11 - PJ20 Physical maltreatment of child or QE82.0

PJ20 Physical maltreatment of child or QE82.0 Personal history of physical abuse as a child

723 Relationship problems and maltreatment Boundaries with other disorders and conditions (differential diagnosis) Boundary with child maltreatment (physical abuse, sexual abuse, psychological abuse, neglect) Caregiver–child relationship problem includes parenting behaviours that are within the normal range given the sociocultural context but that nonetheless have a negative impact on the child. Some caregiving behaviours may be appropriate for many children, but not for the specific child. These caregiver behaviours do not meet the diagnostic requirements for any child maltreatment category. In contrast, in child psychological maltreatment, one or more verbal or symbolic acts of parenting are clearly outside cultural norms, and are – or have reasonable potential to be – harmful to the child. If diagnostic requirements for both caregiver–child relationship problem and a form of child maltreatment are met, both may be assigned. Boundary with oppositional defiant disorder Oppositional defiant disorder is characterized by a pattern of markedly noncompliant, defiant and disobedient disruptive behaviour that is not typical for individuals of comparable age and developmental level. Similar behaviours may be observed in the context of caregiver–child relationship problem, but these are often confined to the specific caregiver–child relationship. In addition, in caregiver–child relationship problem there is often evidence that caregiver behaviours are not optimal for the child. However, if diagnostic requirements for both caregiver– child relationship problem and oppositional defiant disorder are met, both may be assigned. Boundary with reactive attachment disorder and disinhibited social engagement disorder Reactive attachment disorder and disinhibited social engagement disorder are characterized by a history of grossly insufficient care associated with markedly abnormal attachment behaviours exhibited towards adult caregivers, with onset prior to the age of 5 years. Similar abnormal attachment behaviours may be observed in caregiver–child relationship problem. However, if all diagnostic requirements for reactive attachment disorder or disinhibited social engagement disorder are met, a diagnosis of caregiver–child relationship problem is typically not warranted. Physical maltreatment of child or personal history of physical abuse as a child Essential (required) features • At least one non-accidental act of physical force (e.g. pushing or shoving, slapping, punching, throwing something that could cause injury) towards a child or adolescent is required for diagnosis. Problems in relationship between child and current former caregiver and current or past child maltreatment PJ20 / QE82.0

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders • The act causes (or exacerbates) at least one of the following: • any physical injury (e.g. bruises, cuts, sprains, broken bones, loss of consciousness, pain that lasts for several hours); • significant fear; • reasonable potential for significant physical injury. • The act was not committed for physical self-protection (e.g. to ward off an adolescent’s punches) or to protect the child or adolescent (e.g. to prevent a small child from running into a busy street or to prevent an adolescent from attempting suicide). Note: these categories are assigned to the victim, not the perpetrator. If PJ20 Physical maltreatment is diagnosed, the perpetrator–victim relationship (e.g. parent, other relative, stranger) should be specified using the extension codes provided on the ICD-11 platform in the context of the assault field. Similarly, if QE82.0 Personal history of physical abuse is diagnosed, the time of life for current or past episodes (e.g. child aged under 5 years, early adolescence) can be specified using the extension codes provided. Additional clinical features • Physical abuse of a child or adolescent can occur as an isolated incident. However, it can also occur as a pattern of parental or caregiver behaviour. If identified in a child or adolescent, it is important to evaluate whether past injuries were due to child physical abuse. • There are numerous injury types that when presented in a child are likely to have been caused by physical abuse. These include classic metaphyseal lesion (bucket handle fracture of the long bone); femur – metaphyseal and spiral fractures; humerus – metaphyseal and spiral fractures; rib fractures; spinous process fracture; skull – diastatic, across suture lines; subdural/epidural injury; patterned burns; patterned bruising; retinal haemorrhage (bilateral, multilayer). Many other injuries may also be caused by physical abuse of a child. • Child physical abuse is associated with a variety of mental disorders, including depressive disorders, adjustment disorder, anxiety and fear-related disorders, post-traumatic stress disorder, oppositional defiant disorder and conduct-dissocial disorder, as well as attentional problems, academic problems and suicidality. • Among younger children, disturbances in attachment, difficulty separating from parents or caregivers and vague physical complaints (stomach pain, headache) are more common results of physical abuse than psychological symptoms. Boundary with normality (threshold) • Physical discipline (e.g. spanking following perceived negative behaviours of the child) does not necessarily meet the diagnostic requirements for child physical abuse. Physical discipline is differentiated from child physical abuse by its impact. If physical discipline results in injury, has a reasonable potential for causing physical injury or elicits significant fear, a diagnosis of child physical abuse may be warranted. Problems in relationship between child and current former caregiver and current or past child maltreatment