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| Behavioural and emotional disorders |
Behavioural and emotional disorders with
onset usually occurring in childhood and adolescence
Differences in international opinion about the broadness of the concept of hyperkinetic
disorder have been a well-known problem for many years, and were discussed in detail
at the meetings between WHO advisors and other experts held under the auspices of the
WHO-ADAMHA joint project. Hyperkinetic disorder is now defined more broadly in
ICD-10 than it was in ICD-9. The ICD-10 definition is also different in the relative
emphasis given to the constituent symptoms of the overall hyperkinetic syndrome; since
recent empirical research was used as the basis for the definition, there are good reasons
for believing that the definition in ICD-10 represents a significant improvement.
Hyperkinetic conduct disorder (F90.1) is one of the few examples of a combination
category remaining in ICD-10, Chapter V(F). The use of this diagnosis indicates that the
criteria for both hyperkinetic disorder (F90.-) and conduct disorder (F91.-) are fulfilled.
These few exceptions to the general rule were considered justified on the grounds of
clinical convenience in view of the frequent coexistence of those disorders and the
demonstrated later importance of the mixed syndrome. However, it is likely that The
ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic criteria for
research (DCR-10) will recommend that, for research purposes, individual cases in these
categories be described in terms of hyperactivity, emotional disturbance, and severity of
conduct disorder (in addition to the combination category being used as an overall
diagnosis).
Oppositional defiant disorder (F91.3) was not in ICD-9, but has been included in ICD-10
because of evidence of its predictive potential for later conduct problems. There is,
however, a cautionary note recommending its use mainly for younger children.
The ICD-9 category 313 (disturbances of emotion specific to childhood and
adolescence) has been developed into two separate categories for ICD-10, namely
emotional disorders with onset specific to childhood (F93.-) and disorders of social
functioning with onset specific to childhood and adolescence (F94.-). This is because of
the continuing need for a differentiation between children and adults with respect to
various forms of morbid anxiety and related emotions. The frequency with which
emotional disorders in childhood are followed by no significant similar disorder in adult
life, and the frequent onset of neurotic disorders in adults are clear indicators of this - 22 -
need. The key defining criterion used in ICD-10 is the appropriateness to the
developmental stage of the child of the emotion shown, plus an unusual degree of
persistence with disturbance of function. In other words, these childhood disorders are
significant exaggerations of emotional states and reactions that are regarded as normal
for the age in question when occurring in only a mild form. If the content of the
emotional state is unusual, or if it occurs at an unusual age, the general categories
elsewhere in the classification should be used.
In spite of its name, the new category F94.- (disorders of social functioning with onset
specific to childhood and adolescence) does not go against the general rule for ICD-10 of
not using interference with social roles as a diagnostic criterion. The abnormalities of
social functioning involved in F94.- are of a limited number and contained within the
parent-child relationship and the immediate family; these relationships do not have the
same connotations or show the same cultural variations as those formed in the context of
work or of providing for the family, which are excluded from use as diagnostic criteria.
A number of categories that will be used frequently by child psychiatrists, such as eating
disorders (F50.-), nonorganic sleep disorders (F51.-), and gender identity disorders
(F64.-), are to be found in the general sections of the classifications because of their
frequent onset and occurrence in adults as well as children. Nevertheless, clinical
features specific to childhood were thought to justify the additional categories of feeding
disorder of infancy (F98.2) and pica of infancy and childhood (F98.3).
Users of blocks F80-F89 and F90-F98 also need to be aware of the contents of the
neurological chapter of ICD-10 (Chapter VI(G)). This contains syndromes with
predominantly physical manifestations and clear "organic" etiology, of which the
Kleine-Levin syndrome (G47.8) is of particular interest to child psychiatrists.
