Stanford/Packard to Test New Diagnostic Guidelines for Pediatric and Young Adult Mental Disorders

-- Although millions of U.S. children receive psychiatric treatment each year, most diagnostic guidelines for pediatric mental disorders have never been tested in children. But that’s about to change: Field trials will begin in early November to evaluate pediatric diagnoses proposed for the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the standard diagnostic guide for mental illnesses. The Stanford University School of Medicine and Lucile Packard Children’s Hospital have been selected as one of four sites for these trials, the American Psychiatric Association announced today. The APA is sponsoring the research.

“Most diagnoses in prior editions of the DSM had been validated only in adult populations and then applied with minor modifications to children and adolescents,” said Carl Feinstein, MD, professor of psychiatry and behavioral sciences who will lead the Stanford arm of the trials. “As a result, they didn’t fit children very well. Many children ended up with multiple diagnoses, and some children with serious problems didn’t fit any of the diagnostic categories. This made it much harder to select and prioritize treatment options.”

Children are not simply smaller adults when it comes to psychiatric disorders, said Feinstein, who is also division chief of child and adolescent psychiatry at Packard Children’s. “A valid system of diagnosis must take into account their developmental level and the unique demands and contexts they face, such as school and being parented in families. It’s a huge improvement that we're testing the diagnoses in children.”

The last major revision of the manual, DSM-IV, was released in 1994, with a modest revision (DSM-IV-TR) in 2000. The new DSM-5 is due out in 2013. Expert panels have already used recent research and public comment to propose revisions for the manual’s diagnostic criteria. The next step, field-testing, helps assess the practical use of proposed DSM-5 criteria in real clinical settings. The revised diagnostic criteria aim to better match children’s actual constellations of symptoms and clarify the best path to treatment.

The Stanford/Packard team will evaluate criteria for two new diagnoses, avoidant-restrictive food intake disorder in patients ages 6-17 and mixed anxiety-depression in patients ages 6-22, as well as two revised diagnoses, major depressive disorder in patients ages 6-22 and autism spectrum disorder in patients ages 6-25. As an important feature of the trial, the scientists will also examine patients with a wide range of other behavioral and emotional problems.

The ages of the subjects reflect a new approach to psychiatric diagnoses for adolescents and young adults. The DSM-IV sharply demarcated between pediatric disorders — those in children younger than 18 — and adult disorders, diagnosed in those ages 18 and up. But the distinction was not useful.

“This change represents an advance in psychiatrists’ recognition that we need continuity of diagnosis and treatment between late childhood and early adulthood,” said Debra Safer, MD, assistant professor of psychiatry and behavioral sciences at Stanford, who will oversee evaluation of patients ages 18-25 in the Stanford/Packard trial.

“One reason we were selected as a field-trial site is that we have strong clinical facilities for both children and adults,” Feinstein added. “We can work together to use the same protocol in a wider age span, carrying people into young adulthood.”

The field trial will evaluate new and existing patients at different stages of treatment using the proposed DSM-5 diagnostic criteria and measures. It will address several important aspects of the proposed diagnostic criteria, including:

• Feasibility: Are the proposed criteria easy for clinicians to understand and to use?

• Clinical utility: Do the proposed criteria do a good job in describing patients’ psychiatric problems and help clinicians make decisions about treatment plans?

• Reliability: Are the same conclusions reached consistently when the criteria are used by different clinicians?

• Validity: How accurately do the diagnostic criteria reflect the mental disorders they are designed to describe?

In addition, the field trials will test new tools that help clinicians evaluate the severity of symptoms, and whether patients are improving over time; as well as “cross-cutting dimensional assessments” that measure symptoms that occur across a wide range of diagnoses, such as sleep problems.

“Field trials help us to assure that good ideas have value in the real world and will bring benefit to real people,” said Laura Roberts, MD, professor and chair of psychiatry and behavioral sciences at Stanford.

The other three sites selected for pediatric field testing are the University of Colorado Children's Hospital, Aurora, Colo.; Tufts University and Baystate Medical Center, Springfield, Mass; and a consortium of Columbia University/New York State Psychiatric Institute, Weill Cornell Medical Center and the North Shore Child and Family Guidance Center, New York, New York. Seven sites have also been chosen for testing of adult diagnoses for the DSM-5.

More information on all of the participating field trial sites and the specific disorders being tested is available on


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