Complex Needs of Children andYouth
with Dual Diagnosis - a Role for the ICF
Olaf Kraus de Camargo
Email: krausdc@mcmaster.ca
Twitter: @DevPeds

Disclosure
No conflicts of interest to disclose

Outline
1. Complexity
2. ICF and DSM-V
3. Case example
4. Capturing Spectra of Functioning

Complexity
“Complexity arises at the intersection between
individual and her/his environment”

Complexity
v Individual:
§Multiple impairments
§severe/profound intellectual
impairment
§Coexisting mental health issues
§Significant health conditions
§Behaviours of harm, alcohol and/or
drug misuse
§Experiences of trauma or neglect
v Environment
§ Socioeconomic disadvantage
§ Social isolation
§ Lack of service coordination
§ Lack of cross-sector collaboration

Environment
Healthy People 2030, U.S. Department of Health and Human Services, Office of
Disease Prevention and Health Promotion. Retrieved Feb 22, 2021, from
https://health.gov/healthypeople/objectives-and-data/social-determinants-health
1. Economic Stability
2. Education Access and Quality
3. Health Care Access and Quality
4. Neighborhood and Built Environment
5. Social and Community Context
Environmental factors: The physical, social and attitudinal environment
in which people live and conduct their lives; these are either barriers to
or facilitators of the person’s functioning

ICF & RDoC (NIMH)
Body
Functions and
Body
Structures
Activities
and
Participa
tion
Environmental
Factors
https://www.nimh.nih.gov/research-priorities/rdoc/index.shtml

ICF & DSM-V
http://www.dsm5.org/Documents/FAQ for Clinicians 8-1-13.pdf

Health & Functioning
§ Health is ‘the ability to adapt and self-manage in the face of social,
physical and emotional challenges’ (Huber et al. 2011).
§ In other words, functioning (however it is done, regardless of
ability/disability) can be understood as the evidence of health.
Huber M, Knottnerus JA, Green L, et al. How should we define health? BMJ
2011; 343: d4163.

Case Example
§ Adam*, 6 yo
§ Started walking with 3 yo, running with 4 yo
§ Now struggles with fine motor difficulties: printing, self-help
§ Well developed speech, bilingual
§ Good academic performance
§ Socially a bit shy and awkward but has friends
§ Diagnosis: Developmental Coordination Disorder
§ Functioning: limited mobility, some restrictions in social participation
§ SupportTeam: Parents, Occupational Therapist, Pediatrician
*Pseudonym

Case Example
§ Adam, 7 yo
§ Continues with low fine-motor skills, impacting written output
§ School feels he struggles with reading-comprehension, parents disagree
§ Refuses social activities and sports as he feels uncomfortable
§ No supports at school for his motor difficulties, as marks are not so bad
§ Diagnosis: Developmental Coordination Disorder, Query Learning Disability
§ Functioning: limited mobility, limited reading abilities?, some restrictions in
social participation
§ SupportTeam: Parents, Occupational Therapist, Pediatrician

Case Example
§ Adam, 10 yo
§ Struggles with motor tasks persist and more social isolation
§ Developed special interest in trivia and reading non-fiction articles
§ More frequent conflicts with peers, has screaming fits at home when things are
denied
§ Neuropsychological assessment diagnoses Non-verbal Learning Disability and Autism
Spectrum Disorder
§ Diagnosis: Developmental Coordination Disorder, Non-verbal Learning Disability
and Autism Spectrum Disorder
§ Functioning: limited mobility, limited reading abilities, restrictions in social
participation, restrictions in school participation
§ SupportTeam: Parents, OccupationalTherapist, Pediatrician, Community
Psychologist

Case Example
§ Adam, 12 yo
§ Low mood, lying on his bed, crying/angry, feels that life is too difficult
§ Very reluctant to pursue treatment – feels that “nobody can help him”
§ Eventually started on SSRI + CBT from ASD therapist
§ Diagnosis: Developmental Coordination Disorder, Non-verbal Learning
Disability and Autism Spectrum Disorder, Depression, 1st episode
§ Functioning: depressed mood, emotional dysregulation, limited mobility,
limited reading abilities, restrictions in social participation, restrictions in
school participation
§ SupportTeam: Parents, Pediatrician, Community Psychologist, Nurse

Case Example
§ Adam, 15 yo
§ Is in an Autism Social Skills classroom (he says he does not like it)
§ Mood has been stable and mostly positive over 2 yrs
§ Has acquired more social skills and made friendships
§ Is doing academically well
§ Started participating in a weight management program due to obesity
§ Is following well the suggestions for a healthier diet
§ Started to wean off SSRI
§ Diagnosis: Developmental Coordination Disorder, Non-verbal Learning Disability
and Autism Spectrum Disorder,
§ Functioning: emotionally stable, limited mobility, limited reading abilities,
restrictions in social participation, restrictions in school participation
§ SupportTeam: Parents, School-based therapist, Pediatrician, Nurse

Case Example
§ Adam, 16 yo
§ Struggles with pandemic restrictions
§ With lower dose SSRI he became more withdrawn
§ Extremely attached to mother and jealous of father
§ Wants his mother to separate from his father (no marital problems)
§ More angry episodes with sibling and friends
§ Prefers to stay in his room, keeps it dark, plays videogames
§ Referred to Child Psychiatry for additional input
§ Diagnosis: Developmental Coordination Disorder, Non-verbal Learning Disability
and Autism Spectrum Disorder, Depression, 2nd episode
§ Functioning: emotionally stable, limited mobility, limited learning abilities,
restrictions in social and family participation, restrictions in school participation
§ SupportTeam: Parents, Pediatrician, Nurse, Psychiatrist

Case Example
§ Adam, 17 yo
§ Started obsessively following influencers on Social Media and wants to move out of
his parents' home to live with them in a different country
§ Is more verbally aggressive against his father
§ Started also avoiding interactions with his mother
§ Feels that the lockdown is unfair and limits him to pursue his dream of moving out
§ Started therapy again, SSRI + antipsychotic
§ Diagnosis: Developmental Coordination Disorder, Non-verbal Learning Disability
and Autism Spectrum Disorder, Depression, 2nd episode
§ Functioning: emotionally stable, limited mobility, limited learning abilities,
restrictions in social and family participation, restrictions in school participation
§ SupportTeam: Parents, Nurse, Centre Psychologist, Psychiatrist, Pediatrician

Spectra of Functioning
ASD FASD
BF
A&P
EF-Barriers
BS
Xu A, Moore C, Kraus de Camargo O. Comparing the Spectra of Functioning in Children with FASD and ASD. In:WHO - Family of
International Classifications Network Annual Meeting.World Health Organization; 2020. p. 401. DOI: 10.13140/RG.2.2.26358.83524

Q & A Session
Q A
&
Grazie!
ICF Handbook