Child Psychiatric Problem

F70 - F79  MENTAL RETARDATION

Detailed clinical diagnostic criteria that can be used internationally for research cannot be specified for mental retardation in the same way as they can for most of the other disorders in Chapter V (F). This is because the two main components of mental retardation, namely low cognitive ability and diminished social competence, are both profoundly affected by social and cultural influences in the way that they become manifest. Only general guidance can be given here about the most appropriate methods of assessment to use.

1. Level of cognitive abilities
Understanding, Writing mistakes (b or d), (6 or 9), (W or M), Mathematical
Problems, Logic and Concept.
Category Mental retardation I.Q. range
Mental age
F70 Mild
50-69 9 - under
12 years
F71 Moderate
35-49 6 - under 9 years
F72 Severe
20-34 3 - under 6 years
F73 Profound
under 20 below 3 years
2. Level of social competence
Within most European and American cultures the Vineland Social Maturity Scale is recommended for use, if it is judged to be appropriate (modified versions or equivalent scales need to be developed for use in other cultures).
A fourth character may be used to specify the extent of associated impairment of behaviour.
F7x.0 No, or minimal, impairment of behaviour
F7x.1 Significant impairment of behaviour requiring attention or treatment
F7x.8 Other impairments of behaviour
F7x.9 Without mention of impairment of behaviour
Comments: A specially designed multi-axial system is required to do justice to the variety of personal, clinical and social statements needed for the comprehensive assessment of the causes and consequences of mental retardation.

F80 - F89 DISORDERS OF PSYCHOLOGICAL DEVELOPMENTAL
F80 SPECIFIC DEVELOPMENTAL DISORDERS OF SPEECH AND LANGUAGE
F80.0 Specific speech articulation disorder
Note: Also referred to as Specific speech phonological disorder.
A. Articulation (phonological) skills, as assessed on standardized tests, below the 2 standard deviations limit for the child's age.
B. Articulation (phonological) skills at least 1 standard deviation below nonverbal IQ as assessed on a standardizerd test.
C. Language expression and comprehension, as assessed on a standardized test, within the 2 standard deviation limit for the child's age.
D. Absence of neurological, sensory or physical impairments that directly affect speech sound production, or a pervasive developmental disorder (F84.-).
E. Most commonly used exclusion criterion: Nonverbal IQ below 70 on a standardized test.

F80.1 Expressive language disorder A. Expressive language skills, as assessed on standardized tests, below the 2 standard deviation limit for the child's age.
B. Expressive language skills at least 1 standard deviation below nonverbal IQ as assessed on a standardized test.
C. Receptive language skills, as assessed on standardized tests, within the 2 standard deviation limit for the child's age.
D. Use and understanding of non-verbal communication and imaginative language functions within the normal range.
E. Absence of neurological, sensory or physical impairments that directly affect use of spoken language, or of a pervasive developmental disorder (F84.-).
F. Most commonly used exclusion criterion: Nonverbal IQ below 70 on a standardized test.

F80.2 Receptive language disorder
Note: Also referred to as Mixed receptive/expressive disorder.
A. Language comprehension, as assessed on standardized tests, below the 2 standard deviations limit for the child's age.
B. Receptive language skills at least 1 standard deviation below non-verbal IQ as assessed on a standardized test.
C. Absence of neurological, sensory, or physical impairments that directly affect receptive language, or of a pervasive developmental disorder (F84.-).
D. Most commonly used exclusion criterion: Nonverbal IQ below 70 on a standardized test.

F81 SPECIFIC DEVELOPMENTAL DISORDERS OF SCHOLASTIC SKILLS
F81.0 Specific reading disorder

A. Either (1) or (2):
(1) A score on reading accuracy and/or comprehension that is at least 2 standard errors of prediction below the level expected on the basis of the child's chronological age and general intelligence; with both reading skills and IQ assessed on an individually administered test standardized for the child's culture and educational system.
(2) A history of serious reading difficulties, or test scores that met criteria A (1) at an earlier age, plus a score on a spelling test that is at least 2 standard errors of prediction below the level expected on the basis of the child's chronological age and IQ.

B. The disturbance in A significantly interferes with academic achievement or activities of daily living that require reading skills.
C. Not directly due to a defect in visual or hearing acuity, or to a neurological disorder.
D. School experiences within the average expectable range (i.e. there have been no extreme inadequacies in educational experiences).
E. Most commonly used exclusion criterion: IQ below 70 on an individually administered standardized test.
Possible additional inclusion criterion: For some research purposes investigators may wish to specify: "A history of some level of impairment during the preschool years in speech, language, sound categorization, motor coordination, visual processing, attention or activity control or modulation."
Comments: The above criteria would not include general reading backwardness of a type that would fall within the clinical guidelines. The research diagnostic criteria for general reading backwardness would be the same as for specific reading disorder except that criterium A1 would specify reading skills 2 standard error of prediction below the level expected on the basis of chronological age (i.e. not taking IQ into account), and criterium A2 would follow the same principle for spelling. The validity of the differentiation between these two varieties of reading problems is not unequivocally established but it seems that the specific type has a more specific association with language retardation (whereas general reading backwardness is associated with a wider range of developmental disabilities), and shows a stronger male preponderance.

F81.1 Specific spelling disorder
A. A score on a standardized spelling test that is at least 2 standard errors of prediction below the level expected on the basis of the child's chronological age and general intelligence.
B. Scores on reading accuracy and comprehension, and on arithmetic, that are within the normal range (+ 2 standard deviations from the mean).
C. No history of significant reading difficulties.
D. School experience within the average expectable range (i.e. there have been no extreme inadequacies in educational experiences).
E. Spelling difficulties present from the early stages of learning to spell.
F. The disturbance in A significantly interferes with academic achievement or activities of daily living that require spelling skills.
G. Most commonly used exclusion criterion: IQ below 70 on an individually administered standardized test.

F81.2 Specific disorder of arithmetical skills
A. A score on a standardized arithmetic test that is at least 2 standard errors of prediction below the level expected on the basis of the child's chronological age and general intelligence.
B. Scores on reading accuracy and comprehension, and on spelling that are within the normal range (+ 2 standard deviations from the mean).
C. No history of significant reading or spelling difficulties.
D. School experience within the average expectable range (i.e. there have been no extreme inadequacies in educational experience).
E. Arithmetic difficulties present from the early stages of learning arithmetic.
F. The disturbance in A significantly interferes with academic achievement or activities of daily living that require mathematical skills.
G. Most commonly used exclusion criterion: IQ below 70 on an individually administered standardized test.

F82 SPECIFIC DEVELOPMENTAL DISORDER OF MOTOR FUNCTION
A. A score on a standardized test of fine or gross motor coordination that is at least two standard deviations below the level expected for the child's chronological age.
B. The disturbance in A significantly interferes with academic achievement or activities of daily living.
C. No diagnosable neurological disorder.
D. Most commonly used exclusion criterion: IQ below 70 on an individually administered standardized test.

F84 PERVASIVE DEVELOPMENTAL DISORDERS
F84.0 Childhood autism
(1) receptive or expressive language as used in social communication;
(2) the development of selective social attachments or of reciprocal social interaction;
(3) functional or symbolic play.

B. Qualitative abnormalities in reciprocal social interaction, manifest in at least one of the following areas:
(1) failure adequately to use eye-to-eye gaze, facial expression, body posture and gesture to regulate social interaction;
(2) failure to develop (in a manner appropriate to mental age, and despite ample opportunities) peer relationships that involve a mutual sharing of interests, activities and emotions;
(3) A lack of socio-emotional reciprocity as shown by an impaired or deviant response to other people's emotions; or lack of modulation of behaviour according to social context, or a weak integration of social, emotional and communicative behaviours.

C. Qualitative abnormalities in communication, manifest in at least two of the following areas:
(1) a delay in, or total lack of development of spoken language that is not accompanied by an attempt to compensate through the use of gesture or mime as alternative modes of communication (often preceded by a lack of communicative babbling);
(2) relative failure to initiate or sustain conversational interchange (at whatever level of language skills are present) in which there is reciprocal to and from responsiveness to the communications of the other person;
(3) stereotyped and repetitive use of language or idiosyncratic use of words or phrases;
(4) abnormalities in pitch, stress, rate, rhythm and intonation of speech;

D. Restricted, repetitive, and stereotyped patterns of behaviour, interests and activities, manifest in at least two of the following areas:
(1) an encompassing preoccupation with one or more stereotyped and restricted patterns of interest that are abnormal in content or focus; or one or more interests that are abnormal in their intensity and circumscribed nature although not abnormal in their content or focus.
(2) apparently compulsive adherence to specific, non-functional, routines or rituals;
(3) stereotyped and repetitive motor mannerisms that involve either hand or finger flapping or twisting, or complex whole body movements;
(4) preoccupations with part-objects or non-functional elements of play materials (such as their odour, the feel of their surface, or the noise or vibration that they generate);
(5) distress over changes in small, non-functional, details of the environment.

F84.2 Rett's syndrome
A. Apparently normal prenatal and perinatal period and apparently normal psychomotor development through the first six months and
normal head circumference at birth.
B. Deceleration of head growth between five months and four years and loss of acquired purposeful hand skills between six and 30 months of age that is associated with concurrent communication dysfunction and impaired social interactions and appearance of poorly coordinated/unstable gait and/or trunk movements.
C. Development of severely impaired expressive and receptive language, together with severe psychomotor retardation.
D. Stereotyped midline hand movements (such as hand wringing or washing) with an onset at or after the time that purposeful hand movements are lost.

F84.3 Other childhood disintegrative disorder A. An apparently normal development up to the age of at least two years. The presence of normal age-appropriate skills in communication, social relationships, play, and adaptive behaviour at age two years or later is required for diagnosis.

B. A definite loss of previously acquired skills at about the time of onset of the disorder. The diagnosis requires a clinically significant loss of skills (and not just a failure to use them in certain situations) in at least two out of the following areas:
(1) expressive or receptive language;
(2) play;
(3) social skills or adaptive behaviour;
(4) bowel or bladder control;
(5) motor skills

C. Qualitatively abnormal social functioning, manifest in at least two of the following areas:
(1) qualitative abnormalities in reciprocal social interaction (of the type defined for autism);
(2) qualitative abnormalities in communication (of the type defined for autism);
(3) restricted, repetitive and stereotyped patterns of behaviour, interests and activities including motor stereotypies and mannerisms;
(4) a general loss of interest in objects and in the environment.

F84.5 Asperger's syndrome
A. A lack of any clinically significant general delay in spoken or receptive language or cognitive development. Diagnosis requires that single words should have developed by two years of age or earlier and that communicative phrases be used by three years of age or earlier. Self-help skills, adaptive behaviour and curiosity about the environment during the first three years should be at a level consistent with normal intellectual development. However, motor milestones may be somewhat delayed and motor clumsiness is usual (although not a necessary diagnostic feature). Isolated special skills, often related to abnormal preoccupations, are common, but are not required for diagnosis.
B. Qualitative abnormalities in reciprocal social interaction (criteria as for autism).
C. An unusually intense circumscribed interest or restricted, repetitive, and stereotyped patterns of behaviour, interests and activities (criteria as for autism; however it would be less usual for these to include either motor mannerisms or preoccupations with part- objects or non-functional elements of play materials).

F90 - F98 BEHAVIOURAL AND EMOTIONAL DISORDERS WITH ONSET USUALLY OCCURRING IN CHILDHOOD AND ADOLESCENCE
F90 HYPERKINETIC DISORDERS

Note: The research diagnosis of hyperkinetic disorder requires the definite presence of abnormal levels of inattention and restlessness that are pervasive across situations and persistent over time, that can be demonstrated by direct observation, and that are not caused by other disorders such as autism or affective disorders.
Eventually, assessment instruments should develop to the point where it is possible to take a quantitative cut-off score on reliable valid and standardised measures of hyperactive behaviour in the home and classroom, corresponding to the 95th percentile on both measures. Such criteria would then replace G1 and G2 below.
G1. Demonstrable abnormality of attention, activity and impulsivity at home, for the age and developmental level of the child, as evidenced by (1), (2) and (3):
(1) at least three of the following attention problems:
(a) short duration of spontaneous activities;
(b) often leaving play activities unfinished;
(c) over-frequent changes between activities;
(d) undue lack of persistence at tasks set by adults;
(e) unduly high distractibility during study e.g. homework or reading assignment;
(2) plus at least three of the following activity problems:
(a) very often runs about or climbs excessively in situations where it is inappropriate; seems unable to remain still;
(b) markedly excessive fidgeting & wriggling during spontaneous activities;
(c) markedly excessive activity in situations expecting relative stillness (e.g. mealtimes, travel, visiting, church);
(d) often leaves seat in classroom or other situations when remaining seated is expected;
(e) often has difficulty playing quietly.
(3) plus at least one of the following impulsivity problems:
(a) often has difficulty awaiting turns in games or group situations;
(b) often interrupts or intrudes on others (e.g. butts in to others' conversations or games);
(c) often blurts out answers to questions before questions have been completed.

G2. Demonstrable abnormality of attention and activity at school or nursery (if applicable), for the age and developmental level of the child, as evidenced by both (1) and (2):
(1) at least two of the following attention problems:
(a) undue lack of persistence at tasks;
(b) unduly high distractibility, i.e. often orienting towards extrinsic stimuli;
(c) over-frequent changes between activities when choice is allowed;
(d) excessively short duration of play activities;

(2) and by at least three of the following activity problems:
(a) continuous (or almost continuous) and excessive motor restlessness (running, jumping, etc.) in situations allowing free activity;
(b) markedly excessive fidgeting and wriggling in structured situations;
(c) excessive levels of off-task activity during tasks;
(d) unduly often out of seat when required to be sitting;
(e) often has difficulty playing quietly.

G3. Directly observed abnormality of attention or activity. This must be excessive for the child's age and developmental level. The evidence may be any of the following:
(1) direct observation of the criteria in G1 or G2 above, i.e. not solely the report of parent or teacher;
(2) observation of abnormal levels of motor activity, or off-task behaviour, or lack of persistence in activities, in a setting outside home or school (e.g. clinic or laboratory);
(3) significant impairment of performance on psychometric tests of attention.

G4. Does not meet criteria for pervasive developmental disorder (F84), mania (F30), depressive (F32) or anxiety disorder (F41).
G5. Onset before the age of seven years.
G6. Duration of at least six months.
G7. IQ above 50.

F91 CONDUCT DISORDER
The criterion list below apply to all subcategories of F91:
(1) Unusually frequent or severe temper tantrums for the child's developmental level.
(2) Often argues with adults.
(3) Often actively defies or refuses adults' requests or rules.
(4) Often, apparently deliberately, does things that annoy other people.
(5) Often blames others for one's own mistakes or misbehaviour.
(6) Often touchy or easily annoyed by others.
(7) Often angry or resentful.
(8) Often spiteful or vindictive.
(9) Frequent and marked lying (except to avoid abusive treatment).
(10) Excessive fighting with other children, with frequent initiation of fights (not including fights with siblings).
(11) Uses a weapon that can cause serious physical harm to others (e.g. a bat, brick, broken bottle, knife, gun).
(12) Often stays out after dark without permission (beginning before 13 years of age).
(13) Physical cruelty to other people (e.g. ties up, cuts or burns a victim).
(14) Physical cruelty to animals.
(15) Deliberate destruction of others' property (other than by fire-setting).
(16) Deliberate fire-setting with a risk or intention of causing serious damage.
(17) At least two episodes of stealing of objects of value (e.g. money) from home (excluding taking of food).
(18) At least two episodes of stealing outside the home without confrontation with the victim (e.g. shoplifting, burglary or forgery).
(19) Frequent truancy from school beginning before 13 years of age.
(20) Running away from home (unless this was to avoid physical or sexual abuse).
(21) Any episode of crime involving confrontation with a victim (including purse snatching, extortion, mugging).
(22) Forcing another person into sexual activity against their wishes.
(23) Frequent bullying of others (i.e. deliberate infliction of pain or hurt including persistent intimidation, tormenting, or molestation).
(24) Breaks into someone else's house, building or car.

Specification for possible subdivisions
Authorities differ on the best way of subdividing the conduct disorders, though most agree that they are heterogeneous. For determining prognosis, the severity (indexed by number of symptoms) is a better guide than the precise type of symptomatology. The best-validated distinction is that between socialized and unsocialized disorders, defined by the presence or absence of lasting peer friendships. However, it seems that disorders confined to the home may also constitute a meaningful subvariety and a category is provided for this purpose. It is clear that further research is needed to test the validity of all proposed subdivisions of conduct disorder.

F93.0 Separation anxiety disorder of childhood
A. At least three of the following:

(1) Unrealistic and persistent worry about possible harm befalling major attachment figures or the loss of such figures (e.g. fear that they will leave and not return or that the child will not see them again) or persistent concerns about death of attachment figures.
(2) Unrealistic and persistent worry that some untoward event will separate the child from a major attachment figure (e.g. as by the child getting lost, kidnapped, admitted to the hospital, or killed).
(3) Persistent reluctance or refusal to go to school because of fear over separation from a major attachment figure or in order to stay at home (rather than for other reasons such as fear over happenings at school).
(4) Difficulty separating at night as manifested by any of the following:
(a) persistent reluctance or refusal to go to sleep without being near an attachment figure;
(b) often getting up during the night to check on, or to sleep near an attachment figure;
(c) persistent reluctance or refusal to sleep away from home.
(5) Persistent inappropriate fear of being alone, or otherwise without the major attachment figure at home during the day.
(6) Repeated nightmares about separation.
(7) Repeated occurrence of physical symptoms (such as nausea, stomachache, headache, or vomiting) on occasions that involve separation from a major attachment figure, such as leaving home to go to school or
on other occasions where anticipating a separation (holiday, camps, etc.).
(8) Excessive, recurrent distress in anticipation of, or during, or immediately following, separation from a major attachment figure (as shown by: anxiety, crying, tantrums; persistent reluctance to go away from home; excessive need to talk with parents or desire to return home; misery, apathy or social withdrawal).
B. Absence of generalized anxiety disorder of childhood (F93.80).
C. Onset before the age of six.
D. The disorder does not occur as part of a broader disturbance of emotions, conduct, personality, or of a pervasive developmental disorder, psychotic disorder, psychoactive or substance use disorder.
E. Duration of at least four weeks.

F93.3 Sibling rivalry disorder
A. Abnormally intense negative feelings towards an immediately younger sibling.
B. Emotional disturbance as shown by regression, tantrums, dysphoria, sleep difficulties, oppositional behaviour or attention-seeking behaviour with one or both parents (two or more of these must be present).
C. Onset within six months of the birth of an immediately younger sibling.
D. Duration of at least four weeks.

F94 DISORDERS OF SOCIAL FUNCTIONING WITH ONSET SPECIFIC TO CHILDHOOD AND ADOLESCENCE
F94.0 Elective mutism

Note: Also referred to as Selective mutism.
A. Language expression and comprehension, as assessed on individually administered standardized tests, within the 2 standard deviation limit for the child's age.
B. Demonstrable evidence of a consistent failure to speak in specific social situations in which there is an expectation that the child would speak (e.g. in school), despite speaking in other situations.
C. Duration of selective mutism that exceeds four weeks.
D. Absence of a pervasive developmental disorder (F84.-), or a specific speech or language disorder (F80.-) and absence of a lack of fluency in the language that is expected to be spoken in the situation (e.g. because it is a second language for the child).

F95 TIC DISORDERS
F95.0 Transient tic disorder
A. Single or multiple motor or vocal tic(s) or both, that occur many times a day, most days over a period of at least four weeks.
B. Duration twelve months or less.
C. No history of Tourette syndrome, and not due to physical conditions or side effect of medication.
D. Onset before age 18 years.

F95.1 Chronic motor or vocal tic disorder
A. Motor or vocal tics, but not both, that occur many times per day, most days over a period of at least twelve months.
B. No period of remission during that year lasting longer than two months.
C. No history of Tourette syndrome, and not due to physical conditions or side effect of medication.
D. Onset before age 18 years.

F95.2 Combined vocal and multiple motor tic disorder [de la Tourette's syndrome]
A. Multiple motor tics and one or more vocal tics that have been present at some time during the disorder, but not necessarily concurrently.
B. The frequency of tics must be many times a day, nearly every day for more than one year, with no period of remission during that year lasting longer than two months.
C. Onset before 18 years of age.
F95.8 Other tic disorders
F95.9 Tic disorder, unspecified
A non-recommended residual category for a disorder that fulfils the general criteria for a tic disorder but in which the specific subcategory is not specified or in which the features do not fulfil the criteria for F95.0, F95.1 or F95.2.

F98 OTHER EMOTIONAL AND BEHAVIOURAL DISORDERS WITH ONSET USUALLY OCCURRING IN CHILDHOOD
F98.0 Nonorganic enuresis
A. Child aged at least five years, with a mental age of at least four years.
B. Involuntary voiding of urine that occurs at a frequency of at least twice a month in children aged under seven years, and at least once per month in children aged seven or above.
C. Enuresis not a consequence of epileptic attacks, or of neurological incontinence, and not a direct consequence of structural abnormalities of the urinary tract or any other nonpsychiatric medical condition.
D. No other psychiatric disorder that meets the criteria for other ICD-10 categories.
E. Duration of at least three months.
A fifth character may be used, if desired, for further specification:
F98.00 Nocturnal enuresis only
F98.01 Diurnal enuresis only
F98.02 Nocturnal and diurnal enuresis

F98.l Nonorganic encopresis
A. Repeated passage of faeces in places that are not appropriate for that purpose (e.g. clothing, floor), whether involuntary or intentional. (The disorder may involve overflow incontinence secondary to functional faecal retention).
B. A chronological and mental age of at least four years.
C. At least one encopretic event per month.
D. Duration of at least six months.
E. Absence of an organic condition that constitutes a sufficient cause for the encopretic events.
A fifth character may be used, if desired, for further specification:
F98.10 Failure to acquire physiological bowel control.
F98.11 Adequate bowel control by normal faeces deposited in inappropriate places.
F98.12 Soiling that is associated with excessively fluid faeces, such as with retention with overflow.

F98.2 Feeding disorder of infancy and childhood
A. Persistent failure to eat adequately, or persistent rumination or regurgitation of food.
B. Failure to gain weight or loss of weight or other significant health problem over a period of at least one month (in view of the frequency of transient eating difficulties, researchers may prefer a minimum duration of three months for some purposes).
C. Onset of the disorder before age six.
D. Absence of other mental and behavioural disorders in ICD-10 (other than mental retardation (F7)).
E. No organic disease sufficient to account for the failure to eat.

F98.3 Pica of infancy and childhood
A. Persistent or recurrent eating of non-nutritive substances, at a frequency of at least twice per week.
B. Duration of at least one month (for some purposes researchers may prefer a minimum period of three months).
C. Absence of any other mental and behavioural disorders in ICD-10 (other than mental retardation (F7)).
D. A chronological and mental age of at least two years.

F98.5 Stuttering [stammering]
A. Stuttering (i.e. speech, characterized by frequent repetition or prolongation of sounds or syllables or words, or by frequent hesitations or pauses) that is persistent or recurrent and of severity sufficient to markedly disrupt the fluency of speech.
B. Duration of at least three months.

F98.6 Cluttering
A. Cluttering (i.e. a rapid rate of speech with breakdown in fluency, but no repetitions or hesitations) that is persistent or recurrent and of a severity sufficient to give rise to significantly reduced speech intelligibility.
B. Duration of at least three months.