Multiaxial Classification of Child and Adolescent Psychiatric Disorders : The ICD-10 Classification of Mental and Behavioural Disorders in Children and Adolescents

310 Pages·1997·55.813 MB·English

by  World Health Organisation., Sir Michael Rutter

Diagnosis within psychiatry necessarily involves consideration of a
number of different clinical features. In making a diagnosis, individual
psychiatrists tend to vary in the weight they attach to associated psy-
chosocial adversities, or to learning difficulties or to accompanying
somatic disease. By dealing with these features on axes that are separate
from the psychopathological pattern or syndrome, it has proved possible
to record clinically useful information in a manner that is both more
comprehensive and more comparable than that in the usual disease cate-
gory approach.
This volume provides the psychiatric sections of ICD-10 in a multi-
axial form that is adapted for ease of use of those dealing with mental
disorders in childhood and adolescence. Descriptions have been grouped
into axes that have been chosen to provide unambiguous information of
maximum clinical usefulness in the greatest number of cases. Building
on the popular original framework of four axes, the system has been
greatly improved by the inclusion of a new axis for psychosocial situa-
tions and by the addition of a further sixth axis on adaptive level, which
enables clinicians to code an individual's current level of disability.

Multiaxial classification of child and
adolescent psychiatric disorders
The ICD-10 classification of mental and behavioural
disorders in children and adolescents

WORLD HEALTH ORGANIZATION
Multiaxial classification
of child and adolescent
psychiatric disorders
The ICD-10 classification of mental and behavioural
disorders in children and adolescents
with an introduction by
PROFESSOR SIR MICHAEL RUTTER
CAMBRIDGE
UNIVERSITY PRESS
CAMBRIDGE UNIVERSITY PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, Sao Paulo
Cambridge University Press
The Edinburgh Building, Cambridge CB2 8RU, UK
Published in the United States of America by Cambridge University Press, New York
www.cambridge.org
Information on this title: www.cambridge.org/9780521581332
© World health Organization 1996
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 1996
Reprinted 2002
This digitally printed version 2008
A catalogue record for this publication is available from the British Library
Library of Congress Cataloguing in Publication data
World Health organization.
Multiaxial classification of child and adolescent psychiatric
disorders: the ICD-10 classification of mental and behavioural
disorders in children and adolescents / World Health Organization;
with an introduction by Sir Michael Rutter.
p. cm.
Includes index.
ISBN 0 521 58133 8 (hardback)
1. child psychopathology - Classification. I. Title.
[DNLM: 1. Mental Disorders - classification. 2. Mental disorders -
in infancy & Childhood. 3. Mental Disorders - in adoloscence. WM
15 W927m 1996]
RJ504.W67 1996
618.92'89'0012-dc20
DNLM/DLC
for Library of Congress 96-25102 CIP
ISBN 978-0-521-58133-2 hardback
ISBN 978-0-521-06577-1 paperback
Contents
Introduction 1
Principles of a multi-axial framework 2
Use of the Guide - General 3
- Axis One: Clinical Psychiatric Syndromes 4
- Axis Two: Specific Disorders of Psychological Development 6
- Axis Three: Intellectual Level 6
- Axis Four: Medical Conditions 7
- Axis Five: Associated Abnormal Psychosocial Situations 7
- Axis Six: Global Assessment of Psychosocial Disability 8
Axis One (Clinical psychiatric syndromes) 11
List of categories 11
XX No psychiatric disorder 11
F84 Pervasive developmental disorders 14
F90-F98 Behavioural and emotional disorders with onset usually
occurring in childhood or adolescence 22
F00-F09 Organic, including symptomatic, mental disorders 52
F10-F19 Mental and behavioural disorders due to psychoactive substance use 54
F20-F29 Schizophrenia, schizotypal and delusional disorders 59
F30-F39 Mood [affective] disorders 81
F40-F48 Neurotic, stress-related and somatoform disorders 99
F50-F59 Behavioural syndromes associated with physiological
disturbances and physical factors 138
F60-F69 Disorders of adult personality and behaviour 157
F99 Unspecified mental disorder and problems falling short of
criteria for any specified mental disorder 175
Axis Two (Specific disorders of psychological development) 177
List of categories 177
XX No specific disorder of psychological development 177
F80 Specific developmental disorders of speech and language 178
F81 Specific developmental disorders of scholastic skills 185
F82 Specific developmental disorder of motor function 193
F83 Mixed specific developmental disorders 195
F88 Other disorders of psychological development 195
F89 Unspecified disorder of psychological development 195
VIII Contents
Axis Three (Intellectual level) 197
XX Intellectual level within the normal range 197
F70 Mild mental retardation 199
F71 Moderate mental retardation 200
F72 Severe mental retardation 201
F73 Profound mental retardation 201
F78 Other mental retardation 202
F79 Unspecified mental retardation 202
Axis Four (Medical conditions from ICD-10 often associated with mental
and behavioural disorders) 203
Axis Five (Associated abnormal psychosocial situations) 221
List of categories 221
00 No significant distortion or inadequacy of the psychosocial
environment 225
1 Abnormal intrafamilial relationships 226
2 Mental disorder, deviance or handicap in the child's primary
support group 232
3 Inadequate or distorted intrafamilial communication 236
4 Abnormal qualities of upbringing 237
5 Abnormal immediate environment 247
6 Acute life events 254
7 Societal stressors 264
8 Chronic interpersonal stress associated with school / work 266
9 Stressful events/situations resulting from the child's own
disorder/disability 268
Axis Six (Global assessment of psychosocial disability) 271
0 Superior/good social functioning 271
1 Moderate social functioning 272
2 Slight social disability 272
3 Moderate social disability 272
4 Serious social disability 272
5 Serious and pervasive social disability 272
6 Unable to function in most areas 272
7 Gross and pervasive social disability 272
8 Profound and pervasive social disability 272
Acknowledgements 273
Index 275
Introduction
by Professor Sir Michael Rutter
Some 25 years ago, a World Health Organization seminar produced
findings that argued for a multiaxial approach to the classification of
child psychiatric disorder (1). At that time three axes were proposed:
clinical psychiatric syndromes, level of intellectual function and associ-
ated or etiological factors (physical or environmental). Subsequently, the
suggestions included dividing this third axis into its two parts. In 1975,
WHO published a report of trials of these four axes, the first three of
which were taken from the Eighth Edition of the International
Classification of Diseases ICD-8 (2). These trials indicated the increased
reliability associated with the use of the axes. Later in 1975 a multiaxial
schema was introduced in the United Kingdom adding yet one further
axis for specific developmental disorders, which had previously been
included with 'biological factors'. This schema was based on the newly
introduced ICD-9, with a relatively simple list of associated psychoso-
cial situations. Subsequent studies indicated that the reliability of the
psychosocial axis was unacceptably low, and with the prospects that a
new edition of the ICD would be appearing in the 1990s, a working
group was set up to redraft the psychosocial axis, following the same
principles used for the psychiatric disorders in ICD-10. This means that
this axis includes a much more detailed specification of the criteria to be
used for coding each of the separately identified psychosocial stressors.
This book, then, provides a classification of child and adolescent psy-
chiatric disorders that uses the tenth revision of the International
Classification of Diseases (ICD-10), but which places it in a multiaxial
framework. The first four axes use precisely the same diagnostic cate-
gories as in ICD-10, and the same numerical coding, but the categories
have been placed in a somewhat different order so that they fit in with
the muiti-axial format, and so that those most applicable to children and
adolescents appear first. The fifth axis (associated abnormal psychoso-
cial situations) comprises a set of features that are included in ICD-10 as
various 'Z' codes, but are set out in much more detail in this book. The
development of this axis has been described elsewhere (3). The sixth
axis (global assessment of psychosocial disability) is the only one that is
not included as such in ICD-10. It has been added here, however,
Introduction
because the assessment of disability has been recognized by WHO as an
essential feature in psychiatry (4). The axis is based on the Global
Assessment of Disabilities Scale included in the ICD-10 field trials
which, in turn, was derived from the fifth axis in DSM-III-R (5). The
scale has been slightly modified to make it more appropriate for use with
children and adolescents. Its inclusion here should be regarded as a first
step towards the development of a systematic scheme for assessing
social disability in children and adolescents with psychiatric disorder.
It should be noted that there is a different WHO multiaxial classifica-
tion for adult psychiatric disorders, comprising just three axes (10).
Principles of a multiaxial framework
Psychiatric diagnosis necessarily involves several different elements. Thus,
it may be desirable to note the type of mental disorder, whether or not there
is mental retardation, and the presence or absence of associated organic
brain disease. In most cases, there is no single diagnostic term that will
include all these and it is necessary to use multiple codings. Of course, the
ICD makes provision for this but there are no rules as to how many cate-
gories to use or the order in which they should be placed. It has been found
that, in practice, psychiatrists vary greatly in their use of multiple categories
(1,2). This has the result that when a condition is not coded it may mean that
the condition was not present, that it was present but not thought important,
or that it was not coded in spite of being thought important. Moreover, there
is no way of determining from the coding which was the case.
The multiaxial scheme was designed to remedy these deficiencies. In
fact, it is no more than a logical development of the ICD multi-category
scheme in which modifications have been introduced specifically to
meet the difficulties noted above. To ensure adequate coverage of data,
and to ensure comparability, three rules are required: (i) a uniform num-
ber of diagnostic elements must be coded (each element having a sepa-
rate axis); (ii) these codings must always refer to the same elements in
diagnosis; and (iii) they must always occur in the same order.
An infinite variety of elements of diagnosis could be included in such
a multiaxial scheme, but for it to be workable in practice, there must be a
quite restricted number of axes. These need to be chosen on the basis of
providing unambiguous information of maximum clinical usefulness in
the greatest number of cases. With regard to child and adolescent psychi-
atry, the axes that were selected refer to the clinical psychiatric syn-
drome (anorexia nervosa, childhood autism, etc.), to the presence or