EDITORIAL
CURRENT
OPINION New terminology for mental retardation in DSM-5
and ICD-11
James C. Harris
The diagnostic term ‘mental retardation’ is finally
being eliminated in the upcoming international
classifications of diseases and disorders. The term
‘mental retardation’ was introduced by the
American Association on Mental Retardation in
1961 and soon afterwards was adopted by the
American Psychiatric Association (APA) in its Diag-
nostic and Statistical Manual for Mental Disorders
(DSM-5) [1,2]. Mental retardation replaced older
terms such as feeblemindedness, idiocy, and mental
subnormality that had become pejorative. Now,
over 5 decades later, the term ‘mental retardation’
is being eliminated for similar reasons.
The APA’s fifth revision of its DSM-5 [3] and the
WHO in the 11th edition of the International
Classification of Diseases (lCD-11) will revise their
terminology [4]. This is consistent with the aban-
donment of the term by medical and educational
professions and advocacy groups over recent years.
The International Association for the Scientific
Study of Mental Deficiency (IASSMD) has long been
designated the International Association for the
Scientific Study of Intellectual Disability (IASSID).
The Journal of Mental Deficiency Research is now The
Journal of Intellectual Disability Research and the
federal advisory group The United States President’s
Committee on Mental Retardation is now desig-
nated The President’s Committee for Persons With
Intellectual Disabilities. In the United States, a
federal statute (Public Law 111-256, Rosa’s law)
replaces the term ‘mental retardation’ with ‘intel-
lectual disability’ [5] and requires that person first
language be used when referring to those affected in
all federal laws. Rosa’s law is indicative of the senti-
ment for change. Rosa Marcellino, an 8-year-old girl
with Down Syndrome from Maryland, was taunted
frequently and pejoratively called ‘retard’ in a
demeaning manner. With support from her state
representative and US Senator Barbara Mikulski,
legislation was initiated leading to the change in
the law. Such change is important not only to deal
with the pejorative use of the term, but also to
emphasize that these are people with neuro-
developmental disorders requiring intervention
early in the developmental period.
www.co-psychiatry.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The ICD-11 working group proposes replacing
mental retardation with intellectual developmental
disorders (IDDs), a term it defines as ‘a group of
developmental conditions characterized by signifi-
cant impairment of cognitive functions, which are
associated with limitations of learning, adaptive
behavior and skills’ [4]. The new term proposed
for DSM-5 is intellectual disability (ID)/IDD. The
new DSM-5 category is synonymous with the pro-
posed ICD-11 diagnosis of IDDs, in that it refers to a
health condition or disorder [4]. It is semantically
similar to the term ‘intellectual disability’ as used
by the American Association on Intellectual and
Developmental Disabilities (AAIDD), where the
term ‘belongs within the general construct of dis-
ability that has evolved over the past 2 decades’ [6].
In the ICD-11 proposal, IDD as a health condition
or disorder refers to a ‘syndromic grouping or
meta-syndrome that is analogous to the construct
of dementia (major neurocognitive disorder in
DSM-5), which is characterized by a deficit in
cognitive functioning prior to the acquisition of
skills through learning’ [4]. Thus, IDD is classified
as a neurodevelopmental disorder of brain develop-
ment and contrasted with the DSM-5 category
‘Neurocognitive Disorder’ (in DSM-IV, dementia),
in which onset is in late life. In major neurocogni-
tive disorder, there is loss of cognitive capacity and
loss of acquired cognitive skills; degeneration is a
feature. In IDD, there are deficits in the cognitive
capacity beginning in the early developmental
period. In contrast, the term ‘intellectual disability’
as used by the AAIDD is a functional disorder,
explicitly based on the WHO International Classi-
fication of Functioning (ICF).
The Johns Hopkins University School of Medicine, Baltimore, MD, USA
Correspondence to James C. Harris, MD, Professor of Psychiatry and
Behavioral Sciences, Pediatrics, Mental Health and History of Medicine,
The Johns Hopkins University School of Medicine, 12th Floor, Charlotte
R. Bloomberg Children’s Center, 1800 Orleans Street, Baltimore, MD
21287, USA. Tel: +1 410 614 2401; fax: +1 410 955 8691; e-mail:
jharrisd@jhmi.edu
Curr Opin Psychiatry 2013, 26:260–262
DOI:10.1097/YCO.0b013e32835fd6fb
Volume 26  Number 3  May 2013
 New terminology for mental retardation in DSM-5 and ICD-11 Harris
The Working Group on the Classification of
Intellectual Disabilities for ICD-11 conducted
extensive literature reviews using a mixed qualita-
tive approach in reviewing them, and followed up
in a series of meetings of experts to produce con-
sensus-based recommendations combining prior
expert knowledge and available evidence [4].
For DSM-5, the neurodevelopmental workgroup
followed similar procedures with literature review
and expert opinion to reach consensus. No field
trials were conducted. DSM-5 will be released in
May 2013, but ICD-11 is not scheduled for release
until 2015.
Critical components of intelligence proposed in
both DSM-5 and the ICD-11 are verbal comprehen-
sion, working memory, perceptual reasoning, and
cognitive efficacy. The diagnosis in DSM-5 will
emphasize both clinical judgment and standardized
intelligence testing; however, less emphasis is
expected to be placed on the IQ score, but greater
emphasis will be placed on the adaptive reasoning in
academic, social, and practical settings. The require-
ment for both intellectual deficits and adaptive
deficits that fail to meet the standards for personal
independence are proposed to remain in DSM-5,
with greater emphasis on linking intellectual defi-
cits to adaptive deficits through adaptive reasoning
in the three domains listed.
The DSM-5 is not a multiaxial classification as
was DSM-IVTR. Thus, the proposed diagnostic term
‘intellectual disability/intellectual developmental
disorder’ will no longer be on Axis II, but instead
listed along with other mental disorder diagnoses.
Consistent with this change, a definition of intelli-
gence is proposed for inclusion in the definition.
This change is believed necessary to focus on ID/IDD
as a clinical entity and facilitate the clinical inter-
view. Both DSM-5 and the AAIDD refer to the main-
stream science definition of intelligence. This
consensus definition defines intelligence as a gen-
eral mental ability that involves reasoning, problem
solving, planning, thinking abstractly, compre-
hending complex ideas, judgment, academic learn-
ing, and learning from experience [7]. Moreover, as
noted, the proposed plan in DSM-5 is to incorporate
a focus on adaptive reasoning in three contexts:
academic learning, social understanding, and prac-
tical understanding [8]. Schalock [9] refers to this
approach as the multidimensionality approach to
ID. It is one that is increasingly of interest in deter-
mining how best to operationally define ID from
cognitive and adaptive perspectives [10].
Mental retardation has long been divided into
four levels of severity reflecting the extent of
intellectual impairment: mild, moderate, severe,
or profound. These levels of severity are proposed
0951-7367 ß 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
to remain unchanged in ICD-11 [4]. In DSM-5, the
proposal is to use specifiers instead of subtypes to
designate the extent of adaptive dysfunction in
academic, social, and practical domains. The AAIDD
[6] using a disability model focuses instead on the
extent of disability in various settings and considers
the supports needed to normalize an individual’s life
to the extent it is possible.
All of the definitions of an ID (DSM, ICD, and
AAIDD) include, and will continue to require,
deficits in intellectual and adaptive function; how-
ever, each provides a different emphasis, so it is
important to be familiar with each of them. In
applying these definitions, it is important to remem-
ber that specific adaptive abilities often coexist
with strengths in other adaptive skills or personal
capabilities; therefore, adaptive strengths must be
carefully considered in the treatment planning.
Changes proposed for DSM-5 are pertinent to
forensic psychiatry in the United States, where the
IQ test number has often been used inappropriately
to define a person’s overall ability in forensic cases
without adequately considering adaptive intellec-
tual functioning. Appropriate diagnosis of ID/IDD
has become more important in the United States
because of the 2002 Supreme Court decision in
Atkins vs. Virginia. In that case, it was decided that
the execution of people with mental retardation met
the United States Constitution’s Eighth Amend-
ment criteria that forbid cruel and unusual punish-
ments [11,12]. This decision has resulted in placing
greater emphasis in assessment on both cognitive
and adaptive capacities for people with an ID.
Despite the Supreme Court finding in this test case,
Atkins, whose initial IQ was 59, when retested after
several years in prison scored above 70, making him
again eligible for the death penalty under Virginia
law. His case highlights the importance of measur-
ing adaptive intelligence and functioning in making
the diagnosis. Fortunately for Atkins, there was
prosecutorial misconduct sufficient to prevent his
execution; he was given life imprisonment. In for-
ensic situations, a multidimensional [9] model as
proposed for DSM-5 that considers adaptive intelli-
gence in academic, social, and practical domains
may be more appropriate than the DSM-IVTR
definition. Moreover, credulity and gullibility in
persons with an ID are pertinent psychological con-
structs to consider in both community settings and
forensic cases. Those affected often are unaware of
risk and in many circumstances may lack common
sense [13,14]. Thus, greater emphasis on both
cognitive deficits and adaptive reasoning is needed
in forensic settings.
Finally, psychiatric disorders are three to four
times higher in people with an ID diagnosis than in
www.co-psychiatry.com 261
 Neurodevelopmental and neurocognitive disorders
the general population [2]. When criteria are met,
both diagnoses should be made. There is some con-
cern that the elimination of the multiaxial classifi-
cation and removal of Axis II in DSM-5 may result in
the diagnosis of an ID being overlooked without the
requirement to always consider an Axis II diagnosis.
Thus, it is critical to remember when assessing
patients with mental disorders that ID should be
considered as potentially co-occurring. When
assessing for psychiatric disorders in people with
an ID, assessment procedures must be modified to
take into account associated disorders, such as com-
munication disorders, autism spectrum disorder,
and motor, sensory, or other co-occurring con-
ditions. Knowledgeable informants are essential
during assessment to identify changes in irritability,
mood regulation, increased aggression, eating prob-
lems, sleep problems, and changes in adaptive
behavior at work, at home, and in the community
settings. Moreover, the prognosis and outcome of
mental disorder diagnoses may be influenced by the
presence of ID.
Co-occurring diagnoses to consider are major
depressive disorder, which may occur throughout
the range of severity of ID, attention deficit hyper-
activity disorder, bipolar disorders (with and with-
out aggression), anxiety disorders, autism spectrum
disorder, impulse control disorders, major neuro-
cognitive disorder, and stereotypic movement dis-
order (with or without self-injurious behavior) [2].
Self-injurious behavior requires prompt diagnostic
attention and may warrant a separate diagnosis of
stereotypic movement disorder. Individuals with
severe ID are more likely to demonstrate self-injury,
aggression, and disruptive behaviors. Finally, indi-
viduals with a diagnosis of ID with co-occurring
mental disorders are at risk for suicide attempts
and may die from them [15]. Thus, screening for
262 www.co-psychiatry.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
suicidal thoughts is essential in the assessment
process.
Acknowledgements
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Greenspan S, Switzky HN. Forty years of American Association on mental
retardation manuals. In: Switzky H, Greenspan S, editors. What is mental
retardation: ideas for an evolving disability in the 21st century. Washington,
DC: American Association on Mental Retardation; 2006.
2. Harris JC. Intellectual disability: understanding its development, causes,
classification, evaluation, and treatment. New York: Oxford University Press;
2006.
3. American Psychiatric Association. Diagnostic and statistical manual of mental
disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
4. Salvador-Carulla L, Reed GM, Vaez-Azizi LM, et al. Intellectual developmental
disorders: towards a new name, definition and framework for ‘mental retarda-
tion/intellectual disability’ in ICD-11. World Psychiatry 2011; 10:175–180.
5. Public Law. 111-256, §2(b)(2), 5 October 2010, 124 Stat. 2643 (Rosa’s
Law).
6. Schalock RL, Borthwick-Duffy S, Bradley VJ, et al. Intellectual disability:
definition, classification, and systems of supports. 11th ed. Washington, DC:
American Association on Intellectual and Developmental Disabilities; 2010.
7. Gottfredson LS. Mainstream science on intelligence. An editorial with 52
signatories, history, and bibliography. Intelligence 1997; 24:13–23.
8. Greenspan S, Granfield JM. Reconsidering the construct of mental retarda-
tion: implications of a model of social competence. Am J Ment Retard 1992;
96:442–453.
9. Schalock RL. The evolving understanding of the construct of intellectual
disability. J Intellect Dev Disabil 2011; 36:223–233.
10. Tassé MJ, Schalock RL, Balboni G, et al. The construct of adaptive behavior:
its conceptualization, measurement, and use in the field of intellectual dis-
ability. Am J Intellect Dev Disabil 2012; 117:291–303.
11. Greenspan S. Assessment and diagnosis of mental retardation in death
penalty cases: introduction and overview of the special ‘Atkins’ issue. Appl
Neuropsychol 2009; 16:89–90.
12. Tasse MJ. Adaptive behavior assessment and the diagnosis of mental
retardation in capital cases. Appl Neuropsychol 2009; 16:114–123.
13. Greenspan S, Loughlin G, Black R. Credulity and gullibility in persons with
mental retardation. In: Glidden LM, editor. International review of research in
mental retardation. Vol. 24. New York: Academic Press; 2001. pp. 101–135.
14. Greenspan S, Switzky HN, Woods GW. Intelligence involves risk-awareness
and intellectual disability involves risk-unawareness: implications of a theory of
common sense. J Intellect Dev Disabil 2011; 36:242–253.
15. Ludi E, Ballard ED, Greenbaum R, et al. Suicide risk in youth with intellectual
disabilities: the challenges of screening. J Dev Behav Pediatr 2012; 33:431–
440.
Volume 26  Number 3  May 2013