Intellectual Development Disorders

DSM-IV-TR Diagnostic Criteria

Mental Retardation

Mental retardation has many different etiologies and may be seen as a final common
pathway of various pathological processes that affect the functioning of the central nervous
system.

Slide 1:

The essential feature of Mental Retardation is significantly below average general

intellectual functioning (Criterion A)

Intellectual functioning: = the intelligence quotient (IQ) obtained by assessment with one or
more of the standardised, individually administered intelligence tests (e.g. WISC, Stanford-
Binet, Kaufman Assessment Battery for Children).

Significantly sub-average intellectual functioning is defined as an IQ of about 70 or below

(approximately 2 standard deviations below the mean).

It should be noted that there is measurement of error of approximately 5 points in assessing

IQ (may vary from instrument to instrument). Therefore is a child has an IQ of 75 but
displays deficits in adaptive behaviour it is still possible to diagnose them with mental
retardation. However, if a child has an IQ of 70 but does not display significant deficits or
impairments in adaptive functioning then mental retardation should not be diagnosed.

This is accompanied by significant limitations in adaptive functioning in at least two of the

following skill areas: (Criterion B).

Adaptive functioning:

- Concurrent deficits or impairments in present adaptive functioning (i.e. person’s

effectiveness in meeting the standards expected for his or her age by his or her
cultural group) in at least two of the following areas: communication, self-care,
home living, social / interpersonal skills, use of community resources, self-direction,
functional academic skills, work, leisure, health, and safety.

- Adaptive functioning impairments are usually the presenting symptom in individuals

with MR.

- Refers to how effectively individuals cope with common life demands and how well
they meet the standards of personal independence expected of someone in their
particular age group, sociocultural background, and community setting.

- It can be influenced by a number of factors including: education, motivation,

personality characteristics, social and vocational opportunities, and the mental
disorders and general medical conditions that may coexist with MR.
 - PROBLEMS WITH ADAPTATION ARE MORE LIKLEY TO IMPROVE WITH REMEDIAL
EFFORTS THAN THE COGNITIVE IQ WHICH TENDS TO REMAIN A MORE STABLE
ATTRIBUTE.

The onset must occur before age 18 years (Criterion C).

Slide 2
Mild Mental Retardation
 IQ level 50-55 to approximately 70

Moderate Mental Retardation

 IQ level 35-40 to 50-55

Severe Mental Retardation

 IQ level 20-25 to 35-40

Profound Mental Retardation

 IQ level below 20 or 25

DSM-V Diagnostic Criteria

Updated April, 2012

Intellectual Developmental Disorder (IDD) is a disorder that includes both a current

intellectual deficit and a deficit in adaptive functioning with onset during the developmental
period. The following 3 criteria must be met:

A. Intellectual Developmental Disorder is characterized by deficits in general mental

abilities such as reasoning, problem-solving, planning, abstract thinking, judgment,
academic learning and learning from experience.

B. Impairment in adaptive functioning for the individual’s age and sociocultural

background. Adaptive functioning refers to how well a person meets the standards of
personal independence and social responsibility in one or more aspects of daily life
activities, such as communication, social participation, functioning at school or at work, or
personal independence at home or in community settings. The limitations result in the need
for ongoing support at school, work, or independent life.

C. All symptoms must have an onset during the developmental period

Rationale for the name change and placement of IQ testing in the text in DSM-5:
Slide 5:

1. Name change.

Mental Retardation is no longer used internationally or in U.S. federal legislation, so a name

change is required in DSM-5.
This term is used by the AAIDD (American Association for Intellectual Development
Disorders).

WHO = Criteria = developed to define ID as a functional disorder, explicitly in keeping with

the WHO International Classification of Functioning (ICF). The ICF is a classification of
disability, unlike DSM. Rather, DSM is a classification of diseases and disorders. The DSM-5
criteria are harmonized with the International Classification of Diseases (ICD), not with the
ICF.

ICD-11: the DSM-5 Intellectual Developmental Disorder is classified as a

neurodevelopmental disorder of brain development. There are deficits in cognitive capacity
beginning in the developmental period.

Analogous to the DSM-5 category Neurocognitive Disorder (in DSM-IV, dementia) where
onset is typically later in life, there is loss of prior cognitive capacity, and degeneration is
often a feature.

THEREFORE: The term IDD was chosen to be consistent with DSM-5 as a classification of
disorders and to harmonize this diagnosis with the proposed ICD-11.

2. IQ testing moved to the body of the text in the DSM5. In DSM-5, IQ test scores, and
standard deviations from the mean on those tests, included in the diagnostic criteria for
mental retardation in DSM-IV have been moved to the body of the text. However, DSM-5
continues to specify that standardized psychological testing must be included in the
assessment of affected persons, consistent with the AAIDD definition, but that psychological
testing should accompany clinical assessment. The DSM-5 proposal is consistent with the
proposed ICD-11 criteria which do not list IQ test score requirements in the formal
diagnostic criteria and instead place testing requirements in the text.

There are several reasons for this move in DSM-5.

a. Definition of Intelligence. Both the AAIDD and DSM-5 define intelligence as a

general mental ability that involves reasoning, problem solving, planning, thinking
abstractly, comprehending complex ideas, judgment, academic learning, and
learning from experience.

a. In DSM-5, the definition is applied to reasoning in three contexts: academic

learning, social understanding, and practical understanding.

b. Critical components of intelligence include verbal comprehension, working

memory, perceptual reasoning, and cognitive efficacy. These critical
components are identical in the DSM-5 proposal and in ICD-11.

b. The diagnosis of IDD is based on both clinical assessment and standardized testing of
intelligence. The definition of intelligence in DSM-5 is based on the definition of
intelligence from the AAIDD 2010 manual (p. 15). In DSM-5, this definition has been
moved from the text to the diagnostic criteria. This change is necessary to focus on
the clinical entity, IDD. In DSM-IV, mental retardation was an Axis II diagnosis. With
the elimination of the multiaxial classification, IDD in DSM-5 is an Axis I diagnosis and
 clinical diagnostic features require specification. Moving toward a more clinical
diagnosis for IDD.

c. Moreover, the IQ test number has often been used inappropriately to define a
person’s overall ability in forensic cases without adequately considering adaptive
functioning. The clearest example is the Supreme Court decision in Atkins vs. Virginia
(http://en.wikipedia.org/wiki/Atkins_v._Virginia ). Deemed unfit for the death
penalty because of his IQ but was later retested and found eligible.

d. IQ tests in DSM-5. Intellectual functioning is typically measured using standardized

tests of intellectual function. On such tests, the category of IDD is considered to be
approximately 2 standard deviations below the population mean. This level of
impairment equates to an Intelligence Quotient (IQ) score of 70 or below, with a
measurement error of approximately 5 points on each side of the cut point.

a. Assessment procedures and diagnosis must take into account factors other
than IDD that may limit performance (e.g., sociocultural background, native
language, associated communication/language disorder, motor or sensory
handicap). Cognitive profiles are generally more useful for describing
intellectual abilities than a single full-scale IQ score, and clinical training and
judgment are required for interpretation of test results.

e. Elimination of IQ based Subtypes. DSM-5 does not list mild, moderate, severe, and
profound subtypes. Instead, it lists mild, moderate, and severe severity levels.
(Having a profound level or severe/profound is under continued discussion.). A table
is provided with examples of each of these levels of severity. The focus in the
severity levels is on adaptive functioning and not IQ test scores. The criterion for
impairment is adaptive functioning is listed in section 3 that follows.

3. Criterion B for IDD requires significant impairment in adaptive functioning.

Adaptive functioning refers to how well an individual copes with the common tasks of
everyday life in three general domains (i.e., conceptual, social, and practical), and how well
an individual meets the standards of personal independence and social responsibility
expected for someone of a similar age, sociocultural background, and community setting in
one or more aspects of daily life activities, such as communication, social participation,
functioning at school or at work, or personal independence at home or in community
settings.

In IDD, an individual’s adaptive behavior limitations result in the need for ongoing support at
school, work, or independent life. A wide range of skills are contained within the three
domains of adaptive behavior. The conceptual domain involves skills in language, reading,
writing, math, reasoning, knowledge, and memory, among others, used to solve problems.
The social domain involves awareness of others’ experiences, empathy, interpersonal
communication skills, friendship abilities, social judgment, and self-regulation, among
others. The practical domain involves self management across life settings, including
personal care, job responsibilities, money management, recreation, managing one’s
behavior, and organizing school and work tasks, among others.
1. Name change. The term mental retardation was used in DSM-IV and in earlier DSM
definitions. Mental Retardation is no longer used internationally or in U.S. federal
legislation, so a name change is required in DSM-5. The term Intellectual Disability (ID) is
widely used. This term is used by the AAIDD and criteria have been developed to define ID
as a functional disorder, explicitly in keeping with the WHO International Classification of
Functioning (ICF). The ICF is a classification of disability, unlike DSM. Rather, DSM is a
classification of diseases and disorders. The DSM-5 criteria are harmonized with the
International Classification of Diseases (ICD), not with the ICF. Thus, the DSM-5 Intellectual
Developmental Disorder is classified as a neurodevelopmental disorder of brain
development. Its inclusion in the manual is analogous to the DSM-5 category
Neurocognitive Disorder (in DSM-IV, dementia) where onset is typically later in life, there is
loss of prior cognitive capacity, and degeneration is often a feature. In Intellectual
Developmental Disorder (IDD), there are deficits in cognitive capacity beginning in the
developmental period. The term IDD was chosen to be consistent with DSM-5 as a
classification of disorders and to harmonize this diagnosis with the proposed ICD-11.

2. IQ testing moved to the body of the text in the DSM5. In DSM-5, IQ test scores, and
standard deviations from the mean on those tests, included in the diagnostic criteria for
mental retardation in DSM-IV have been moved to the body of the text. However, DSM-5
continues to specify that standardized psychological testing must be included in the
assessment of affected persons, consistent with the AAIDD definition, but that psychological
testing should accompany clinical assessment. The DSM-5 proposal is consistent with the
proposed ICD-11 criteria which do not list IQ test score requirements in the formal
diagnostic criteria and instead place testing requirements in the text. There are several
reasons for this move in DSM-5.

a. The diagnosis of IDD is based on both clinical assessment and standardized testing
of intelligence. The definition of intelligence in DSM-5 is based on the definition of
intelligence from the AAIDD 2010 manual (p. 15). In DSM-5, this definition has been moved
from the text to the diagnostic criteria. This change is necessary to focus on the clinical
entity, IDD. In DSM-IV, mental retardation was an Axis II diagnosis. With the elimination of
the multiaxial classification, IDD in DSM-5 is an Axis I diagnosis and clinical diagnostic
features require specification.

Moreover, the IQ test number has often been used inappropriately to define a person’s
overall ability in forensic cases without adequately considering adaptive functioning. The
clearest example is the Supreme Court decision in Atkins vs. Virginia
(http://en.wikipedia.org/wiki/Atkins_v._Virginia ). In that case, the execution of individuals
with mental retardation was deemed a violation of the United States Constitution’s Eighth
Amendment ban on cruel and unusual punishment. Despite this decision, Mr. Atkins, the
defendant, was retested on standardized IQ tests after several years in prison. His IQ score
on the next testing was above 70, which was considered high enough to make him eligible
for the death penalty. Fortunately for Mr. Atkins, due to evidence of prosecutorial
misconduct, his execution was commuted and he was given life imprisonment.

b. Definition of Intelligence. Both the AAIDD and DSM-5 define intelligence as a

general mental ability that involves reasoning, problem solving, planning, thinking
abstractly, comprehending complex ideas, judgment, academic learning, and learning from
experience. In DSM-5, the definition is applied to reasoning in three contexts: academic
learning, social understanding, and practical understanding. Critical components of
intelligence include verbal comprehension, working memory, perceptual reasoning, and
cognitive efficacy. These critical components are identical in the DSM-5 proposal and in ICD-
11.

c. IQ tests in DSM-5. Intellectual functioning is typically measured using

standardized tests of intellectual function. On such tests, the category of IDD is considered
to be approximately 2 standard deviations below the population mean. This level of
impairment equates to an Intelligence Quotient (IQ) score of 70 or below, with a
measurement error of approximately 5 points on each side of the cut point. Assessment
procedures and diagnosis must take into account factors other than IDD that may limit
performance (e.g., sociocultural background, native language, associated
communication/language disorder, motor or sensory handicap). Cognitive profiles are
generally more useful for describing intellectual abilities than a single full-scale IQ score, and
clinical training and judgment are required for interpretation of test results.

d. Elimination of IQ based Subtypes. DSM-5 does not list mild, moderate, severe,
and profound subtypes. Instead, it lists mild, moderate, and severe severity levels. (Having a
profound level or severe/profound is under continued discussion.). A table is provided with
examples of each of these levels of severity. The focus in the severity levels is on adaptive
functioning and not IQ test scores. The criterion for impairment is adaptive functioning is
listed in section 3 that follows.

3. Criterion B for IDD requires significant impairment in adaptive functioning. Adaptive

functioning refers to how well an individual copes with the common tasks of everyday life in
three general domains (i.e., conceptual, social, and practical), and how well an individual
meets the standards of personal independence and social responsibility expected for
someone of a similar age, sociocultural background, and community setting in one or more
aspects of daily life activities, such as communication, social participation, functioning at
school or at work, or personal independence at home or in community settings. In IDD, an
individual’s adaptive behavior limitations result in the need for ongoing support at school,
work, or independent life. A wide range of skills are contained within the three domains of
adaptive behavior. The conceptual domain involves skills in language, reading, writing,
math, reasoning, knowledge, and memory, among others, used to solve problems. The
social domain involves awareness of others’ experiences, empathy, interpersonal
communication skills, friendship abilities, social judgment, and self-regulation, among
others. The practical domain involves self management across life settings, including
personal care, job responsibilities, money management, recreation, managing one’s
behavior, and organizing school and work tasks, among others.
 Conceptual Domain Social Domain Practical Domain

For preschool children, there may be no Compared to typically developing agemates, the person is Person may function age-appropriately in personal
obvious conceptual differences. For school- immature in social interactions. For example, there may be care, though in childhood these skills may not be age-
aged children and adults, person has difficulty in accurately perceiving peers’ social cues. appropriate. Persons need some support with complex
difficulties and limitations in acquisition of Communication and language are more concrete than tasks in comparison to peers. In adulthood supports
academic skills involving reading, writing, expected for age. There may be difficulties regulating typically involve grocery shopping, transportation,
arithmetic, time, money, and needs support emotion and behavior in age-appropriate fashion. These organizing home and childcare, nutritious food
in at least some of these areas in order to difficulties are noticed and are generally accommodated for preparation, banking and money management.
meet age-related expectations. In adults, by peers in social situations. Social judgment is immature Recreational skills resemble those of age-mates,
abstract thinking, executive function for age and the person is at risk of being manipulated by though judgment related to wellbeing and organization
(planning, strategizing, setting priorities, others (gullibility). around recreation requires support. As adults, persons
and cognitive flexibility) and short term can work in competitive employment in jobs that do
memory are impaired. Older children and not emphasize conceptual skills. Persons generally
adults may have a concrete approach to need support to make health care decisions, legal
problems and solutions compared to decisions, and to learn to perform a vocation
agemates. There are usually lifelong competently. Support is typically needed to raise a
limitations in these areas. family.
Mild Level of Severity
 All through development, the person’s Person shows marked differences from peers in social and Person can care for personal needs involving eating,
conceptual skills lag markedly behind peers. communicative behavior across development. Spoken dressing, elimination, hygiene as an adult, though an
For preschoolers, language and pre- language is typically a primary tool for social extended period of teaching and time is needed to
academic skills develop slowly. Progress in communication but is less complex than peers. People have become independent in these areas. Similarly,
reading, writing, math, time, and money social motivation for relationships with family and peers, participation in all household tasks can be achieved by
occurs gradually across the school years. and may have successful friendships across life and adulthood, though an extended period of teaching and
For adults, academic skill development is sometimes romantic relations in adulthood. However, support is needed. Independent employment may be
typically at an elementary rather than people may not perceive or interpret social cues accurately. achieved, but considerable support from co-workers,
Moderate Level of Severity

secondary level. Ongoing assistance on a Social judgment and decision-making abilities are limited, supervisors, and coaches is needed to manage social
daily basis is needed to complete and caretakers must assist the person with life expectations, complexities of the job, and ancillary
conceptual tasks of day to day life. decisions. Friendships with typically developing peers are responsibilities such as scheduling, transportation,
often affected by communication or social health benefits, and money management. A variety of
limitations. Social and communicative support is needed in recreational skills can be developed and typically
work settings for success. requires additional supports and learning opportunities
over an extended period of time. Maladaptive behavior
is present in a significant minority and causes social
problems.

Attainment of conceptual skills is extremely Persons generally use nonverbal communication to initiate Person requires support for all activities of daily living,
limited. Person may understand use of and respond to social attention and interactions. Language, including meals, dressing, bathing, elimination. Person
objects as tools, may be able to complete if used or understood, involves names of objects and people requires supervision at all times. Person may make
Severe Level of Severity

simple cause and effect actions with and simple phrases tied to everyday events. Persons may choices for preferred objects, activities, and people.
objects. Person lacks understanding of respond to direct emotional communications and Person cannot make responsible decisions
written language. Person lacks concepts understand simple social cues but in general lack regarding wellbeing of self or others. As an adult,
involving number, quantity, time, understanding of social context. Relationships involve participation in practical and vocational activities
money. Caretakers provide all supports for family, caretakers and other long term ties and are more requires ongoing support and assistance. Recreational
this area throughout life. typical of attachment relations than of reciprocal activities require long-term teaching and ongoing
friendships. support. Maladaptive behavior, including self injury, is
present in a significant minority.