally relevant across substances, such as tobacco. In addition, the hazardous-use criterion is somewhat developmentally bound. Hazardous use is relatively common in adult samples but less common in adolescents.
CRAVING The implications for diagnosing adolescents with the addition of the craving criterion are not clear. There are clinical observations that many youth who have escalated to regular use report strong cravings for substances.5 The way in which this symptom is defined and operationalized could make a large difference in its observed prevalence (e.g., sign of continued appetitive urges or behaviors? withdrawal-related phenomena?). More research is needed to examine the validity of craving as a criterion of SUDs in adolescents.
CONCLUSION Despite some favorable changes, the DSM-5 SUD criteria do not go far enough toward improving SUD diagnosis for youth. Some targeted developmentally informed adjustments based on the trajectory of youth SUD, including clearer operational symptom definitions, are missing. For future diagnostic revisions, we recommend excluding the hazardous-use criterion and clarifying the operational definitions of tolerance, withdrawal, and craving. In addition, the critical choice of a diagnostic threshold for SUDs deserves further study and discussion. & Accepted January 30, 2015. Dr. Kaminer is with the University of Connecticut Health Center, Farmington. Dr. Winters is with the University of Minnesota Medical School, Minneapolis. Disclosure: Drs. Kaminer and Winters report no biomedical financial interests or potential conflicts of interest. Correspondence to Yifrah Kaminer, MD, University of Connecticut Health Center, Alcohol Research Center and Injury Prevention Center, 263 Farmington Avenue, Farmington, CT 06030; e-mail: [email protected]
WITHDRAWAL
0890-8567/$36.00/ª2015 American Academy of Child and Adolescent Psychiatry
Withdrawal symptoms are a fairly rare phenomenon in adolescents given that they generally emerge only after years of
http://dx.doi.org/10.1016/j.jaac.2015.01.016
REFERENCES 1. Winters KC, Kaminer Y. Screening and assessing adolescent substance use disorders in clinical population. J Am Acad Child Adolesc Psychiatry. 2008;47:740-744. 2. Martin CS, Chung T, Langenbucher JW. How should we revise diagnostic criteria for substance use disorders in the DSM-V? J Abnorm Psychol. 2008;117:561-575. 3. Volkow ND, Baler RD, Compton WM, Weiss SRB. Adverse health effects of marijuana use. N Engl J Med. 2014;370:2219-2227.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 54 NUMBER 5 MAY 2015
4. Martin CS, Chung T, Kirisci L, Langenbucher JW. Item response theory analysis of diagnostic criteria for alcohol and cannabis use disorders in adolescents: implications for DSM-V. J Abnorm Psychol. 2006;115: 807-814. 5. Chung T, Martin CS. Adolescent substance use and substance use disorders: prevalence and clinical course. In: Kaminer Y, Winters KC, eds. Clinical Manual of Adolescent Substance Abuse Treatment. Washington, DC: American Psychiatric Association; 2011:1-23.
www.jaacap.org
351
MD, AND
W
hen faced in a clinical setting with an adolescent suspected of, or known to have, a substance abuse problem, it is important to integrate the assessment process with potential treatment decisions. The initial assessment phase involves efficient identification of substance use and related problems, psychiatric comorbidity, and psychosocial maladjustment.1 This objective can be achieved by conducting a comprehensive assessment of these content domains, including whether the adolescent meets criteria for DSM-5 substance use disorders (SUDs). The end result of this assessment is a designed treatment plan that identifies the adolescent’s clinical needs. Reports on performance of physicians who need to assess adolescent substance abuse have not been encouraging. The reasons for these troubling figures include unfamiliarity with assessment, lack of training to manage positive screening results, the need to triage competing multidimensional problems, lack of treatment resources, and insufficient time.1 The objective of this commentary is to examine the potential merits and limitations of applying the SUD diagnostic criteria in the DSM-5 for adolescents and clinicians on a learning curve for assessing and treating adolescents with SUDs.
DIFFERENCES BETWEEN DSM-IV AND DSM-5 The changes in diagnostic criteria for SUDs present one of the most drastic differences between the DSM-IV and DSM-5 diagnostic formulations of any disorder. The new criteria eliminate the diagnosis of substance abuse and substance dependence. Instead, the DSM-5 relies on a set of 11 criteria to define a single SUD for all substance classes, such as alcohol use disorder. A count of criteria determines the level of SUD (2–3, mild; 4–5, moderate; 6, severe). Thus, a threshold of 2 of 11 criteria suffices to meet a SUD diagnosis. Replacing the DSM-IV distinction between abuse and dependence and combining these constructs into a single criterion set in the DSM-5 has some empirical support.2 For example, factor and latent class analyses of DSM-IV symptoms indicate a single dimension of substance problems.3 Also, the decision to eliminate the “legal problems” symptom in the DSM-5, which in adolescents was poorly associated with drug involvement problem severity and likely confounded by gender and coexisting conduct disorder,3 also has the potential of strengthening the validity of the DSM-5 SUD diagnosis when applied to youth. However, there are considerable conceptual and pragmatic limitations in applying these DSM-5 criteria for youth.
350
www.jaacap.org
Ken C. Winters,
PhD
The DSM-5 workgroup on SUDs changed the title to “substance related and addictive disorders.” The term addiction was derived from the Latin “bound to” or “enslaved by.” It has been associated with continued and compulsive drug use in the presence of negative consequences. In prior DSM systems, this severe end of drug use was accompanied by a less advanced but clinically relevant concept of abuse particularly appropriate for youth. The reframing of SUDs as a severity continuum within a single addiction dimension might be problematic when applied to adolescents. Empirical data indicate that the progression from drug use, which usually begins in adolescence, to a severe end state of addiction represents a heterogeneous clinical continuum. Furthermore, there is emerging evidence that alcohol consumption and use of marijuana by adolescents that might not rise to the level of meeting the DSM-5 criteria for a SUD are associated with substantial neurocognitive damage.3 Therefore, we are particularly concerned that the DSM-5’s lack of a developmental perspective will contribute to many youth not receiving a DSM-5 diagnosis but remaining nonetheless involved with drugs in a harmful or hazardous manner. There is a large body of scientific literature that addresses the differences among patterns, trajectories, and implications for intervention for adolescent and adult drug involvement.4 This body of work, often referred to as a biobehavioral developmental perspective, indicates that adolescents with a SUD, with or without a coexisting mental or behavioral disorder, are not simply “miniature adults.” This perspective supports the notion that drug involvement by youth at the early, pre-addiction stage routinely involves the emergence of significant social and psychological consequences that merit early intervention. By organizing the DSM-5 around an adult concept of addiction, the public health value and significance of early detection and referral to non-intensive treatment are greatly diminished. Those clinicians and clinical researchers working with teenagers and their families are aware how difficult it is to engage with these adolescents and motivate them to come for an assessment and treatment without coercion. Although we appreciate that there is growing acceptance of the concept of addiction in our society, we are concerned that this perception is far from the truth for youth and their families. Families too often might reject the term, which might enable the perception that their child does not have a drug problem. This can needlessly add to the help-seeking barriers that already exist. The purpose of a nosology is to improve communication among all stakeholders, not just the scientific community. JOURNAL
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 54 NUMBER 5 MAY 2015
EDITORIAL
This goal would not be accomplished by further alienating our patients and their families from treatment for fear of stigmatization. Further, the title change has implications for public policy and people for whom health services are made available. For example, more than 40% of college students report heavy drinking. These emerging adults are usually younger than 25 years, and patients in primary care who might manifest drinking-related problems would not react well to screening and brief interventions if labeled as addicts. Perhaps there has been a significant degree of support for the use of the word addiction as a diagnosis for adults, and the introduction of dimensional severity is a thoughtful novelty. Yet we believe there is an almost unanimous lack of support among those in the adolescent drug abuse prevention and treatment community. There are other limitations for the DSM-5 criteria for youth.
THE 2-SYMPTOM THRESHOLD FOR SUD The 2-of-11 threshold for SUD in youth deserves further research. Although we noted earlier that the new criteria might miss youth who are using at harmful levels, there is also the issue that the proposed criteria could mistakenly over-diagnose mild cases that might not rise to a clinicallevel problem. If the 2þ threshold is too liberal, many adolescents might be unnecessarily stigmatized as having a problem. Another limitation is that some of the DSM-5 criteria for SUD have questionable validity when applied to adolescent substance users.
TOLERANCE Tolerance to substances, particularly to alcohol, is a relatively mild symptom, can present without significant harm or distress, and might be normative in adolescent and young adult drinkers,5 when individuals typically escalate their substance use patterns from experimentation to more regular use. Tolerance implicitly references an undefined temporal comparison, which makes it excessively developmentally sensitive such that it is much easier to meet this criterion earlier in the career of the substance user. Also, neurodevelopmental changes during adolescence can contribute to variability of developmental sensitivity to substances among teenagers who are only a few years apart in age.
heavy drug use. Withdrawal reflects severe substance problems and could have prognostic significance only in the few adolescents who report it. Thus, its inclusion in the DSM-5 is important but mainly for adults.
HAZARDOUS USE There is controversy as to whether hazardous use clearly reflects a compulsive pattern of use and is equally relevant across substances, such as tobacco. In addition, the hazardous-use criterion is somewhat developmentally bound. Hazardous use is relatively common in adult samples but less common in adolescents.
CRAVING The implications for diagnosing adolescents with the addition of the craving criterion are not clear. There are clinical observations that many youth who have escalated to regular use report strong cravings for substances.5 The way in which this symptom is defined and operationalized could make a large difference in its observed prevalence (e.g., sign of continued appetitive urges or behaviors? withdrawal-related phenomena?). More research is needed to examine the validity of craving as a criterion of SUDs in adolescents.
CONCLUSION Despite some favorable changes, the DSM-5 SUD criteria do not go far enough toward improving SUD diagnosis for youth. Some targeted developmentally informed adjustments based on the trajectory of youth SUD, including clearer operational symptom definitions, are missing. For future diagnostic revisions, we recommend excluding the hazardous-use criterion and clarifying the operational definitions of tolerance, withdrawal, and craving. In addition, the critical choice of a diagnostic threshold for SUDs deserves further study and discussion. & Accepted January 30, 2015. Dr. Kaminer is with the University of Connecticut Health Center, Farmington. Dr. Winters is with the University of Minnesota Medical School, Minneapolis. Disclosure: Drs. Kaminer and Winters report no biomedical financial interests or potential conflicts of interest. Correspondence to Yifrah Kaminer, MD, University of Connecticut Health Center, Alcohol Research Center and Injury Prevention Center, 263 Farmington Avenue, Farmington, CT 06030; e-mail: [email protected]
WITHDRAWAL
0890-8567/$36.00/ª2015 American Academy of Child and Adolescent Psychiatry
Withdrawal symptoms are a fairly rare phenomenon in adolescents given that they generally emerge only after years of
http://dx.doi.org/10.1016/j.jaac.2015.01.016
REFERENCES 1. Winters KC, Kaminer Y. Screening and assessing adolescent substance use disorders in clinical population. J Am Acad Child Adolesc Psychiatry. 2008;47:740-744. 2. Martin CS, Chung T, Langenbucher JW. How should we revise diagnostic criteria for substance use disorders in the DSM-V? J Abnorm Psychol. 2008;117:561-575. 3. Volkow ND, Baler RD, Compton WM, Weiss SRB. Adverse health effects of marijuana use. N Engl J Med. 2014;370:2219-2227.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 54 NUMBER 5 MAY 2015
4. Martin CS, Chung T, Kirisci L, Langenbucher JW. Item response theory analysis of diagnostic criteria for alcohol and cannabis use disorders in adolescents: implications for DSM-V. J Abnorm Psychol. 2006;115: 807-814. 5. Chung T, Martin CS. Adolescent substance use and substance use disorders: prevalence and clinical course. In: Kaminer Y, Winters KC, eds. Clinical Manual of Adolescent Substance Abuse Treatment. Washington, DC: American Psychiatric Association; 2011:1-23.
www.jaacap.org
351