Emotional/Mood Disorders
Disorder
Depressive Disorder of Early
Childhood
(2) Major Depressive Disorder
DC 0 – 5
All criteria must be met:
A. Depressed mood or irritability across activities
more days than not for at least 2 weeks as
indicated by expression or observation by
others (child appears sad or tearful, flat affect,
frequent tantrums)
B. Anhedonia – marked diminished pleasure or
interest in all or almost all activities such as
initiation of play interaction with others more
days than not for at least 2 weeks indicated
by a child’s direct report or observation
C. Two or more of the ff must be present:
1. Significant change in appetite
2. Insomnia
3. Psychomotor agitation or sluggishness
4. Fatigue or loss of energy
5. Feelings of worthlessness, excessive
guilt or self-blame in play or speech
across activities
6. Diminished ability to concentrate,
persist, and make choices for at least 2
weeks
7. Preoccupation with themes of death or
suicide or attempts at self-harm
demonstrated in speech, play or
behavior
D. Same as B1-B5 of Separation Anxiety
Age: Diagnosis should be made with caution in
young children less than 24 months old
Duration: Symptoms must be present more days
than not for at least 2 weeks
Associated Features & Supporting Diagnosis:
Young children may not be able to express their
emotional distress verbally. Depressed mood may
be present as sad facial expression and
tearfulness that are persistent, intense, and
pervasive across settings and relationships.
Irritability may present as temper tantrums.
Course: Same pattern of recurrence and
persistence as depression in older children and
adults. Young children with depression are much
more likely to have depression in later childhood.
Risk & Prognostic Features: Temperament, high
negative emotionality, low emotional positivity,
behavioral inhibition. Genetic factors. Maternal
depressive and anxiety symptoms. Early stressful
life events. Experience of chronic illness, multiple
adverse health conditions.
Differential Diagnosis:
DSM – 5
A. Five (or more) of the following symptoms have
been present during the same 2-week period and
represent a change from previous functioning: at
least one of the symptoms is either (1) depressed
mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly
attributable to another medical condition.
1. Depressed mood most of the day, nearly every day,
as indicated by either subjective report (e.g., feels
sad, empty, hopeless) or observation made by others
(e.g.,
appears tearful). (Note: In children and adolescents,
can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or
almost all, activities most of the day, nearly every day
(as indicated by either subjective account or
observation).
3. Significant weight loss when not dieting or weight
gain (e.g., a change of more than 5% of body weight
in a month), or decrease or increase in appetite nearly
every day. (Note: In children, consider failure to make
expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation (making
movements without meaning to) nearly every day
(observable by others, not merely subjective feelings
of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly
every day (not merely self-reproach or guilt about
being sick).
8. Diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective
account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for committing
suicide.
B. The symptoms cause clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.
C. The episode is not attributable to the physiological
effects of a substance or to another medical condition.
Note: Criteria A-C represent a major depressive
episode.
Note: Responses to a significant loss (e.g.,
bereavement, financial ruin, losses from a natural
disaster, a serious medical illness or disability) may
include the feelings of intense sadness, rumination
about the loss, insomnia, poor appetite, and weight
loss noted in Criterion A, which may resemble a
depressive episode. Although such symptoms may be
understandable or considered appropriate to the loss,
Page 1 of 26
Relationship Specific Disorder of Infancy/EC the presence of a major depressive episode in
Reactive Attachment Disorder addition to the normal response to a significant loss
DDAA should also be carefully considered. This decision
Adjustment disorder with depressive features inevitably requires the exercise of clinical judgment
based on the individual’s history and the cultural
Comorbidity: norms for the expression of distress in the context of
Anxiety disorders loss.
ADHD D. The occurrence of the major depressive episode is
Reactive Attachment Disorder not better explained by schizoaffective disorder,
Phobias schizophrenia, schizophreniform disorder, delusional
disorder, or other specified and unspecified
schizophrenia spectrum and other psychotic
disorders.
E. There has never been a manic (A person may feel
uncontrollably elated and very high in energy) episode
or a hypomanic (persistent disinhibition and mood
elevation (euphoria), people may feel very good and
function well) episode.
Note: This exclusion does not apply if all of the manic-
like or hypomanic-like episodes are substance-
induced or are attributable to the physiological effects
of another medical condition.

Features:
At least 5 or more symptoms within 2 weeks:
 Depressed mood or loss of interest
(anhedonia)
 Social withdrawal
 Mood may be irritable
 Changes in appetite, sleep habits/patterns,
psychomotor activities
 Fatigue, tiredness
 Feeling of worthlessness
 Negative evaluation of self-worth

Severity: Mild, Moderate, Severe, With psychotic

features, In partial remission, In full remission
Major depression in remission
Whether or not a patient is being treated for
depression (i.e., counseling and/or medication), in
partial remission is defined as symptoms of the
immediately previous major depressive episode are
present, but full criteria are not met, or there is a
period lasting less
than 2 months without any significant symptoms of a
major depressive episode. In full remission is defined
as no significant signs or symptoms of the disturbance
were present during the past 2 months.

Prevalence:
Twelve-month prevalence of major depressive
disorder in the United States is approximately 7%,
with marked differences by age group such that the
prevalence in 18- to 29-year-old individuals is
threefold higher than the prevalence in individuals age
60 years or older. Females experience 1.5- to 3-fold
higher rates than males beginning in early
adolescence.

Page 2 of 26

Disorder of Dysregulated A subset of young children’s struggle to develop
Anger and Aggression of Early the capacity to regulate emotions and behavior in
Childhood early childhood, resulting in impairment, stigma,
and exclusion from age appropriate activities.
(1) Disruptive Mood
These children exhibit severe, frequent, and
Dysregulation Disorder (New intense temper tantrums coupled with persistent
Criteria under DSM 5) irritable or angry mood.
Central component of DDAA is the focus on
irritability and dysregulation of anger as
expressions of emotion dysregulation. This
component of DDAA is a powerful predictor of
adverse outcomes, including functional impairment
and clinical diagnoses in older children.
All criteria must be met:
A. Pervasive and persistent patterns of mood and
behavioral dysregulation as evidenced by at
least 3 of the ff 4 clusters:
1. Substantial anger and temper dysregulation
demonstrated by:
a. difficulty calming down when angry
b. angers easily and is irritable more days
than not
c. shows intense or extreme temper
Development and Course:
In the United States, incidence appears to peak in the
20s; however, first onset in late life is not uncommon.
Risk and Prognostic Factors:
Temperamental. Neuroticism (negative affectivity)
Environmental. Adverse childhood experiences
Genetic and physiological. First-degree family
members
Gender-Related Diagnostic issues:
In women, the risk for suicide attempts is higher, and
the risk for suicide completion is lower.
Differential Diagnosis:
 Manic episodes with irritable mood or mixed
episodes
 Mood disorder due to another medical
condition
 Substance/medication-induced depressive
or bipolar disorder. (withdrawal from drugs,
etc.)
 ADHD
 Adjustment disorder with depressed mood.
 Sadness.
Comorbidity:
Substance related disorders, panic disorder,
obsessive-compulsive disorder, anorexia nervosa,
bulimia nervosa, and borderline personality disorder
All criteria must be met.
A. Severe recurrent temper outbursts manifested
verbally (e.g., verbal rages) and/or behaviorally (e.g.,
physical aggression toward people or property) that
are grossly out of proportion in intensity or duration to
the situation or provocation.
B. The temper outbursts are inconsistent with
developmental level.
C. The temper outbursts occur, on average, three or
more times per week.
D. The mood between temper outbursts is persistently
irritable or angry most of the day, nearly every day,
and is observable by others (e.g., parents, teachers,
peers).
E. Criteria A-D have been present for 12 or more
months. Throughout that time, the individual has not
had a period lasting 3 or more consecutive months
without all of the symptoms in Criteria A-D.
F. Criteria A and D are present in at least two of three
settings (i.e., at home, at school, with peers) and are
severe in at least one of these.
G. The diagnosis should not be made for the first time
before age 6 years or after age 18 years.
H. By history or observation, the age at onset of
Criteria A-E is before 10 years.
I. There has never been a distinct period lasting more
Page 3 of 26
 outbursts or anger reactions more…
d. verbally/ physically aggressive toward
self or others in response to frustration or
limit setting
2. Noncompliance and rule breaking
demonstrated by:
a. Arguing with adults more days that not
b. Actively defying adults more…
c. Not following routine directions that they
child has the capacity to comply with,
even with repeated prompts, more…
d. Breaking rules when an adult is watching
at least daily
e. Taking things from other people or stores
when it is forbidden
3. Reactive aggression (aggression when angry,
upset, scared/under threat) demonstrated by:
a. Hits, bites, kicks or throws things or
attempts to do so at caregivers more…
b. Hits, bites, kicks or throws things at
young children other than siblings
c. Breaks things on purpose at least once a
week
4. Proactive aggression demonstrated by:
a. Often (at least once a week) is coercive
and controlling in play with peers
b. Often (at least once a week) says things
or does things that hurt other people’s
feelings
c. Physically or verbally frightens others
d. Starts physical fights
e. Uses or threatens to use an object to
harm others
B. Symptoms must be present in more than one
setting or in more than one relationship
C. Symptoms are not better explained by other
Axis 1 (Neurological, Sensory Processing,
Anxiety, Mood, OCD, Sleeping, Eating, and
Crying, Trauma, Stress, and Deprivation, and
Relationship disorders) disorder.
D. Same as B1-B5 of Separation Anxiety
Age: The child is at least 24 months old
Duration: Symptoms must be present for at least 3
months
Specify if:
1. Presence of limited prosocial behaviors
and emotions, demonstrated by at least
two of the following:
a) Patterns are present for at
least 6 months
b) Lack of observable remorse or
guilt
c) Lack of observable empathy
for others
than 1 day during which the full symptom criteria,
except duration, for a manic or hypomanic episode
have been met.
Note: Developmentally appropriate mood elevation,
such as occurs in the context of a highly positive event
or its anticipation, should not be considered as a
symptom of mania or hypomania.
J. The behaviors do not occur exclusively during an
episode of major depressive disorder and are not
better explained by another mental disorder (e.g.,
autism spectrum disorder, posttraumatic stress
disorder, separation anxiety disorder, persistent
depressive disorder [dysthymia]).
Note: This diagnosis cannot coexist with oppositional
defiant disorder, intermittent explosive disorder, or
bipolar disorder, though it can coexist with others,
including major depressive disorder,
attention-deficit/hyperactivity disorder, conduct
disorder, and substance use disorders. Individuals
whose symptoms meet criteria for both disruptive
mood dysregulation disorder and oppositional defiant
disorder should only be given the diagnosis of
disruptive mood dysregulation disorder. If an individual
has ever experienced a manic or hypomanic episode,
the diagnosis of disruptive mood dysregulation
disorder should not be assigned.
K. The symptoms are not attributable to the
physiological effects of a substance or to another
medical or neurological condition.
Development and Course:
The onset of disruptive mood dysregulation disorder
must be before age 10 years, and the diagnosis
should not be applied to children with a developmental
age of less than 6 years. Because
the symptoms of disruptive mood dysregulation
disorder are likely to change as children mature, use
of the diagnosis should be restricted to age groups
similar to those in which validity has been established
(7-18 years).
Risk and Prognostic Factors:
Temperamental. chronic irritability, have symptoms
that also meet criteria for attention-deficit/hyperactivity
disorder (ADHD) and for an anxiety disorder, with
such diagnoses often being present from a relatively
early age. For some children, the criteria for major
depressive disorder may also be met.
Genetic and physiological. exhibit both commonalities
and differences in information-processing deficits (e.g.
face-emotion labeling deficits).
Gender-Related Diagnostic issues. predominantly
male
Suicide Risk: Children with DMDD are twice as likely
to report suicide attempts.
Page 4 of 26
 d) Lack of observable concern
about performance
2. Aggression type: none, predominantly
reactive, predominantly proactive, or
combined proactive/reactive
Developmental Features. Rates of temper
tantrums and aggressive behaviors are highest in
young children 3-5 years old when compared to
other periods across the life span.
Course: Proactive aggression and related conduct
problems are related to school-age conduct
disorder as well as ADHD and defiance.
Risk & Prognostic Features: Prenatal period –
genetic factors, temperament, parental mental
health, prenatal care, exposure to stressors or
toxins.
Postnatal period – exposure to coercive parenting,
lack of warmth, low family cohesion, young child
maltreatment, family socioeconomic status & other
family risk factors.
Differential Diagnosis (share common
characteristics):
Major depressive disorder
Anhedonia (inability to feel pleasure)
GAD – irritability
PTSD
Limited language development
ASD – routine disruption, difficulty understanding
another person’s experience, limited language
Sensory Over-Responsivity Disorder
Comorbidity (conditions occur simultaneously):
ADHD
PTSD
Depressive Disorder of Early Childhood
*Comorbidity should not be considered when all
symptoms described in DDAA are also described
in another disorder.
Other Mood Disorder of Early All of the following criteria must be met.
Childhood
A. The child has one or more persistent
(3) Unspecified Depressive symptoms of a mood disorder but does not
meet the full criteria for DDEC or DDAAEC
Disorder
B. The symptoms are not already encompassed
in another disorder for which the child meets
full criteria
C. Same as B1-B5 of Separation Anxiety
Specify:
1. The disorder that best explains the
young child’s symptoms
2. Why the young child does not meet the
full criteria
Can impair quality of life, school performance, and
relationships.
Differential Diagnosis (share common characteristics):
Bipolar disorder (1: Manic, 2: Hypomanic/Depressive)
Oppositional defiant disorder (ODD)
Attention-deficit/hyperactivity disorder
Major Depressive Disorder
Anxiety Disorders
Autism Spectrum Disorder
Intermittent explosive disorder
Comorbidity. (conditions occur simultaneously):
Rates of comorbidity in disruptive mood dysregulation
disorder are extremely high.
It is rare to find individuals whose symptoms meet
criteria for disruptive mood dysregulation disorder
alone. Comorbidity between disruptive mood
dysregulation disorder and other DSM-defined
syndromes appears higher than for many other
pediatric mental illnesses; the strongest overlap is with
oppositional defiant disorder.
Used to be called DD-NOS (DSM-4R)
This category applies to presentations in which
symptoms characteristic of a depressive disorder that
cause clinically significant distress or impairment in
social, occupational, or other important areas of
functioning predominate but do not meet the full
criteria for any of the disorders in the depressive
disorders diagnostic class. The unspecified
depressive disorder category is used in situations in
which the clinician chooses not to specify the reason
that the criteria are not met for a specific depressive
disorder, and includes presentations for which there is
insufficient information to make a more specific
diagnosis (e.g., in emergency room settings).
Specify if:
Page 5 of 26
With anxious distress: Anxious distress is defined as
the presence of at least two of the following symptoms
during the majority of days of a major depressive
episode or persistent depressive disorder (dysthymia):
1. Feeling keyed up or tense.
2. Feeling unusually restless.
3. Difficulty concentrating because of worry.
4. Fear that something awful may happen.
5. Feeling that the individual might lose control of
himself or herself.

Specify current severity:

 Mild: Two symptoms.
 Moderate: Three symptoms.
 Moderate-severe: Four or five symptoms.
 Severe: Four or five symptoms and with
motor agitation.

With mixed features:

A. At least three of the following manic/hypomanic
[manic (A person may feel uncontrollably elated and
very high in energy) episode or a hypomanic
(persistent disinhibition and mood elevation
(euphoria), people may feel very good and function
well)] symptoms are present nearly every day during
the majority of days of a major depressive episode:
1. Elevated, expansive mood.
2. Inflated self-esteem or grandiosity.
3. More talkative than usual or pressure to keep
talking.
4. Flight of ideas or subjective experience that
thoughts are racing.
5. Increase in energy or goal-directed activity (either
socially, at work or school, or sexually).
6. Increased or excessive involvement in activities that
have a high potential for painful consequences (e.g.,
engaging in unrestrained buying sprees, sexual
indiscretions, foolish business investments).
7. Decreased need for sleep (feeling rested despite
sleeping less than usual; to be contrasted with
insomnia).

B. Mixed symptoms are observable by others and

represent a change from the person’s usual behavior.

C. For individuals whose symptoms meet full criteria

for either mania or hypomania, the diagnosis should
be bipolar I or bipolar II disorder.

D. The mixed symptoms are not attributable to the

physiological effects of a substance (e.g., a drug of
abuse, a medication or other treatment).

Note: Mixed features associated with a major

depressive episode have been found to be a
significant risk factor for the development of bipolar I
or bipolar II disorder.

Page 6 of 26
With melancholic (loss of pleasure in almost all
activities or a lack of reactivity to usually pleasurable
stimuli is present) features
A. One of the following is present during the most
severe period of the current episode:
1. Loss of pleasure in all, or almost all, activities.
2. Lack of reactivity to usually pleasurable stimuli
(does not feel much better, even temporarily, when
something good happens).

B. Three (or more) of the following;

1. A distinct quality of depressed mood characterized
by profound despondency,
despair, and/or moroseness or by so-called empty
mood.
2. Depression that is regularly worse in the morning.
3. Early-morning awakening (i.e., at least 2 hours
before usual awakening).
4. Marked psychomotor agitation or retardation.
5. Significant anorexia or weight loss.
6. Excessive or inappropriate guilt.

Note: The specifier “with melancholic features” is

applied if these features are present at the most
severe stage of the episode.

With atypical features: This specifier can be applied

when these features predominate during the majority
of days of the current or most recent major depressive
episode or persistent depressive disorder.
A. Mood reactivity (i.e., mood brightens in response
to actual or potential positive events).

B. Two (or more) of the following:

1. Significant weight gain or increase in appetite.
2. Hypersomnia.
3. Leaden paralysis (i.e., heavy, leaden feelings in
arms or legs).
4. A long-standing pattern of interpersonal rejection
sensitivity (not limited to episodes of mood
disturbance) that results in significant social or
occupational impairment.

C. Criteria are not met for “with melancholic features”

(loss of pleasure in almost all activities or a lack of
reactivity to usually pleasurable stimuli is present) or
“with catatonia” (clinical syndrome characterized by a
distinct constellation of psychomotor disturbances)
during the same episode.

With psychotic features: Delusions and/or

hallucinations are present.
With mood-congruent psychotic features: The content
of all delusions and hallucinations is consistent with
the typical depressive themes of personal inadequacy,
guilt, disease, death, nihilism (negativism), or
deserved punishment.

With mood-incongruent psychotic features: The

Page 7 of 26
 content of the delusions or hallucinations does not
involve typical depressive themes of personal
inadequacy, guilt, disease, death, nihilism
(negativism), or deserved punishment, or the content
is a mixture of mood-incongruent and mood-congruent
themes.

With catatonia (Abnormal state of unresponsiveness,

affecting behavioral and motor functions in a person
who is apparently awake; involuntary repetition or
imitation of another person’s actions; repetition of
another person’s spoken words; rigid body posture;
inability to respond or move to stimuli)

With peripartum onset (most recent episode of major

depression if onset of mood symptoms occurs during
pregnancy or in the 4 weeks following delivery).
Delusional thoughts – things that harm the infant.

With seasonal pattern (a particular time of the year

(e.g., in the fall or winter); occur at a characteristic
time of the year (e.g., depression disappears in the
spring)
Pattern must have occurred in two years and the
symptoms should happen during the specific seasons.

Specify if:
In partial remission: Symptoms of the immediately
previous major depressive episode are present, but
full criteria are not met, or there is a period lasting less
than 2 months without any significant symptoms of a
major depressive episode following the end of such an
episode.
In full remission: During the past 2 months, no
significant signs or symptoms of the disturbance were
present
(6) Bipolar Disorder For a diagnosis of bipolar I disorder, it is necessary to
meet the following criteria for a manic episode. The
manic episode may have been preceded by and may
be followed by hypomanic or major depressive
episodes.
Manic Episode (Bipolar I)
A. A distinct period of abnormally and persistently
elevated, expansive, or irritable mood and
abnormally and persistently increased goal-
directed activity or energy, lasting at least 1 week
and present most of the day, nearly every day (or
any duration if hospitalization is necessary).

B. During the period of mood disturbance and

increased energy or activity, three (or more) of the
following symptoms (four if the mood is only irritable)
are present to a significant degree and represent a
noticeable change from usual behavior:

1. Inflated self-esteem or grandiosity.

2. Decreased need for sleep (e.g., feels rested after
only 3 hours of sleep).
3. More talkative than usual or pressure to keep

Page 8 of 26
talking.
4. Flight of ideas or subjective experience that
thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to
unimportant or irrelevant external stimuli), as reported
or observed.
6. Increase in goal-directed activity (either socially, at
work or school, or sexually) or psychomotor agitation
(i.e., purposeless non-goal-directed activity).
7. Excessive involvement in activities that have a high
potential for painful consequences (e.g., engaging in
unrestrained buying sprees, sexual indiscretions, or
foolish business investments).

C. The mood disturbance is sufficiently severe to

cause marked impairment in social or occupational
functioning or to necessitate hospitalization to prevent
harm to self or others, or there are psychotic features.

D. The episode is not attributable to the physiological

effects of a substance (e.g., a drug
of abuse, a medication, other treatment) or to another
medical condition.
Note: Criteria A-D constitute a manic episode. At least
one lifetime manic episode is required for the
diagnosis of bipolar I disorder.

Hypomanic Episode (Bipolar II)

A. A distinct period of abnormally and persistently
elevated, expansive, or irritable mood and abnormally
and persistently increased activity or energy, lasting at
least 4 consecutive days and present most of the day,
nearly every day.
B. During the period of mood disturbance and
increased energy and activity, three (or more) of the
following symptoms (four if the mood is only irritable)
have persisted, represent a noticeable change from
usual behavior, and have been present to a significant
degree (Same as B1-B7 of Manic Episode)
C. The episode is associated with an unequivocal
(explicit) change in functioning that is uncharacteristic
of the individual when not symptomatic.
D. The disturbance in mood and the change in
functioning are observable by others.
E. The episode is not severe enough to cause marked
impairment in social or occupational functioning or to
necessitate hospitalization. If there are psychotic
features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological
effects of a substance (e.g., a drug
of abuse, a medication, other treatment).

Major Depressive Episode

A. Five (or more) of the following symptoms have
been present during the same 2-week period and
represent a change from previous functioning; at least
one of the symptoms is either (1) depressed mood or
(2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly
attributable to another medical condition.
Page 9 of 26
1. Depressed mood most of the day, nearly every day,
as indicated by either subjective report (e.g., feels
sad, empty, or hopeless) or observation made by
others (e.g., appears tearful). (Note: In children and
adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or
almost all, activities most of the day, nearly every day
(as indicated by either subjective account or
observation).
3. Significant weight loss when not dieting or weight
gain or decrease or increase in appetite nearly
everyday
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every
day (observable by others; not merely subjective
feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly
every day (not merely self-reproach or guilt about
being sick).
8. Diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective
account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for committing
suicide.
B. The symptoms cause clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.
C. The episode is not attributable to the physiological
effects of a substance or another medical condition.
Note: Criteria A-C constitute a major depressive
episode. Major depressive episodes are common in
bipolar I disorder but are not required for the diagnosis
of bipolar I disorder.

Bipolar I Disorder (Manic)

A. Criteria have been met for at least one manic
episode (Criteria A-D under “Manic Episode” above).
B. The occurrence of the manic and major depressive
episode(s) is not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder,
delusional disorder, or other specified or unspecified
schizophrenia spectrum and other psychotic disorder.

Bipolar II Disorder (Hypomanic/Depressive Episode)

A. Criteria have been met for at least one hypomanic
episode (Criteria A-F under “Hypomanic Episode”
above) and at least one major depressive episode
(Criteria A-C under “Major Depressive Episode”
above).
B. There has never been a manic episode.
C. The occurrence of the hypomanic episode(s) and
major depressive episode(s) is not better explained by
schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder, or
other specified or unspecified schizophrenia spectrum
and
Page 10 of 26
other psychotic disorder.
D. The symptoms of depression or the unpredictability
caused by frequent alternation between periods of
depression and hypomania causes clinically
significant distress or impairment in social,
occupational, or other important areas of functioning.

Cyclothymic
Cyclothymic disorder is a mental disorder. It is a mild
form of bipolar disorder (manic depressive illness), in
which a person has mood swings over a period of
years that go from mild depression to emotional highs.

Cyclothymic disorder usually begins early in life and is

manageable with treatment. Less than half of people
with the condition will go on to develop bipolar
disorder. Some people will experience cyclothymic
disorder as a chronic condition which lasts a lifetime,
while others will find it goes away over time.

Symptoms:
1. Frequent swings between high and low
mood. These swings are extreme enough to
be classified as hypomania and depression,
though not as extreme as those found in
bipolar disorder.
2. The frequency of mood swings in
cyclothymic disorder is higher than in bipolar
disorder. There may be no periods of stable
mood between episodes, and periods of
stable mood will last for less than two
months. Depressive symptoms will have
lasted for at least two years or one year for
children and teenagers. High and low
moods will be experienced for at least half
the time.
3. People with cyclothymic disorder tend to
have extreme reactions to external events or
stimuli. They can be overly happy and
enthusiastic in response to a positive event,
such as:
 Success at work
 A period of good weather
 Feelings created by substances,
like drugs and alcohol
They can also be overly pessimistic and
depressed by negative events, such as:
 A relationship setback
 Onset of winter
 Stressful situations, such as
moving house

The average age of bipolar onset is around 25 years

old, although it can vary. Sometimes bipolar
symptoms start in childhood or later in life. However,
the most frequent range of onset is between the ages
of 14 to 21 years. Childhood bipolar is relatively rare,
with only up to 3%Trusted Source of children
receiving this diagnosis.

Page 11 of 26
OCD A. Presence of obsessions, compulsions, or both:

(7) OCD (p. 272) Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or
impulses that are experienced, at some time during
the disturbance, as intrusive and unwanted, and that
in most individuals cause marked anxiety or distress.

2.The individual attempts to ignore or suppress such

thoughts, urges, or images, or to neutralize them with
some other thought or action (i.e., by performing a
compulsion).

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering,
checking) or mental acts (e.g., praying, counting,
repeating words silently) that the individual feels
driven to perform in response to an obsession or
according to rules that must be applied rigidly.
2.The behaviors or mental acts are aimed at
preventing or reducing anxiety or distress, or
preventing some dreaded event or situation; however,
these behaviors or mental acts are not connected in a
realistic way with what they are designed to neutralize
or prevent, or are clearly excessive.

Note: Young children may not be able to articulate the

aims of these behaviors or mental acts.

B. The obsessions or compulsions are time-

consuming (e.g., take more than 1 hour per day) or
cause clinically significant distress or impairment in
social, occupational, or other important areas of
functioning.

C. The obsessive-compulsive symptoms are not

attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication) or another
medical condition.

D. The disturbance is not better explained by the

symptoms of another mental disorder (e.g., excessive
worries, as in generalized anxiety disorder;
preoccupation with appearance, as in body
dysmorphic disorder; difficulty discarding or parting
with possessions, as in hoarding disorder; hair pulling,
as in trichotillomania [hair-pulling disorder]; skin
picking, as in excoriation [skin-picking] disorder;
stereotypies, as in stereotypic movement disorder;
ritualized eating behavior, as in eating disorders;
preoccupation with substances or gambling, as in
substance-related and addictive disorders;
preoccupation with having an illness, as in illness
anxiety disorder; sexual urges or fantasies, as in
paraphilic disorders; impulses, as in disruptive,
impulse-control, and conduct disorders; guilty
ruminations, as in major depressive disorder; thought
insertion or delusional preoccupations, as in
schizophrenia spectrum and other psychotic
Page 12 of 26

PTSD In infants/ young children, PTSD always requires
exposure to a frightening/terrifying even or a series
(5) PTSD of events, such as exposure to physical or sexual
abuse, intimate partner or community violence,
natural disasters, armed conflict, motor vehicle
accidents, painful and frightening medical
procedures, or similar events.
disorders; or repetitive patterns of behavior, as in
autism spectrum disorder).
Specify if:
With good or fair insight: The individual recognizes
that obsessive-compulsive disorder beliefs are
definitely or probably not true or that they may or may
not be true.
With poor insight: The individual thinks obsessive-
compulsive disorder beliefs are probably true.
With absent insight/delusional beliefs: The individual is
completely convinced that obsessive-compulsive
disorder beliefs are true.
Tic-related: The individual has a current or past history
of a tic disorder.
Diagnostic Features:
Obsessions are repetitive and persistent thoughts
(e.g., of contamination), images (e.g., of violent or
horrific scenes), or urges (e.g., to stab someone).
Importantly, obsessions are not pleasurable or
experienced as voluntary: they are intrusive and
unwanted and cause marked distress or anxiety in
most individuals. The individual attempts to ignore or
suppress these obsessions (e.g., avoiding triggers or
using thought suppression) or to neutralize them with
another thought or action (e.g., performing a
compulsion).
Compulsions (or rituals) are repetitive behaviors (e.g.,
washing, checking) or mental acts (e.g., counting,
repeating words silently) that the individual feels
driven to perform in response to an obsession or
according to rules that must be applied rigidly. Most
individuals with OCD have both obsessions and
compulsions. Compulsions are typically performed in
response to an obsession (e.g., thoughts of
contamination leading to washing rituals or that
something is incorrect leading to repeating rituals until
it feels "just right")· The aim is to reduce the distress
triggered by obsessions or to prevent a feared event
(e.g., becoming ill). However, these compulsions
either are not connected in a realistic way to the
feared event (e.g., arranging items symmetrically to
prevent harm to a loved one) or are clearly excessive
(e.g., showering for hours each day). Compulsions are
not done for pleasure, although some individuals
experience relief from anxiety or distress.
Prevalence:
Females are affected at a slightly higher rate than
males in adulthood, although males are more
commonly affected in childhood.
Criterion A: stressor (one required)
The person was exposed to: death, threatened death,
actual or threatened serious injury, or actual or
threatened sexual violence, in the following way(s):
o Direct exposure
o Witnessing the trauma
o Learning that a relative or close friend was
Page 13 of 26
The infant/young child may experience the event
directly, witness it as it occurred to others, or learn
that event occurred to a significant person in their
life.
In addition to trauma exposure as specified in
Criterion A, the following symptoms must be
present: at least one symptom from Cluster B, at
least one symptom from Cluster C or Cluster D.
and at least 2 symptoms from Cluster E. In
addition, the conditions describe in Criterion F
must be present.
A. The infant/young child was exposed to
significant threat of or actual serious
injury, accident, illness, medical trauma,
significant loss, disaster, violence (e.g.,
partner violence, community violence,
war or terrorism), or physical/sexual
abuse in one or more of the following
ways:
1. Directly experiencing the traumatic event
2. Hearing or seeing, in person, the event
as it occurred to others
3. Learning that the traumatic event
occurred to a significant person in the
infant’s or young child’s life.
B. The infant/young child shows evidence
of re-experiencing the traumatic event/s
by demonstrating at least one of the
following:
1. Play or behavior that reenacts some
aspect of trauma/s.
2. Preoccupation with the traumatic event/s
conveyed by repeated statements or
questions about some aspect of the
event/s. Distress is not necessarily
apparent.
3. Repeated nightmares, the content of
which may or may not be linked to the
traumatic event/s, which increase in
frequency after the traumatic event/s.
4. Significant distress at reminders of the
traumatic event/s.
5. Marked physiological reactions (e.g.,
sweating, agitated breathing, changes in
color) at reminders of traumatic event/s.
6. Dissociative episodes. Beginning after
the traumatic event/s, in which the
infant/young child freezes, stills, or
stares and is unresponsive to
environmental stimuli for seconds to
minutes in response to reminders of the
traumatic event/s.
C. The infant/young child persistently
attempts to avoid trauma related stimuli
through efforts to avoid people, places,
activities, conversations, or interpersonal
exposed to a trauma
o Indirect exposure to aversive details of the
trauma, usually in the course of professional
duties (e.g., first responders, medics)
Criterion B: intrusion symptoms (one required)
The traumatic event is persistently re-experienced in
the following way(s):
o Unwanted upsetting memories
o Nightmares
o Flashbacks (dissociative reactions)
o Emotional distress after exposure to
traumatic reminders
o Physical reactivity after exposure to
traumatic reminders (physiological
reactions)
Criterion C: avoidance (one required)
Avoidance of trauma-related stimuli after the trauma,
in the following way(s) – (Trauma-related thoughts or
feelings; Trauma-related external reminders)
- Persistence avoidance to stimuli: avoids
people or situations that would remind them
of the situation
- Negative avoidance to stimuli: negative
emotional states (fear, guilt, etc); diminished
interest in play and social activities
Criterion D: negative alterations in cognitions and
mood (two required)
Negative thoughts or feelings that began or worsened
after the trauma, in the following way(s):
o Inability to recall key features of the trauma
o Overly negative thoughts and assumptions
about oneself or the world
o Exaggerated blame of self or others for
causing the trauma
o Negative affect
o Decreased interest in activities
o Feeling isolated
o Difficulty experiencing positive affect
Criterion E: alterations in arousal and reactivity
Trauma-related arousal and reactivity that began or
worsened after the trauma, in the following way(s):
o Irritability or aggression
o Risky or destructive behavior
o Hypervigilance
o Heightened startle reaction
o Difficulty concentrating
o Difficulty sleeping
o Criterion F: duration (required)
o Symptoms last for more than 1 month.
Criterion F: functional significance (required)
Symptoms create distress or functional impairment
(e.g., social, occupational).
Page 14 of 26
 situations that are reminders of trauma.
D. The infant/young child experiences a
dampening of positive emotional
responsiveness that appears or
intensifies after the trauma/s and is
revealed by at least one of the following:
1. Increased social withdrawal
2. Reduced expression of positive
emotions
3. Markedly diminished interest or
participation in activities such as play
and social interactions
4. Increased fearfulness or sadness
E. After traumatic event, an infant/young
child may exhibit onset or intensification
of sings of increased arousal, as
revealed by at least two of the following:
1. Difficulty going to sleep, evidenced by
strong bedtime protest, difficulty falling
asleep, or repeated night waking
unrelated to nightmares.
2. Difficulty concentrating
3. Hypervigilance
4. Exaggerated startle response
5. Increased irritability, outbursts of anger
or extreme fussiness, or temper
tantrums
F. Symptoms of the disorder, or caregiver
accommodations in response to the
symptoms, significantly affect the
infant’s/young child’s and family’s
functioning on one or more of the
following ways:
1. Cause distress to the infant/young child
2. Interfere with the infant’s/young child’s
relationships
3. Limit the infant’s/young child’s
participation in developmentally
expected activities or routines
4. Limit the family’s participation in
everyday activities or routines
5. Limit the infant’s/young child’s ability to
learn and develop new skills or interfere
with developmental progress.
Criterion G: exclusion (required)
Symptoms are not due to medication, substance use,
or other illness.
Two specifications:
Dissociative Specification In addition to meeting
criteria for diagnosis, an individual experiences high
levels of either of the following in reaction to trauma-
related stimuli:
 Depersonalization. Experience of being an
outside observer of or detached from
oneself (e.g., feeling as if "this is not
happening to me" or one were in a dream).
 Derealization. Experience of unreality,
distance, or distortion (e.g., "things are not
real").
Delayed Specification. Full diagnostic criteria are not
met until at least six months after the trauma(s),
although onset of symptoms may occur immediately.
Risk and Prognostic Factors:
Pre-traumatic factors
1. Temperament
2. Environment
3. Genetic and physiological
Peri-traumatic factors
1. Environment – injury, violence, etc.
Post-traumatic factors
1. Temperament – negative appraisals,
inappropriate coping mechanisms
2. Environment

Age of onset: The diagnosis should be made with

caution in infants less than 12 months old.

Duration: The symptoms in clusters B-E must be

present for at least one month following the
exposure/s in Criterion A.

Associated Features:
 Trauma must have many effects on
infants/young children other than PTSD.
 Oppositional behavior is often a feature
as well as Separation anxiety
 Some children with emerging expressive
language skills may retain their skills but

Page 15 of 26
 show selective regression when
referencing the traumatic experience.
Prevalence:
 PTSD is underrecognized
infants/young children because of their
rates of exposure to major stressors and
trauma are much higher than the
number of infants/young children
brought in for assessment and
treatment.
Course:
 No significant diminution of PTSD in
infants/young children within the first 2
years following exposure to trauma.
 Long-term course of PTSD into middle
childhood and adolescence is unknown.
Differential Diagnosis:
 Other Trauma, Stress, and Deprivation
Disorder of Infant/Early Childhood – if
children do not meet the criteria for
PTSD and whose symptoms extend
beyond 3 months
Comorbidity:
 Oppositional behavior
 Cognitive, language, and motor delays
(4) Schizophrenia
in
A. Two or more of the following for at least a
one-month (or longer) period of time, and at
least one of them must be 1, 2, or 3:
o Delusions: “a fixed idea that’s not
consensually held,” in the person’s culture,
and “is not consistent with the world at
large.” – Grandiose, somatic, jealous,
paranoid delusions, mixed delusions
o Hallucinations: “a sensory experience that
occurs in the absence of an external
stimulus.” Hallucinations can occur in any of
the five senses: auditory, visual, olfactory
(smell), tactile, gustatory
o Disorganized speech (incoherence, frequent
derailment)
o Grossly disorganized or catatonic behavior:
Catatonia is a clinical syndrome
characterized by a distinct constellation of
psychomotor disturbances. Retarded and
excited. Catatonia of the retarded type is
associated with signs reflecting a paucity of
movement, including immobility, staring,
mutism, rigidity, withdrawal and refusal to
eat, along with more bizarre features such
as posturing, grimacing, negativism, waxy
flexibility, echolalia or echopraxia,
stereotypy, verbigeration, and automatic
obedience. Excited catatonia, on the other
hand, is characterized by severe
psychomotor agitation, potentially leading to
life-threatening complications such as
hyperthermia, altered consciousness, and
autonomic dysfunction.
o Negative symptoms, such as diminished
Page 16 of 26
 emotional expression

B. Impairment in one of the major areas of

functioning for a significant period of time
since the onset of the disturbance: Work,
interpersonal relations, or self-care.

C. Some signs of the disorder must last for a

continuous period of at least 6 months. This
six-month period must include at least one
month of symptoms (or less if treated) that
meet criterion A (active phase symptoms)
and may include periods of residual
symptoms. During residual periods, only
negative symptoms (Lack of pleasure,
Trouble with speech, flattening of affect,
Withdrawal, struggling with the basics of
daily life, no follow-through) may be present.

D. Schizoaffective disorder and bipolar or

depressive disorder with psychotic features
have been ruled out:
o No major depressive or manic episodes
occurred concurrently with active phase
symptoms
o If mood episodes (depressive or manic)
have occurred during active phase
symptoms, they have been present for a
minority of the total duration of the active
and residual phases of the illness.
o The disturbance is not caused by the effects
of a substance or another medical condition
o If there is a history of autism spectrum
disorder or a communication disorder
(childhood onset), the diagnosis of
schizophrenia is only made if prominent
delusions or hallucinations, along with other
symptoms, are present for at least one
month
o Associated Features
o There are a number of symptoms that
contribute to a diagnosis of schizophrenia.
o Inappropriate affect (laughing in the
absence of a stimulus)
o Disturbed sleep pattern
o Dysphoric mood (can be depression,
anxiety, or anger)
o Anxiety and phobias
o Depersonalization (detachment or feeling of
disconnect from self)
o Derealization (a feeling that surrounding
aren’t real)
o Cognitive deficits impacting language,
processing, executive function, and/or
memory
o Lack of insight into disorder
o Social cognition deficits
o Hostility and aggression

Page 17 of 26
 E. Cognitive impairments caused by the
disorder may persist when other symptoms
are in remission. This contributes to
impairments in functioning in employment,
interpersonal relationships, and the ability to
engage in proper self-care.
F. History of ASD or communication disorder –
Schizophrenia is only made if prominent
delusions or hallucinations are present for at
least 1 month

Risk and Prognostic Factors

 Environmental
- Adoption
- Home with a parent with schizophrenia
 Genetic & Physiological
- Family: sibling and twin studies
- Brain structure (abnormal prefrontal cortex,
abnormal hippocampus shape and size)
- Birth complications – perinatal hypoxia
(30%)
- Prenatal viral exposure: mothers exposed to
influenza
- Allele: one of two or more alternative forms
of a gene that arise by mutation and are
found at the same place on a chromosome.
- Risk allele: in the context of a disease, this
is the allele that confers a risk of developing
the disease

Differential Diagnosis
 Bipolar disorder with psychotic features
 PTSD
 Schizoaffective disorder
 Delusion
 OCD, body dysmorphic disorder
 ASD

Comorbid Diagnosis:
 Substance related disorder
 Anxiety disorder
 OCD
 Panic Disorder

Suicide Risk
Five to 6% of people with schizophrenia die by
suicide, about 20% make suicide attempts on more
than one occasion, and many more have significant
suicidal thoughts. Suicidal behavior can be in
response to hallucinations and suicide risk remains
high over the lifespan of individuals with
schizophrenia.

Functional Consequences
Schizophrenia is associated with social and
occupational dysfunction. Completing education and
maintaining employment are negatively impacted by
symptoms of the illness, and most individuals
Page 18 of 26
 diagnosed with schizophrenia are employed at a lower
level than their parents. Many have few or limited
social relationships outside of their immediate family.

In most people with schizophrenia, symptoms

generally start in the mid- to late 20s, though it can
start later, up to the mid-30s. Schizophrenia is
considered early onset when it starts before the age
of 18. Onset of schizophrenia in children younger than
age 13 is extremely rare.

Behavioral Disorders

Disorder DC 0 – 5 DSM – 5
(8) Oppositional Defiant Disorder A. A pattern of angry/irritable mood,
(p. 496) argumentative/defiant behavior, or vindictiveness
lasting at least 6 months as evidenced by at least four
symptoms from any of the following categories and
exhibited during interaction with at least one individual
who is not a sibling.
Angry/Irritable Mood
1. Often loses temper.
2. Is often touchy or easily annoyed.
3. Is often angry and resentful.
Argumentative/Defiant Behavior
4. Often argues with authority figures or, for
children and adolescents, with adults.
5. Often actively defies or refuses to comply
with requests from authority figures or with
rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes
or misbehavior.
Vindictiveness (Cruelty)
8. Has been spiteful or vindictive at least twice
within the past 6 months.

Note: The persistence and frequency of these

behaviors should be used to distinguish a behavior
that is within normal limits from a behavior that is
symptomatic. For children younger than 5 years, the

Page 19 of 26
 behavior should occur on most days for a period of at
least 6 months unless otherwise noted (Criterion A8).
For individuals 5 years or older, the behavior should
occur at least once per week for at least 6 months,
unless otherwise noted (Criterion A8). While these
frequency criteria provide guidance on a minimal level
of frequency to define symptoms, other factors should
also be considered, such as whether the frequency
and intensity of the behaviors are outside a range that
is normative for the individual’s developmental level,
gender, and culture.

B. The disturbance in behavior is associated with

distress in the individual or others in his or her
immediate social context (e.g., family, peer group,
work colleagues), or it impacts negatively on social,
educational, occupational, or other important areas of
functioning.

C. The behaviors do not occur exclusively during the

course of a psychotic, substance use, depressive,
or bipolar disorder. Also, the criteria are not met for
disruptive mood dysregulation disorder.

Specify current severity:

Mild: Symptoms are confined to only one setting (e.g.,
at home, at school, at work, with peers).
Moderate: Some symptoms are present in at least two
settings.
Severe: Some symptoms are present in three or more
settings.

DMDD is more severe than ODD and cannot be

diagnosed comorbidly.

(9) Conduct Disorder (p.503) A. A repetitive and persistent pattern of behavior in

which the basic rights of others or major age
appropriate societal norms or rules are violated, as
manifested by the presence of at least three of the
following 15 criteria in the past 12 months from any of
the categories below, with at least one criterion
present in the past 6 months:
Aggression to People and Animals
1. Often bullies, threatens, or intimidates others.
2. Often initiates physical fights.
3. Has used a weapon that can cause serious physical
harm to others (e.g., a bat, brick, broken bottle,
knife, gun).
4. Has been physically cruel to people.
5. Has been physically cruel to animals.
6. Has stolen while confronting a victim (e.g.,
mugging, purse snatching, extortion, armed robbery).
7. Has forced someone into sexual activity.
Destruction of Property
8. Has deliberately engaged in fire setting with the
intention of causing serious damage.
9. Has deliberately destroyed others’ property (other
than by fire setting).
Deceitfulness or Theft
10. Has broken into someone else’s house, building,
Page 20 of 26
or car.
11. Often lies to obtain goods or favors or to avoid
obligations (i.e., “cons” others).
12. Has stolen items of nontrivial value without
confronting a victim (e.g., shoplifting, but without
breaking and entering; forgery).
Serious Violations of Rules
13. Often stays out at night despite parental
prohibitions, beginning before age 13 years.
14. Has run away from home overnight at least twice
while living in the parental or parental surrogate
home, or once without returning for a lengthy period.
15. Is often truant from school, beginning before age
13 years.

B. The disturbance in behavior causes clinically

significant impairment in social, academic, or
occupational functioning.

C. If the individual is age 18 years or older, criteria are

not met for antisocial personality disorder.

Specify whether:
312.81 (F91.1) Childhood-onset type: Individuals
show at least one symptom characteristic of conduct
disorder prior to age 10 years.
312.82 (F91.2) Adolescent-onset type: Individuals
show no symptom characteristic of conduct disorder
prior to age 10 years.
312.89 (F91.9) Unspecified onset: Criteria for a
diagnosis of conduct disorder are met, but there is not
enough information available to determine whether the
onset of the first symptom was before or after age 10
years.
Specify if:
With limited prosocial emotions: To qualify for this
specifier, an individual must have displayed
at least two of the following characteristics persistently
over at least 12 months and in multiple relationships
and settings. These characteristics reflect the
individual’s typical pattern of interpersonal and
emotional functioning over this period and not just
occasional occurrences in some situations.

Thus, to assess the criteria for the specifier, multiple

information sources are necessary. In addition to the
individual’s self-report, it is necessary to consider
reports by others who have known the individual for
extended periods of time (e.g., parents, teachers, co-
workers, extended family members, peers).

Lack of remorse or guilt: Does not feel bad or guilty

when he or she does something wrong (exclude
remorse when expressed only when caught and/or
facing punishment). The individual shows a general
lack of concern about the negative consequences of
his or her actions. For example, the individual is not
remorseful after hurting someone or does not care
about the consequences of breaking rules.

Page 21 of 26
Callous lack of empathy: Disregards and is
unconcerned about the feelings of others.
The individual is described as cold and uncaring. The
person appears more concerned about the effects of
his or her actions on himself or herself, rather than
their effects on others, even when they result in
substantial harm to others.

Unconcerned about performance: Does not show

concern about poor/problematic performance at
school, at work, or in other important activities. The
individual does not put forth the effort necessary to
perform well, even when expectations are clear, and
typically blames others for his or her poor
performance.

Shallow or deficient affect: Does not express feelings

or show emotions to others, except in ways that seem
shallow, insincere, or superficial (e.g., actions
contradict the emotion displayed; can turn emotions
“on” or “off” quickly) or when emotional expressions
are used for gain (e.g., emotions displayed to
manipulate or intimidate others).

Specify current severity:

Mild: Few if any conduct problems in excess of those
required to make the diagnosis are present, and
conduct problems cause relatively minor harm to
others (e.g., lying, truancy, staying out after dark
without permission, other rule breaking).

Moderate: The number of conduct problems and the

effect on others intermediate between those specified
in “mild” and those in “severe” (e.g., stealing without
confronting a victim, vandalism).

Severe: Many conduct problems in excess of those

required to make the diagnosis are present, or
conduct problems cause considerable harm to others
(e.g., forced sex, physical cruelty, use of a weapon,
stealing while confronting a victim, breaking and
entering).

Subtypes:
In childhood-onset conduct disorder, individuals are
usually male, frequently display physical aggression
toward others, have disturbed peer relationships, may
have had oppositional defiant disorder during early
childhood, and usually have symptoms that meet full
criteria for conduct disorder prior to puberty. Many
children with this subtype also have concurrent
attention-deficit/hyperactivity disorder (ADHD) or other
neurodevelopmental difficulties. Individuals with
childhood-onset type are more likely to have
persistent conduct disorder into adulthood than are
those with adolescent-onset type.
As compared with individuals with childhood-onset
type, individuals with adolescent-onset conduct
disorder are less likely to display aggressive behaviors
and tend to have more normative peer relationships
Page 22 of 26

(10) Attention Deficit All of the following criteria must be met:
Hyperactivity Disorder (ADHD)
(p. 97) A. Present with at least six symptoms
- Predominantly from the inattention cluster or at least
six symptoms form the hyperactivity-
Inattentive
impulsivity cluster.
- Predominantly 1. Inattention cluster
Hyperactive/Impulsive
a. Usually not careful and is inattentive to
details in play, activities of daily living,
Attention Deficit/Hyperactivity or structured activities (e.g., makes
Disorder developmentally unexpected
accidents or mistakes).
- Overactivity Disorder of b. Usually has a hard time maintaining
focus on activities or play.
Toddlerhood
c. Often fails to attend to verbal
requests/demands, especially when
engaged in a preferred activity (e.g.,
caregiver needs to call the young
child’s name multiple times before
he/she appears to notice).
d. Often gets derailed when attempting
to follow multistep instructions and
does not complete the activity.
e. Often has a hard time executing age-
appropriate sequential activities (e.g.,
getting dressed, following routines in
childcare or home).
f. Frequently avoids or objects to
activities that require prolonged
attention (e.g., reading a book with a
parent or working on a puzzle).
g. Loses track of things that are used
regularly (e.g., favorite stuffed animal,
shoes, or a school bag).
h. Frequently gets distracted by sounds
and sights (e.g., sounds from another
room or objects or activities out the
window).
i. Frequently seems to forget what
he/she is doing in common routines or
(although they often display conduct problems in the
company of others). These individuals are less likely
to have conduct disorder that persists into adulthood.
The ratio of males to females with conduct disorder is
more balanced for the adolescent-onset type than for
the childhood-onset type.
Development and Course
The onset of conduct disorder may occur as early as
the preschool years, but the first significant symptoms
usually emerge during the period from middle
childhood through middle adolescence. Oppositional
defiant disorder is a common precursor to the
childhood-onset type of conduct disorder. Conduct
disorder may be diagnosed in adults, however,
symptoms of conduct disorder usually emerge in
childhood or adolescence, and onset is rare after age
16 years.
A. A persistent pattern of inattention and/or
hyperactivity-impulsivity that interferes with
functioning or development, as characterized by (1)
and/or (2):
1. Inattention: Six (or more) of the following symptoms
have persisted for at least 6 months to a degree that is
inconsistent with developmental level and that
negatively impacts directly on social and
academic/occupational activities:
Note: The symptoms are not solely a manifestation of
oppositional behavior, defiance, hostility, or failure to
understand tasks or instructions. For older
adolescents
and adults (age 17 and older), at least five symptoms
are required.
a. Often fails to give close attention to details
or makes careless mistakes in schoolwork,
at work, or during other activities (e.g.,
overlooks or misses details, work is
inaccurate).
b. Often has difficulty sustaining attention in
tasks or play activities (e.g., has difficulty
remaining focused during lectures,
conversations, or lengthy reading).
c. Often does not seem to listen when spoken
to directly (e.g., mind seems elsewhere,
even in the absence of any obvious
distraction).
d. Often does not follow through on
instructions and fails to finish schoolwork,
chores, or duties in the workplace (e.g.,
starts tasks but quickly loses focus and is
easily sidetracked).
e. Often has difficulty organizing tasks and
activities (e.g., difficulty managing
sequential tasks; difficulty keeping materials
and belongings in order; messy,
disorganized work; has poor time
management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to
engage in tasks that require sustained
mental effort (e.g., schoolwork or homework;
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 activities.
2. Hyperactivity-Impulsivity Cluster
a. Frequently squirms or fidgets when
expected to be still, even for short
periods of time.
b. Usually gets up from seat during
activities when sitting is expected
(e.g., circle time, mealtime, worship).
c. Often climbs on furniture or other
inappropriate objects.
d. Usually seems to make more noise
than other young children and has
difficulty playing quietly.
e. Often shows excessive motor activity
and nondirected energy (as if “driven
by a motor”).
f. Usually talks too much.
g. Often has a hard time taking turns in
conversation or interrupts others in
conversations (e.g., talks over others).
h. Often has difficulty taking turns in
activities or waiting for needs to be
met.
i. Is frequently intrusive in play or other
activities (e.g., takes over toys or
activities from other young children,
interrupts an established game).
B. Symptoms in Criterion A must be
excessive when compared with
developmentally and culturally
expected norms.
C. Symptoms must be confirmed to be
present in at least two contexts of the
young child’s life (e.g., two different
physical settings [home and out-of-
home settings] or within two different
relationships [caregiver, teacher/child
care provider, clinician]).
D. Symptoms of the disorder, or
caregiver accommodations in
response to the symptoms,
significantly affect the young child’s
and family’s functioning in one or
more of the following ways:
1. Cause distress to the young
child;
2. Cause distress to the family;
3. Interfere with the young child’s
relationships;
4. Limit the young child’s
participation in developmentally
expected activities or routines;
5. Limit the family’s participation in
everyday activities or routines; or
for older adolescents and adults, preparing
reports, completing forms, reviewing lengthy
papers).
g. Often loses things necessary for tasks or
activities (e.g., school materials, pencils,
books, tools, wallets, keys, papenwork,
eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous
stimuli (for older adolescents and adults,
may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g.,
doing chores, running errands; for older
adolescents and adults, returning calls,
paying bills, keeping appointments).
2. Hyperactivity and impulsivity: Six (or more) of the
following symptoms have persisted for at least 6
months to a degree that is inconsistent with
developmental level and that negatively impacts
directly on social and academic/occupational
activities:
Note: The symptoms are not solely a manifestation of
oppositional behavior, defiance, hostility, or a failure
to understand tasks or instructions. For older
adolescents
and adults (age 17 and older), at least five symptoms
are required.
a. Often fidgets with or taps hands or feet or
squirms in seat.
b. Often leaves seat in situations when
remaining seated is expected (e.g.,
leaves his or her place in the classroom,
in the office or other workplace, or in
other situations that require remaining in
place).
c. Often runs about or climbs in situations
where it is inappropriate. (Note: In
adolescents or adults, may be limited to
feeling restless.)
d. Often unable to play or engage in leisure
activities quietly.
e. Is often “on the go,” acting as if “driven by
a motor” (e.g., is unable to be or
uncomfortable being still for extended
time, as in restaurants, meetings; may be
experienced by others as being restless
or difficult to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before a
question has been completed (e.g.,
completes people’s sentences; cannot
wait for turn in conversation).
h. Often has difficulty waiting his or her turn
(e.g., while waiting in line).
i. Often interrupts or intrudes on others
(e.g., butts into conversations, games, or
activities; may start using other people’s
things without asking or receiving
permission; for adolescents and adults,
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 6. Limit the young child’s ability to
learn and develop mew skills or
interfere with developmental
progress.
Age: The child must be at least 36 months old.
Duration: The symptoms must be present for at
least 6 months.
Associated Features Supporting Diagnosis: The
young child with ADHD in the preschool years at
higher risk of other developmental delays,
including mild intellectual impairment,
developmental deficits, poor academic skills,
motor coordination problems, and difficulties in
social interactions.
Preschoolers with ADHD also have executive
functioning deficits. They may receive SPED
services (or be eligible for these supports) at
higher rates than typically developing young
children. Some of the most prevalent difficulties
linked to ADHD are learning problems and
academic failure.
Not all young children with ADHD will have a
family history of attention problems or
hyperactivity-impulsivity. However, presence of
a family history of ADHD is an important
associated feature for young children who meet
criteria for ADHD.
may intrude into or take over what others
are doing).
B. Several inattentive or hyperactive-impulsive
symptoms were present prior to age 12
years.
C. Several inattentive or hyperactive-impulsive
symptoms are present in two or more
settings (e.g., at home, school, or work; with
friends or relatives; in other activities).
D. There is clear evidence that the symptoms
interfere with, or reduce the quality of,
social, academic, or occupational
functioning.
E. The symptoms do not occur exclusively
during the course of schizophrenia or
another psychotic disorder and are not
better explained by another mental disorder
(e.g., mood disorder, anxiety disorder,
dissociative disorder, personality disorder,
substance intoxication or withdrawal).
Specify whether:
314.01 (F90.2) Combined presentation: If both
Criterion A1 (inattention) and Criterion A2
(hyperactivity-impulsivity) are met for the past 6
months.
314.00 (F90.0) Predominantly inattentive presentation:
If Criterion A1 (inattention) is met but Criterion A2
(hyperactivity-impulsivity) is not met for the past 6
months.
314.01 (F90.1) Predominantly hyperactive/impulsive
presentation: If Criterion A2 (hyperactivity-impulsivity)
is met and Criterion A1 (inattention) is not met for the
past 6 months.
Specify if:
in partial remission: When full criteria were previously
met, fewer than the full criteria have been met for the
past 6 months, and the symptoms still result in
impairment in social, academic, or occupational
functioning.
Specify current severity:
Mild: Few, if any, symptoms in excess of those
required to make the diagnosis are present, and
symptoms result in no more than minor impairments in
social or occupational functioning.
Moderate: Symptoms or functional impairment
between “mild” and “severe” are present.
Severe: Many symptoms in excess of those required
to make the diagnosis, or several symptoms that are
particularly severe, are present, or the symptoms
result in marked impairment in social or occupational
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functioning.

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