Diagnostic Criteria for Childhood Disorders

Parenting is an emotional journey. All children and adolescents experience stages of emotional and mental growth in different ways. When these milestones aren’t reached, and a child’s actions and behaviors extend beyond what is considered developmentally appropriate, parenting and caregiving can be challenging.

For parents and caregivers, understanding the diagnostic criteria and process for childhood disorders is an important first step in ensuring their child receives the diagnosis and care they need.

According to the Centers for Disease Control and Prevention (CDC), 1 in 7 children between the ages of three and seventeen have a current diagnosed mental or behavioral health condition.^[1]. If you believe your child is experiencing a mental or behavioral health disorder, they will need to be assessed for a formal diagnosis. This article provides an overview of what that process looks like.

Diagnostic Criteria for Childhood Disorders

With childhood disorders, an accurate diagnosis is crucial to ensuring the child receives the appropriate care and support. For children and teens, early intervention is key to improving mental and behavioral health outcomes over their entire lifespan.

While parents and caregivers may spend hours pouring over resources and diagnostic criteria, a true and accurate diagnosis is one that comes directly from a professional. There is a wide range of factors that can affect typical development and behaviors, and a professional can discern not only the underlying reason but also external and internal factors that could affect the condition.

Misdiagnosis and delayed diagnosis lead to missed opportunities to provide the child with the treatment and support they need. When a professional assesses a child, they rely on a set of well-established and accepted diagnostic criteria. This includes the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) 5th edition, especially as it pertains to child mental health disorders.

Examples of DSM-5 diagnostic criteria for childhood disorders include:

• Attention Deficit Hyperactivity Disorder (ADHD): Symptoms need to have persisted for at least six months and in at least two or more different settings (childcare, school, home, etc.). Symptoms need to have interfered with the child’s academic, social, and occupational functioning.
• Children under 17 years need to display at least six symptoms for an ADHD diagnosis, while those 17 and older must display at least five symptoms. Initial symptoms must present before the child turns 12 years of age.
• Autism Spectrum Disorder (ASD): A child must display persistent deficits in non-verbal communication used for social interaction, social-emotional reciprocity, and developing/maintaining relationships.
• Additionally, the child must display at least two of the following – stereotyped/repetitive movements, inflexibility/need for sameness and routines, abnormal fixated interests, and hyper/hypoactivity to sensory inputs. Symptoms that are present will cause impairment in social, occupational, and other key areas of functioning.
• Tourette’s Disorder: A child must experience both motor and vocal tics, although they do not need to present simultaneously. The child should have experienced the tics for a period of at least one year, and the tics need to first appear before the age of 18. There should be no other outside cause, such as medication or medical condition that could be causing the tics.
• Separation Anxiety Disorder: A child will experience at least three developmentally inappropriate traits of fear or anxiety surrounding separation from an attached individual. In children and adolescents, these traits must persist for at least four weeks and cause significant distress in academic, social, or other areas of daily functioning.

Understanding Childhood Mental Health Disorders

Childhood mental health disorders are more common than many people realize, and the prevalence is growing. Between 2012 and 2018, there was a 34.6 percent increase in the prevalence of child diagnosis.^[2]

While this number is concerning, parents and caregivers should realize that along with this, there has been an increased awareness of childhood disorders, prompting an increase in evaluations and diagnoses. With greater awareness and advocacy comes improved treatment options and programs to address the needs of the child and adolescent population.

The prevalence of childhood disorders is dependent on the specific condition and the age group. Here is a brief overview of some of the most commonly diagnosed disorders in children and adolescents.

Anxiety and Mood Disorders

Generalized anxiety, separation anxiety, and social anxiety are conditions that fall under the category of anxiety disorders in children. Signs of anxiety disorders include irritability, constant worrying, negative thoughts, feeling fidgety, difficulty sleeping, increased clinginess, and some physical symptoms, such as tummy aches.^[3]

Mood disorders in children can extend beyond anxiety to include depression. While bipolar disorder is typically diagnosed during late adolescence and early adulthood, it is possible for younger children to experience symptoms.^[4] Both depression and bipolar disorder can present with symptoms such as emotional dysregulation, manifesting in ways such as sadness, irritability, and unpredictable mood swings.

Attention-Deficit/Hyperactivity Disorder (ADHD)

ADHD is considered a neurodevelopmental disorder. These are conditions that are typically characterized by certain impairments that parents and caregivers are often the first to notice. These can include impairments in communication, cognition, motor skills, and behavior. Symptoms can appear as mild or severe, depending on the child.

Oppositional Defiant Disorder (ODD): Children with oppositional defiant disorder will display a consistent pattern of anger, irritability, defiance, and argumentativeness. While opposing authority to some degree is a common way for children and adolescents to test their own boundaries, those with ODD may argue excessively with adults and consistently question rules.

Other signs of ODD include frequent temper tantrums, refusal to comply with adult requests, using hateful or mean language when upset, not taking age-appropriate accountability for their actions, and a tendency toward being spiteful.^[5]

Autism Spectrum Disorder (ASD)

Autism spectrum disorder is a developmental disorder with symptoms that typically appear in early childhood. Currently, the CDC reports as many as 1 in 36 children has been diagnosed with ASD.^[6] The symptoms of ASD vary widely in severity, and currently, scientists believe there isn’t one single cause but rather multiple causes interplaying to cause characteristic differences in the brain.

Tourette Syndrome

Children with Tourette Syndrome will exhibit repetitive, involuntary behaviors in the form of movements or vocalizations. These involuntary movements are called tics. They can range from something barely noticeable, such as blinking or nose twitching. They can also be more noticeable and complex.

For example, a child with Tourette Syndrome may jerk part of their body or repetitively touch people. They may also display noticeable vocal tics, such as repetitive through clearing or grunting. Research indicates that Tourette Syndrome occurs in approximately 1 out of 162 children.^[7]

These represent just some of the most common childhood disorders. Others, such as stress-related disorders, trauma-related disorders, pervasive developmental disorders, and eating disorders, are additional examples.

How Are Childhood Disorders Diagnosed?

Receiving a diagnosis for your child is a multi-step process. It can begin by bringing up concerns with the child’s pediatrician or health care provider; however, their primary care physician might not be qualified to thoroughly assess and diagnose the child on their own. Instead, receiving a diagnosis is often a team effort that also involves mental health professionals who specialize in child diagnosis.

A clinical interview is often the first step. During this interview, the clinic will meet with the child, as well as the parents or caregivers, and take a detailed history of the child’s development and behaviors. They will also discuss symptoms that the child is experiencing.

The clinician may want to observe the child in their natural settings to provide the most accurate picture of how various symptoms manifest in the child’s daily environment. The clinician will consider the behaviors and symptoms and compare them against diagnostic criteria to rule out and confirm a diagnosis.

It’s extremely important to consider developmental stages during the diagnostic process. Children go through stages where their behaviors and abilities begin to change and shift. In a neurotypical child, these changes happen on a somewhat predictable trajectory, with room for individual variance.

When a childhood disorder is present, this trajectory of development doesn’t display clinically predictable progress. While tantrums and short attention spans are normal developmental behaviors for a toddler, the same behavior in an older child can signal a developmental disorder. During the diagnostic process, clinicians account for these developmental differences.

Diagnostic Criteria and Tools

The primary diagnostic tool that clinicians use in diagnosing children’s disorders is the Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition (DSM-5). The DSM-5 provides a framework that specifically outlines the diagnostic criteria for each childhood diagnosis. Along with diagnostic symptoms, there are also criteria for the number of symptoms the child must display and the duration they have experienced them that are required for a diagnosis.

For example, an ADHD diagnosis requires the presence of six or more symptoms for children up to 18 years of age and five or more symptoms for adolescents 17 years or older.^[8] This is important for parents to know, considering the presence of one or two worrisome symptoms might not be sufficient for a diagnosis.

The DSM-5 has also developed more precise criteria for several childhood disorders. These include Autism Spectrum Disorder, Attention Deficit/Hyperactivity Disorder, Post Traumatic Stress Disorder, Specific Learning Disorder, and Eating Disorders.

In addition to the DSM-5 criteria, there are a number of emotional and developmental assessment tools that can be used to gather more information about the symptoms and behaviors the child is experiencing.

As an example, the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) is used as a diagnostic tool for children ages 6 through 18. Other tools, such as the Child Behavioral Checklist (CBCL) are used to assess emotional and behavioral problems in children.

The CBCL considers a wide spectrum of behaviors, from a child feeling anxious or depressed to problems with social skills, attention, and aggression, along with somatic complaints.^[9]

Parents and caregivers should feel comfortable asking which diagnostic tools are being used and ensure they understand the function of these tools. The most accurate child diagnosis comes from a blended approach that uses structured criteria and individualized child assessments.

Behavioral and Emotional Evaluations

Evaluating a child’s behavior and emotional state can be a challenging task. Professionals must work to understand how the child is feeling, not just in a clinical setting but in their different daily settings as well. Some children respond with very different behaviors depending on where they are and who they are with.

To start the process, the professional will often begin with questionnaires and structured interviews. They use a number of tools, depending on the needs of the child, to assess their emotional and behavioral wellness.

• Strength and Difficulties Questionnaire (SDQ): A behavior diagnosis screening tool that is used to assess emotional symptoms, along with screening for issues such as hyperactivity, conduct problems, prosocial behavior, and peer relationships.^[10] This is a brief questionnaire designed for assessing 2-17-year-olds.
• Children’s Depression Inventory (CDI 2): A self-report that measures symptoms of depression in children and adolescents between the ages of 7 and 17. The CDI 2 evaluates areas of emotional distress, negative self-esteem, and interpersonal problems.
• Revised Children’s Anxiety and Depression Scale (RCADS): A self-report questionnaire that measures symptoms of anxiety and depression in children and adolescents. This includes symptoms of major depressive disorder, panic disorder, social phobia, generalized anxiety disorder, separation anxiety, and obsessive-compulsive disorder.
• Behavior Assessment System for Children (BASC-3): Evaluates behavioral and emotional function in children, adolescents, and young adults ages 2 – 21. BASC-3 utilizes parent, teacher, and self-report questionnaires for a multi-perspective approach to understanding the child’s strengths and challenges.

Cognitive and Academic Assessments

Evaluating a child’s academic performance and cognitive abilities is critically important in the diagnostic process. These assessments help to provide clearer insights into how the child learns, thinks, and solves problems.

• Cognitive Assessments: Can be used to assess the child’s capabilities in areas of memory, attention, reasoning, and processing speed. For children who are being assessed for learning disabilities and ADHD, cognitive assessments are extremely important.
• Academic Assessments: Different in how they focus on specific skills rather than general capabilities. Academic assessments measure areas such as reading, math, and writing to determine if the child is aligned with current academic expectations based on their age.
• Combined Approach: By combining both cognitive and academic assessments, professionals can gain a more comprehensive picture of the child’s capabilities. For parents, the results of these developmental assessments can provide clarity and a starting point for helping their children in their struggles.

Multidisciplinary Approach

They say it takes a village to raise a child. It also takes a team with a multidisciplinary approach to accurately provide a childhood diagnosis. A multidisciplinary approach brings together professionals, such as pediatricians, child psychologists, and child psychiatrists. In some cases, speech, language, and occupational therapists may also play a role.

Parents, teachers, and other caregivers also play a crucial role in providing insights into how the child functions in different environments. Together, a collaborative process ensures that the child receives the most comprehensive assessment and, as a result, the most accurate diagnosis. This is the foundation for developing a personalized plan that supports them in all areas of development.

Challenges in Diagnosing Childhood Disorders

Diagnosing disorders in children can be challenging. Issues such as overlapping symptoms that are present in multiple conditions can present difficulties in achieving a diagnosis. For example, impulsivity is a common sign of ADHD, but it can also be present in trauma and anxiety disorders. The same is true for irritability and mood swings that can point to multiple disorders.

There are also comorbidities to consider when assessing and diagnosing a child. It’s not uncommon for a child to have more than one disorder. For example, autism is also associated with sensory processing issues, and ADHD is associated with learning challenges. The problem with comorbidities is that they can exacerbate or mask symptoms, making the diagnostic process more complex.

And finally, there’s the very nature of childhood development. Some behaviors that seem problematic to parents or caregivers might actually fall within the range of normal, age-appropriate behavior. This is especially true for younger children who often lack the ability to articulate their feelings.

Childhood disorder diagnosis is a complex process that demands a collaborative approach among professionals, parents, teachers, and others who play an important role in the child’s life. The use of evidence-based tools and a multidisciplinary approach is the most effective path forward for understanding and meeting the child’s needs. With the right support, families can travel this journey knowing their child is receiving the best care.