The reclassification of neurodevelopmental disorders in ICD-11
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- 01.10.2025
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Abstract
Introduction
Developmental disorders (DDs) represent the first main nosological category in the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), preceding all other psychiatric–psychosomatic disorder entities [2]. By contrast in ICD-10 they were grouped in three different chapters: F7 on mental retardation; F8 on disorders of psychological development; and F9 on behavioral and emotional disorders with onset usually occurring in childhood and adolescence (hyperkinetic disorders and/or attention deficit hyperactivity disorder [ADHD] and tic disorders; [3]).
This reorganization is convincing not only because these entities are often associated with one another, but also because they all represent typical patterns of perceptual and emotional information processing, general and social cognition, language, and motor skills, which, upon closer inspection, already manifest themselves in the first decade of life. They are structural constants throughout life, which is why the concept of a “structural diagnosis” has been proposed [4‐6].
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Even in milder forms (broader autism/ADHD/tic phenotype), the particularities of personality functioning manifest early in life and are experienced as “being different.” However, the exact nature of this difference is often misunderstood by those affected as well as by their relatives and caregivers. This lack of understanding of their own nature and how they differ from their peers often leads to typical patterns of relationship problems, conflict patterns, and problematic behaviors. These then form the psychodynamic background for disturbances in the development of the self (e.g., self-image, self-esteem, and identity development), which can be accompanied by frustration, feelings of lack of acceptance and recognition, and states of tension, anxiety, and depression. Aggressive and psychotic decompensations may also occur. The latter usually take center stage at the time of referral to the psychiatric–psychotherapeutic support system. If the underlying structural diagnoses are not recognized—which is often the case, especially in mild and subsyndromal forms—the psychodynamics and causality of the resulting psychological symptoms cannot be properly understood. Essential elements of symptom dynamics are overlooked in therapy planning. Therefore, it is important to be familiar even with milder forms of ES, although they are not necessarily understood as diseases in themselves (see Table 1).1
Table 1
Classification of various developmental disorders (DDs) according to ICD-11 in comparison with ICD-10 and DSM‑5 (modified from [1])
DDs according to ICD-11 | DDs according to ICD-10 | DDs according to DSM‑5 | ||
|---|---|---|---|---|
6A00 | Disorders of intellectual development | F7 | Mental retardation F70–F79 | Intellectual disability |
6A01 | Developmental speech or language disorders | F80, F98.5, F98.6 | Specific developmental disorders of speech and language, stuttering (stammering), cluttering | Communication disorders |
6A02 | Autism spectrum disorder (ASD) | F84 | Pervasive developmental disorders | Autism spectrum disorder |
6A03 | Developmental learning disorder | F81 | Specific developmental disorders of scholastic skills | Specific learning disorder |
6A04 | Developmental motor coordination disorder | F82 | Specific developmental disorder of motor function | Motor disorders |
6A05 | Attention deficit hyperactivity disorder | F90 | Hyperkinetic disorders | Attention-deficit/hyperactivity disorder |
6A06 | Stereotyped movement disorder | F98.4 | Stereotyped movement disorders | Stereotypic movement disorder |
6E60 | Secondary neurodevelopmental syndrome | – | – | – |
6A0Y | Other specified neurodevelopmental disorders | F88 | Other developmental disorders | Other specified developmental disorders |
6A0Z | Neurodevelopmental disorders, unspecified | F89 | Unspecified developmental disorders | Unspecified neurodevelopmental disorders |
8A | Movement disorders | Motor disorders | ||
8A05.0 | Primary tics or tic disorders | F95 | Tic disorders | Tourette’s disorder Persistent motor or vocal tic disorder |
6A00 disorders of intellectual development according to ICD-10 F7
The term “intellectual disability” (ICD-10) is replaced by the term “intellectual development disorder.” As before, a distinction is made between the two core areas of impaired intellectual performance and impaired adaptive skills, with greater emphasis now being placed on the heterogeneity of impairment profiles and the impairment of functions (cf. International Classification of Functioning, Disability, and Health [ICF]; [7]). The classification into mild (~ IQ 55–69), moderate (~ IQ 40–54), and severe (~ IQ < 40) is retained, with emphasis on the fact that objective quantification is hardly possible in the very low IQ range [8]. The “most severe intellectual disability” according to ICD-10 (estimated IQ < 20) is now referred to as profound intellectual disability (for more details, see AWMF S2k guidelines; [7, 8]).
6A02 autism spectrum disorder according to ICD-10 F84.-
Autism spectrum disorder (ASD) largely follows the changes already outlined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‑5; [9, 10]). The ICD-10 autism subcategories (early childhood autism, F84.0; atypical autism, F84.1; and Asperger syndrome, F84.5) have been replaced by the term “autism spectrum disorder.” The core autistic syndrome has been restructured into two main criteria: deficits in social communication and interaction; and restrictive, repetitive patterns of behavior, interests, activities, and patterns of perception. Compared to the ICD-10, greater weight is given to the second main criterion, which is now also supplemented by sensory characteristics as a qualitative feature. The operationalization of syndromal ASD is less strict than in the DSM‑5. No defined number of symptoms is required for the main criteria, and only symptomatic examples are listed. Unlike in the DSM‑5, severity is not operationalized. Specific reference is made to the phenomenon of compensation. This means that symptoms such as lack of eye contact can be concealed so well through targeted practice, especially in cases of high intelligence, that they go unnoticed for a long time. Pragmatic language deficit symptoms are clearly emphasized.
Furthermore, frequent comorbidities within the ES, such as those between ASD and ADHD, are now more clearly recognized. While the ICD-10 still excluded dual diagnoses of ASD and ADHD, they can now be recognized as comorbid conditions.
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Gender-related aspects are also emphasized more strongly. For example, women and girls with autism often have better social skills, are less conspicuous, and show less expansive behavior. This means they are often not recognized or diagnosed. This can have very negative consequences [5, 11], a point that is now underscored more strongly. Finally, the distinction between the spectrum and other mental disorders, and the spectrum of normality in particular, is clearer. Subsyndromal variants of ASD, in the sense of structural diagnoses as normal variants (“broader autism phenotype”), have long been recognized in the specialist literature [4]. Despite being less severe, these can be highly significant, particularly in psychotherapy, in helping to understand interpersonal problems and conflicts as well as the resulting adjustment disorders, anxiety disorders, depression, or personality disorders that can develop ([4, 6]; Table 2).
Table 2
Classification of autism spectrum disorders (ASDs) in ICD-11, ICD-10, and DSM‑5 (modified from [1])
ASD according to ICD-11 | ASD according to ICD-10 | ASD according to DSM‑5 | ||
|---|---|---|---|---|
6A02 | Autism spectrum disorder | F84 | Pervasive developmental disorders | Autism spectrum disorder |
6A02.0 | Autism spectrum disorder without disorder of intellectual development and with mild or no impairment of functional language | F84.0, F84.1, F84.5 | Childhood autism, atypical autism, Asperger’s syndrome | Additional codes for: severity, accompanying intellectual impairment, accompanying language impairment, connection with a known physical illness, genetic or environmental condition, comorbidities |
6A02.1 | Autism spectrum disorder with disorder of intellectual development and with mild or no impairment of functional language | |||
6A02.2 | Autism spectrum disorder without disorder of intellectual development and with impaired functional language | |||
6A02.3 | Autism spectrum disorder with disorder of intellectual development and with impaired functional language | |||
6A02.5 | Autism spectrum disorder with disorder of intellectual development and with absence of functional language | |||
6A02.Y | Other specified autism spectrum disorder | F84.8 | Other pervasive developmental disorders | – |
6A02.Z | Autism spectrum disorder, unspecified | F84.9 | Pervasive developmental disorders, unspecified | – |
6A05 attention deficit hyperactivity disorder
As with ASD, the far-reaching changes to the DSM‑5 with regard to attention deficit hyperactivity disorder (ADHD) are essentially being adopted. The ICD-10 terminology of hyperkinetic disorder of social behavior or simple activity and attention disorder is replaced by ADHD. While the ICD-10 classification focused almost exclusively on children and adolescents, the new classification also takes adults into account. Hyperactivity symptoms, which are more prevalent in childhood and adolescence, are now more firmly embedded within a broader range of symptoms. Compared to the DSM‑5, the criteria for diagnosing ADHD are vaguer and less clearly defined, potentially resulting in more diagnoses. While the age criterion was 5 years in the ICD-10, the critical time window has now been raised to 12 years. Furthermore, as with ASD, diagnoses are permitted in which symptoms only become apparent when social demands exceed the compensatory potential of affected individuals. This allows for a broader and later initial diagnosis, which will lead to an increase in prevalence. Overall, the clinical phenotype description in ICD-11 is much more comprehensive and detailed. It also addresses the difficulty of distinguishing ADHD from other mental disorders and from normal variants (“broader ADHD phenotype”), as well as the differences between boys/men and girls/women [4]. In contrast to the DSM‑5, the severity of ADHD is not operationalized in the ICD-11 ([2, 9]; Table 3).
Table 3
Classification of attention deficit hyperactivity disorder (ADHD) in ICD-11, ICD-10, and DSM‑5 (modified from [1]).
ADHD according to ICD-11 | ADHD according to ICD-10 | ADHD according to DSM‑5 | ||
|---|---|---|---|---|
Code | Terminology | Code | Terminology | Terminology |
6A05 | ADHD | F90 | Hyperkinetic disorders | ADHD |
6A05.0 | Attention deficit hyperactivity disorder, predominantly inattentive presentation | F90.0 | Disturbance of activity and attention | ADHS, predominantly inattentive presentation |
6A05.1 | Attention deficit hyperactivity disorder, predominantly hyperactive-impulsive presentation | ADHS, predominantly hyperactive/impulsive presentation | ||
6A05.2 | Attention deficit hyperactivity disorder, predominantly combined presentation | ADHS, combined presentation | ||
6A05.Y | Attention deficit hyperactivity disorder, other specified presentation | F90.1, F90.8 | Hyperkinetic conduct disorder, other hyperkinetic disorders | Other specified ADHD |
6A05.Z | Attention deficit hyperactivity disorder, presentation unspecified | F90.9 | Hyperkinetic disorders, unspecified | Unspecified ADHD |
8A05.0 primary tics or tic disorder according to ICD-10: F95
In the case of tic disorders (TD), a fundamentally new classification has been established in the ICD-11: They are now classified as neurological disorders rather than psychiatric disorders [13]. However, they are listed in the DD chapter as a related category under a neurological code (see Table 4). In the DSM‑5, however, TS are classified as a DD.
Table 4
Classification of tic disorders in ICD-11, ICD-10, and DSM‑5 (modified from [1])
Tic disorders according to ICD-11 | Tic disorders according to ICD-10 | Tic disorders according to DSM‑5 | ||
|---|---|---|---|---|
8A05.0 | Primary tics or tic disorders | F95 | Tic disorders | Tic disorders |
8A05.00 | Tourette syndrome | F95.2 | Combined vocal and multiple motor tic disorder (Tourette syndrome) | Tourette disorder Persistent (chronic) motor or vocal tic disorder |
8A05.01 | Chronic motor tic disorder | F95.1 | Chronic motor or vocal tic disorder | Persistent (chronic) motor or vocal tic disorder |
8A05.02 | Chronic phonic tic disorder | |||
8A05.03 | Transient motor tics | F95.0 | Transient tic disorder | Transient tic disorder |
8A05.0Y | Other specified primary tics or tic disorders | F95.8 | Other tic disorders | Other tic disorders |
8A05.0Z | Primary tics or tic disorders, unspecified | F95.9 | Tic disorder, unspecified | Tic disorder, unspecified |
8A05.1 | Secondary tics | |||
Regarding terminology, the term “phonic tics” is now used instead of “vocal tics.” However, there has been no fundamental change in the description of the phenotype. Specific reference is made to the frequent co-occurrence of TD with other DDs, such as ADHD or ASD, as well as with other mental health conditions, including obsessive-compulsive disorders. The distinction between primary TD and secondary TD, where at least probable etiological or pathogenetic factors can be identified, continues to be made [13, 14].
6E60 secondary neurodevelopmental syndrome
In the ICD-11 classification system, all DDs are divided into primary idiopathic and secondary variants. The latter are listed in a separate chapter (6E60). In the case of DD in particular, specific genetic syndromes (e.g., 22q11 and fragile X) and acquired conditions (e.g., inflammatory or immunological central nervous system diseases and fetal alcohol syndrome) can be identified as possible, probable, or certain causes of ES. In such cases, they would be classified as secondary disorders according to the ICD-10 category of organic mental disorders (ICD-10 F0). For more information on specific diagnostic and therapeutic approaches, please refer to the comprehensive literature [14].
Practical conclusion
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Compared to the ICD-10, the ICD-11 introduced fundamental changes and reorganizations to the classification of developmental disorders (DDs).
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In terms of content, these were largely prepared by corresponding reclassifications in the DSM‑5.
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Developmental disorders are described as patterns of perception, intellectual development, social cognition, emotionality, language and motor skills, as well as learning and behavioral organization, which deviate from the average norm. If the presentation is fully syndromic, they are usually diagnosed in the first decade of life.
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They are persistent in nature, although they can often be compensated for so effectively by learning strategies in cases of good intellectual development that they are less noticeable.
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The dimensional conceptualization of the ICD-11 (based on the DSM-5) places greater emphasis on transitional forms of all DD. These are usually less pronounced and are often subsyndromal phenotypes (“broader autism/ADHD/tic phenotype”).
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In these cases, the diagnosis is often not made initially. However, such structural diagnoses, in the sense of nonpathological nosological entities, can still be relevant for the development of interpersonal problems and conflicts and subsequent mental disorders, such as acute stress reactions, adjustment disorders, depressive episodes, obsessive-compulsive disorders, disorders of self and identity development, and personality development disorders, as well as for therapy planning.
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Knowledge of such syndromal and subsyndromal DDs is therefore important not only in child and adolescent psychiatry and psychotherapy, but also in adult psychiatry, psychotherapy, and psychosomatics, because a comprehensive understanding of the genesis and psychodynamics of many psychological maldevelopments, conditions, and chronic conflict situations cannot be achieved without considering these structural particularities of a person.
Declarations
Conflict of interest
L. Tebartz van Elst, A. Riedel and M. Biscaldi-Schäfer declare that they have no competing interests.
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For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical standards indicated in each case.
The supplement containing this article is not sponsored by industry.
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