• Significantly subaverage intellectual functioning: an IQ of approximately 70 or below on an individually administered IQ test (for infants, a clinical judgment of significantly subaverage intellectual functioning).

• Concurrent deficits or impairments in present adaptive functioning (i.e., the 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.

• The onset is before age 18 year

  IQ level 50–55 to approximately 70

• Significantly subaverage intellectual functioning: an IQ of approximately 70 or below on an individually administered IQ test (for infants, a clinical judgment of significantly subaverage intellectual functioning).

• Concurrent deficits or impairments in present adaptive functioning (i.e., the 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.

• The onset is before age 18 years.

  IQ level 35–40 to 50–55

• Significantly subaverage intellectual functioning: an IQ of approximately 70 or below on an individually administered IQ test (for infants, a clinical judgment of significantly subaverage intellectual functioning).

• Concurrent deficits or impairments in present adaptive functioning (i.e., the 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.

• The onset is before age 18 years.

  IQ level 20–25 to 35–40

• Significantly subaverage intellectual functioning: an IQ of approximately 70 or below on an individually administered IQ test (for infants, a clinical judgment of significantly subaverage intellectual functioning).

• Concurrent deficits or impairments in present adaptive functioning (i.e., the 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.

• The onset is before age 18 years.

  IQ level below 20 or 25

• Reading achievement, as measured by individually administered standardized tests of reading accuracy or comprehension, is substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education.

• The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require reading skills.

• If a sensory deficit is present, the reading difficulties are in excess of those usually associated with it.

• Mathematical ability, as measured by individually administered standardized tests, is substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education.

• The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require mathematical ability.

• If a sensory deficit is present, the difficulties in mathematical ability are in excess of those usually associated with it.

• Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person's chronological age, measured intelligence, and age-appropriate education.

• The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g., writing grammatically correct sentences and organized paragraphs).

• If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.

• Performance in daily activities that require motor coordination is substantially below that expected given the person's chronological age and measured intelligence. This may be manifested by marked delays in achieving motor milestones (e.g., walking, crawling, sitting), dropping things, "clumsiness," poor performance in sports, or poor handwriting.

• The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living.

• The disturbance is not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or muscular dystrophy) and does not meet criteria for a Pervasive Developmental Disorder.

• If Mental Retardation is present, the motor difficulties are in excess of those usually associated with it.

• The scores obtained from standardized individually administered measures of expressive language development are substantially below those obtained from standardized measures of both nonverbal intellectual capacity and receptive language development. The disturbance may be manifest clinically by symptoms that include having a markedly limited vocabulary, making errors in tense, or having difficulty recalling words or producing sentences with developmentally appropriate length or complexity.

• The difficulties with expressive language interfere with academic or occupational achievement or with social communication.

• Criteria are not met for Mixed Receptive-Expressive Language Disorder or a Pervasive Developmental Disorder.

• If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems.

• The scores obtained from a battery of standardized individually administered measures of both receptive and expressive language development are substantially below those obtained from standardized measures of nonverbal intellectual capacity. Symptoms include those for Expressive Language Disorder as well as difficulty understanding words, sentences, or specific types of words, such as spatial terms.

• The difficulties with receptive and expressive language significantly interfere with academic or occupational achievement or with social communication.

• Criteria are not met for a Pervasive Developmental Disorder.

• If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems.

• Failure to use developmentally expected speech sounds that are appropriate for age and dialect (e.g., errors in sound production, use, representation, or organization such as, but not limited to, substitutions of one sound for another [use of /t/ for target /k/ sound] or omissions of sounds such as final consonants).

• The difficulties in speech sound production interfere with academic or occupational achievement or with social communication.

• If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the speech difficulties are in excess of those usually associated with these problems.

• Disturbance in the normal fluency and time patterning of speech (inappropriate for the individual's age), characterized by frequent occurrences of one or more of the following:

  • sound and syllable repetitions

  • sound prolongations

  • interjections

  • broken words (e.g., pauses within a word)

  • audible or silent blocking (filled or unfilled pauses in speech)

  • circumlocutions (word substitutions to avoid problematic words)

  • words produced with an excess of physical tension

  • monosyllabic whole-word repetitions (e.g., "I-I-I-I see him")

• The disturbance in fluency interferes with academic or occupational achievement or with social communication.

• If a speech-motor or sensory deficit is present, the speech difficulties are in excess of those usually associated with these problems.

• A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):

  • qualitative impairment in social interaction, as manifested by at least two of the following:

    • marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction

    • failure to develop peer relationships appropriate to developmental level

    • a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)

    • lack of social or emotional reciprocity

  • qualitative impairments in communication as manifested by at least one of the following:

    • delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)

    • in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others

    • stereotyped and repetitive use of language or idiosyncratic language

    • lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

  • restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

    • encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus

    • apparently inflexible adherence to specific, nonfunctional routines or rituals

    • stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)

    • persistent preoccupation with parts of objects

• Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.

• The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder.

• All of the following:

  • apparently normal prenatal and perinatal development

  • apparently normal psychomotor development through the first 5 months after birth

  • normal head circumference at birth

• Onset of all of the following after the period of normal development:

  • deceleration of head growth between ages 5 and 48 months

  • loss of previously acquired purposeful hand skills between ages 5 and 30 months with the subsequent development of stereotyped hand movements (e.g., hand-wringing or hand washing)

  • loss of social engagement early in the course (although often social interaction develops later)

  • appearance of poorly coordinated gait or trunk movements

  • severely impaired expressive and receptive language development with severe psychomotor retardation

• Apparently normal development for at least the first 2 years after birth as manifested by the presence of age-appropriate verbal and nonverbal communication, social relationships, play, and adaptive behavior.

• Clinically significant loss of previously acquired skills (before age 10 years) in at least two of the following areas:

  • expressive or receptive language

  • social skills or adaptive behavior

  • bowel or bladder control

  • play

  • motor skills

• Abnormalities of functioning in at least two of the following areas:

  • qualitative impairment in social interaction (e.g., impairment in nonverbal behaviors, failure to develop peer relationships, lack of social or emotional reciprocity)

  • qualitative impairments in communication (e.g., delay or lack of spoken language, inability to initiate or sustain a conversation, stereotyped and repetitive use of language, lack of varied make-believe play)

  • restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, including motor stereotypies and mannerisms

• The disturbance is not better accounted for by another specific Pervasive Developmental Disorder or by Schizophrenia.

• Qualitative impairment in social interaction, as manifested by at least two of the following:

  • marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction

  • failure to develop peer relationships appropriate to developmental level

  • a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)

  • lack of social or emotional reciprocity

• Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

  • encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus

  • apparently inflexible adherence to specific, nonfunctional routines or rituals

  • stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)

  • persistent preoccupation with parts of objects

• The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.

• There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years).

• There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.

• Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.

• Either (1) or (2):

  • six (or more) of the following symptoms of inattention  have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

    Inattention 

    • often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

    • often has difficulty sustaining attention in tasks or play activities

    • often does not seem to listen when spoken to directly

    • often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

    • often has difficulty organizing tasks and activities

    • often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)

    • often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

    • is often easily distracted by extraneous stimuli

    • is often forgetful in daily activities

  • six (or more) of the following symptoms of hyperactivity-impulsivity  have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

    Hyperactivity 

    • often fidgets with hands or feet or squirms in seat

    • often leaves seat in classroom or in other situations in which remaining seated is expected

    • often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

    • often has difficulty playing or engaging in leisure activities quietly

    • is often "on the go" or often acts as if "driven by a motor"

    • often talks excessively

    Impulsivity 

    • (g) often blurts out answers before questions have been completed

    • (h) often has difficulty awaiting turn

    • (i) often interrupts or intrudes on others (e.g., butts into conversations or games)

• Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

• Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).

• There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

• The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

• 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 three (or more) of the following criteria in the past 12 months, 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, 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 parental or parental surrogate home (or once without returning for a lengthy period)

  • (15) is often truant from school, beginning before age 13 years

• The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

• If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

• A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:

  • often loses temper

  • often argues with adults

  • often actively defies or refuses to comply with adults' requests or rules

  • often deliberately annoys people

  • often blames others for his or her mistakes or misbehavior

  • is often touchy or easily annoyed by others

  • is often angry and resentful

  • is often spiteful or vindictive

  Note:  Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

• The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

• The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.

• Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

• Persistent eating of nonnutritive substances for a period of at least 1 month.

• The eating of nonnutritive substances is inappropriate to the developmental level.

• The eating behavior is not part of a culturally sanctioned practice.

• If the eating behavior occurs exclusively during the course of another mental disorder (e.g., Mental Retardation, Pervasive Developmental Disorder, Schizophrenia), it is sufficiently severe to warrant independent clinical attention.

• Repeated regurgitation and rechewing of food for a period of at least 1 month following a period of normal functioning.

• The behavior is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux).

• The behavior does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa. If the symptoms occur exclusively during the course of Mental Retardation or a Pervasive Developmental Disorder, they are sufficiently severe to warrant independent clinical attention.

• Feeding disturbance as manifested by persistent failure to eat adequately with significant failure to gain weight or significant loss of weight over at least 1 month.

• The disturbance is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux).

• The disturbance is not better accounted for by another mental disorder (e.g., Rumination Disorder) or by lack of available food.

• The onset is before age 6 years.

• Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. (A tic  is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.)

• The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.

• The onset is before age 18 years.

• The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or postviral encephalitis).

• Single or multiple motor or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations), but not both, have been present at some time during the illness.

• The tics occur many times a day nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.

• The onset is before age 18 years.

• The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or postviral encephalitis).

• Criteria have never been met for Tourette's Disorder.

• Single or multiple motor and/or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations)

• The tics occur many times a day, nearly every day for at least 4 weeks, but for no longer than 12 consecutive months.

• The onset is before age 18 years.

• The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or postviral encephalitis).

• Criteria have never been met for Tourette's Disorder or Chronic Motor or Vocal Tic Disorder.

• Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional.

• At least one such event a month for at least 3 months.

• Chronological age is at least 4 years (or equivalent developmental level).

• The behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation.

Enuresis (Not Due to a General Medical Condition)

• Repeated voiding of urine into bed or clothes (whether involuntary or intentional).

• The behavior is clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.

• Chronological age is at least 5 years (or equivalent developmental level).

• The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition (e.g., diabetes, spina bifida, a seizure disorder).

• Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:

  • recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated

  • persistent and excessive worry about losing, or about possible harm befalling, major attachment figures

  • persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)

  • persistent reluctance or refusal to go to school or elsewhere because of fear of separation

  • persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings

  • persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home

  • repeated nightmares involving the theme of separation

  • repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated

• The duration of the disturbance is at least 4 weeks.

• The onset is before age 18 years.

• The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.

• The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not better accounted for by Panic Disorder With Agoraphobia

• Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations.

• The disturbance interferes with educational or occupational achievement or with social communication.

• The duration of the disturbance is at least 1 month (not limited to the first month of school).

• The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.

• The disturbance is not better accounted for by a Communication Disorder (e.g., Stuttering) and does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder.

• Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1) or (2):

  • persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness)

  • diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures)

• The disturbance in Criterion A is not accounted for solely by developmental delay (as in Mental Retardation) and does not meet criteria for a Pervasive Developmental Disorder.

• Pathogenic care as evidenced by at least one of the following:

  • persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection

  • persistent disregard of the child's basic physical needs

  • repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care)

• There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).

• Repetitive, seemingly driven, and nonfunctional motor behavior (e.g., hand shaking or waving, body rocking, head banging, mouthing of objects, self-biting, hitting own body).

• The behavior markedly interferes with normal activities or results in self-inflicted bodily injury that requires medical treatment (or would result in an injury if preventive measures were not used).

• If Mental Retardation is present, the stereotypic or self-injurious behavior is of sufficient severity to become a focus of treatment.

• The behavior is not better accounted for by a compulsion (as in Obsessive-Compulsive Disorder), a tic (as in Tic Disorder), a stereotypy that is part of a Pervasive Developmental Disorder, or hair pulling (as in Trichotillomania).

• The behavior is not due to the direct physiological effects of a substance or a general medical condition.

• The behavior persists for 4 weeks or longer.