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Vol. 128, N o . 11, M a y 1972

Mental Retardation: Development of an International

Classification Scheme Michael J. Begab and Gerald D. La Veck

Fifth WHO Seminar on Psychiatric Diagnosis, Classification,

and Statistics

Some Thoughts on the Classification of Mental Retardation

in the United States of America George Tarjan and Leon Eisenberg

Differing Concepts of Diagnosis as a Problem in Classification

Jack R. Ewalt

Comments on the ICD Classification of Mental Retardation

Joseph Wortis

A Note on the International Statistical Classification of

Mental Retardation Jack Tizard

The Problem of the Classification of Mental Retardation

G.E. Suhareva

Classification and Mental Retardation: Issues Arising in the

Fifth WHO Seminar on Psychiatric Diagnosis, Classification,
and Statistics G. Tarjan, J. Tizard, M. Rutter, M. Begab,
E.M. Brooke, F. de la Cruz, T.-y. Lin, H. Montenegro,
H. Strotzka, and N. Sartorius

Publication of this supplement was supported by contract NIH-

72-C-563 from the National Institute of Child Health and
Human Development, National Institutes of Health.

Copyright 1972 American Psychiatric Association

Classification of Mental Retardation

Mental Retardation: Development of an

International Classification Scheme

M ENTAL RETARDATION is a universal phenomenon. It occurs, with

varying degrees of frequency, in families from all walks of life in
both developed and underdeveloped countries. In its most severe forms
it is a source of great trauma, hardship, and despair to parents and is
an economic and social burden to communities. Even the milder forms
of intellectual handicap pose serious threats to individual self-fulfill-
ment, family security, and national productivity. The most affluent of
nations can ill afford such losses in their human resources.
The prevention and treatment of mental retardation on both the
individual and societal levels rest fundamentally on a fuller under-
standing of its causes and pathogenesis, on concerned and skilled pro-
fessional practitioners, and on the commitment of appropriate re-
sources at all levels of government. Efforts to reach the first of these
goalswhich is essential to classificationhave been greatly enhanced
in recent decades through basic and applied research. During this peri-
od we have identified additional clinical syndromes, developed a tech-
nology for prenatal diagnosis and prevention, improved nutritional and
medical intervention techniques, and made progress toward solving the
mysteries surrounding the transmission of genetic materials at the cel-
lular level.
In the behavioral sciences much has been learned about the impact of
environmental deprivation on mental growth and the compensating ef-
fects of early stimulation, about methods for promoting language
development and reading skills, and about the untapped capacities of
many retarded individuals for socially useful living. Perhaps most im-
portant of all is the growing recognition that in most forms of retarda-
tion, even where a single etiological factor can be isolated, the
individual's functional performance is the product of the interaction of
his biological makeup and environmental events and can be modified.
The potential for behavioral change, sometimes to the point of reversi-
bility, represents one of the most significant concepts in the field to
emerge in recent years.
The changing attitudes of psychiatrists, pediatricians, and obstetri-
cians toward the mentally retarded stem in part from this new concep-
tualization of the problem and the growing conviction that even where
"cures" are not possible, informed treatment of the individual and his
family can significantly aid life adjustment. To capitalize more fully on
this burgeoning interest, these disciplines need more precise informa-
tion on hazards to fetal development, symptomatology and treatment
potentials for specific diagnostic conditions, and the values and limita-
tions of psychological test measurements. Furthermore, to keep abreast
of new discoveries and program developments, these disciplines must
share a terminology and language that permit communication. Our
failure in this latter area has seriously handicapped efforts of profes-
sionals from different countries to learn from one another.
The World Health Organization, mindful of these deficiencies and of
our increasing fund of knowledge, has embarked upon a series of
seminars to develop an international scheme for the diagnosis, classifi-
cation, and reporting of statistics in psychiatric disorders, including
mental retardation. This effort comes at a most opportune time. Com-
parative data among countries on the incidence and prevalence of
mental retardation and the factors with which specific conditions are
associated are not highly reliable. Although there are significant varia-
tions in prenatal care, population homogeneity, disease control, degree
of environmental deprivation, and other factors causative or contributo-
ry to mental retardation, reported statistical differences may be more
artifactual than real. Differences in the definition and conceptualization
of mental retardation, inadequacies and variations in classification
schemes used, confusion of terminology, and cultural variability in
demands and expectations for human performance are only a few of the
artifacts that preclude valid comparisons. Within and among countries,
meaningful planning for the retarded cannot be accomplished until
these issues are resolved.
The 1969 seminar, cosponsored by the World Health Organization
and the National Institute of Child Health and Human Development,
was a milestone in the realization of these goals. It is clear that the
complex issues confronted will require continuing attention, but mean-
ingful dialogue has begun and a sounder base for assessing the extent
and diversity of this problem is being established. Community planners
and professional practitioners should profit from this activity, but the
ultimate beneficiaries and the raison d'etre of the seminar will be the
mentally retarded and their families.
Fifth WHO Seminar on Psychiatric Diagnosis,
Classification, and Statistics

This report describes in detail the problems ciples had been previously adopted.
of adequately classifying mental retardation 1. The study of the process of psychiatric
and the recommendations made for the diagnosis, as provided by the diagnostic ex-
forthcoming ninth revision of the Interna- ercise, should be used as the basis for under-
tional Classification of Diseases. In general standing the different schemes that psychia-
the Seminar agreed that the current classifi- trists of different schools employ. Major
cation of mental retardation is inadequate sources of variation and error should be
and that a multiaxial scheme should be identified in order to improve the reliability
adopted. This scheme would consist of three and validity of psychiatric diagnosis.
axes: 1) intellectual level, 2) associated or .2. In view of the variety of theoretical
etiological factors, and 3) clinical psychiatric concepts regarding the etiology and path-
system, and would require that each axis be ogenesis of mental disorders, and because
recorded. Information that should be of the paucity of evidence that might lead to a
considered in classifying mental retardation choice between theories, emphasis should be
includes: degree, organic aspects, psychiatric placed on the use of solid clinical facts as a
and behavioral aspects, and psychosocial as- starting point in developing a classification.
pects. The participants also considered the 3. The definition of terms should be
need to develop a glossary and how best to operational and capable of clinical applica-
promote the effective use of the ICD. tion.
4. Any scheme agreed upon at a seminar
will be tested through national and interna-

T HIS SEMINAR was the fifth in the World

Health Organization's (WHO) ten-year
program on "Psychiatric Diagnosis, Classi-
tional exercises and through further refine-
ment and revision before a final recom-
mendation is made for the revision of
fication, and Statistics." Previous seminars' the International Classification of Diseases
dealt with "Problems of Functional Psy- (ICD) in 1975.
choses, Particularly Schizophrenia" ( 2 ) , The following activities that were carried
"Reactive Psychoses" (3), "Mental Disorders out in different countries since the last semi-
in Children" (4), and "Psychiatric Disorders nar were reported by the participants (see
of Old Age" (5). In the development of a appendix 1): 1) Diagnostic exercises using
classification of mental disorders, four prin- case histories from previous seminars were
carried out in Bulgaria, Czechoslovakia, Ja-
pan, and the U.S.S.R.; 2) glossaries and
diagnostic manuals were prepared in a num-
ber of countries that were represented at the
Seminar; 3) trial use of the Paris classifica-
tion of children's disorders is being planned
in France, the United Kingdom, and the
United States. The importance of such ex-
periments was particularly stressed by many
participants as being essential for the im-
provement of the ICD.

Diagnostic Exercises
The procedure, which had been successfully
used in previous seminars, of beginning with a
detailed discussion of problems arising from appreciated, and there was general comment
the analysis of case histories and of video- throughout the meeting on the outstandingly
tapes, was again used in this one. Here the good choice of cases that highlighted the chief
purpose was to enable participants first, to issues to be considered during the discussions.
study a common set of case materials relating
to mental retardation and to record their Videotape Diagnostic Exercise
judgments about it; second, to discuss dis- Three patients who were representative of
agreements, ambiguities, and points of different types of problems were shown on
controversy; and third, through the elucida- videotape to the participants. The purpose of
tion of specific problems to approach general this exercise was, again, to illustrate different
principles of diagnosis, classification, and facets of the diagnostic problem by showing a
statistics in this area. videotaped interview. The three patients
shown illustrated problems of the differential
Case History Exercise
diagnosis of developmental disorders and
Several months before the meeting partic- mental retardation, the problem of the dif-
ipants received case histories of 11 patients ferential diagnosis of child psychosis and
that they were asked to read and to analyze. mental retardation, and a diagnostic problem
The cases were chosen to illustrate problems that was complicated by the fact that one of
that were related to difficulties in diagnosis the patients was an identical twin. Following
regarding level of intellectual retardation, the a recommendation made at a past confer-
causes of the patients' retardation, the diag- ence, the technique adopted at the Seminar
nosis of psychiatric disorder accompanying was first to show the videotape to the partic-
the mental retardation, and the differential ipants, who were asked to rate the patient
diagnosis of mental retardation and devel- according to his behavioral characteristics,
opmental disorders. The patients included knowing only his sex and age. Participants
some who were typical and others who were were then given a case history and were
borderline or had an uncertain diagnosis that invited to ask for additional information that
posed considerable problems. Each case his- was not included in it. They then made a final
tory followed a standard format, giving the diagnosis of the patient, rating this as either
reasons for the patient's admission, his family firm or provisional.
history, information about his siblings, his The method of presentation of the video
developmental history, his history of neuro- material proved to be reasonably satisfactory
logical and physical illnesses, the results of in that it enabled analyses to be made of rat-
current physical examination, neurological ings of observed behavior and of this together
examination, laboratory findings, and psy- with the written case material. It was
chological evaluation, and some information thought, however, that the discussion would
about his hospital course or disposal. Partic- have been more fruitful had the videotapes
ipants were invited to make a diagnosis of been available for replay during the discus-
the patient, using their own terminology, to sion, and it was recommended that arrange-
indicate whether the diagnosis was firm or ments be made for this in future seminars.
provisional, and to code their diagnosis ac- It was also recommended that for future sem-
cording to the ICD rubrics by using one or inars there be testing and revision of the
more than one category. They were given evaluation sheets before the meeting.
standardized forms on which to record their
judgments; these were then returned to WHO
for analysis. Summaries of the data indicat- Principal Topics of Discussion
ing diagnostic agreement and disagreement Agreement on Diagnosis and Classification
on the patients, as well as the comparison of
diagnoses, were handed out at the meeting Level of intellectual retardation. For each
and participants brought with them the case of the patients in the case history exercise, the
material they had been sent. The excellent participants were asked to categorize the
preparation of case histories by the U.S. col- level of mental retardation according to the
leagues in the preparatory committee and in six-point coding (310-315) given in the eighth
the National Institute of Child Health and revision of ICD (ICD-8) (6). In most cases
Human Development (NICHD) was widely this caused no major difficulties, and there
was a high level of agreement80 to 90 per-
cent of the participants giving the same cod- overlaps other parts of ICD-8, and there is no
ing for the level of retardation. The only clear instruction as to whether the same
patient over whom there was appreciable dis- condition should be recorded under one or
agreement was a six-week-old boy with both headings. Everyone agreed that it was
chromosomal abnormalities. It was agreed most important to record the biological dis-
that it was not possible to make a meaningful orders underlying mental retardation, but
assessment of intelligence in infancy and that dissatisfaction was expressed with the fourth-
judgments on level of retardation in very digit coding in that it necessitated judgments
young children could only be approximate. about hypothetical causes (which were shown
Participants were unanimous in agreeing that to be unreliable) rather than recording asso-
the greatest difficulties in assessing retarda- ciated neurological handicaps. This issue was
tion existed for individuals from minority returned to later in the Seminar.
groups, from cultures other than those in Psychiatric or behavioral disorder accom-
which the participants were living, and from panying mental retardation. Several of the
socially deprived communities. Whereas patients showed disorders of behavior, as well
intelligence tests are of great value in assess- as mental retardation. For example, the third
ing level of retardation, they should never be patient in the case history exercise was a hos-
used in isolation from clinical considerations tile, extremely hyperactive child who had
of social-adaptive functioning. When started several fires and who had gotten into
individuals come from cultures other than frequent fights. However, only ten of the 16
those used for the standardization of intelli- participants made a diagnosis outside of the
gence quotient (IQ) tests, the tests are of mental retardation section and even these ten
limited value. coded psychiatric disorder under three dif-
Causation of retardation. The fourth digit ferent headings. The same issue arose in
in the ICD-8 mental retardation coding, that connection with one of the patients shown in
which specifies the cause of the disorder, gave the videotape exercise. Most of the partici-
rise to no difficulties in patients who had pants diagnosed psychosis of some type, but
a clearly defined disease or disorder. Thus, this was coded in several different ways.
cases of phenylketonuria and chromosomal Some coded 295.8 ("childhood schizo-
a b n o r m a l i t y r e s u l t e d in u n a n i m o u s phrenia") without recording anything in the
agreement on fourth-digit codings of .2 and mental retardation section; some coded 310.7
.5, respectively. ("mental retardation following major psy-
However, in patients who did not have a chiatric disorder") without coding the type of
definite brain dysfunction or who did have disorder separately; some diagnosed psy-
some probable or definite organic brain dis- chosis but coded it under 308 ("behavior dis-
order, but one that did not fit the criteria for orders of childhood"); and some diagnosed
any specific disease, agreement on fourth- psychosis but coded only mental retardation.
digit coding was extremely poor. This was It was generally agreed that this state of
due to uncertainties about etiology and to the affairs was most unsatisfactory. In spite of a
problems of multiple factors in etiology; thus high level of agreement on diagnosis, there
different participants coded different etio- was a very low level of agreement on coding.
logic factors. For example, in case one, a child This arose through three factors: 1) no satis-
with a definite neurological disorder of an factory means of coding child psychiatric or
unknown type that had been present since behavior disorders; 2) no instruction on how
birth, codings of .1, .2, .3, .4, .6, and .9 were many diagnoses to code when a psychiatric
all used, and one participant made a diagno- disorder accompanies mental retardation;
sis under Section VI (Diseases of the Nervous and 3) unfamiliarity with sections of ICD-8
System and Sense Organs) rather than under outside of Section V. This issue was further
Section V (Mental Disorders). discussed in relation to the report of the Paris
This patient and several others caused two Seminar.
important points to be raised: 1) Most cases Developmental disorder. Several of the
of mental retardation, even those due to or- patients in both the case history and in the
ganic brain dysfunction, are not associated videotape exercises showed a severe delay in
with clearly diagnosable diseases, and 2) the the development of speech and/or language
fourth digit of the mental retardation coding that could not be accounted for in terms of
mental retardation. For example, the second was "intellectual level," and the third was
patient in the videotape exercise was a five- "associated and etiological factors."
year-old boy whose language comprehension The present Seminar recommended that
was at the three-year level and whose the proposals of the Paris Seminar for the
language expression was even more retarded classification of child psychiatric disorders be
in spite of an overall IQ of 78 and of per- accepted and noted that the classification of
formance abilities at above-age level. Some mental retardation posed similar problems.
participants noted only the child's cognitive It was agreed that a similar scheme was
difficulties in their diagnosis. However, even needed for mental retardation but that some
those participants who made a primary modifications might be required.
diagnosis of a specific disorder of language
Principles of Classification
for this boy did not agree in their coding,
some coding under 306 ("special symptoms It was agreed that the diagnosis of mental
not elsewhere classified"), some under 308 retardation necessarily involved recording
("behavior disorders of childhood"), and several different and independent aspects of a
some under 310 ("mental retardation"). This case. Thus, at a minimum, it was essential
case also emphasized the lack of instructions that the degree of retardation, as well as the
on how to deal with multiple diagnoses. It basic disorder (where present), be classified.
also demonstrated the lack of a suitable cod- Obviously, it would be totally unsatisfactory
ing for developmental disorders (also noted in if it were only possible to record that a patient
1967 at the Paris Seminar). This arose partly had either Down's syndrome or moderate re-
through a lack of suitable categories in the tardation. In fact, both statements are re-
ICD and partly through the scattered and ill- quired for a diagnosis of his condition. In
defined nature of such categories. addition, many mentally retarded patients
show some major emotional or behavioral
Considerations of the Paris Seminar Report disorder that must be recorded for the pur-
Concerning Child Psychiatry poses of providing medical care.
In discussing the case histories it was noted It was decided that this problem could be
several times that the same problems were solved by either a multiaxial scheme, as
being encountered as those previously dis- proposed at the Paris Seminar, or by a mul-
cussed at the Paris Seminar on child psy- ticategory scheme. In both cases a clear set of
chiatric disorders. The Paris Seminar (4) had instructions would have to be provided to
noted that there was no adequate provision ensure that each axis or category was rou-
for child psychiatric disorders in ICD-8, and tinely recorded for all patients. It was decided
decided that any scheme for the inclusion of that at least three major axes or categories
such disorders must be simple and practical, were required, namely, those outlined in the
must include only a basic minimum of Paris Seminar. For all mentally retarded pa-
information (in this respect classification tients the intellectual level, the associated or
necessarily differed from both a diagnostic etiological factors, and the clinical psychiat-
formulation and nomenclature), and must ric syndrome would need to be recorded.
include unambiguous coding since the chief Whether a multiaxis or a multicategory
purpose of a classification is to facilitate scheme is adopted would be dependent on
communication. decisions made by WHO in relation to the
Two main issues had arisen out of the case organization of the ICD as a whole.
histories presented at the Paris Seminar: 1) The three classes of information needed to
Some psychiatric diagnoses for children were provide a satisfactory classification of mental
not included in the current ICD, and 2) the retardation correspond with those proposed
same diagnoses were coded differently by for child psychiatry, and the seminar foresaw
different psychiatrists because of a lack of no great problem in working out a scheme
explicit instructions about what the coding that would serve the needs of both disciplines
should include. As a result of these issues the while retaining compatibility with the rest of
Paris Seminar (4) recommended a triaxial the ICD. The essential feature of the scheme
scheme of classification in which all three is that for each patient three categories of
axes had to be coded. The first axis was information should be provided. Codings
"clinical psychiatric syndrome," the second should be available that note where informa-
tion is not known or where no abnormality is our environment and our development;
present. CONSIDERING the danger of giving wrong
It was noted that the necessity for clear guidance to our youth and workers through
instructions on how to code multiple diag- continued use of these ill-adapted tests;
CONSIDERING the importance of having tests
noses is one common to all parts of the ICD that are adapted to studying and using our human
that concern mental disorders. It was rec- resources to better advantage; RECOMMENDS
ommended that a similar multiaxial or 1) that studies be undertaken by Member States,
multicategory system be considered for the wherever possible, to establish properly adapted
psychiatric section of the ICD as a whole. psycho-technical tests; 2) that OAU, with the as-
Degree of mental retardation. It was sistance of the United Nations Specialized Agen-
agreed that the degree of mental retardation cies (UNESCO: WHO: FAO: UNICEF) and the
should constitute a principal dimension in the ICC take part in these studies.-
diagnostic classification. Discussion centered The Seminar considered the Fifteenth Re-
around three issues in this connection: 1) the port of the WHO Expert Committee on
criteria to be used in the assessment of re- Mental Health on the "Organization of
tardation, 2) the level below which retarda- Services for the Mentally Retarded" (8). It
tion would be regarded as present, and 3) the recommended that its suggestions on classi-
subdivision into degrees of retardation. fication by degree of mental retardation be
It is now known that intelligence is not a accepted. The Committee had criticized the
fixed and immutable quality, and in the pres- classification of those with an IQ in the range
ent state of knowledge, prognostications of 68-85 as being "borderline mentally re-
about future intellectual development are tarded," noting that this vastly widened the
necessarily rather uncertain. In view of these concept of mental retardation, in that at least
considerations it was agreed that, in line with 16 percent of the general population would be
the recommendations of the Paris Seminar, considered retarded. The Committee also
mental retardation should be assessed on the expressed itself as being strongly opposed to
basis of current level of functioning without this expansion of the concept, taking the view
regard to its nature or causation. that a level of functioning equivalent to an IQ
It was also agreed that retardation con- two standard deviations below the mean, i.e.,
cerned intellectual functioning and that social about 70, was a most useful upper demarca-
handicaps due to other disorders, e.g., sensory tion of mental retardation. The Seminar
defects or physical handicaps, should not be expressed the view, however, that IQ limits
included. When used appropriately, intelli- should constitute only a guide, it always being
gence tests could provide valuable guidelines necessary to take clinical considerations of
to assess the level of retardation. However, social and adaptive functioning into account.
IQ scores should not be used in isolation; The Seminar concurred with the recom-
rather, they should be taken in conjunction mendation of the Expert Committee that the
with clinical judgments regarding the term "borderline mental retardation" had no
patient's social and adaptive behavior and place in a medical classification and that it
development. should be dropped from the ICD. As it was
It was noted that intelligence tests were the necessary in all patients to make some coding
least useful and, indeed, might sometimes be under the rubric of "current level of intellec-
quite inappropriate for individuals from tual functioning," it was recommended that
populations in which the social and cultural the coding of "borderline mental retarda-
factors were quite different from those found tion" be replaced by a coding of "normal
in the populations on which the tests were variations in intelligenceincluding border-
standardized. Attention was drawn to the line intelligence."
Resolution on Psycho-Technical Tests ( 7 ) The Seminar concurred with the recom-
passed by the Educational, Scientific, Cul- mendations of the Expert Committee on the
tural, and Health Commission of the Organi- various degrees of mental retardation, name-
zation of African Unity (OAU). This reads as
CONSIDERING that the psycho-technical
tests at present used in our countries are ill-
adapted and do not correspond with our culture,
ly that the categories of "mild," "moderate," ry of "associated and etiologic factors" use,
"severe," and "profound" be retained. How- where appropriate, ICD codings from other
ever, in view of the advice that IQ scores sections. The organization of this method of
should never be the sole measure of degree of coding needs further consideration and it may
retardation, it was recommended that IQ be necessary to provide special codings for
levels that define the categories be omitted definite neurological disorders that do not
from the category headings. Instead, the constitute a clearly defined disease of a rec-
terms should be carefully defined in the ognized type. A working party needs to be
Manual on Psychiatric Disorders and Classi- set up to determine how this should best be
fications. Where appropriate, the IQ ranges done. Alternatives to be considered by the
proposed by the Expert Committee should be working party are that the fourth digits
used as a guide instead of the current limits should merely indicate the presence of an as-
ICD-8 suggests.3 However, the IQ limits sociated physical condition that would then
should constitute just one aspect of the defini- be coded under its ICD number, or that the
tion of categories that should include a care- provision for coding such disorders under the
ful description of the degree of handicap in fourth digits be revised to provide a more
social and adaptive terms. satisfactory system. The list of available
The category "unspecified mental retarda- terms in ICD-8 should be reviewed to ensure
tion" (315 in ICD-8) should be retained but that all diagnoses required for the satisfacto-
instructions to coders should indicate very ry classification of mental retardation were
clearly that it be used as sparingly as pos- available and that added provision be made
sible; it is intended solely for patients whose where necessary. The Seminar recommended
current level of intellectual functioning can- that the terms describing conditions com-
not be assessed either by standardized tests monly found and reported in the classifica-
or by clinical judgments (e.g., a newborn). tion of mental retardation be brought to-
Associated or etiological organic factors. gether in a glossary accompanying the
As the case history exercise showed, the classification.
fourth-digit coding for mental retardation Occasionally more than one associated
proved to be quite unreliable. This is partly organic condition may be present. For ex-
because it demands a knowledge of the etiol- ample, one of the patients in the exercise had
ogy of the retardation, which is often lacking diabetes, as well as epilepsy, but only a small
due to the pathogenesis of mental retardation number of the participants coded diabetes. It
being only imperfectly understood. Further- was recommended that, as a rule, the diag-
more, nine of the fourth digits combine into nosis of the condition most closely associated
groups a larger number of conditions repre- with the pathogenesis of mental retardation
sentative of many areas of ICD-8, so that as a be recorded. Where feasible, and where the
statement of etiology, they are inadequate. patient's condition demands this for purposes
Moreover, clinicians or coders who work of medical care, more than one diagnosis
mainly with Section V of ICD-8 do not al- should be entered on the second axis. (The
ways have the complete manual available to problems of dealing with data involving
them; hence they may be unable to code cor- multiple coding present no difficulties in
rectly conditions other than those specifically modern computer technology, but coding
mentioned as inclusions of the fourth digits as more than one diagnosis may present prob-
listed, and in some cases, they may fail to re- lems to the personnel involved in maintaining
cord relevant information on diagnosis.
records systems.) Where there are no organic
The Seminar recommended that these dif- features associated with the patient's re-
ficulties be eliminated by making the catego- tardation, this fact should be recorded on the
second axis.
Associated or etiological psychosocial fac-
tors. Problems of intellectual retardation
arise not infrequently in relation to psy-
chosocial factors, and the Seminar considered
it desirable that there be provisions for the
coding of such factors. The provision and
definition of categories of psychosocial
influences posed difficulties beyond the scope account of disorders in children, neurotic
of the present Seminar, but it was recom- disorders, personality disorders, psy-
mended that a working party4 be set up to chosomatic disorders, and other clinical
develop appropriate definitions for psy- syndromes could be included in existing cod-
chosocial factors, both those important in the ings. By redefining psychoses and by provid-
pathogenesis of mental retardation and also ing extra digits, child psychoses could also be
those influences, familial and other than fa- included under the current codings. Normal
milial, that are important in the pathogenesis variation, conduct disorder, and manifesta-
of emotional and behavioral disorders. In tion of mental subnormality only would need
view of the importance of psychosocial additional codings. Adaptation reaction
influences it was recommended that this be a would need an extra coding, but this might be
separate axis or category to be recorded for provided by a redefinition and reorganization
all patients instead of the present fourth digit, of category 307, "transient situational dis-
.8, that associates mental retardation with turbances." Specific developmental disorders
psychosocial (environmental) deprivation and also need a special category but this might
that was felt to be insufficient. be provided by a reorganization of category
Genetic factors in mental retardation. 306.
Some cases of mental retardation are due to
specific diseases that are genetic in origin. Mental Retardation in Adults
These should be noted in the category re-
Whereas the Seminar spent the majority
cording etiological or associated physical
of its time discussing mental retardation in
conditions. In addition, however, cases of
children, it was recognized that any classifi-
mental retardation not due to any brain
cation scheme must also apply to adult pa-
disease often result from an interaction be-
tients. It was thought that the scheme sug-
tween polygenic factors and environmental
gested by the Seminar would be equally
influences. Although the science of behav-
appropriate for all age groups.
ioral genetics is rapidly advancing, the Sem-
inar recognized that in the current state of Glossary and Instructions on Use
knowledge it is usually not possible to differ-
entiate genetic influences from psychosocial Throughout its deliberations, the Seminar
influences of an environmental kind. stressed the need for a glossary that would
Associated psychiatric and behavioral bring together terms commonly used in de-
conditions. The Seminar agreed that coding scribing mentally retarded patients, whether
any associated psychiatric condition consti- or not these were found in Section V of ICD-8
tuted an essential part of the diagnosis and or in other sections. An essential task is to
classification of mental retardation. An axis define terms. Several countries and profes-
or category should be included to deal with sional organizations have produced glossaries
this dimension. As far as adult patients were concerning mental retardation, that put out
concerned, Section V of ICD-8 provided by the American Association on Mental
suitable categories, and as far as child pa- Deficiency being the most comprehensive (9).
tients were concerned the recommendations The Seminar welcomed the initiative of
of the Paris Seminar should be accepted. WHO, which has undertaken to produce a
glossary of mental disorders, taking into ac-
Classification of Child Psychiatric Disorder count the existing national glossaries. A pub-
It was noted that the recommendations on lication incorporating a glossary should also
child psychiatric disorders necessitated only a contain a manual that would give clear cod-
few extra codings and that provision might be ing instructions about what should be
made for these by transferring the ICD-8 included in, and excluded from, any partic-
category 308 and utilizing categories 316 to ular category of the classification. Where the
319 that are at present not assigned. By ap- instructions state that a particular diagnosis
propriate adjustments to the glossary to take should not be included in a particular cate-
gory, there should be clear instructions about
where the diagnosis should be coded.
Consistency is essential; this cannot be
achieved unless coding instructions are unam-
biguous and unless they cover most contin- pressed its appreciation of the lead that
gencies. WHO had taken in this field and stressed the
Classifications for Different Purposes vital part it could play in promoting further
The Seminar agreed that no classification studies.
would meet all purposes: Statistical data on The point was made that a decision by a
mental retardation are of interest not only to member country or by a professional or-
clinicians, but also to geneticists, other med- ganization to use the ICD routinely for re-
ical scientists, and psychologists, educators, porting purposes could have a beneficial
and social service agencies concerned with effect not only upon the standard of case re-
health, education, and welfare. The Seminar porting, but also upon the attention paid to
noted that whereas the ICD was originally diagnosis and classification in medicine. If,
designed to provide a basis for vital statistics for example, pediatricians were constantly
and for public health purposes, increasing at- reminded of the need for early diagnosis and
tention was paid in the future to health service classification, this would lead not only to
needs, including the utilization of hospital their making better use of the ICD, but it
and other medical care facilities. However, it would also influence the attention paid to
was recognized that a classification that diagnosis and classification during medical
served these needs would not necessarily be and pediatric training. Use of the ICD might
entirely satisfactory to educators and to so- thus have an influence upon medical educa-
cial agencies concerned with welfare, or in the tion in a more general sense.
treatment of offenders who did not present Attention should also be paid to providing
psychiatric or other medical problems. While medical students with training in classifica-
it took cognizance of these problems, the tion and in the use of the ICD scheme. This
group recognized that they fell outside the topic should be included in the curricula of
scope of medicine; and for the purposes of the clinical training. Case history exercises might
ICD it is important that categories included be a suitable method of teaching in this con-
in it be relevant to medical needs. If classifi- nection.
cations for different needs are produced, they At a local level there needs to be close col-
should be capable of translation into the ICD laboration among biostatisticians, clinicians,
categories. However, no classification should and coding officers in medical records de-
be used unless it has been satisfactorily tested partments regarding the use of the ICD. Rec-
in practice, and in general the use of different ords officers require training in the use of the
classifications for different purposes should ICD and of the manual of coding instruc-
be discouraged. tions, and they should be encouraged to work
closely with clinicians and to return to them
Recommendations to Other Working Groups for clarification records that do not permit
The Seminar noted that the current ICD-8 ambiguous coding. Seminars and short cours-
classification of neurological disorders asso- es in the correct use of the ICD according to
ciated with mental retardation is not entirely the manual and glossary would do much to
satisfactory, for example, in relation to epi- improve the quality of statistical reporting;
lepsy and to certain types of encephalopathy and regular feedback both for queries re-
not diagnosed as specific diseases. The Sem- garding particular patients and for material
inar called the attention of the Working fed to a central statistical office would ensure
Group on Neurological Disorders to this that record keeping achieves and maintains
shortcoming. Neurological disorders often high standards.
accompany mental retardation, and the Sem- Professional organizations (including local
inar expressed the wish that the working and national medical societies and associa-
group should be cognizant of the problems tions for the scientific study of mental re-
of mental retardation in its deliberations. tardation) can also help to educate their
members in the use of the ICD. Studies
Promoting the Effective Use of ICD should be planned and carried out with the
The Seminar discussed what steps could be help of statisticians who should be consulted
taken to ensure that the ICD be used in the early and with whom analyses of data should
most effective manner possible, both within be discussed at each stage of inquiry-research
a given country and internationally. It ex- and fact-finding. At an international level the
support of the International Association for Seminar on Psychiatric Diagnosis, Classifi-
the Scientific Study of Mental Deficiency cation, and Statistics, that dealing with child
should be sought. psychiatry (4). This would require that for
The Seminar was impressed by the useful- each patient, the following four types of
ness of the diagnostic case reports and vid- information would be recorded: 1) degree of
eotape exercises in bringing to light specificmental handicap, 2) etiological or associated
problems and in clarifying concepts. biological or organic factors, 3) associated
National Centers of Health Statistics and psychiatric disorder, and 4) psychosocial fac-
professional organizations should be en- tors. For each patient, all four types of
couraged to work together to adapt the ICD information would be routinely reported,
to more specialized purposes, thus ensuring instead of only the degree of mental handi-
that when they themselves are involved in cap.
collecting statistical data, the data would be Degree of mental retardation. In the as-
put in a form that would allow the use of the sessment of the degree of mental retardation,
ICD. relevant information about the sociocultural
Even in countries capable of carrying out background of a patient and his social and
case reporting and videotape exercises on adaptive functioning must be taken into ac-
their own, the initiative of WHO in sponsor- count. The grade of mental retardation rec-
ing such exercises by bringing together ommended by the Expert Committee on
experts from different countries and in pro- Mental Health (8) should be used in the ninth
viding case materials and videotapes from revision of ICD. These comprise ICD cate-
different countries had been of great impor- gories 311-314"mild," "moderate," "se-
tance in efforts to promote uniformity in vere," and "profound" mental retardation,
diagnosis and in case reporting. It was rec- together with category 315"unspecified
ommended that WHO should promote fur- mental retardation." Category 310, "border-
ther exercises of this type at local and line mental retardation," which includes
regional levels. It was also hoped that WHO backwardness, borderline intelligence, de-
would be able to make readily available ficientia intelligentiae, borderline mental
case materials from different centers in deficiency, or subnormality, and an IQ range
different countries and that it would further of 68 to 85 should be replaced by a category
promote or facilitate seminars concerned of normal variations in intelligence in ICD-9.
with diagnosis and classification. The Seminar departed from the recom-
Arising from the deliberations at hand, themendations of the WHO Expert Committee
Seminar emphasized the importance of pre- on Mental Retardation in recommending
that IQ ranges should not be included in the
paring at an early date and of testing in prac-
tice a provisional classification on the linesICD manual, but rather, should be specified
suggested earlier. The results of any field in an accompanying glossary that would draw
studies that use the proposed classification attention to the limitations, as well as to the
and that should, by preference, be carried outusefulness, of IQ data for the assessment of
in more than one country, should be reported intellectual handicaps. The glossary should
back to WHO. A future seminar that would also stress that in evaluating the grade of
take up the problems raised but not settled inintellectual retardation, social and cultural
this one would be invaluable. The group rec- background be taken into account.
ognized that WHO could take a lead in stim- Organic aspects. The second type of
ulating these developments. Indeed, without information to be recorded for each patient
WHO's sponsorship they are unlikely to oc- should, at a minimum, consider the principal
cur at all. organic feature, if any, associated with the
retardation. If no such features are reported,
Summary and Recommendations this should be recorded. Users should employ
The Ninth Revision of ICD multiple coding on this axis, etiological and
The Seminar considered alternative ap- other diagnoses being included where appro-
proaches to the problems of classification in priate.
mental retardation. It decided in favor of a Psychiatric and behavioral aspects. The
scheme compatible with, and derived from, third class of information should include
the proposals recommended by the Third psychiatric symptoms or syndromes catego-
rized in a form compatible with that used in instructions to accompany ICD-9. It wel-
child psychiatry and elsewhere in the ICD. comed both WHO initiative and the efforts of
The same considerations regarding multiple national and of professional organizations in
coding that apply to the previous section taking steps to provide an acceptable glos-
should apply to this one. sary. The group recommended that the glos-
Psychosocial factors. The Seminar recog- sary should bring together terms commonly
nized the importance of psychosocial factors applicable to the mentally retarded and found
in the pathogenesis of mental retardation and in all sections of the ICD, and that the ac-
recommended that psychosocial influences be companying manual of instructions should
recorded on a separate axis or category. A give guidance to users concerning where par-
working party is needed to develop appro- ticular diagnoses should or should not be
priate categories and to provide definitions placed.
for them.
Promoting the Effective Use of the ICD
Adequacy of ICD Rubrics
A small working group should review the The Seminar recommended that WHO
rubrics used in sections of the ICD other than should consult with government agencies and
Section V to see whether they will provide on international and professional organizations
the axes of the proposed classification a about steps that might be taken to promote
comprehensive list of terms for classification the effective use of the ICD in member
in mental retardation. This working group countries. These steps include: further diag-
should include representatives from the sem- nostic exercises, national and regional semi-
inar on child psychiatry to ensure com- nars organized on the lines successfully pio-
patibility between the two systems of classi- neered in the series of WHO seminars on
fication, and between them and the rest of the classification, and short training courses for
ICD. medical students and for persons particularly
The same working group should discuss responsible for coding and classification.
with WHO the possibility of incorporating The Need for Field Trials
sociocultural factors in the diagnostic classi-
fication, linking this with the attempt now The Seminar recommended that WHO
being made by WHO to classify socioenvi- should consider as soon as it can the possi-
ronmental factors leading to hospitalization bility of sponsoring field trials in different
or to a need for medical care. countries in which the proposed classification
Recommendations Concerning Other Scien- would be tried in practice. The results of any
tific Groups field studies should be reported back to
WHO. It was also recommended that a fu-
Because mental retardation is so frequently ture meeting be convened to discuss the re-
associated with neurological disorders, sults of the field trials and also the integration
including epilepsy, the Seminar expressed the of the various recommendations of the semi-
hope that the scientific group considering nars on different mental disorders.
neurological disorders would bear in mind The Seminar endorsed the recommenda-
the problems of mental retardation in mak- tions of the Paris Seminar with regard to the
ing their recommendations. It was also hoped need for an adequate provision of categories
that the forthcoming seminars concerned regarding child psychiatric disorders in ICD-
with character disorders and with neuroses 9.
would give some consideration to any partic- The 1969 recommendation of the Educa-
ular problems arising in relation to mental tional, Scientific, Cultural, and Health
retardation. Commission of OAU (7) was noted with ap-
Glossary and Manual of Instructions proval. The recommendation proposes that
The Seminar was greatly impressed by the appropriate intelligence tests be developed
need for a glossary5 and for a manual of for different cultures and that tests developed
for one culture should not be applied without
modification in very different cultures. The
Seminar considered that the same issue might
apply to different cultures within one
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in Old Age. Leningrad, Institute of Psychiatry, 1968 gram Director, Mental Retardation, the Neuro-
6. World Health Organization: International Classifi- psychiatry Institute, 760 Westwood Plaza, Los
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7. Educational, Scientific, Cultural, and Health
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ordinary session, Addis Ababa, Ethiopia, June Dr. Philip R. Dodge, Professor of Pediatrics and
30-July4, 1969
Neurology and Chairman, Department of Pedi-
8. Organization of services for the mentally retarded.
WHO Techn Rep Ser 392, 1968 atrics, Washington University, and Physician-in-
9. Heber R: A manual on terminology and classifica- Chief, St. Louis Children's Hospital, 500 S. Kings
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Defic 65 (monograph suppl), April 1961 Dr. Leon Eisenberg, Professor of Psychiatry,
Harvard Medical School, and Psychiatrist-in-
APPENDIX 1 Chief, Massachusetts General Hospital, Fruit St.,
Boston, Mass. 02114, U.S.A. (Rapporteur)
List of P a r t i c i p a n t s Dr. Julius B. Richmond, Chairman and Profes-
sor of Pediatrics, and Dean, College of Medicine,
M e m b e r s of Nuclear G r o u p Upstate Medical Center, 766 Irving Ave., Syr-
acuse, N.Y. 13210, U.S.A.
Dr. Jack R. Ewalt, Bullard Professor of Psy- Dr. Joseph Wortis, Director of Developmental
chiatry, Harvard Medical School, and Super- Services and Studies, Maimonides Medical
intendent, Massachusetts Mental Health Center, Center, 4802 Tenth Ave., Brooklyn, N.Y. 11219,
74 Fenwood Rd., Boston, Mass. 02115, U.S.A. U.S.A.
Dr. Masaaki Kato, Division of Adult Mental
Health, National Institute of Mental Health, P a r t i c i p a n t s from O t h e r Countries
Konodai, Ichikawa City, Chiba-Ken, Japan
Dr. Morton Kramer, Chief, Biometry Branch, Dr. Augusto Aguilera, Director, Mental Health
National Institute of Mental Health, 5454 Wis- Department, Ministry of Public Health, and As-
consin Ave., Chevy Chase, Md. 20014, U.S.A. sociate Professor of Psychiatry, University of San
Dr. Ornuly O. Odegard, Medical Superinten- Carlos, 5 Ave. 8-33, Zona 4, Guatemala City,
dent, Overlege Ved Gausted Sykebus, Vinderen, Guatemala, Central America
Oslo, Norway Dr. Stanislau Krynski, Professor of Child Psy-
Dr. H. Rotondo, Professor of Psychiatry, San chiatry, and Director, Mental Retardation Insti-
Fernando Medical School, San Marcos Univer- tute, Federal University, Escola Paulista Medi-
sity, Lima, Peru6 cina, Sao Paulo, Brazil
Dr. Michael L. Rutter, Institute of Psychiatry, Dr. Denis Lazure, Professeur agrege de psy-
De Crespigny Park, Denmark Hill, London chiatrie, University de Montreal, P.O. Box 6128,
S.E. 5, England Montreal 3, Quebec, Canada
Dr. Raymond Sadoun, Directeur de Recherche, Dr. Hernan Montenegro, Child Psychiatrist,
Institut National de la Sante et de la Recherche Department of Pediatrics, Hospital Roberto del
Medicale, 3 rue Leon-Bonnat, 75 Paris 16e, Rio, Universidad de Chile, Martin Alonso Pinzon
France 6702, Santiago de Chile, Chile (Rapporteur)
Dr. Z.N. Serebrjakova, Chief Specialist in Psy- Dr. Carlos E. Sluzki, Director, Centro de
Investigaciones Psiquiatricas, Paraguay 1373,
Buenos Aires, Argentina
Dr. Dario Urdapilleta, Director, Children's Dr. W.P.D. Logan, Director, Division of Health
Psychiatric Hospital, Ingenieros 32-101, Mexico Statistics, World Health Organization, 1211
City 18 D.F., Mexico Geneva 27, Switzerland
Dr. Norman Sartorius, Medical Officer, Mental
T e m p o r a r y Advisors Health Unit, World Health Organization, 1211
Geneva 27, Switzerland (Secretary)
Dr. Tsung-yi Lin, Professor of Mental Health
and Psychiatry, University of Michigan, Ann Ar- Official Observers
bor, Mich. 48106, U.S.A.
Dr. Jack Tizard, Professor of Child Develop- Dr. Sterling Garrard, Professor of Pediatrics,
ment, Institute of Education, University of Upstate Medical Center, State University of New
London, Malet St., London W.C.I, England York, 750 E. Adams St., Syracuse, N.Y. 13210,
Secretariat Dr. Robert E. Luckey, Consultant, Program
Services, National Association for Retarded
Dr. Michael J. Begab, Head, Mental Retarda- Children, 420 Lexington Ave., New York, N.Y.
tion Research Centers Program, National Insti- 10017, U.S.A.
tute of Child Health and Human Development, Dr. I.M. Moriyama, Health Services and
Bethesda, Md. 20014, U.S.A. Mental Health Administration, National Center
Ms. Eileen Brooke, Mental Health Consultant, for Health Statistics, Washington, D.C. 20201,
World Health Organization, 1211 Geneva 27, U.S.A.
Switzerland Mr. David B. R a y , E x e c u t i v e D i r e c t o r ,
Dr. Felix de la Cruz, Special Assistant for President's Committee on Mental Retardation,
Pediatrics, Mental Retardation Program, Na- Department of Health, Education, and Welfare,
tional Institute of Child Health and Human Rm. 3760, Washington, D.C. 20201, U.S.A.
Development, Bethesda, Md. 20014, U.S.A. Ms. Winthrop Rockefeller, President's Com-
Dr. Rene Gonzalez, Regional Advisor in mittee on Mental Retardation, Department of
Mental Health, Pan American Health Organiza- Health, Education, and Welfare, Rm. 3760,
tion, 525 Twenty-third St., N.W., Washington, Washington, D.C. 20201, U.S.A.
D.C. 20037, U.S.A. Dr. Paul T. Wilson, Principal Investigator,
Dr. B.A. Lebedev, Chief, Mental Health Unit, Information Processing Project, American Psy-
World Health Organization, 1211 Geneva 27, chiatric Association, 1700 18th St., N.W., Wash-
Switzerland ington, D.C. 20009, U.S.A.

Some Thoughts on the Classification of

Mental Retardation in the United States of America

It is desirable to reach a generally accepted

international resolution that assures that pa-
tients afflicted with severe emotional disor-
T HE MOST COMMONLY USED classification
system in mental retardation in the
United States of America is the one con-
ders and manifesting the symptomatology of tained in the Manual on Terminology and
mental retardation are classified into the
same category. The solution advocated by the
current Diagnostic and Statistical Manual of
Mental Disordersplacing first emphasis
on mental retardationoffers the most for
comparability of biostatistical information
from diversified geographic settings. Further,
the manual's encouragement of multiple
psychiatric diagnoses assures against loss of
Classification in Mental Retardation, second toms, motor dysfunctions, cultural conformi-
edition, of the American Association on ty, and reading and arithmetic skills. The
Mental Deficiency (AAMD)(1). Its catego- utilization of all dimensions in the AAMD
rization of medical diagnoses is similar to classification system provides, in addition
that of the Diagnostic and Statistical Manual to basic typology, a reasonably adequate
of Mental Disorders, second edition {DSM- profile of the patient.
II), published by the American Psychiatric
Association (APA) (2). Both manuals define Controversial Issues of Diagnosis
mental retardation in a similar fashion. Sociocultural Retardation
According to AAMD, "Mental retardation
refers to subaverage general intellectual The first of the two special issues we wish
functioning which originates during the de- to discuss pertains to sociocultural retarda-
velopmental period and is associated with tion, a category frequently used in the United
impairment in adaptive behavior" (1, p. 3). States but not in some other countries. In the
APA's definition substitutes for "impairment AAMD classification two diagnostic catego-
in adaptive behavior" the following phrase: ries are applicable to this group within the
"impairment of either learning and social major class of "mental retardation due to
adjustment or maturation, or both" (2, uncertain (or presumed psychologic) cause
p. 14). with the functional reaction alone manifest."
We will first briefly discuss the parameters They are: "cultural-familial mental retarda-
of classification of mental retardation in tion" (code no. 81) and "psychogenic mental
common use in the United States of Ameri- retardation associated with environmental
ca; then we will focus on two issues of diag- deprivation" (code no. 82). In DSM-II the
nosis that are often subjects of controversy in appropriate category is mental retardation
the United States. "with psycho-social (environmental) depri-
vation" (subdivision .8), which includes two
P a r a m e t e r s of Classification of Mental subclasses: "cultural-familial mental re-
Retardation tardation" and mental retardation "asso-
ciated with environmental deprivation." Two
The diagnosis of mental retardation in the decades ago the diagnoses usually assigned to
United States usually takes into account two the same group of patients were "familial"
dimensions: medical classification based on and, less frequently, "undifferentiated" men-
assignment to one of a number of specified tal deficiency (3).
syndromes and severity of retardation based A general description of the patients who
on standardized developmental or intelli- qualify for these diagnoses follows. In most
gence tests. Both of these dimensions are instances retardation is of a mild degree, with
present in the AAMD and APA manuals. In IQs in the range of 50 to 70. The condition is
these respects the two manuals are very simi- usually not diagnosed prior to the individual's
lar, except for the fact that AAMD places entrance into school, and the overt diagnosis
first emphasis on medical classification and generally disappears when he reaches
DSM-II emphasizes degree of retardation. adulthood. Thus most patients are of school
Both medical classifications assign a primary age, i.e., six to 18 years old. An important
role to causation in their definitions of cause of the age specificity of the diagnosis
syndromes and use syndromes of a descrip- results from the basic clinical definition of
tive nature only when etiology is unknown. mental retardation in the United States,
The AAMD classification system uses one which requires that subaverage general intel-
major dimension not contained in DSM-II, lectual functioning and impairment in adap-
i.e., classification by degree of impairment in tive behavior be present concurrently. The
adaptive behavior, based on global clinical correlation between these two impairments is
judgment, in comparison to descriptive vi- highest during school years, when academic
gnettes of age-specific adaptive behavior demands make evident deficits that may not
deficits. Systematized ratings can also be be apparent when the practical skills of the
made in more than 20 supplementary cate- patient function adequately in the job mar-
gories, among which are genetic factors, im- ket.
pairments of special senses, psychiatric symp- These generally mildly retarded patients
are normal in appearance and show no con- behavioral scientists, and the syndrome ac-
comitant physical disabilities or abnormal quired its labels: sociocultural deprivation,
laboratory findings. The morbidity and mor- psychosocial deprivation, cultural-familial
tality rates of the group are fairly average. retardation, etc. (6).
Children with economically, socially, and Two current etiological questions that have
educationally underprivileged backgrounds a bearing on diagnostic classification need
have a high risk for this diagnosis. A con- discussion. The first involves the role of or-
servative estimate places the risk of mild ganic factors in the causation of sociocultural
retardation, including sociocultural retarda- retardation. The AAMD manual describes
tion, at a level 15 times higher for impover- mental retardation due to "uncertain (or
ished urban and rural children than for those presumed psychologic) cause with the func-
of middle-class suburban origin (4). tional reaction alone manifest" as suited only
Debates are still common about the etiol- for those instances of mental retardation that
ogy of sociocultural retardation. Children so occur "in absence of any clinical or historical
retarded are usually born to mothers who indication of organic disease or pathology
were undernourished during their adolescence which could reasonably account for the re-
and whose pregnancies occurred at a young tarded intellectual functioning" (1, p. 39).
age and with high frequency. The prematurity "Cultural-familial mental retardation" and
rate is twice the national average. Prenatal mental retardation "associated with envi-
care is either nonexistent or limited, and ronmental deprivation," into which groups
perinatal and postnatal care is below average. patients with sociocultural retardation are
During infancy and early childhood the pa- placed, are two subclasses of this major
tients' nutrition is often inadequate. The category. If clinicians were to adhere literally
children are exposed to a series of somatic to the category description, they might not
noxae, including infections, poisons, and diagnose anyone as socioculturally retarded
traumata, and they are often unprotected by because, in most instances, the history of poor
customary public health measures. It is medical care and the multiple exposures to
therefore not difficult to conceptualize a somatic noxae in themselves would contra-
variety of biomedical models (5) that explain dict the requirement of absence of historical
the causation of this type of retardation on indications of organic disease.
the basis of the cumulative effects of organic Observations on the longitudinal devel-
insults to the central nervous system. Some opment of impoverished children and on the
clinicians prefer such biomedical models, effects of major changes in the mode of rear-
while others proffer a genetic explanation for ing favor the psychosocial etiological model.
this syndrome on the theory of assortative On the other hand, the uncritical acceptance
mating of the mildly retarded. of pure functional causation does not take
But these are also children who are usually into account the probable effects of the bio-
unwanted, unplanned, and conceived acci- medical traumata. As a consequence, the er-
dentally and, frequently, extramaritally. roneous conclusion might be drawn that
They are raised in homes with absent fathers somatic noxae do not play a role in the
and with physically or emotionally una- causation of sociocultural retardation.
vailable mothers. During infancy they are not The second etiologic question involves the
exposed to the same quality and quantity of specific roles of the various elements of de-
tactile and kinesthetic stimulations as other privation. Global conclusions have been
children. Often they are left unattended in a drawn concerning the total effect of depriva-
crib or on the floor of the dwelling. Although tion without specific information on the com-
there are noises, odors, and colors in their ponents of deprivation in regard to quality,
environment, the stimuli are not as organized quantity, specificity, or timing.
as those found in middle-class and upper- Transcultural studies, in addition to solv-
class environments. For example, the number ing diagnostic and classification problems,
of words they hear is limited, with sentences have much to offer toward a better under-
brief and most commands carrying a negative standing of the causation of sociocultural re-
connotation. From these empirical observa- tardation (7). More specifically, much is to be
tions a causal model of environmental de- gained from such studies about the roles of
privation has been constructed by American genetic, somatic, and experiential forces as
they interact in producing that mild, and tism and who, on the basis of evaluations of
age-specific, type of retardation that has a his intellectual and adaptive performances,
high prevalence in impoverished population qualifies for a diagnosis of retardation in this
groups and that is generally labeled in the framework, would be placed into the category
United States as sociocultural retardation. of "pseudo-retardation."
The controversy about the interrelationship
Relationship Between the Diagnoses of Early
between psychosis and retardation, when both
Childhood Psychoses and Mental Retarda-
coexist, is not yet resolved. The AAMD clas-
sification provides two categories for these
The second controversial problem pertains patients: code no. 83, "psychogenic mental
to the relationship between the diagnoses of retardation associated with emotional dis-
early childhood psychoses and mental re- turbance," and code no. 84, "mental retarda-
tardation. It is not uncommon to find chil- tion associated with psychotic (or major
dren in the United States who sequentially, personality) disorder." The underlying as-
and in any combination, acquire a series of sumption is that mental retardation in these
diagnoses that include early infantile autism, patients is due to psychologic causes, and
mental retardation, childhood schizophrenia, therefore the diagnosis of mental retarda-
brain damage, early childhood autism, and tion should be made with the presumed psy-
minimal brain dysfunction. At times the chologic causation being specified. DSM-II
clinical pictures in these patients are furtherprovides one major category for this group:
complicated by a variety of organic or func- mental retardation "following major psy-
tional sensory impairments. chiatric disorder" (subdivision .7). The
On the surface this problem may appear underlying philosophy is essentially the same
quite limited in scope, but closer scrutiny as that found in the AAMD manual.
calls attention to a number of ramifications. It is unquestionable that severe mental
One example of the consequences of diag- disturbances in infancy and early childhood
nostic and classificatory uncertainty is the impair intellectual adaptive performances.
varied use of the term "pseudo-retardation" As a consequence, such patients fulfill the
among clinicians in the United States (8). requirements of the diagnosis of mental
Some use the term to describe the sociocul- retardation by both AAMD and APA stan-
turally retarded, i.e., those in whom no cen- dards. Moreover, measurable IQ in such pa-
tral nervous system damage can be dem- tients functions as the best single prognosti-
onstrated; others restrict the term to those cator of outcome (9). On the other hand, one
in whom sensory or motor deficits produce might argue that the primary disease in these
some of the symptoms of retardation. Advo- children is the psychosis or the emotional
cates of these concepts often argue that in disorder, with mental retardation being one
these cases true retardation (or deficiency), of the several manifestations of the severe
per se, is not present and that the impairment emotional pathology. At the present time no
in measured intelligence is more a function of firm scientific conclusions can be drawn on
the inadequacies of the psychological tests the basis of etiologic research. The argument,
than of the impairment in the patient's cog- although often heated, therefore remains a
nitive functions. philosophic and semantic one.
Some clinicians prefer to use the term
"pseudo-retardation" in those instances in S u m m a r y
which, in their judgment, retarded intellec-
tual performance and inadequate adaptive For the benefit of national and interna-
behavior are explainable on the basis of tional professional communications, it is
underlying psychogenic mechanisms. desirable to reach a generally accepted res-
"Pseudo-retardation" in this context refers to olution that assures that patients who are af-
those patients in whom mental retardation flicted with severe emotional disorders and
results from psychosis, severe emotional dis- who manifest the symptomatology of mental
turbance, neurotic disorder, or other types of retardation are classified into the same cate-
major personality disorders during infancy gory, independent of the idiosyncrasies of
and early childhood. For example, the child clinicians. The solution advocated by DSM-
who during infancy manifests the signs of au- II has the most to offer to bring order into
this semantic chaos. It states: "'Mental re- tistical Manual for the Use of Institutions for Men-
tardation is placed first to emphasize that it is tal Defectives, 3rd ed. New York, National Com-
mittee for Mental Hygiene, 1946
to be diagnosed whenever present, even if due 4. Tarjan G: Some thoughts on socio-cultural retarda-
to some other disorder" (2, p. 1). The manu- tion, in Social-Cultural Aspects of Mental Retarda-
al's encouragement of multiple psychiatric tion. Edited by Haywood CH. New York, Appleton-
diagnoses assures against loss of information. Century-Crofts, 1970, pp 745-758
The decision of the manual might seem arbi- 5. Tarjan G: The next decade: expectations from the
biological sciences. JAMA 191:226-229, 1965
trary, but it offers the most for comparability 6. Eisenberg L: Social class and individual develop-
of biostatistical information from diversified ment, in Crosscurrents in Psychiatry and Psy-
geographic settings. choanalysis. Edited by Gibson RW. Philadelphia, JB
Lippincott Co, 1967, pp 65-88
REFERENCES 7. Cravioto J, Delicarde ER, Birch HG: Nutrition,
growth, and neurointegrative development. Pediat-
1. Heber R: A manual on terminology and classifica- rics 38:319-372, 1966
tion in mental retardation, 2nd ed. Amer J Ment 8. Eisenberg L: Emotional determinants of mental
Defic 65 (monograph suppl), April 1961 deficiency. Arch Neurol Psychiat 80:114-121, 1958
2. American Psychiatric Association: Diagnostic and 9. Rutter M: The influence of organic and emotional
Statistical Manual of Mental Disorders, 2nd ed. factors on the origins, nature and outcome of child-
Washington, DC, APA, 1968 hood psychosis. Develop Med Child Neurol 7:518-
3. American Association on Mental Deficiency: Sta- 528. 1965

Differing Concepts of Diagnosis

as a Problem in Classification

The author discusses the differences in the lustrated by international diagnostic exer-
British and U.S. concepts of mental retarda- cises (1) and by a joint exercise of the United
tion that make achieving a uniform interna- States and the United Kingdom (2).
tional classification difficult. Although U.S. International uniformity in classification
and British definitions and classifications may be easier to achieve for the disorders
of mental retardation seem to be similar, a known as mental retardation or mental sub-
basic conflict exists. The British define mental normality than for the psychoses, neuroses,
retardation as an arrested or incomplete and character disorders. However, differences
development of the brain, while the United in the concepts and interpretations of disor-
States defines it as a person's mental status dered behavior between countries must be
current at a given time but that may be c o n s i d e r e d in our a t t e m p t s to r e a c h
subject to change. agreement on a scheme of classification for
mental retardation. In the British Glossary of
Mental Disorders (3), mental retardation is

M AJOR PROBLEMS in reaching agreement

on an international classification of
diseases may be attributed to: 1) differences
divided by degree of severity into six catego-
ries; these categories appear to be the same as
those in the eighth revision of the Interna-
in the perception of symptoms, and 2) differ- tional Classification of Diseases (ICD-8) (4)
ences in the inference and interpretation of and as those in the second edition of the Di-
the meaning of a symptom in diagnostic agnostic and Statistical Manual of Mental
terms. These problems have been amply il- Disorders (DSM-II) (5). All of these systems
define their subdivisions by estimates of the
levels of retardation expressed in terms of
numerical IQs, as well as in descriptive
phrases ranging from " b o r d e r l i n e " to
"severe." This apparent agreement between
British and U.S. classifications is not firm,
however, since it seems that the manner in
which the level of retardation is assessed and
the attitude about prognosis vary; herein lies ican Association on Mental Deficiency
the problem in comparative statistics. (AAMD). The DSM-II section dealing with
mental retardation is essentially a modifica-
British Concepts tion of the manual in order to make it con-
formto ICD-8.
The British define subnormality (by quot- The AAMD classification has two large
ing from the England and Wales Mental categories, which are organized in DSM-II as
Health Act of 1959) as "a state of arrested or subgroups (fourth-digit items) under each of
incomplete development of mindwhich the five degrees of retardation. The two cate-
includes subnormality of intelligence and is gories are 1) Medical Classification, and
of a nature or degree which requires or is 2) Behavioral Classification.
susceptible to medical treatment or other Medical Classification includes the fol-
special care and training of the patient" (3, lowing groups: 1) diseases due to infection;
p. 22). Severe subnormality is defined as "a 2) diseases due to intoxication; 3) disease due
state of arrested or incomplete development to trauma or physical agents; 4) diseases due
of mind which includes subnormality of to disorder of metabolism, growth, or nu-
intelligence and is of such a nature or degree trition; 5) diseases due to new growths; 6)
that the patient is incapable of living an in- disease due to unknown prenatal influence;
dependent life or of guarding himself against 7) disease due to unknown or uncertain
serious exploitation or will be so incapable causes, with structural reactions manifest;
when of age to do so" (3, p. 22). They also and 8) disease due to an uncertain cause with
state that the term "severe subnormality" the functional reaction alone manifest and
does not always relate exactly to that posi- presumed psychologic.
tion in their six-point classification. They Under Behavioral Classification, behavior
discuss the difficulties of assessing IQ levels is considered in two dimensionsmeasured
and how test scores will vary among different intelligence and adaptive behavior. Thus, ac-
IQ tests. cording to the manual:

U.S. Concepts Mental retardation refers to subaverage general

intellectual functioning which originates during
the developmental period and is associated with
DSM-II uses similar terms in defining impairment in adaptive behavior.... The defini-
mental retardation, but it is apparent that tion specifies that the subaverage intellectual
these terms do not mean exactly the same functioning must be reflected by impairment in
thing as the British ones. DSM-II states that: adaptive behavior. Adaptive behavior refers pri-
"Mental retardation refers to subnormal marily to the effectiveness of the individual in
general intellectual functioning which origi- adapting to the natural and social demands of his
nates during the developmental period and environment. Impaired adaptive behavior may be
reflected in: (1) maturation, (2) learning, and/or (3)
is associated with impairment of either learn- social adjustments. These three aspects of adapta-
ing and social adjustment or maturation, or tion are of different importance as qualifying
both" (5, p. 14). It also states: conditions of mental retardation for different age
It is recognized that the intelligence quotient groups (6, p. 3).
should not be the only criterion used in making a
diagnosis of mental retardation or in evaluating its The manual also mentions that objective
severity. It should serve only to help in making a measures for adaptive behavior, especially for
clinical judgment of the patient's adaptive behav- degree of maturation and for quality of social
ioral capacity. This judgment should also be based adjustment, are not sufficiently developed to
on an evaluation of the patient's developmental allow easy assessment.
history and present functioning, including Currently, one can only make estimates of
academic and vocational achievement, motor impairment in adaptive behavior by compar-
skills, and social and emotional maturity (5, p. ing the patient's performance with that of
persons of the same age level in the general
In the United States, the most widely used population. The objective measures of general
' glossary for mental retardation is A Manual intelligence must be ". .. supplemented by
on Terminology and Classification in Men- evaluation of the early history of self-help and
tal Retardation. 2nd edition (6), of the Amer- social behavior, by clinical evaluation of pres-
ent behavior, and by whatever measures of will arise over the less severely retarded and
academic achievement, motor skills, social in the classification of persons who have been
maturity, vocational level, and community successfully rehabilitated and who are func-
participation are available and appropriate" tioning satisfactorily in an ordinary envi-
(6, p. 4). Impairment in any one of these ronment. The U.K. use of the term, which, to
spheres reflecting the subaverage intellectual the best of my knowledge, somewhat accu-
function is all that is required for a diagnosis rately reflects the general attitude on the
of mental retardation. However, it is rare that Continent, describes prognostic qualities of
a person shows mental retardation in only the condition and in some way reflects their
one of these categories. attitude toward the term "psychoses." In the
At first glance, these statements are in es- United States, on the other hand, the term
sential agreement with those in the British "mental retardation" describes a combina-
glossary. However, the A A M D glossary tion of behaviors manifest in an individual at
continues: the time of examination, and while the term
has some prognostic implications, a bad
Within the framework of the present definition,
mental retardation is a term descriptive of the prognosis is not seen as an essential element
current status of the individual with respect to in arriving at the diagnosis. This attitude may
intellectual functioning and adaptive behavior. cause an overinclusion of patients in the U.S.
Consequently, an individual may meet the criteria series, especially patients in whom retarda-
of mental retardation at one time and not at tion is due to educational, language, and so-
another. A person may change status as a result of cial problems, and whose retardation might
changes in social standards or conditions or as a be largely corrected by proper environmental
result of changes in efficiency of intellectual func- and educational experiences, but who at the
tioning, with level of efficiency always being de- time of assessment were definitely retarded in
termined in relation to the behavioral standards their mental and and social functioning.
and norms for the individual's chronological age
group (6, p. 4). REFERENCES

This latter attitude is somewhat in conflict 1. Shepherd M, Brooke EM, Cooper JE, et al: An
with the British definition: "a state of arrested experimental approach to psychiatric diagnosis. Ac-
ta Psychiat Scand 44 (suppl 201), 1968
or incomplete development of mind which
2. Kramer M: Cross-national study of diagnosis
includes subnormality of intelligence and is of the mental disorders: origin of the problem. Amer
of such a nature or degree that the patient is J Psychiat 125 (April suppl): 1-11, 1969
incapable of living an independent life or of 3. Subcommittee on Classification of Mental Disorders
guarding himself against serious exploitation of the Registrar General's Advisory Committee on
Medical Nomenclature and Statistics: A Glossary of
or will be so incapable when of age to do Mental Disorders. London, Her Majesty's Sta-
so" (3). tionery Office, 1968.
4. World Health Organization: International Classifi-
Summary cation of Diseases, 8th revision. Geneva, WHO, 1968
5. American Psychiatric Association: Diagnostic and
The difference in these concepts of mental Statistical Manual of Mental Disorders, 2nd ed.
Washington, DC, APA, 1968
retardation will cause little if any confusion 6. Heber R: A manual on terminology and classifica-
in the classification of patients with severe tion in mental retardation, 2nd ed. Amer J Ment
structural changes of the brain. Confusion Defic 65 (monograph suppl), April 1961
Comments on the ICD Classification of
Mental Retardation

Strictly speaking, mental retardation is not a who are the children of migratory parents; some
disease but a symptom; it may be the result of who have been kept from school; some who have
biological deficits, vicissitudes of experience, attended a religious school, where they learned
or both. The author believes that ways must little but sewing and writing; some who have
be found to avoid the misleading implications changed their school too often; some also who are
foreigners and understand little French, and lastly,
and consequences of dealing with it as a some who have been kept back in their studies by
disease. Toward this end, he proposes a mul- unrecognized myopia ... (1, p. 47).
tidimensional system of classification that
distinguishes between the biologic and psy- T h e Problem with Standardized Tests
chosocial causes of mental retardation.
Since one's level of intellectual perfor-
mance, or intelligence, is always a product of
ISTORICALLY the International Classifi- both biological equipment and educational
H cation of Diseases {ICD) began as a
classification of the causes of death; it was
experience, and since social and educational
opportunity cannot be said to be uniformly
later extended to include a classification of available to all, it is unreasonable to assume
diseases. Mental retardation is not a cause of that intelligence is normally distributed on a
death and can scarcely be called a disease. Gaussian curve. Yet standardized tests, like
The historical origin of the classification of the Stanford-Binet Intelligence Scale, have
mental retardation was of a different nature been trimmed and altered in an attempt to
and related mainly to the needs of educators achieve just such a distribution, although
to group their pupils on the basis of attained some s k e w n e s s to the left c a n n o t be
levels of mental development. These origins avoided (2). A test constructed in such a way
are connected with the names of Binet and will inevitably disclose that a minimum of 15
Simon, both of whom dissociated themselves percent of the population utilized (i.e., IQs
from the tendency (most pronounced in the two standard deviations from the mean) is
United States) to equate IQ scores with in- mentally retarded. But since IQs vary with
nate biological capacity. Half a century ago social class, the percentage will be much
they wrote: higher in the lower classes. The American
Negro population, most of whom are poor
As a general rule, the children classed as retard-
ed are the victims of disease, constitutional debility and socially deprived, was excluded from the
or malnutrition. We find included in our lists some Stanford-Binet standardization; it is not sur-
prising therefore that at least half of the
American Negro child population, whose
mean IQ is currently about 85, could be stig-
matized with the disease or condition called
mental retardation, by the criteria (one stan-
dard deviation) of the eighth revision of ICD
(ICD-8)(3). In the Puerto Rican rural popu-
lation the percentage is even higher (4). These
absurdities are compounded when a test
whose standardization is based on a white,
somewhat middle-class population is applied
to the population of a foreign nation.
The other horn of the dilemma is this: If
the test is restandardized and is thus adapted causes, and other and unspecified. These
to a foreign nation, under the assumption that subcategories are not complete and are not
the intelligence of that nation's populace is mutually exclusive, logically consistent, or
normally distributed, one will again find that systematic; in some instances mental re-
about 15 percent of the population is mental- tardation "follows" the presumptive cause, in
ly retarded, since a standardized test must others it is "associated with" the cause, and in
yield roughly that percentage one or more others it is "due to" the cause. This pragmat-
standard deviations from the mean. Com- ically accords with the general pattern of
parative statistics thus become meaningless ICD-8, which makes no claim to com-
and even historical changes within the same pleteness, logical consistency, mutually ex-
country elude analysis, since the tests must be clusive categories, or systematic organiza-
constantly restandardized. tion, although it has attempted to move
An IQ score, at best, can indicate where an toward these goals. Current usage must be
individual stands in intellectual performance reckoned with, and a practical classification
compared to others. What others? His na- has to be a compromise between usage and
tion? His social class? His ethnic group? No ideals.
intelligence test that has ever been devised An important source of some of the dif-
can surmount all of these complicating ficulties in classification derives from the
considerations and claim universal validity. failure to make distinctions among etiology,
International criteria based on IQ scores thus true pathology, physiological malfunction,
have no validity, and are, at best, rough indi- level of performance, and capacity for
cators of one's relative rank in roughly com- development (5).
parable groups, for example, in the urban Virchow's theory of cellular pathology
populations of New York City and of served a useful function in its day but has
London. One may question whether any im- been partly superseded by the concept of
portant scientific interest is served in ICD-8 pathophysiological dysfunction as the basis
by the use of IQ criteria for the diagnosis of for disease. In other words, it is not the ana-
mental retardation; and one may ask whether tomical lesion or defect that causes the disease
these interests could not be served more or disability but the resulting physiological
modestly, yet more effectively, by the use of malfunction. Some anatomic defects may not
well-defined clinical judgments as indicators significantly impair function, and conversely,
of general adaptive capacity.
some malfunctions may be due to chemical,
electrophysiological, or other deficiencies not
Shortcomings of C u r r e n t Classifications associated with anatomical disease. Some-
times the anatomical lesion is only a late
The principle that different purposes re- product of the malfunction. To take an ex-
quire different classifications is clearly rec- treme example, an exhausted, overstimu-
ognized in the introduction to ICD-8 (3). A lated, poorly nourished child may have seri-
classification designed for educational needs ous and chronic learning difficulties because
should be based on different criteria and of his condition, but, strictly speaking, he is
categories than a medical classification is not diseased and his condition is reversible,
based on. Is there not a certain confusion of up to a point. Beyond this point irreversible
aims involved in our present classification? pathophysiological malfunction may super-
ICD-8 lists five categories under "mental vene and at a later stage pathological ana-
retardation" (310-314) that are based on tomical lesions may appear.
IQs, spaced by standard deviations from the
mean, on intelligence tests developed under Suggestions for a New Classification
the assumption that intelligence is normally
distributed. There is also a category for "un- Since mental retardation is not a disease
specified mental retardation" (315). There but a level of development or a level of func-
are nine subcategories (.0-.9) based on classes tion, perhaps it would be better to list it as a
of etiology, i.e., infections, trauma, metabolic symptom in a subcategory rather than as a
disorders, brain disease, prenatal influences, primary disease diagnosis. From this point of
chromosomal abnormalities, prematurity, view, the suggestion of a triaxial system of
major psychiatric disorder, psychosocial diagnosis in child psychiatry has merit (6).
Perhaps a lesson can be learned from the made (10). If this were done, there would be a
American Heart Association (7), which de- category for known or presumed biological
cided long ago to employ the following four- defect and a category for presumed biological
dimensional system of cardiac diagnosis: 1) intactness. Appropriate terms or numerals
etiological (e.g., rheumatic); 2) anatomical could be applied to each. Thus a post-
(e.g., mitral stenosis); 3) physiological (e.g., encephalitic patient with an IQ of 65 would
auricular fibrillation); 4) functional (e.g., no longer carry the same primary diagnosis
dyspneic at rest); and in addition to these: 5) as that of a biologically normal slum dweller
possible heart disease; and 6) potential heart with the same IQ. In many cases a presump-
disease. tive diagnosis of biological handicap would
If such a system were applied to mental have to be made on the basis of a compromis-
retardation, performance level could be ing medical history, delayed developmental
measured by an intelligence test or an adap- milestones, motor awkwardness, soft
tive scale, while physiological efficiency could neurological signs, and empirical teaching
be measured by Pavlovian paradigms, evoked experience with the child, all leading to an
potentials, electroencephalograms, expec- assumption of, biological inadequacy with no
tancy curves, intersensory transfer, inhibitory further specification possible. As our diag-
and discriminatory capacity, or other nostic skill improved this nonspecific cate-
measures of basic cognitive function that are gory would in time be reduced as more de-
relatively uncontaminated by vicissitudes of finitive diagnoses became possible.
experience. The situation would be quite dif- From an empirical point of view, the most
ferent if we had some measure of cerebral ef- common labels I apply to patients are: 1)
ficiency at levels low enough to permit objec- encephalopathy, cause unknown; 2) en-
tivity, but high enough to be relevant to cephalopathy, presumed or definite cause;
intellectual processes. While we do not have 3) mental retardation, cause unknown, pre-
such reliable measures, perhaps it is not too sumed biological; 4) mental retardation,
early to begin to use all available data to cause unknown, presumed psychosocial; and
make judgments on the physiological intact- 5) mental retardation, cause unknown, pre-
ness or efficiency of an individual's cerebral sumed mixed causes.
functions as a basis for appropriate manage- Of the specific disease entities that are
ment. Such an approach would help sharpen diagnosable, mongolism is by far the most
our diagnostic skills and should serve to common and is likely to be found in about 15
break down the harmful assumptions of to 20 percent of the patients seen in a medical
homogeneity implied in our current depen- setting with a presenting complaint of re-
dence on IQ scores. tardation (11). Encephalopathy is likely to be
Intelligence tested to show an IQ above 50 diagnosed in about 45 percent but etiology
correlates closely with social class. Mild and can seldom be established, and in about 15
borderline retardation is largely an accom- percent it is not even possible to assume the
paniment of poverty (8, 9). It seems highly presence of an encephalopathy. About 15
desirable to make diagnostic formulations percent of these patients have other primary
that would distinguish more sharply between psychiatric disorders. All other specific med-
biologic mental retardation and psychosocial ical causes make up, at most, a small per-
mental retardation. By using the same pri- centage of the retarded population, using
mary diagnosis for both types of mental re- currently available diagnostic knowledge and
tardation, as is the current trend, this distinc- resources. But in spite of their rarity, specific
tion tends to be obscured, and dissimilar diagnoses should be encouraged, and the fre-
problems with dissimilar needs are likely to quency of such diagnoses should increase. In
be lumped together, as is the case in our former years much emphasis was placed on a
schools. presumed idiopathic form of mental retarda-
Because there is a practical difference be- tion as an aspect of normal variation in native
tween the two broad categories of biological intelligence. With our increased awareness of
handicap and of psychosocial deprivation, I biological causation on the one hand and
think the earlier method of distinguishing psychosocial causation on the other, the fre-
between the two groups should be restored, quency of this diagnosis has declined and in
even when well-validated diagnoses cannot be some settings it is rarely made. Where it oc-
curs it can either be subsumed under the to recommend the creation of four broad
category "mental retardation, cause un- major categories that would help in our ap-
known, presumed biological," or, less de- proach to these cases: 1) presumed biologic
sirable, a category of idiopathic mental re- cause, 2) presumed psychosocial cause, 3)
tardation can be created. On the whole we do presumed mixed cause, and 4) unknown
not get very far with our current classifica- cause. Where a concurrent presence of a true
tion, since so many patients are not specifi- disease and of mental retardation exists,
cally diagnosable. With the exception of some suitable designation should be devised
mongolism, most diagnoses are still based on to indicate whether or not there is a presumed
clinical judgments that have strong subjective causal relationship between the two.
1. Binet A, Simon T: Mentally Defective Children.
ICD-8 realistically and pragmatically dis- Translated by Drummond WB. New York, Long-
claims logical consistency, completeness, and man, Green Co, 1914, p47
even modernity. It attempts to note all cur- 2. Terman LM, Merrill MA: Stanford-Binet Intelli-
rent designations for diseases or conditions gence Scale, 3rd ed. Boston, Houghton-Mifflin Co,
requiring medical attention and to supply 3. World Health Organization: International Classifi-
labels and numbers for them in order that cation of Diseases, 8th revision. Geneva, WHO, 1968
they can be counted. It thus uses eponyms, 4. Albizu-Miranda C, Matlin N: Psychosocial aspects
anatomical lesions, metabolic disorders, and of cultural deprivation, in Proceedings of the First
Congress of the International Association for the
a number of overlapping categories so that a Study of Mental Deficiency. Edited by Richards
given condition or disease can often be la- BW. Reigate, England, M Jackson Publishing Co,
beled in several different ways. From this 1968, pp 466-474
point of view the acceptance by ICD-8 of the 5. Heber R: A manual on terminology and classifica-
condition called mental retardation is a tion in mental retardation, 2nd ed. Amer J Ment
Defic 65 (monograph suppl), April 1961
simple reflection of contemporary practice. 6. Rutter M, Lebovici S, Eisenberg L, et al: A tri-axial
In ICD-8, Section XVI is devoted to Symp- classification of mental disorders in childhood. An
toms and Ill-Defined Conditions and lists international study. J Child Psychol Psychiat
such things as coma, sleep disturbances, 10:41-61, 1969
7. American Heart Association: Diseases of the Heart
speech impediments, fainting, hiccoughs, and Blood Vessels: Nomenclature and Criteria for
nausea, sweating, fatigue, unknown fever, Diagnoses, 6th ed. Boston, Little, Brown and Co,
malingering, and the like. There is even a 1964
category for "mental observation." From this 8. Ginzberg E, Bray DW: The Uneducated. New York,
point of view mental retardation, although Columbia University Press, 1953
9. Gruenberg EM: Epidemiology, in Mental Retarda-
not a disease, could also be included here. It tion. Edited by Stevens HA, Heber R. Chicago,
would be better, however, if it could be more University of Chicago Press, 1964, pp 259-306
clearly designated as a symptom rather than 10. Mental Retardation: Improving the Classification
as a disease. The primary diagnosis would Through Research. Work conference sponsored by
the American Association on Mental Deficiency,
then be the disease, if diagnosable, or a cate- Columbus, Ohio, Sept 23-25, 1965 (processed)
gory of diseases, such as encephalopathy, if it 11. Wortis J, Wortis H: Who comes to a retardation
could not be further diasnosed. I would like clinic? Amer J Public Health 58:1746-1752, 1968
A Note on the International Statistical Classification
of Mental Retardation

The author feels that classification in mental ties, none of which is primary, and because
retardation should be multiaxial. While it is the classification has to serve more than one
unimportant whether diseases or conditions function. ICD-8 is better than previous revi-
associated with it are included in Section V sions because its categorization is more logi-
(Mental Disorders) of the World Health Or- cal and because its use of a fourth digit per-
ganization's International Classification of mits a biaxial system of classification. The
Diseases or elsewhere, it is important that primary axis is a division by grade of defect;
terms be used consistently and that a glossary five grades are distinguished (borderline, IQ
that is comprehensive and operational in of 68 to 85; mild, IQ of 52 to 67; moderate,
definition accompany the classification man- IQ of 36 to 51; severe, IQ of 20 to 35; and
ual. profound, IQ of less than 20).
This classification was criticized by the
WHO Expert Committee on Mental Health
A CLASSIFICATION, whether of diseases or
of any other phenomena, will be used
only if it is found useful. To be really useful, a
(2) on two main counts. The first was that al-
though IQ ranges were used to describe the
five categories, no indications were given of
classification of mental retardation must the mean and standard deviation on which
serve a variety of purposes: medical (clinical, these ranges were based. The second criticism
genetic, and epidemiological) as well as so- was that the classification of individuals with
cial (giving guidelines for education and an IQ in the range 68 to 85 as "borderline
training and for the planning of services). mentally retarded" would vastly widen the
A useful classification of mental retarda- concept of mental retardation; on this basis,
tion must accommodate children and adults. 16 percent of the general population would be
It cannot be too elaborate or no one will use considered mentally retarded. The WHO
it; yet it must also be both comprehensive and committee was strongly opposed to this
compatible with other sections of the eighth expansion of the concept of mental retarda-
revision of the International Classification of tion; it held the view that an IQ of 70 (two
Diseases (ICD-8) (1). standard deviations below the mean) was the
traditional and most useful upper borderline
The Eighth Revision of the ICD measure.
Although for some purposes a single axis The WHO committee advocated slightly
of classification is adequate, this is not true in different IQ ranges to define the various
psychiatry. In mental retardation a single grades of intellectual retardation: mild, 2 to
axis is unsatisfactory because the mentally -3.3 standard deviations from the mean of
retarded commonly have multiple disabili- 100, i.e., IQ of 50 to 70; moderate, 3.3 to
-4.3 standard deviations from the mean, i.e.,
IQ of 35 to 50; severe, 4.3 to 5.3 standard
deviations from the mean, i.e., IQ of 20
to 35; and profound, more than 5.3 stan-
dard deviations from the mean, i.e., IQ
of less than 20. It should be stressed, the
committee said, that these are not exact
measurements, and they should not be
considered the sole criteria for diagnosis.
In practice the categories will tend to over- United States who sequentially, and in any com-
lap, but the IQ has some value within the bination, acquire a series of diagnoses that include
range of mental retardation both as a diag- early infantile autism, mental retardation, child-
nostic and a prognostic guide. hood schizophrenia, brain damage, early child-
Although some of the terms used in both hood autism, and minimal brain dysfunction. At
times the clinical pictures in these patients are
the ICD-8 (1) and the WHO report (2) to de- further complicated by a variety of organic or
scribe the gravity of intellectual handicaps functional sensory impairments. . . .
are perhaps somewhat sanguine, the actual At the present time no firm scientific conclu-
division by grade makes good clinical sense. sions can be drawn on the basis of etiologic re-
Unfortunately, however, the intention that all search [as to which is primary]. The argument, al-
mentally retarded persons should be catego- though often heated, therefore remains a phil-
rized first by the severity of their intellectual osophic and semantic one (3, p. 17).
handicap may be nullified if ICD-8 category
315, "unspecified mental retardation," allows Nonetheless, they feel that it is desirable
clinicians to avoid making judgments about that children who have both severe emotional
the grade of defect. It would be preferable to disorders and symptoms of mental retarda-
require that particulars of grade of defect be tion be classified in a consistent fashion,
recorded for all patients classified as mental- independent of the idiosyncrasies of clini-
ly retarded, a clinical estimate being given cians. They themselves favor the solution re-
if no psychometric data were available. cently advocated by the American Psychi-
atric Association (APA): "Mental retarda-
It is therefore recommended that in future
tion is placed first to emphasize that is to be
revisions of ICD-8, category 315 should be
diagnosed whenever present, even if due to
omitted. Every person classified as mentally
some other disorder" (4, p. 1). This decision,
retarded should be assigned to one or other of
they say, might seem arbitrary, but it offers
the grades finally agreed upon. (In the case of
the most for comparability of biostatistical
infants the grading must be provisional, but
information from diversified geographic set-
this could be specified in the instructions).
The second axis in ICD-8 (the fourth digit)
ICD-8 uses one of the fourth digits for this
is broadly medical, and disorders are divided
type of patient (category .7, "following major
into ten categories. Most of these are
psychiatric disorder"). The word "fol-
reasonably satisfactory, although they are too
lowing," however, prejudges the issue; the
broad. (Category .2, for example, lumps to-
term "with major psychiatric disorder"
gether "disorders of metabolism, growth, or
would be better.
nutrition," and category .5 is for those "with
chromosomal abnormalities.") It is recom- The other type of mental retardation that
mended that the second axis be expanded to Tarjan and Eisenberg discuss (3) is that
two digits to allow for finer differentiation usually referred to as sociocultural retarda-
within each category. tion or, as in ICD-8 category .8, retardation
"with psycho-social (environmental) depri-
While several categories in the present
vation." Both the APA and the American
fourth-digit subdivision would probably
Association on Mental Deficiency (AAMD)
benefit from the results of discussion among
classifications (4, 5) divide sociocultural re-
pediatricians and psychiatrists (e.g., category
tardation into two categories: "cultural-fa-
.6, mental retardation "associated with pre-
milial mental retardation" and either mental
maturity"), there are two categories in par-
retardation "associated with environmental
ticular that are important for behavioral
deprivation" (APA) or "psychogenic men-
scientists. These are category .7 ("following
tal retardation" (AAMD).
major psychiatric disorder") and category .8
("with psycho-social [environmental] depri- As Tarjan and Eisenberg point out, both
vation"). categories discount the possible effects of
biomedical traumata in bringing about func-
Tarjan and Eisenberg discuss these prob- tional retardation. "As a consequence, the
lems in relation to the classification of mental erroneous conclusion might be drawn that
retardation in the United States of America somatic noxae do not play a role in the cau-
(3). They point out: sation of sociocultural retardation. . . .
It is not uncommon to find children in the [Moreover] global conclusions have been
drawn concerning the total effect of depriva- classification and for morbidity classification
tion without specific information on the where the main interest is not in the mental
components of deprivation in regard to state, these categories [describing conditions
quality, quantity, specificity, or timing" (3, which are secondary to physical conditions]
p. 16). should not be used, but assignment made to
ICD-8's categorization of mental retarda- the underlying cause." Does this mean that a
tion "with psycho-social (environmental) grossly defective spastic or epileptic child,
deprivation" is both clumsy and inaccurate. who is referred to a department of neurology
"Psycho-social (environmental)," like "so- or pediatrics, is likely to be classified differ-
ciocultural" and "cultural-familial," tells us ently from the way in which he would be if
no more than the older terms "familial," referred to a department of child psychology
"undifferentiated," "residual," "aclinical," or to a mental retardation clinic?
"subcultural," or "primary." The term "de- The problem of differential classification
privation" is also a misnomer because it al- according to place of referral may not have
most inherently contains the value judgment been of great importance in the past because
that anyone who has not had a middle-class of the lack of interest by departments of
upbringing is somehow deprived. pediatrics, neurology, and psychiatry in pa-
At the present time there is no way of tients (especially children) with chronic
disentangling the effects of genetic, biologi- neurological and behavioral handicaps. But
cal, and social factors in the causation of so- this situation is changing, and it is important
ciocultural retardation, and it would seem to anticipate future developments. The prob-
more honest to acknowledge that fact lem is one that affects child psychiatry in
particularly since doing so is likely to lead to particular. Most mentally retarded patients
a more reliable, and hence more useful, sys- first come to notice as children, and for
tem of classification. Moreover, the degree of planning purposes it is necessary to monitor
environmental deprivation is usually judged changes in prevalence and to highlight
by the social circumstances of the family. A inadequate case finding.
more useful indicator of sociocultural re- Hence an effort should be made to inte-
tardation can probably be obtained from two- grate the proposed triaxial system of clas-
way tables that record the social class of the sification proposed by the working group in
parents and the clinical condition of the child. child psychiatry with that proposed for men-
Is "psycho-social (environmental) depriva- tal retardation. This could be done by
tion" worth recording as a cause of mental expanding the second axis of the triaxial
defect at the present time? classification in child psychiatry (that con-
Compatibility of the Various Sections cerned with intelligence, which, incidentally,
makes no separate provision for very bright
of ICD-8
children) and by making the other two axes in
The working group in child psychiatry of the classification proposed for child psychia-
the Third WHO Seminar on Standardization try compatible with those to be proposed for
of Psychiatric Diagnosis held in Paris in 1967 mental retardation. The clinical axis in the
(6) opted for a triaxial system in which the child psychiatry classification is more ade-
first axis described the "clinical psychiatric quate than the corresponding axis in the
syndrome," the second the "intellectual lev- mental retardation section of ICD-8. The
el," and the third the "associated or etiologi- etiological axes have much in common and
cal factors." The group made little reference could probably be integrated, especially if a
to the classification of mental retardation in two-digit system is to be usedas is proposed
ICD-8 and assigned mental retardation only in the child psychiatry working paper (6).
a single number9.0on the clinical axis. It I hope that the seminar will consider how
would be extremely unsatisfactory if diagno- classification in mental retardation can be
sis in child psychiatry were to remain in this integrated with that in child psychiatry. A
form, for the classification of a patient would multiaxial system has much to commend it
become a function of the place of referral or on theoretical grounds, but it would clearly
the allegiance of a clinician. need to be tried out in practice before being
This is, of course, the case today. ICD-8's incorporated into the ICD. I therefore rec-
instructions say: "For primary mortality ommend that WHO assume responsibility
for pilot studies to provide information about REFERENCES
the feasibility of such a system. 1. World Health Organization: International Classifi-
cation of Diseases, 8th revision. Geneva, WHO, 1968
C o m p r e h e n s i v e n e s s of C l a s s i f i c a t i o n 2. Organization of services for the mentally retarded.
WHO Techn Rep Ser 392, 1968
3. Tarjan G, Eisenberg L: Some thoughts on the clas-
Whether or not a triaxial system common sification of mental retardation in the United States
to child psychiatry and mental retardation is of America. Amer J Psychiat 128 (May suppl): 14-
developed, consideration should be given to 18, 1972
the possibility of including additional physi- 4. American Psychiatric Association: Diagnostic and
cal handicaps from other sections of ICD-8 in Statistical Manual of Mental Disorders, 2nd ed.
Washington, DC, APA, 1968
the mental retardation scheme. It is absurd, 5. Heber R: A manual on terminology and classifica-
for example, that cerebral palsy and epilepsy tion in mental retardation, 2nd ed. Amer J Ment
should not find a place in a classification of Defic 65 (monograph suppl), April 1961
mental retardation. 6. Rutter M, Lebovici S, Eisenberg L, et al: A tri-
axial classsification of mental disorders in child-
For mental retardation, therefore, a useful hood. An international study. J Child Psychol Psy-
and feasible classification would require four chiat 10:41-61, 1969
axes: 1) grade of intellectual functioning; 2) 7. Wing L: Observations on the psychiatric section of
etiological and medical diagnosis; 3) psy- the International Classification of Diseases and the
British Glossary of Mental Disorders. Psycho Med
chiatric aspects; and 4) additional physical 1:79-85, 1970
handicaps (to include epilepsy, cerebral
palsy, cleft palate, sensory handicaps, etc.).
It is easy to envisage that a system of clas-
sification could be devised that would be The first draft of this paper was sent for com-
common to child psychiatry, developmental ment to a number of colleagues ' in Britain,
neurology, and mental retardation and that Europe, and the United States; many of their sug-
would also serve the needs of the adult re- gestions have been incorporated into the text.
tarded. The inclusion of "associated physical Several colleagues felt that two aspects of the
handicaps" would involve the introduction of classification system required more discussion.
categories and terms that are rightly included Dr. Michael Begab, of the National Institute of
Child Health and Human Development, explained
in other sections of ICD-8. As Wing (7) has
this point of view as follows:
pointed out, this could be accomplished if the
classification were accompanied by a glos- The terms "sociocultural," "cultural-
sary, the need for which is manifest in any familial," and "psychosocial deprivation" are
case because of the confusion that surrounds indeed vague categories because of the uncertain
etiological factors underlying. Biological and
terminology in mental retardation. Wing
genetic contributors may well be involved but
states: their significance to intellect and function (when
It would therefore be useful for the Glossary to too minimal to measure with current tech-
include all sub-headings given in Section V of the niques) is yet to be established. In the absence of
LCD. manual [so that it could be used by doctors more definitive substitutes, I doubt whether we
or clerical workers assigning codes without having can do away with the only classification denot-
to search for appropriate labels in two different ing the role of social-environmental circum-
books].... stances as a cause of retardation. I am con-
A consistent policy for cross-references would cerned this would lead to a conceptualization of
be desirable. . . . [and] . . . it would be most retardation as one deriving from biological de-
helpful if the Glossary also included parts of the terminants alone, thus drawing attention away
LCD. manual, other than Section V, which might from the major dimensions of the problem. Al-
be useful in classifying psychiatric problems (7). though admittedly imprecise, the emphasis on
In summary, classification in mental re-
tardation should be multiaxial. While it is
unimportant whether diseases or conditions
associated with it are included in Section V of
LCD or elsewhere, it is important that terms
be used consistently and that a glossary that
is comprehensive and operational in defini-
tion accompany the manual.
cultural deprivation has been an important index of current performance or future adapta-
stimulant to educational, social and nutritional tion and we continue to struggle with more
intervention and research programs. If this refined measures of behavior. I doubt whether
category were deleted in favor of an interaction- the clinical classification proposed by the
ist conceptminor neurological impairment, Working Group on Child Psychiatry would
genetic endowment and psychosocial depriva- adequately cover this dimension. While I agree
tionwe may be back to an undifferentiated, that compatibility with other sections of the
waste-basket classification. ICD is important, the sacrifice to mental re-
My other point of contention is your implicit tardation is, in my view, too great. If we delete
discard of the supplementary adaptive behavior this element because of limitations in
classification. There is considerable disen- measurement, we may discourage research on
chantment in this country with the IQ as an adaptive behavior scales.

The Problem of the Classification of

Mental Retardation

The author proposes a new system of classi- this process wide use has been made of the
fying the various forms of mental retarda- latest findings in medical genetics, embry-
tion. Using the time of exposure to a path- ology, biochemistry, and teratology and of
ogenic agent and its etiology as a basis, she the clinical observations of obstetricians,
classifies the forms of mental retardation into pediatricians, psychiatrists, psychologists,
three groups: 1) those caused by a pathologi- and neuropathologists. The work of these
cal condition of the reproductive cells of the specialists has made it possible to establish
parents; 2) those caused by harmful factors the etiology, pathogenesis, and clinical mani-
that act during the intrauterine period; and 3) festations of many forms of mental retarda-
those caused by damage to the central ner- tion and to outline new ways of treating them.
vous system in the perinatal period or in the In this way the latest findings on the etiol-
first three years of life. ogy and pathogenesis of various forms of
mental retardation have enabled psychiatrists
to come closer to solving the intricate task,

A s A RESULT of the great progress that

has been made in the biological sciences
(luring the last few decades, a more solid
set over 50 years ago, of breaking down this
complex group into its component clinical
theoretical basis has been established for
studying the etiology and pathogenesis of Early Classifications
various forms of mental retardation.' Armed
with new and improved methods of research, Attempts to differentiate among various
workers in various branches of theoretical forms of mental deficiency were made by
and clinical medicine have begun to study the psychiatrists as long ago as the 19th century.
causes and mechanisms of anomalies in the Various criteria were proposed (for example,
development of the human organism. During for etiology whether a defect was congenital
or acquired and for the degree of intellectual
deficiency whether idiocy, imbecility, or fee-
blemindedness was present). However, at that
time there was no generally accepted classi-
fication, since the selection of a criterion de-
pended largely on the purpose the classifica-
tion was to serve. Thus, to determine the
possibility of teaching a mentally retarded
child or adolescent, use was commonly made 4. Mental retardation with gross underde-
of a classification in which three degrees of velopment of the prefrontal areas of the brain
mental underdevelopment were distin- and that is characterized by specific changes
guished. If feeblemindedness was present, the in personality and motor activity. This form
child was sent to auxiliary schools, while pa- is of an exogenous etiology.
tients who were imbeciles were taught to per- 5. Mental retardation combined with
form elementary forms of work. Persons at damage to the subcortical structures. This
the level of idiocy needed supervision and form includes underdevelopment of the cog-
care and could not adapt to an independent nitive faculty and psychopathic behavior.
way of life.
However, this method of settling the prob- Need for a New Classification System
lem of mental retardation is not adequate for
properly organizing teaching of and therapy However, a different classification scheme
with the mentally retarded or for determining is required for the purposes of clinical prac-
their working capacity and recommending tice and for scientific research; preferably,
the best forms of work for them to do. Even if this would be a classification system based on
their degree of intellectual deficiency is ex- the criterion of etiology and pathogenesis. A
actly the same, the working capacity of pa- criterion of this type for classifying mental
tients may differ depending on their level of retardation has been used by many eminent
activity and drive. If there is marked asthenia scientists who have studied the condition. Al-
or apathy and if the intellectual defect is though these classifications reflect very well
combined with psychopathic manifestations, the multiplicity of forms of mental retarda-
the patient's activity is always reduced to a tion encountered in clinical practice, no
greater or lesser extent. In the case of atypi- generally accepted classification exists. The
cal and complicated forms of mental defi- lack of unanimity on this question is not dif-
ciency, the clinical picture of signs of local ficult to explain if it is remembered that the
defects, e.g., whether in hearing, in vision, or very concept of mental retardation is inter-
in speech, and disturbances in cognitive ac- preted differently by different workers.
tivity and working capacity may be con- For this reason I thought it necessary, be-
siderable, even though the patient's intellec- fore describing my classification scheme, to
tual deficiency is slight. insert a short introduction describing my
For these reasons, coupled with the needs point of departure in defining the concept of
of those who teach the mentally retarded and mental retardation and in delimiting it from
the need for expert assessment of the working other clinical manifestations of intellectual
capacity of the mentally retarded, use has defect. In studying the clinical features of
been made of a system of classification that mental retardation in children and in adoles-
reflects the structure of the deficiency. An cents, I thought it essential to make a strict
outline of this kind has been proposed by distinction between the following two con-
Pevzner(l). She distinguishes five clinical cepts: 1) an intellectual defect that is the
forms of mental retardation: manifestation of the anomalous development
1. An uncomplicated form without gross of the brain, and 2) intellectual disturbances
deficiencies in any particular analyzer and caused by damage to brain structures that
without marked emotional disturbances or have already been formed. This distinction
disorders of volition. This form is usually fully accords with the ideas prevalent in tera-
hereditary in nature. tology; the investigator sets himself the task
2. A form of mental retardation compli- of distinguishing a developmental defect from
cated by hydrocephalus in which the intellec- a disablement caused by damage to an organ
tual defect is combined with a behavioral that has already been formed.
disturbance and a reduction in working ca- The clear-cut differentiation between these
pacity that includes an increased tendency to two concepts makes it possible to distinguish
tire quickly and attacks of headache. This two forms of deficiency that differ in struc-
form is due to external causes. ture. The first, oligophrenic dementia, is a
3. Mental retardation combined with focal nonprogressive, pathological condition that
disorders of hearing, speech, or the spatial constitutes a form of mental underdevelop-
synthesis of the motor system. ment. The second is dementia in the sense of a
decay of mental functions that have already tion (appendix 1). Considering it to be a
been established and as a result of a process special form of dysontogenesis of the brain,
that has produced the dementia. and sometimes of the body as a whole, I
I consider mental retardation to be a group thought it essential to take into account the
of pathological conditions with different laws governing the occurrence of develop-
etiologies, but with one factor in common mental defects in general. Experimental re-
all of the conditions represent clinical search has shown that a developmental de-
manifestations of dysontogenesis, an anom- fect depends not only on the nature, intensity,
aly of the development of the brain often and acuteness of the pathogenic factor, but
combined with developmental defects in also, and mainly, on the time of exposure,
other body systems. Assigned to the group are i.e., the stage of ontogenesis at which the
those forms of general mental underdevel- organism was damaged.
opment characterized by: 1) the presence of a For this reason two criteriathe time of
defect in cognitive activity, and 2) the exposure and the nature of the pathogenic
nonprogressive nature of the condition. agent (its etiology)were put forward as a
It is important to emphasize that mental basis for differentiating mental retardation
retardation is characterized by the particular into different clinical forms. In accordance
complexity of its clinical manifestations; it is with this, all of the clinical forms of mental
a matter of the underdevelopment of the retardation are divided into three groups,
highest forms of cognitive activity, which depending on the time of exposure to the
cannot develop without the participation of harmful factor.
the ontogenetically and phylogenetically The first group is caused by a pathological
youngest brain structures. These structures condition of the reproductive cells of the
mature late and are formed most intensively parents, i.e., hereditary disease, a chromo-
during the first few years of postnatal devel- somal aberration, and a pathological con-
opment. That is why a disease process that dition caused by exposure to harmful external
attacks the central nervous system of a child agents (ionizing radiation).
during his first years of life can lead not only The second group is dependent on harmful
to the destruction of previously formed sys- factors acting during the intrauterine period
tems, but also to the underdevelopment of (embryopathies and pathologies of the fetus).
those structures that, at the time, have not yet The third group includes those forms of
taken final shape. In view of this the forms of mental retardation caused by damage to the
mental retardation should include, in addi- central nervous system in the perinatal period
tion to the hereditary and congenital forms, or in the first three years of life, i.e., during
those forms acquired in the first few years of the period where the ontogenetically young
life (up to three years of age). structures of the brain have not yet been
If this concept of the essence of mental re- completely formed. Within each of these
tardation were adopted, the boundaries of the three groups different clinical forms are dis-
condition would become more clear-cut. The tinguished on the basis of etiology.
forms should exclude, first, all those intellec-
tual disturbances that occur at later stages in Conclusions
the development of the child during various
progressive pathological processes affecting The scheme proposed here for the classifi-
the brain, or in the residual period, and that cation of mental retardation cannot be
represent the decay of intellectual functions considered to be perfect and exhaustive. In
that have already been formed; and second, addition to the forms listed here, the causes of
milder forms of disturbances in intellectual which are more or less clear, there are a
activity that are due to a slow rate of devel- number of other forms (the so-called undif-
opment (infantilism), incorrect child rearing, ferentiated forms of mental deficiency) for
asthenia from somatic causes, and behavior which no accurate findings are available on
disorders. the causes and origins. The difficulty of dif-
ferentiation on the basis of pathogenesis is
A T h r e e - G r o u p Classification
also due to the fact that some clinically well-
These were my initial assumptions when I defined forms of mental retardation have
undertook a classification of mental retarda- been insufficiently studied with respect to
etiology. In addition, forms are quite often 6. Laurence-Moon-Biedl syndrome
seen in clinical practice that have multiple 7. Mental retardation combined with the distur-
causes, and it is difficult in each concrete case bance of endochondral ossification, with con-
to isolate the principal cause of the disease. genital epiphyseal dysplasia
At the present time it is still not clear what 8. Mental retardation combined with ichthyosis
(Rud's syndrome)
forms of enzymopathy can be considered to
9. Some of the nevoid defects with a nonpro-
be mental deficiences. It is often difficult to
gressive course
make a differential diagnosis between an en- 10. Mental retardation caused by damage to the
z y m o p a t h y form of mental retardation and reproductive cells of the parents through
dementia caused by a progressive enzymo- exposure to exogenous factors, e.g., ionizing
p a t h y disease. It can only be said that the radiation
earlier the hereditary chemical defect is 11. Other genetic forms
discovered, the more often are observed
symptoms of the underdevelopment of cog- Enzymopathic F o r m s of Mental R e t a r d a t i o n
nitive activity of a mental deficiency type. Disturbances of Protein Metabolism
In other words, it is still difficult to deter- 1. Phenylketonuria (blockage of phenylalanine-
mine a classification of mental retardation hydroxylase)
that can be accepted as completely satisfac- 2. Maple syrup urine disease (disorders in the
metabolism of valine, isoleucine, and leucine)
tory. The only thing that is clear is the way we
3. Hyperlysinemia (disturbed metabolism of ly-
should proceed if we wish to solve this prob- sine)
lem in the future. The systematics of mental 4. Hypervalinemia (disturbed metabolism of
retardation, as of other forms of disease, valine)
must mainly be based on data regarding path- 5. Histidinemia (disturbed metabolism of his-
ogenesis. tidine)
T h e p a t h o g e n e s i s of v a r i o u s t y p e s of 6. Citrullinuria (disturbed metabolism of citrul-
mental retardation depends not only on the line)
severity and nature of the etiological factor, 7. Homocystinuria (disturbed metabolism of
but also, and mainly, on the stage of onto- methionine)
8. Arginosuccinicaciduria (disturbed metabolism
genesis at which the organism was damaged.
of arginine)
The more carefully we study the type of
reactivity of the nervous system at various Disturbances of Carbohydrate Metabolism
periods in antenatal and postnatal devel- 9. Galactosemia (a disturbance in the action of
opment, the easier it will be to establish a the enzyme galactose-L-phosphate-uridyl-
classification of mental retardation, and the transferase)
10. Fructosuria (hyperaminoaciduria)
better that classification will be.
11. Sucrosuria (intolerance of saccharose)
REFERENCE Disturbances in Pigment Metabolism
12. Methemoglobinemia (blockage of the enzyme
1. Pevzner MS: Mentally Retarded Children. Moscow, needed to convert methemoglobin into hemo-
Academy of Pedagogical Sciences Press, 1959 globin)
13. Deficiency of glucuronyl transferase and in-
APPENDIX 1 capability of converting indirectly acting
T h e Classification of M e n t a l R e t a r d a t i o n bilirubin into the directly acting form (Crigler-
i n t o Three Groups Najjar syndrome)
Clinical Forms of Mental R e t a r d a t i o n
Group 1
Caused by C h r o m o s o m a l Aberrations
Pathological Condition of t h e Reproductive 1. Mental retardation caused by a chromosomal
Cells of t h e P a r e n t s aberration in Group A chromosomes (ring
Genetic Forms of Mental Retardation chromosomes)
1. Familial forms with a polygenic type of 2. Mental retardation caused by an aberration in
inheritance Group B that is connected with the deletion of
2. True microcephalus the short arm of the fourth pair of chromo-
3. Arachnodactylia (Marfan's syndrome) somes (Wolfs syndrome)
4. Craniofacial dysostosis (Crouzon's disease) 3. Mental retardation connected with deletion of
5. Craniofacial dysostosis with syndactylia the short arm of the fifth pair of chromosomes
(Apert's disease) ("Cri du chat" syndrome)
4. Mental retardation connected with a trisomy 3. Mental retardation caused by the mother
in Group D, 13th to 15th pairs of chro- catching measles during pregnancy (embryo-
mosomes (Patau's syndrome) pathia rubeolaris)
5. Mental retardation connected with an aberra- 4. Mental retardation caused by other viruses
tion in Group E; a trisomy of the 18th pair of (influenza, mumps, infectious hepatitis, cy-
chromosomes (Edward's syndrome) tomegalic inclusion disease)
6. Mental retardation connected with deletion of 5. Mental retardation caused by toxoplasmosis
the short arm of the 18th pair of chromosomes and listeriosis
(De Grouchy's syndrome) 6. Mental retardation associated with congenital
7. Mental retardation connected with deletion of syphilis
the long arm of the 18th pair of chromosomes 7. Clinical forms of mental retardation caused
(Lejeune's syndrome) by hormonal disturbances in the mother and
8. Mental retardation caused by a trisomy of the by toxic factors (exotoxins and endotoxins)
21st pair of chromosomes (Down's syndrome) 8. Mental retardation caused by hemolytic
9. Mental retardation connected with an aberra- disease of the newborn.
tion in the system of sex chromosomes
(Klinefelter's syndrome) Group 3
10. Turner's syndrome
11. The triple X syndrome
12. Mental retardation in men connected with an The third group is comprised of types of mental
extra Y chromosome. retardation caused by harmful factors acting dur-
ing the perinatal period and the first three years of
Group 2 the postnatal period. The clinical forms in this
group occur following exposure to various ex-
The second group is comprised of types of ogenous factors, e.g., birth injury, postnatal inju-
mental retardation caused by harmful factors act- ries, asphyxia during labor, and injuries and in-
ing during the intrauterine period. Making a dis- toxications during the first years of life. These
tinction between the various clinical forms of clinical forms of mental retardation are more
mental retardation on an etiological basis is complex in structure since, in their clinical and
considerably more difficult in this group than in morphological characteristics, signs of underde-
the previous one, since it is not always possible to velopment are combined with residual manifesta-
determine which pathogenic factor is preventing tions of the disease concerned.
the establishment of the optimum environment for The following clinical types of mental retarda-
the development of the embryo and the fetus (the tion may be distinguished in this group:
supply of nutritive substances and of oxygen). 1. Mental retardation due to birth injury and
These pathogenic factors may be different at dif- asphyxia.
ferent stages in intrauterine development. There is 2. Mental retardation caused by craniocerebral
no doubt that disturbances in uteroplacental blood injury in the postnatal period (early child-
circulation, cardiovascular diseases in the mother, hood)
diseases of the kidney and liver, and late pregnancy 3. Mental retardation caused by general infec-
toxemia are of great importance in this respect. tions during the first three years of life
In defining this group a distinction has been (influenza, measles, pneumonia, dysentery,
drawn only between those clinical forms of mental severe forms of dyspepsia)
retardation whose etiology has been more or less 4. Mental retardation caused by encephalitis,
clearly determined. The forms in this group are as meningoencephalitis, or meningitis in early
follows: childhood
1. Mental retardation arising under the influence 5. Mental retardation caused by severe disorders
of immunopathological factorsincompat- of sensory functions (blindness, deafness)
ibility of the antigenic properties of the ma- 6. Mental retardation combined with speech de-
ternal and fetal blood with regard to blood fects
type and rhesus factors 7. Mental retardation due to craniostenosis
2. Mental retardation associated with Little's 8. Mental retardation combined with congenital
disease hydrocephalus
Classification and Mental Retardation: Issues
Arising in the Fifth WHO Seminar on Psychiatric
Diagnosis, Classification, and Statistics

In conjunction with the official report of the inar but, in expanding upon the reasoning
seminar, this paper discusses in more detail behind the official recommendations, we can
some of the chief issues considered at the necessarily only speak for ourselves. For the
seminar and outlines the reasoning behind the decisions made at the seminar, readers are
recommendations. The issues considered in- referred to the official report (1).
clude the integration of child psychiatry and
mental retardation, multiaxial classification, Integration of Child Psychiatry and
choice of axes, assessment of intellectual re- Mental Retardation
tardation, values and limitations of IQ tests,
assessment of social competence, classifica-
tion of biological factors, application of the Although the classification of mental re-
multiaxial scheme to adult patients, and field tardation in adults was discussed at the sem-
trials to test new schemes of classification. inar, most of the discussions concentrated
on the problems associated with mental re-
tardation in children. It became clear early in
HIS PAPER by the officers of the Fifth the seminar that the issues which arose at an
T WHO Seminar on Psychiatric Diagno-
sis, Classification, and Statistics gives an
earlier seminar in this program, the Paris
seminar (Third WHO Seminar on Standard-
outline of some of the main issues discussed ization of Psychiatric Diagnosis, Classifi-
at the seminar in order to clarify the reasons cation, and Statistics held in Paris in 1967),
for the decisions listed in the official report of with respect to child psychiatry (2), applied
the seminar. We have tried to faithfully rep- equally to mental retardation. Retarded
resent the tenor of the discussion at the sem- children may present psychiatric disorders
that require diagnosis and treatment in the
same way as do children of normal intelli-
It was found that the current International
Classification of Diseases (ICD-8) (3) has
inadequate provision for the coding of psy-
chiatric disorders in children. Most disorders
tend to be coded under category 308, "behav-
ior disorders of childhood," a vague term that
implies that psychiatric disorders in child-
hood cannot be further differentiated. This
"rubbish-basket" coding no longer represents
the state of knowledge in the subject (3). The
seminar recommended that the outline pro-
vided by the Paris seminar (which gives ten
main categories) be accepted as a provisional
scheme to be tried out internationally in or-
der to arrive at a more definitive scheme it constituted an important part of the diag-
when the ICD is next revised in 1975. nosis. Of course, if only one condition is to be
Similarly, the concept of mental retarda- coded, the selection will depend upon the
tion is very relevant to the child psychiatrist special interests of the diagnostician. The pa-
who sees many children with educational or tient, however, may receive care or treatment
intellectual handicaps. Although in the past not only from physicians but from teachers,
child psychiatrists may not have been so industrial instructors, psychotherapists, and
concerned with the subject of mental re- social workers. In order that the person con-
tardation, this is less true today. Child psy- cerned with a retarded child successfully per-
chiatry is developing, and child psychiatrists form his function, he must have not only the
see many children with educational or intel- information necessary for his own work, but
lectual handicaps. The mentally retarded also a comprehensive picture of the child's
child requires expert assessment and treat- problems and handicaps. Hence all essential
ment with regard to intellectual, emotion- data need to be coded.
al, behavioral, social, and medical factors. ICD-8 does make some provision for the
Because his handicaps are often multiple, combined coding of physical disorder in as-
the retarded child may attend a retarda- sociation with mental retardation through the
tion clinic, a psychiatric unit, or a pediatric use of a fourth digit. However, it is not satis-
department. In order to make comparisons factory because only a limited number of
between different centers it is essential to conditions are covered and because they are
have a classification that encompasses each grouped together. Thus mental retardation
of these dimensions and that is equally ap- with hypothyroidism and mental retardation
plicable to different kinds of clinics. The with phenylketonuria both have the same
multiaxial scheme suggested for use in child fourth-digit category. Although it is possible
psychiatry seemed just as well suited for to code Down's syndrome with mental re-
mental retardation, and it was recommended tardation by using a fourth digit, it is not
that the scheme be adopted for mental re- possible to thus code, for example, cerebral
tardation also, with the addition of one palsy with mental retardation.
further axis. It was pointed out at the seminar that ICD-
8 does allow the coding of different elements
Multiaxial Classification by the use of multiple categories. Thus it is
quite possible to classify the retarded, epilep-
The necessity for a multiaxial or multi- tic, psychotic child within categories 311
category classification scheme arose at the ("mild mental retardation"), 345 ("epilep-
Washington seminar (as it did at the Paris sy"), and 295.8 ("other," including child-
seminar) during the case history exercise hood schizophrenia). However, there are no
when patients showed a psychiatric disorder as rules as to how many categories to use; as the
well as mental retardation, or a physical dis- diagnostic exercise clearly showed, partici-
order as well as mental retardation. For ex- pants varied on how many codings they em-
ample, at the Paris seminar there was a case ployed, and when they used only one, they
of a mentally retarded epileptic girl who differed on which one they chose. Further-
showed, in addition, a psychotic disorder. more, in a number of medical centers the rule
Participants at the seminar agreed that it was is to code only one diagnosis per patient.
appropriate to record three elements (psy- In discussion it was agreed that in most
chosis, mental subnormality, and chronic cases there is little logic used in selecting the
brain conditions) but, in fact, most people single coding to be used. It might represent
recorded only one, with a fairly even split the referral problem, the interest of the par-
among the three categories as to which one ticular clinician, the most "serious" condition
was chosen for classification. in clinical terms, or the condition that is most
Similarly, at the Washington seminar there relevant to the administrative action taken
was a case of a mentally retarded child with a (i.e., admission to a pediatric ward, psychi-
severe conduct disorder. More than one-third atric unit, or a hospital for the mentally sub-
of the participants did not record the conduct normal). Exactly the same problem arose in
disorder in their classification coding in spite multicategory coding with respect to which
of the fact that they agreed in discussion that disorder was coded first. Modern computer
techniques allow the analysis of multiple codings selected. Secondly, ICD-8 has no
codings, but in practice frequently only the provision for "no abnormality" with respect
first-coded category is analyzedgiving rise to these three areas. If such a coding is added,
to precisely the same problems as when only a multiaxial scheme of the type proposed by
one category is employed. the Paris seminar is arrived at.
The fact that a condition is not coded can A multiaxial classification simply regroups
lead to multiple contradictory interpreta- the categories of ICD-8 (with appropriate
tions. It may mean that the condition was not modification where necessary) under broad
present, that it was present but not thought headings called "axes," provides a "no ab-
important, or it may just reflect the fact that normality" coding in each, and requires that
it was not coded in spite of being thought every case receive some coding on each axis.
important. In short, a multiaxial scheme is just a reor-
A multiaxial scheme is no more than a dering of a multicategory scheme with the
logical development of a multicategory addition of simple rules on usage in order to
scheme (such as ICD-8), which introduces ensure that everyone interprets the scheme in
modifications specifically to meet these dif- the same way.
ficulties. Thus ICD-8 could specify that three Unreliability in classification may be due
categories must always be coded in order to to several factors, including unreliability in
ensure that everyone codes the same number diagnosis and unreliability in coding. A mul-
of categories. However, this would leave open tiaxial scheme is designed to reduce the errors
the question of which categories to code, and in coding and so enable a more valid picture
clinicians might well decide to record quite of morbidity. Serious distortions may stem
different aspects. A short example easily il- from faulty and incomplete recording of
lustrates this point. If a child is knocked conditions. All the diagnostic exercises in the
down by a car and receives severe head inju- seminars in the program on the Standardiza-
ries resulting in hemiparesis, fits, an IQ of 58, tion of Psychiatric Diagnosis, Classification,
and the later development of a schizophrenic and Statistics showed that even when ev-
state, the three codings could be any com- eryone agreed on diagnosis, there were of-
bination of categories 343 ("cerebral spas- ten serious disagreements on classification,
tic infantile paralysis"), 345 ("epilepsy"), 311 purely through uncertainty on how to code
("mild mental retardation"), E814 (injury re- when there was a multiple handicap disorder.
sulting from "motor vehicle traffic accident It is hoped that a multiaxial scheme will
involving collision with pedestrian"), 293 eliminate this particular problem and so en-
("psychosis associated with other cerebral hance the value of classification for the pur-
condition"), and possibly 295 ("schizophre- pose of unambiguous communication. How
nia"). 1 Even if only three conditions were to successful it will be will need to be tested in
be recorded, it would be necessary to provide field trials, some of which are in preparation
rules for precedence in selection. and others of which are already being carried
Of course, a multicategory scheme could out. The remaining problem of the same
overcome the problem of selecting from sev- diagnostic term being coded to different
eral categories by specifying that the three categories can be overcome only by means of
categories must refer to: 1) clinical psychiatric a glossary, a first draft of which has been
syndrome, 2) intellectual level, and 3) medi- prepared (by WHO) and is being tried out.
cal condition. But here there are two further
problems. In the first place, for purposes of Choice of Axes
data processing it would be necessary to en-
sure that the same disorder was always re- Once it had been decided to recommend
corded in the same position among the three the adoption of a multiaxial scheme, there
had to be a choice of axes. It is obvious that
any given clinical case has many clinically
important aspects, and in order to have a
workable and relatively simple scheme, it was
necessary to restrict the number of axes. Axes
were chosen on the basis of providing unam-
biguous information of maximum clinical
usefulness in the greatest number of cases. was evident that medical classification must
With mental retardation, one axis had to include an axis for this information. Thus a
pertain to intellectual level, for this has been third axis was called "associated or etiolog-
shown to be of both medical and educational ical biological or organic factors." In ICD-
or occupational importance. Nearly all in- 8 the fourth digit of the mental retardation
dividuals with an IQ below 50 have demon- codings was intended to meet this need. Un-
strable brain disease or damage, whereas for fortunately, it proved unreliable in the case
those with an IQ above 50, social factors are history exercise, and an alternative was evi-
of greater importance in etiology, though an dently needed. Ideally, this axis should pro-
important minority of cases are due to brain vide a summary classification of the physical
disorders (4, 5). Thus retarded children with disorders coded elsewhere in the ICD, but the
IQs below 50 come from all social groups, means for doing so were left to be decided
with a distribution similar to that of the gen- later. The principles upon which such an axis
eral population. In sharp contrast, retarded might be based are considered in more detail
children with IQs above 50 only infrequently later in this paper.
come from professional families; most come Finally, it was recognized that in mental
from socially deprived sections of the com- retardation, as in other types of psychiatric
munity. disorder, psychological and social factors
The IQ level is also of considerable educa- might be of prime importance in etiology.
tional importance. Nearly all children with Accordingly, it was recommended that there
IQs above 50 can learn to read and1 write and should be a fourth axis for the coding of these
can attain useful scholastic competence in factors. There is already an E section in ICD-
other subjects. A few children with IQs from 8 dealing with external causes (such as acci-
35 to 50 will gain at least some primitive dents and excessive heat or cold), so that this
reading skills, whereas virtually no children recommendation does not introduce a new
with IQs below 35 will do so. Similarly, most principle. Nevertheless, there is at present no
adults with IQs above 50 but without other available scheme for the classification of
gross handicaps are employable, whereas few psychosocial factors, and it was thus neces-
of those with IQs between 35 and 50 are ca- sary to recommend that a working party be
pable of working in open employment, but formed to develop appropriate categories and
can work in a sheltered environment. Of to provide definitions for them.
those adults with IQs below 35, none is likely
to gain a job outside an institution, and most Assessment of Intellectual R e t a r d a t i o n
will be capable of only the most simple tasks
under detailed supervision (6-8). Several issues arose in connection with the
It should be emphasized that there is no assessment of intellectual retardation.
qualitative distinction between these various
Intellectual Functioning
IQ levels. Rather, the point is that on the
continuum of intellectual ability, a person's First it was agreed that mental retardation
level is of considerable predictive importance. referred solely to intellectual functioning and
Many retarded children are under care not to social impairment due to other handi-
largely because of the psychiatric problems caps (such as sensory defects, physical han-
they present, and it was therefore necessary to dicap, emotional disorder, or behavioral dis-
record the clinical psychiatric syndrome on turbance). Although mental subnormality
another axis. Retarded individuals can suffer has sometimes been used as a portmanteau
from any of the syndromes found in those of category to include psychopathy and delin-
normal intelligence, and there is only a very quency even when intelligence is normal or
weak association between intellectual level above normal (9), it was apparent that such
and type of clinical psychiatric syndrome. usage would be likely to lead only to diag-
Accordingly, it was decided to use the same nostic confusion. It was therefore recom-
scheme as that employed for individuals of mended that mental retardation be diagnosed
normal intelligence. For children, this meant only when there is intellectual impairment.
the scheme suggested by the Paris seminar.
Current State
Many cases of mental retardation are as-
sociated with brain disease or disorder, and it It was recognized that intelligence is not a
fixed and immutable quality and that in the Use of Intelligence Tests
present state of knowledge prognostications The issue concerning the assessment of in-
about future intellectual development are tellectual retardation proved to be more con-
necessarily uncertain. Heber has clearly troversial. The WHO Expert Committee re-
stated that "a person may meet the criteria of porting on the "Organization of Services for
mental retardation at one age level and not at the Mentally Retarded" (11) had advised that
another; he may change status as a result of IQ scores should be used to define the level of
'real' changes in intellectual functioning; or intellectual retardation; this approach was
he may move from [a] retarded to [a] non- favored by some participants. The arguments
retarded category as a result of a training for this method have been detailed else-
programme which has increased his level of where (12, 13). However, although it was
adaptive behaviour" (10, p. 238). There was agreed that the IQ constituted an important
general agreement with this view. Classifica- guide to intellectual level, the seminar par-
tion and diagnosis must be firmly based on ticipants differed from the WHO Expert
the present and not on crystal-gazing into Committee on the weight to be attached to
the future. The coding on this axis must the IQ.
therefore deal only with the person's current It was recommended that the clinical con-
state. siderations of social and adaptive functioning
Behavioral Criteria should always be taken into account and that,
in evaluating the grade of intellectual re-
The Paris seminar was quite explicit in tardation, note should be taken of the in-
advising that the coding of intellectual level dividual's social and cultural background.
should be based on the child's current level of Thus a diagnosis of mental retardation im-
intellectual functioning without regard to its plies that the person so diagnosed is both in-
nature. This ruling was necessary because of tellectually retarded and socially incompe-
theoretical disagreements about the nature of tent. Not all intellectually retarded persons
certain sorts of retardation. For example, would be classed as suffering from mental
where there is both psychosis and mental re- retardation, but all mentally retarded persons
tardation there is no agreement among clini- must show intellectual retardation. Because
cians on how to decide whether the psychosis the use of intelligence tests proved to be so
caused the retardation, whether the retarda- controversial, this issue will be discussed
tion caused the psychosis, or whether both are more fully.
due to a third factor, such as organic brain
disease. To avoid differences in coding due
solely to such theoretical disagreements it is Values a n d Limitations of
necessary to specify that the coding of intel- Intelligence Tests
lectual level be based on the current level of
functioning without regard to views on pos- In Western Europe, North America, and
sible pathogenesis. many other parts of the world where English
A similar problem arises in cases of mental and French are widely spoken, intellectual
retardation associated with psychosocial de- ability is usually assessed by means of intel-
privation. Participants at the seminar agreed ligence tests. An intelligence test is made up
that mental retardation may be secondary to of a series of subtests or tasks, each of which
environmental influences and that in such is thought to require intelligence for its suc-
cases the current functioning may bear little cessful completion. That is, the items selected
or no relationship to innate intelligence. By for inclusion in a test battery will be those on
its very nature, innate intelligence is a con- which intelligent or clever people (as judged
cept that cannot be directly measured. The by other criteria) tend to be successful,
coding of intellectual retardation should be whereas unintelligent or stupid people of the
based solely on the current level of function- same age tend to fail.
ing, and it should be recognized that the cod- Sophisticated statistical methods are used
ing carries no necessary implications about to select items for inclusion in intelligence
innate intelligence. It is a behavioral desig- test batteries and, in standardizing an intelli-
nation, not a speculation about hypothetical gence test, extensive field trials are first car-
potentialities. ried out on samples of the population to
which the test will later be applied. During for bright preschool children to 0.97 for dull
the standardization trials, items that are school children (14). This level of accuracy is
found not to discriminate between dull and considerably above that obtained by clinical
bright individuals (as judged by other criteria) assessments, and it is important to note that
are eliminated, as are items on which one sex IQ tests are most reliable in their assessment
shows superiority over the other. In selecting of retarded individuals. In many branches of
items, efforts are made to choose those that medicine relatively little attention has been
depend as little as possible upon specialized paid to the problems of reliability, but where
knowledge (e.g., literacy or computational they have been examined, all clinical exami-
facility) for their solution. nations have been found to have considerable
Because of the way in which tests are con- error rates (15).
structed, the most widely used intelligence Nevertheless, even this low rate of error
tests (such as the various modifications of carries implications for classification, as
Binet's original test and the scales devised by Shapiro (16) has pointed out. For example, a
Wechsler) have been found to give compara- school child with an obtained IQ of 69 (indi-
ble distributions of scores when used in dif- cating mild intellectual retardation) would
ferent industrialized countries. The Wechsler have IQ scores between 64 and 74 in 19 tests
scales have been translated into different out of 20 if he were retested an infinite num-
languages, and it has been found that only ber of times. The practical result of this is
minor modifications need to be made in the that a child may score in the intellectually
wording to make the scales usable in different retarded range one day and not the next.
countries. In order to show the extent of these error
This factand it is a factcoupled with limits, Shapiro recommended that psychol-
the demonstration that clinical ratings, un- ogists routinely include a statement on them
standardized judgments, and psychophysiol- in a test report. Thus, for the child with an IQ
ogical measures of intellectual ability are of 69, the report might say that his score was
highly unreliable and that assessments based 69 plus or minus 5, meaning that in 95 per-
on them correlate poorly with what is ordi- cent of the times a child was tested the limits
narily regarded as intelligence or intelligent of that child's IQ lay within 5 points on either
behavior, has led to the widespread use of in- side of 69. This would indicate that the test
telligence tests to assess intellectual ability. result only showed that the child's intelli-
Within a given culture there is no better way gence lay somewhere in that range (64 to 74)
of making comparative judgments of intel- and that it was not possible to be more precise
lectual ability, and it is a mistake to think than that. This also applies to clinical judg-
that "clinical" procedures produce better es- ment of adaptive skills.
timates. Unfortunately, too few countries
have properly developed and standardized 2. Errors in Test Construction
tests. In addition to the inherent unreliability of
Even so, the considerable limitations to in- tests there are systematic errors that arise
telligence tests are still not sufficiently ap- from the manner in which tests are stan-
preciated, although psychologists have long dardized. Although tests are expected to have
been aware of them. They include the fol- a mean and median of 100, this is not always
lowing: the case in practice. For example, one study
carried out by Dearborn and Rothney(17)
/. Error Factors
revealed that the median score for nine intel-
All measurement is subject to error, due to ligence tests administered at different times
a variety of causes. The only satisfactory way over a period of years to 320 children ranged
to assess error is to see what happens when from 94 to 110. There are also differences in
different examiners give the same test (or an the spread (or standard deviation) of scores
equivalent form of it) to the same individuals on different tests (on some tests the spread is
on different occasions. When this is done, IQ uneven, although it should not be), and dif-
tests are found to have a low number of er- ferent tests measure slightly different abili-
rors. For example, on the Terman-Merrill ties. For all these reasons it is possible for
revision of the Stanford-Binet Scale, the test- someone to score in the mentally retarded
retest correlations obtained range from 0.83 range on one test but not on another test. This
also applies to different types of clinical influence will and should be reflected in the test.
judgments. Moreover if we rule out cultural differentials from
a test we might thereby lower its prognostic
3. Errors in Administering Tests validity. The same cultural differentials that im-
An IQ test makes certain assumptions: pair an individual's test performance are likely to
handicap him in school work, job performance, or
for example, that the person can hear the in- any other activity we are trying to predict....
structions, that he can understand the lan- Tests cannot compensate for cultural deprivation
guage, and that he is physically able to make by eliminating its effects from their scores. On the
the responses. If a test that relies on spoken contrary, tests should reveal such effects, so that
instructions is given to a deaf child, then the appropriate remedial steps can be taken. To con-
result will be meaningless. If the psychologist ceal the effects of cultural disadvantages by re-
speaks English and the child understands on- jecting tests or by trying to devise tests that are in-
ly Spanish, the IQ score obtained will be sensitive to such effects can only retard progress
valueless. No competent psychologist will toward a genuine solution of social problems. Such
make such obvious and elementary errors, reactions towards tests are equivalent to breaking
a thermometer because it registers a body tem-
but the fact remains that administrative de- perature of 101.
cisions are sometimes (quite wrongly) made
on the basis of IQ tests given in a totally If the diagnostician, being aware of the
inappropriate way. This is, of course, a criti- dangers in the interpretation of IQ tests, de-
cism of the usage rather than of the tests cides to ignore manifest signs of intellectual
themselves. retardation in certain of his patients on the
grounds that nearly all people living in their
4. Cultural Factors in the Content of Tests particular circumstance "behave like sim-
Children brought up in different societies pletons," he will do a serious disservice to
are likely to have different experiences. These those retarded persons who do not have the
differences in experience may mean that intellectual resources to cope in other than
items in IQ tests may have quite different sheltered circumstances. The needs that led to
implications for them. To take an absurd ex- the provision of special services for mentally
ample, asking a Spanish child to name the retarded persons in developed countries do
president of the United States is a much more not cease to exist in developing ones; indeed,
difficult question than it is to a native New they may actually be greater.
Yorker. But in more subtle ways, experiences On the other hand, unless the IQ test that is
of language in the home may influence chil- used has been thoroughly tested out in the
dren's responses to items testing verbal skills. cultural context in which it is to be applied,
In an attempt to bypass these difficulties, a the test norms given in the manual cannot be
few years ago attempts were made to devise taken at face value. It would obviously be
first "culture-free" and then "culture-fair" wrong to use a test dependent on a particular
teststhat is, in the first case, tests that were set of culture-bound experiences to measure
genuinely free from or removed from cultural the intelligence of a child from a different
context or bias and, in the second case, tests culture in order to predict his performance in
that only drew upon elements that might be his own culture. Attempts to do so are likely
presumed to exist in any human culture. to lead to serious underestimates of an in-
Theoretically, this is a dubious procedure, dividual's intellectual capacity and, on a
and it has not worked in practice. Children wider scale, to give rise to absurdly inflated
from developing countries or from slums and estimates of the rates of mental retardation.
ghettos in Western societies have often scored This holds for any society, not merely an
even lower on these tests than they have on impoverished one. Unfortunately, there are
traditional tests. still many societies in the world in which IQ
tests have not been standardized.
Anastasi(18) has put the matter suc-
cinctly: However, the difficulty is not solved by
simply being ignored. Psychiatrists and psy-
To criticise tests because they reveal cultural in- chologists working with impoverished and il-
fluences is to miss the essential nature of tests. literate or semiliterate patients therefore
Every psychological test measures a sample of have a responsibility to ensure that before
behaviour. Insofar as culture affects behaviour its making judgments, which are essentially
comparative, about the intellectual ability of test. It is necessary to differentiate between
their patients, they first provide themselves items failed and items not attempted, be-
with the bases upon which such comparisons tween items where the person has really ap-
can be made. Where normative data are few, plied himself to the problem and items where
only the grossest of handicaps can be diag- there has been only a token effort. Where
nosed with confidence. Again, it should be there is a marked discrepancy between an IQ
emphasized that these difficulties apply to score and a person's performance in the real
clinical judgments in the same way as they do life situation, it is essential to analyze the
to IQ scores. reasons for the discrepancy.
J. Cultural Factors in the Response to Tests Nevertheless, given care and attention to
detail, an IQ test remains the best way of
A person's performance on IQ tests de- making comparative judgments of intellec-
pends on motivational and situational fac- tual ability within a given culture. Because a
tors (18-20) as well as on intellectual ca- test only assesses behavior, and not potential,
pacity. This means that great care must be no test can tell us how an individual would
taken in ensuring that tests are given under have functioned if he had been brought up in a
the best circumstances for the testee and in different environment. Accordingly, as Ver-
making sure that he is interested and involved non (23) has pointed out, cross-cultural
in the test. In order to determine that this has comparisons of "innate" intelligence are fu-
been achieved, it is important to assess the tile exercises.
validity of the IQ score in relation to the
manner of the child's response to the test, his Assessment of Social Competence
behavior at home and in other settings, and
all other relevant findings from observation Because of these limitations in the use of
and investigations. This is of course an in- IQ tests, the seminar recommended that as-
trinsic part of a proper psychological as- sessments of intellectual level be made from
sessment, but clinicians need to beware of a combination of standardized tests and clin-
carelessly using tests in a rigid and narrow ical judgments on social and adaptive ca-
fashion. pacity. Properly applied, this may result
However, there are more specific examples in the most valid measures of current intel-
of the influence of motivational factors with lectual performance. Nevertheless, it is im-
regard to the testing of individuals from cer- portant to also bear in mind the limitations
tain minority subcultures. It appears from inherent in the assessment of social compe-
research both in Britain and the United tence. It has already been pointed out that
States (21,22) that attitudes toward racial such measures are subject to the same error
differences so influence rapport that white factors that apply to IQ tests, that in the same
testers have a subtle deleterious effect on way that different IQ tests measure slightly
Negro subjects' scores. This effect probably different intellectual functions, so assess-
only applies in a competitive situation when ments of social and adaptive capacity will
Negro subjects know that they are being di- vary according to which clinical criterion is
rectly compared with white subjects. It is not used. The same difficult diagnostic problems
yet clear how general or how marked this ef- arise when assessments have to be made of
fect is, but the fact that it does exist means persons who do not share or who only
that it would be wise to use testers of the same somewhat share the cultural background of
racial background as the subject whenever the clinician.
there is the slightest doubt about intellectual The hope that clinical judgments will be
assessment. Similar effects are likely to apply less subject to social biases than IQ tests has
to an interview situation; care must therefore not been borne out in practice; this means
also be taken with respect to clinical assess- that this factor should receive particular at-
ments. tention in the training of clinicians. Indeed,
These caveats on the use of intelligence where tested, clinical judgments have gener-
tests undoubtedly imply that tests cannot ally fared worse than tests. For example, in
meaningfully be used in a blind fashion. Test- Britain, as a result of a proper concern over
ers must be alert to the total situation and the possible social biases of IQ tests as used in
how it influences the person's response to the the assessment of children's scholastic abili-
ties, some local authorities have dropped their strengths and weaknesses. The seminar
standardized tests and replaced them with recognized this and recommended that intel-
teachers' judgments for the purpose of lectual level be assessed by thoughtfully ap-
choosing the most able children for selective plying the fullest possible information on in-
schooling. The result has been an increase in tellectual functioning to the current situation,
the discrimination against working-class with proper regard for the person's social
children in that fewer intelligent children situation and relevant motivational factors.
from poor backgrounds are being chosen for
the academic schools (24). Whether there Classification of Biological Factors
would be the same result at the other end of
the intellectual scale is not yet known. It has already been stated that the assess-
At present there are few standardized tests ment of a mentally retarded person must in-
of social and adaptive skills, and those that clude both psychological and medical fea-
do exist suffer from important defects for the tures. It is important to know whether the
purpose of measuring intellectual retarda- retardation is associated with a neurological
tion. For example, the Vineland Social Ma- and physical condition, since this may influ-
turity Scale has been found to be a poor ence both treatment and prognosis. The
predictor of scholastic performance, con- fourth-digit system of ICD-8 has proven
siderably worse than IQ tests (25). Other inadequate for this purpose, and the seminar
scales have been found to be influenced by recommended that a working party be con-
deviant behavior (26,27) so that it is not vened by WHO to consider how this need
readily possible to distinguish social in- might best be met. In the meantime, some
capacity due to intellectual impairment from provisional decision had to be reached to
that due to mental disorder or illness. proceed with the field trials (discussed later in
A further difficulty stems from the fact this paper) of the scheme proposed by the
that criteria for social adaptation are de- Paris and Washington seminars. It may be
pendent on how exacting the demands happen appropriate here to consider the alternatives
to be at that point in time (28). An individual that are available.
cannot be considered in isolation from his In general, there are three different ap-
social setting; a person's intellectual func- proaches that may be followed. Pathogenic
tioning may be influenced by his environ- factors or causal influences may be classified,
mental circumstances, as may his mood or physical handicaps may be classified without
affective level. Nevertheless, insofar as social regard to their causation, or classification
adaptation is taken as the main diagnostic may be principally concerned with recogniz-
feature of any disorder, there is a danger that able medical conditions. The decision as to
fluctuations, for example, in availability of which is preferable depends on considerations
work, may lead to purely artifactual altera- of what is practical and on which method
tions in the prevalence of that disorder. gives the most useful clinical information and
Thus, when employment conditions are the greatest predictive power.
bad, more intellectually limited people will It is sometimes thought that an ideal clas-
be unable to work, and a diagnosis based on sification should always be based on etiolog-
social adaptation will lead to the conclusion ical mechanisms. However, this depends on
that the prevalence of mental subnormality the purpose for which the classification is re-
has risen. This is clearly nonsense, but the quired. For example, a classification of frac-
argument is important because so long as tures based on whether the bone was broken
social criteria define mental subnormality, by the patient's falling from a tree or being
there is a danger that illiberal and unthinking hit by a car is useful when preparing statistics
authorities may cause some people to lose designed to foster the prevention of accidents,
their liberty by admitting them to a hospital but from the viewpoint of treatment it is less
for the mentally subnormal purely because useful than one based on the nature and ex-
employment happens to be scarce at that tent of bony- and soft-tissue damage (i.e.,
moment. simple, compound, complex, and commi-
It should be clear that there is no perfect nuted fractures). Which method is best for
measure of intellectual retardation; clinical mental retardation is therefore an empirical
measures and standardized tests both have question, subject only to the condition that a
diagnosis should, above all, be descriptive. sensory impairment. Such a system would
ICD-8's fourth-digit system for use with undoubtedly provide clinically useful in-
categories of mental retardation is based on formation. The physical handicaps of a re-
pathogenesis. Thus a fourth-digit coding of .3 tarded person may be of crucial importance
in mental retardation means an association in planning services to meet his needs. On the
with gross (postnatal) brain disease, and .5 other hand, in using such a system it would
denotes an association with chromosomal not be at all easy to differentiate important
abnormalities. There are three major prob- conditions such as Down's syndrome. Fur-
lems with this system. First, most cases of thermore, most patients have multiple handi-
mental retardation are of unknown etiology, caps, and the use of five or six codings on this
and a classification based on causes tends to axis alone would be tedious and complicated
do no more than express the clinician's to handle statistically. A classification of
theoretical predilections. Berg and Kirman's handicaps may be the must useful system, in
survey of hospitalized mentally retarded pa- conjunction with other categories, for re-
tients (29) showed that the only large group search or clinical purposes, but it does not
of known etiology were patients suffering seem suitable as the prime principle of coding
from Down's syndrome (23 percent of the on the axis for associated or etiological bio-
patients). There were another ten percent with logical factors.
known disorders and four percent with a The third systemthat of coding medical
probable disorder; but for 32 percent of the conditionsis more of a compromise and in
patients it was only possible to surmise the some ways less pure and less logical than the
cause, and for 31 percent the cause was other two, but in practice it appears to be the
unknown. most satisfactory system. In this system, for
The second difficulty is that in many cases example, cerebral palsy would be coded rath-
of mental retardation there is multiple er than the fact that it is thought to be due
causation, and certain pathogenic influences, to perinatal damage. This means that in-
by their very nature, group together. For ex- formation on how the cerebral palsy was
ample, in the fourth-digit system .6 (prema- caused is lost, but information about the
turity) is frequently due to .4 (prenatal influ- physical and neurological handicap is re-
ences), which is in turn associated with .1 tained in more precise form. Cerebral palsy
(perinatal trauma). It is now known that the may be due to perinatal damage or to a vari-
cerebral damage in premature infants is often ety of postnatal insults occurring during in-
caused by severe hypoglycemia in the post- fancy (e.g., encephalitis, head injury, cerebral
natal period, which would further necessitate abscess). However, for most purposes it is
a coding of .2 (disorder of metabolism, more important to know that a child is cur-
growth, or nutrition). It is by no means clear rently hemiparetic than to know what caused
which of these four codings should have the disorder many years ago.
precedence. It was in part this kind of con- In cases where there is a one-to-one rela-
fused overlap that led to the unreliability of tionship between cause and condition the
the fourth-digit coding in the Washington coding will of course give the same informa-
seminar case history exercise. tion as a pathogenic classification. This is
The third major difficulty associated with a true of all the well-defined diseases of known
pathogenic classification is that different etiology, such as Down's syndrome, phenyl-
disorders may be due to the same cause, and ketonuria, and hepatolenticular degenera-
thus the classification will not reflect impor- tion. The difference chiefly occurs with
tant diagnostic distinctions. For example, the conditions of variable and often unknown
fourth-digit system cannot tell one whether etiology, such as cerebral palsy and epilepsy.
mental retardation is associated with cerebral However, since these are common disorders
palsy because often both are due to the same that are better coded on the "condition" sys-
perinatal causes. tem, the advantages probably lie with this
An alternative system is to totally omit approach. Because of this, it was chosen for
questions of either etiology or physical the field studies testing out the classification
disease and instead code the accompanying scheme proposed by the Paris and Washing-
handicap. Thus one might code convulsive ton seminars. However, as with each of the
disorder, motor defect, visual handicap, and three methods of classifying associated or
etiological biological factors, there are prob- cause of their unreliability.
lems in deciding how to deal with some con- As a result of this preparation there is a
ditions. Time and testing will show whether reasonable chance that any proposed changes
this proves to be the best system. in the classification will be an improvement
over what existed before. Nevertheless, the
Application of the Multiaxial proposal of changes or modifications marks
Classification to Adult Patients the beginningnot the endof the process of
revising the ICD. It was agreed at the outset
Little time was spent at the seminar in dis- that any scheme agreed upon at a seminar
cussing classification of mentally retarded will be tested through national and interna-
adults. In the same way that the classification tional exercises for further refinement and
of child psychiatric disorders must be com- revision before a final recommendation is
patible with the scheme used to classify adult made for the revision of the ICD in 1975.
psychiatric disorders, so must the classifica- Accordingly, field trials of the multiaxial
tion of mental retardation be developed in scheme proposed by the Paris and Washing-
such a way as to apply to all age groups. ton seminars are now in progress in the
In general, it was agreed that the mul- United Kingdom, France, the United States,
tiaxial scheme devised for children should be and Scandinavia. The results of these trials
equally suitable for adult patients. It is just as will be reported to future seminars so that
necessary in adults as in children to classify findings regarding any one part of the classi-
the degree of intellectual impairment, asso- fication may be taken into account in con-
ciated biological condition, associated psy- sidering other parts of the classification.
chosocial factors, and accompanying mental
disorder or clinical psychiatric syndrome. Summary
However, there is a less close relationship
between intellectual level and school at- In conjunction with the official report of
tainment. This means that there will be a the Fifth WHO Seminar on Psychiatric
more tenuous relationship between IQ and Diagnosis, Classification, and Statistics (2),
social handicap in adults and, furthermore, this paper discusses in more detail some of
that many retarded individuals who were the chief issues considered at the seminar and
handicapped in childhood will not be retarded outlines the reasoning behind the recom-
as adults (30). These are matters of detail, mendations. The issues considered include the
however, and the principles of classification integration of child psychiatry and mental
are the same at all age levels. Whether in fact retardation, multiaxial classifications, choice
the scheme proposed works as well for adults of axes, assessment of intellectual retarda-
as for children is an empirical question that tion, values and limitations of IQ tests, as-
needs to be answered by field trials. sessment of social competence, classification
of biological factors, application of the mul-
Field Trials tiaxial scheme to adult patients, and field
trials to test new schemes of classification.
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