In general, ICD-10 and DSM-IV do not require impairment of social functioning to be present in order to make a diagnosis. There are exceptions, thus in DSM-IV, oppositional-defiant disorder does require impairment. With many qualitatively distinct adult disorders, having no impairment criterion makes sense, so that a person experiencing the delusions and hallucinations characteristic of schizophrenia but able to go to work and form relationships while on neuroleptics still has schizophrenia. But should a child who says he is afraid of dogs and crosses to the other side of the pavement on seeing one, but otherwise functions well, be deemed to suffer from a phobia? If impairment criteria are not applied, very high rates of disorder are obtained in epidemiological surveys. This lacks credibility with the general public who may then dismiss all psychiatric problems in children, and is unrealistic for clinicians and health planners who would not see most of the identified individuals as cases needing treatment. For example, Bird et al.(30> in a large epidemiological survey found that using DSM-III criteria, 50 per cent of children and adolescents had a diagnosis. However, when an impairment criterion was added, the figure came down to 18 per cent. This would appear to be a much more realistic figure. However, it could be argued that social impairment is too constraining, and for example would exclude an adolescent who is fairly depressed but able to function. The term 'impact' can be used to include subjective distress as well as impairment, and is gaining in popularity among many child psychiatrists. (31
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