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42 Neurodevelopmental Disorders Language Disorder Diagnostic Criteria 315.32 (F80.2) A. Persistent difficulties in the acquisition and use of language across modalities (i.e., spoken, written, sign language, or other) due to deficits in comprehension or produc- tion that include the following: 1. Reduced vocabulary (wo...
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prehending language messages. Language skills need to be assessed in both expressive and receptive modalities as these may differ in severity. For example, an individual’s ex- pressive language may be seve rely impaired, while his recept ive language is hardly im- paired at all. Language disorder usually affects vocab...
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Language Disorder 43 Associated Features Supporting Diagnosis A positive family history of language disorders is often present. Individuals, even chil- dren, can be adept at accommodating to their limited language. They may appear to be shy or reticent to talk. Affected individuals may prefer to communicate only with f...
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Genetic and physiological. Language disorders are highly heritable, and family mem- bers are more likely to have a history of language impairment. Differential Diagnosis Normal variations in language. Language disorder needs to be distinguished from nor- mal developmental variations, and this distinctio n may be diffic...
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44 Neurodevelopmental Disorders Comorbidity Language disorder is strongly associated with other neurodevelopmental disorders in terms of specific learning d isorder (literacy and numeracy), attention-deficit/hyperactiv- ity disorder, autism spectrum disorder, and developmental coordination disorder. It is also associa...
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nological disorder and articulation disorder . A speech sound disorder is diagnosed when speech sound production is not what would be expected based on the child’s age and devel- opmental stage and when the deficits are not the result of a physical, st ructural, neurological, or hearing impairment. Among typically deve...
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Childhood-Onset Fluency Disorder (Stuttering) 45 developmental pattern, which is reflected in the age norms of standardized tests. It is not unusual for typically developing children to use developmental processes for shortening words and syllables as they are learning to talk, but their progression in mastering speec...
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associated with specific learning disorders. Differential Diagnosis Normal variations in speech. Regional, social, or cultural/ethnic variations of speech should be considered before making the diagnosis. Hearing or other sensory impairment. Hearing impairment or deafness may result in abnormalities of speech. Defici t...
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ate for the individual’s age and language skills, persist over time, and are characterized by frequent and marked occurrences of one (or more) of the following:  1. Sound and syllable repetitions. 2. Sound prolongations of consonants as well as vowels.
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46 Neurodevelopmental Disorders 3. Broken words (e.g., pauses within a word). 4. Audible or silent blocking (filled or unfilled pauses in speech). 5. Circumlocutions (word substitutions to avoid problematic words). 6. Words produced with an excess of physical tension. 7. Monosyllabic whole-word repetitions (e.g., “I-I-...
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see him”). The disturbance in fluency interferes with academic or occupational achieve- ment or with social communication. The extent of the disturbance varies from situation to situation and often is more severe when there is special pressure to communicate (e.g., giv- ing a report at school, interviewing for a job) ...
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encies. As the disorder progresses, the dysfluencies become more frequent and interfering, occurring on the most meaningful words or phr ases in the utterance. As the child becomes aware of the speech difficulty, he or she may develop mechanisms for avoiding the dys- fluencies and emotional responses, including avoidan...
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Social (Pragmatic) Communication Disorder 47 cover from the dysfluency, with severity of fl uency disorder at age 8 years predicting re- covery or persistence into adolescence and beyond. Risk and Prognostic Factors Genetic and physiological. The risk of stuttering among first-degree biological rela- tives of individua...
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“adult-onset dysfluency” rather than a neurodevelopmental disorder . Adult-onset dysflu- encies are associated with specific neurologic al insults and a variety of medical conditions and mental disorders and may be specified with them, but they are not a DSM-5 diagnosis. Tourette’s disorder. Vocal tics and repetitive ...
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48 Neurodevelopmental Disorders 4. Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meanings of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation). B. The deficits result in functional limitations in ef...
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guage impairment, which is characterized by a history of delay in reaching language mile- stones, and historical, if not current, structur al language problems (see “Language Disorder” earlier in this chapter). Individuals with social communication deficits may avoid social inter- actions. Attention-deficit/hype racti...
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Unspecified Communication Disorder 49 Differential Diagnosis Autism spectrum disorder. Autism spectrum disorder is the primary diagnostic con- sideration for individuals presenting with social communication de ficits. The two disor- ders can be differentiated by the presence in autism spectrum disorder of restricted/...
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delay. Social communication skills may be deficient among individuals with global de- velopmental delay or in tellectual disability, but a separa te diagnosis is not given unless the social communication deficits are clearl y in excess of the intellectual limitations. Unspecified Communication Disorder 307.9 (F80.9) Th...
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50 Neurodevelopmental Disorders Autism Spectrum Disorder Autism Spectrum Disorder Diagnostic Criteria 299.00 (F84.0) A. Persistent deficits in social communication and social interaction across multiple con- texts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see t...
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phrases). 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day). 3. Highly restricted, fix...
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Autism Spectrum Disorder 51 E. These disturbances are not better explained by intellectual disability (intellectual devel- opmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spec- trum disorder and intellectua...
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order, record autism spectrum disorder associated with (name of condition, disorder, or factor) (e.g., autism spectrum disorder associated with Rett syndrome). Severity should be recorded as level of support needed for ea ch of the two psychopa thological domains in Table 2 (e.g., “requiring very substantial support fo...
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52 Neurodevelopmental DisordersTABLE 2 Severity levels for autism spectrum disorder Severity level Social communication Restricted, repetitive behaviors Level 3 “Requiring very substantial support”Severe deficits in verbal and nonverbal social com- munication skills cause severe impairments in func- tioning, very limi...
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Difficulty initiating social interactions, and clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who is able to speak in full sentences and engages in communication but whose to-and-fro con- versat...
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Autism Spectrum Disorder 53 To use the specifier “with or without acco mpanying language impairment,” the cur- rent level of verbal functioning should be ass essed and described. Ex amples of the specific descriptions for “with accompanying language impairment” might include no intelligible speech (nonverbal), single w...
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which functional impairment becomes obvious will vary according to characteristics of the individual and his or her environment. Co re diagnostic features are evident in the developmental period, but intervention, co mpensation, and current supports may mask difficulties in at least some contexts. Manifestations of the...
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show little or no initiation of social interaction and no sharing of emotions, along with re- duced or absent imitation of others’ behavior . What language exists is often one-sided, lacking in social reciprocity, and used to re quest or label rather th an to comment, share feelings, or converse. In adults without inte...
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lacking in social reciprocity, and used to re quest or label rather th an to comment, share feelings, or converse. In adults without inte llectual disabilities or language delays, deficits in social-emotional reciprocity may be most apparent in difficulties processing and re- sponding to complex social cues (e.g., when...
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54 Neurodevelopmental Disorders Deficits in nonverbal communicative behavi ors used for social interaction are mani- fested by absent, reduced, or atypical use of eye contact (relative to cultural norms), ges- tures, facial expressions, body orientation, or speech intona tion. An early feature of autism spectrum diso...
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Older individuals may struggle to understand what behavior is considered appropriate in one situation but not another (e.g., casual beha vior during a job interview), or the different ways that language may be used to communic ate (e.g., irony, white lies). There may be an apparent preference for solitary activities or...
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havior (e.g., repetitive questioning, pacing a perimeter). Highly restricted, fixated interests in autism spectrum disorder tend to be ab normal in intensity or focus (e.g., a toddler strongly attached to a pan; a child preoccupied with vacuum cleaners; an adult spending hours writing out timetables). Some fascination...
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sounds or textures, excessive smelling or touc hing of objects, fascination with lights or spinning objects, and sometimes apparent indi fference to pain, heat, or cold. Extreme re- action to or rituals involving taste, smell, te xture, or appearance of food or excessive food restrictions are common and ma y be a pres...
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Autism Spectrum Disorder 55 Criterion D requires that the features must ca use clinically significant impairment in so- cial, occupational, or other impo rtant areas of current function ing. Criterion E specifies that the social communication defici ts, although sometime s accompanied by intellectual disabil- ity (inte...
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disorder to experience a marked deterioratio n in motor symptoms an d display a full cata- tonic episode with symptoms such as mutism, posturing, grimacing and waxy flexibility. The risk period for comorbid catatonia appears to be greate st in the adolescent years. Prevalence In recent years, reported frequencies for ...
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year of life. Some children with autism spectrum disorder experience developmental pla- teaus or regression, with a gradual or relatively rapid deterioration in social behaviors or use of language, often du ring the first 2 years of life. Such losses are rare in other disor- ders and may be a useful “red flag” for auti...
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use of language, often du ring the first 2 years of life. Such losses are rare in other disor- ders and may be a useful “red flag” for autism spectrum disorder. Much more unusual and warranting more extensive medical invest igation are losses of skills beyond social communication (e.g., loss of se lf-care, toileting, m...
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56 Neurodevelopmental Disorders second birthday (see also Rett syndrome in the section “Differential Diagnosis” for this disorder). First symptoms of autism spectrum disorder frequently involve delayed language de- velopment, often accompanied by lack of social interest or unusual social interactions (e.g., pulling in...
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dently in adulthood; those who do tend to have superior lang uage and intellectual abilities and are able to find a niche that matches thei r special interests and skills. In general, indi- viduals with lower levels of impairment may be better able to function independently. However, even these individuals may remain ...
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In later life, intervention or compensation, as well as current supports, may mask these dif- ficulties in at least some co ntexts. However, symptoms remain sufficient to cause current impairment in social, occupational, or other important areas of functioning. Risk and Prognostic Factors The best established prognost...
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The best established prognostic factors for individual outcome wi thin autism spectrum disorder are presence or absence of associa ted intellectual disability and language impair- ment (e.g., functional language by age 5 years is a good prognostic sign) and additional mental health problems. Epilepsy, as a comorb id di...
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Autism Spectrum Disorder 57 Genetic and physiological. Heritability estimates for au tism spectrum disorder have ranged from 37% to higher than 90%, based on twin concordance rates. Currently, as many as 15% of cases of autism spec trum disorder appear to be associated with a known genetic mutation, with different d...
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ities may hamper learning, especially learning through social interaction or in settings with peers. In the home, insistence on rout ines and aversion to change, as well as sensory sensitivities, may interfere with eating and sleeping and make routine care (e.g., haircuts, dental work) extremely difficult. Adaptive ski...
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and settings. Even in settings where the child is mute, social reciprocity is not impaired, nor are restricted or repetitive patterns of behavior present.
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58 Neurodevelopmental Disorders Language disorders and social (p ragmatic) communi cation disorder. In some forms of language disorder, there may be problems of communication an d some secondary so- cial difficulties. However, specific language disorder is not usually associated with abnor- mal nonverbal communication...
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Stereotypic movement disorder. Motor stereotypies are among the diagnostic charac- teristics of autism spectrum disorder, so an additional diagnosis of stereotypic movement disorder is not given when such repetitive be haviors are better explained by the presence of autism spectrum disorder. However, when stereotypies ...
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grammar), which should be noted under the relevant specifiers when applicable. Many in- dividuals with autism spectrum disorder have psychiatric sympto ms that do not form part of the diagnostic criteria for the disorder (about 70% of individuals with autism spectrum dis- order may have one comorbid mental disord er, a...
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the diagnostic criteria for the disorder (about 70% of individuals with autism spectrum dis- order may have one comorbid mental disord er, and 40% may have two or more comorbid mental disorders). When criteria for both ADHD and autism spectrum disorder are met, both diagnoses should be given. This same principle applie...
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Attention-Deficit/Hyperactivity Disorder 59 disorders, and other comorbid diagnoses. Among individuals who are nonverbal or have language deficits, observable si gns such as changes in sleep or eating and increases in chal- lenging behavior should trigger an evaluation fo r anxiety or depression. Specific learning dif...
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work is inaccurate). b. Often has difficulty sustaining attention in tasks or play activities (e.g., has diffi- culty remaining focused during lectures, conversations, or lengthy reading). c. Often does not seem to listen when spoken to directly (e.g., mind seems else- where, even in the absence of any obvious distract...
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60 Neurodevelopmental Disorders 2.Hyperactivity and impulsivity: Six (or more) of the following symptoms have per- sisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: Note: The symptoms are not sole...
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activities; may start using other people’s things without asking or receiving per- mission; for adolescents and adults, may intrude into or take over what others are doing). B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. C. Several inattentive or hyperactive-impulsive sympt...
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In partial remission: When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning. Specify current severity: Mild: Few, if any, symptoms in excess of those required to make the di...
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Attention-Deficit/Hyperactivity Disorder 61 Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning. Diagnostic Features The essential feature of attent ion-...
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tablishing precise childhood onset retrospectively. Adult recall of childhood symptoms tends to be unreliable, and it is bene ficial to obtain ancillary information. Manifestations of the disorder must be presen t in more than one setting (e.g., home and school, work). Confirmation of substantial symptoms across settin...
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dren with ADHD display incr eased slow wave electroenc ephalograms, reduced total brain volume on magnetic resonance imaging, and possibly a delay in posterior to anterior cortical maturation, but thes e findings are not diagnostic . In the uncommon cases where there is a known genetic cause (e.g., Fragile X syndrome,...
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ADHD presentation should still be diagnosed. Prevalence Population surveys sugge st that ADHD occurs in most cultures in about 5% of children and about 2.5% of adults.
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62 Neurodevelopmental Disorders Development and Course Many parents first observe excessive motor activity when the child is a toddler, but symp- toms are difficult to distinguish from highly variable normative be haviors before age 4 years. ADHD is most often identified during elementary school years, and inattention...
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though ADHD is correlated with smoking du ring pregnancy, some of this association reflects common genetic risk. A minority of c ases may be related to reactions to aspects of diet. There may be a history of child abuse, neglect, multiple foster placements, neurotoxin exposure (e.g., lead), infectio ns (e.g., encephal...
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tion in attitudes toward or interpretations of children’s behaviors. Clinical identification rates in the United States for African Americ an and Latino populations tend to be lower than for Caucasian populations. Informant symptom ratings may be influenced by cul- tural group of the child and the informant, su ggestin...
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Attention-Deficit/Hyperactivity Disorder 63 Gender-Related Diagnostic Issues ADHD is more frequent in males than in fema les in the general population, with a ratio of approximately 2:1 in children and 1.6:1 in ad ults. Females are more likely than males to present primarily with inattentive features. Functional Conseq...
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tic/occupational adjustment. Academic deficits, school-relat ed problems, and peer neglect tend to be most associ- ated with elevated symptoms of inattention, whereas peer reje ction and, to a lesser extent, accidental injury are most salient with mark ed symptoms of hyperactivity or impulsivity. Differential Diagnosi...
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ized and not characterized by repetitive ster eotypic movements. In Tourette’s disorder,
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64 Neurodevelopmental Disorders frequent multiple tics can be mistaken for the generalized fidgetiness of ADHD. Prolonged observation may be needed to differentiate fidgetiness from bouts of multiple tics. Specific learning disorder. Children with specific learning disorder may appear inat- tentive because of frustrati...
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Anxiety disorders. ADHD shares symptoms of inattent ion with anxiety disorders. Indi- viduals with ADHD are inattentive because of their attraction to external stimuli, new activities, or preoccupation with enjoyable activities. This is distinguished from the inat- tention due to worry and rumination seen in anxiety d...
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nosed separately. Substance use disorders. Differentiating ADHD from su bstance use disorders may be problematic if the first presentation of ADHD symptoms follows the onset of abuse or fre- quent use. Clear evidence of ADHD before su bstance misuse from informants or previous records may be essential for differential ...
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Other Specified Attention-Deficit/Hyperactivity Disorder 65 Personality disorders. In adolescents and adults, it may be difficult to distinguish ADHD from borderline, narcissistic, and other person ality disorders. All these disorders tend to share the features of disorganization, social intrusiveness, emotional dysre...
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quarter with the predominantly inattentive presentation. Conduct disorder co-occurs in about a quarter of children or adolescents with the combined presentation, depending on age and setting. Most children and adolescent s with disruptive mood dysregulation dis- order have symptoms that also meet criteria for ADHD; a ...
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66 Neurodevelopmental Disorders the specific reason that the presentation does not meet the criteria for attention-deficit/ hyperactivity disorder or any specific neur odevelopmental disorder. This is done by re- cording “other specified attention-deficit/hyperactivity disorder” followed by the specific reason (e.g., “...
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what is read). 3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants). 4. Difficulties with written expression (e.g., makes multiple grammatical or punctua- tion errors within sentences; employs poor paragraph organization; written expres- sion of ideas lacks clarity). 5. Difficulties m...
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Specific Learning Disorder 67 B. The affected academic skills are substantially and quantifiably below those expected for the individual’s chronological age, and cause significant interference with academic or occupational performance, or with activiti es of daily living, as confirmed by individu- ally administered sta...
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and poor spelling abilities. If dyslexia is used to specify this particular pattern of dif- ficulties, it is important also to specify any additional difficulties that are present, such as difficulties with reading comprehension or math reasoning. 315.2 (F81.81) With impairme nt in written expression: Spelling accuracy...
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68 Neurodevelopmental Disorders Moderate: Marked difficulties learning skills in one or more academic domains, so that the individual is unlikely to become proficient without some intervals of intensive and specialized teaching during the school years. Some accommodations or supportive services at least part of the day...
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the basis for abnormalities at a cognitive level that are associated with the behavioral signs of the disorder. The biological origin includes an interaction of geneti c, epigenetic, and en- vironmental factors, which affect the brain’s ab ility to perceive or process verbal or non- verbal information efficiently and a...
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ing scales, or descriptions in previous educational or psychological assessments. The learning difficulties are persistent, not transitory. In ch ildren and adolescents, persistence is defined as restricted progress in learning (i.e., no evidence that the individual is catching up with class-
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difficulties are persistent, not transitory. In ch ildren and adolescents, persistence is defined as restricted progress in learning (i.e., no evidence that the individual is catching up with class- mates) for at least 6 months despite the provision of extra help at home or school. For example, difficulties learning t...
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Specific Learning Disorder 69 learning disorder. Evidence of persistent learning difficulties may be derived from cumulative school reports, portfolios of the child’s evalua ted work, curriculum-based measures, or clinical interview. In adults, persistent difficulty refers to ongoing difficulties in literacy or numer...
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low the population mean for age, which translates to a standard score of 78 or less, which is below the 7th percentile) are need ed for the greatest diagnostic certainty. However, precise scores will vary according to the particular standardized tests that are used. On the basis of clinical judgment, a more leni ent th...
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that the specific learning disabilities are not part of a more general learning difficulty as manifested in intellectual disability or global developmental delay. Specific learning dis-
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that the specific learning disabilities are not part of a more general learning difficulty as manifested in intellectual disability or global developmental delay. Specific learning dis- order may also occur in individuals identified as intellectually “gifted.” These individuals may be able to sustain apparently adequa...
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70 Neurodevelopmental Disorders Finally, the learning difficulty may be restricted to one academic skill or domain (e.g., read- ing single words, retrieving or calculating number facts). Comprehensive assessment is required. Specifi c learning disorder can only be diagnosed after formal education starts bu t can be di...
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learning disorder. An uneven profile of abilities is common , such as above-average abili- ties in drawing, design, and other visuospatial abilities, but slow, effortful, and inaccurate reading and poor reading comprehension and written expression. Individuals with spe- cific learning disorder typica lly (but not inva...
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Prevalence The prevalence of specific learning disorder across the academic domains of reading, writ- ing, and mathematics is 5%–15% among school-age children across different languages and cultures. Prevalence in adults is unknown but appear s to be approximately 4%.
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ing, and mathematics is 5%–15% among school-age children across different languages and cultures. Prevalence in adults is unknown but appear s to be approximately 4%. Development and Course Onset, recognition, and diagnosis of specific learning disorder usually occurs during the elementary school years when children ar...
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Specific Learning Disorder 71 mathematics. However, precursors such as la nguage delays or defi cits, difficulties in rhyming or counting, or difficulties with fine motor skills required for writing commonly occur in early childhood before the start of formal schooling. Manifestations may be be- havioral (e.g., a relu...
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“cowboy” into “cow” and “boy”) and trouble reco gnizing words that rhyme (e.g., cat, bat, hat). Kindergarten-age children also may have trouble connecting letters with their sounds (e.g., let- ter b makes the sound /b/) and may be unable to recognize phonemes (e.g., do not know which in a set of words [e.g., dog, man,...
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sound alike (e.g., “tornado” for “volcano”) . They may have trouble remembering dates, names, and telephone numbers and may have trouble completing homework or tests on time. Children in the middle grades also may have poor comprehension with or without slow, effortful, and inaccurate reading, and they may have trouble...
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They may get the first part of a word correctly , then guess wildly (e.g., read “clover” as “clock”), and may express fear of read ing aloud or refuse to read aloud. By contrast, adolescents may have mastered word decoding, but reading remains slow and effortful, and they are likely to show ma rked problems in reading...
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72 Neurodevelopmental Disorders avoid activities that demand reading or arit hmetic (reading for pl easure, reading instruc- tions). Adults with specific learning disord er have ongoing spelling problems, slow and effortful reading, or problems making impo rtant inferences from numerical information in work-related wri...
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learning difficulties compared with those wi thout them. Family hist ory of reading diffi- culties (dyslexia) and parental literacy skills predict literacy problems or specific learning disorder in offspring, indicating the combin ed role of genetic and environmental factors. There is high heritability for both reading...
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written symbol systems and cultural and educational practices. For example, the cognitive processing requirements of reading and of wo rking with numbers vary greatly across or- thographies. In the English language, the observable hallmark clinical symptom of diffi- culties learning to read is inaccurate and slow readi...
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thographies. In the English language, the observable hallmark clinical symptom of diffi- culties learning to read is inaccurate and slow reading of single words; in other alphabetic languages that have more direct mapping be tween sounds and letters (e.g., Spanish, Ger- man) and in non-alphabetic la nguages (e.g., Chin...
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Specific Learning Disorder 73 slow but accurate reading. In English-language learners, assessment should include con- sideration of whether the source of reading difficulties is a limited proficiency with Eng- lish or a specific learning disorder. Risk fact ors for specific learning disorder in English- language learn...
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Differential Diagnosis Normal variations in academic attainment. Specific learning disorder is distinguished from normal variations in academic attainment due to external factors (e.g., lack of edu- cational opportunity, consistently poor instru ction, learning in a second language), be- cause the learning difficulties...
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74 Neurodevelopmental Disorders Attention-deficit/hyperactivity disorder. Specific learning disorder is distinguished from the poor academic performance associated with ADHD, because in the latter condition the problems may not necessarily reflect specific difficulties in learning academic skills but rather may reflect...
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as well as slowness and inaccuracy of performance of motor skills (e.g., catching an object, using scissors or cutlery, handwriting, riding a bike, or participating in sports). B. The motor skills deficit in Criterion A significantly and persistently interferes with activ- ities of daily living appropriate to chronolo...
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Developmental Coordination Disorder 75 with age. Young children may be delayed in achi eving motor milestones (i.e., sitting, crawling, walking), although many achieve typical motor milestones. They also may be delayed in de- veloping skills such as negotiating stairs, peda ling, buttoning shirts, completing puzzles, a...
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must be in the early developmental period. However, developmental coordination disorder is typically not diagnosed before age 5 years because there is considerable variation in the age at acquisition of many motor skills or a lack of st ability of measurement in early childhood (e.g., some children catch up) or because...
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disorder and 3% with probable developmental coordination disorder). Males are more of- ten affected than females, with a male:female ratio between 2:1 and 7:1.
dsm5.pdf
a7f36fafa5db-0
disorder and 3% with probable developmental coordination disorder). Males are more of- ten affected than females, with a male:female ratio between 2:1 and 7:1. Development and Course The course of developmental coordination disord er is variable but stable at least to 1 year follow-up. Although there may be improvement...
dsm5.pdf
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76 Neurodevelopmental Disorders dinated movements continue th rough adolescence in an esti mated 50%–70% of children. Onset is in early childhood. Delayed motor mile stones may be the first signs, or the disor- der is first recognized when the child attempts tasks such as holding a knife and fork, but- toning clothes,...
dsm5.pdf