Original Article : An Autism Assessment Service II
Developing an Autism
Assessment Service II: Analysis
of the First 81 Cases Seen
Vanessa Moore, Josie Titcomb, Chris Johnson,Elaine Cronk, Sue Baker, Laura Thysson, & Chris Rolles
This paper presents an analysis of the first 81 cases seen in the recently
established assessment service for children with autism and related
disorders in Southampton. The children presenting for assessment are
described in terms of a number of biographical, educational, behavioural,
and medical features and the characteristics of our sample are compared
with published findings. The future development of the service is
considered in the light of current developments and common features and
concerns of the families seen.
Keywords: Service development; autism; assessment
Introduction
The evolution of the assessment service in Southampton
and the assessment procedure are described in an earlier
paper in this issue (Moore et al., 1998). In this paper, a
detailed analysis of the first 81 cases seen is presented.
Since Kanner’s (1943) first description of ‘early infantile
autism’, a large and confusing variety of diagnostic criteria
have emerged. In current practice, the two internationally
accepted diagnostic systems of the World Health Or-
ganisation (1993) (International classification of diseases—
currently ICD-10) and the American Psychiatric Associ-
ation (1994) (Diagnostic and statistical manual—currently
DSM-IV) are widely used to classify autistic children. In
keeping with this practice our service employs ICD-10
criteria, which relate directly to our use of the ADI
(Autism Diagnostic Interview; Le Couteur et al., 1989)
described in the earlier paper. The characteristics of our
sample will first be described and their relationship to
published literature then discussed.
Description of referrals to the Southampton
assessment service
Table 1 gives a breakdown of the first 81 cases seen,
according to age and diagnosis. It can be seen that over
two thirds of the children assessed were diagnosed as
autistic and that the majority of referrals (78%) were of
children under the age of 8 years ; 85% of the autistic
children and 77% of the nonautistic children were boys.
Within the autistic group were seven children diagnosed as
having Asperger’s Syndrome. These children ranged in
age from 6 to 17 years.
Sixteen of the 26 children not diagnosed as autistic (62%)
showed behaviours characteristic of autism. In all cases
the onset of difficulties was before the age of 3 years and in
six cases the behavioural features were sufficient to
warrant a diagnosis of atypical autism. The remaining 10
cases were characterised by a receptive language disorder,
usually accompanied by behaviour problems. A further
Table 1. Age and diagnosis of first 81 cases seen
Age
Preschool(2–4 years)
NonautisticAutistic
21 (38%)
First School(5–7 years)
Middle School(8–12 years
Senior School(12+years)
Total(Range: 2yrs 9m–17yrs 9m)
23 (42%)
6 (11%)
5 (9%)
55
10 (38%)
9 (35%)
4 (15%)
3 (12%)
26
Vanessa Moore
Consultant Clinical
Psychologist,
Josie Titcomb
Consultant Child
Psychiatrist,
Chris Johnson
Consultant Clinical
Psychologist,
Elaine Cronk
Director of Education
Services,
Sue Baker
Teacher,
Laura Thysson
Assistant Psychologist,
&
Chris Rolles
Consultant
Paediatrician,
Paediatric Medical Unit,
G Level, Southampton
General Hospital,
Tremona Road,
Southampton
SO16 6YD
Child Psychology & Psychiatry Review Volume 3, No. 3, 1998 121
Original Article : An Autism Assessment Service II
Table 2. Level of intellectual functioningof autistic and nonautistic children
Intellectual level
Normal (IQ 70+)
42%
Mild learningdisability (IQ 50–70)
Moderatelearning disability (IQ 35–49)
Severe/profoundlearning disability (IQ<35)a
Autisticb
(N = 52)Nonautistic
(N = 22)
a The severe and profound categories are combinedas a result of the practical difficulties of accuratediscrimination at this level of functioning.b The missing data apply to cases where accurateassessment was impossible.
29%
12%
17%
50%
14%
9%
27%
eight nonautistic children (31%) were found to have a
learning disability but were not thought to be autistic. Of
the remaining children, one was considered to have normal
development and one had a conduct disorder.
Whilst the proportion of children diagnosed as autistic
versus nonautistic was found to be fairly constant across
the age range, a greater number of younger nonautistic
children showed a combination of language delay and
behaviour problems, whereas more of the older non-
autistic children showed a generalised learning disability.
The level of intellectual functioning (as measured by the
use of appropriate nonverbal test materials) of children in
the autistic and nonautistic groups is shown in Table 2. It
is worth noting the relatively high proportion of autistic
children within the normal range of intelligence, as well as
the finding that over a quarter of the nonautistic children
had a severe learning disability. Table 3 shows the
percentage of autistic and nonautistic children at each
level of intellectual functioning in whom spoken language
was absent. As expected, the proportion of children in
each group without speech increased with increasing
severity of learning disability. However, more children in
the autistic group had no speech at the higher ability
levels.Unfortunately, since therewas no SALT in the team
for the earlier assessments, it is not possible to present
formal data on expressive language and communication
skills. However, informal assessment indicated that the
quality of spoken language and communication skills
differentiated the children in the two groups, in that the
autistic children were more likely to show disordered
Intellectual level
Normal intelligence 9%
Mild learning disability
Moderate learningdisability
Severe/profoundlearning disability
Autisticb
(N = 52)Nonautistic
(N = 22)
7%
17%
89%
0%
0%
0%
75%
Table 3. Percentage of autistic and nonautisticchildren showing an absence ofspoke language at each level ofnonverbal intelligence
language development and abnormalities of nonverbal
communication (see also Fig. 1).
In terms of receptive language, all children in both groups
showed delayed verbal comprehension (assessed on the
basis of the SALT’s judgement or, if formal testing was
possible, a test score at least two standard deviations
below the mean), except those within the normal range of
intelligence, where 36% of autistic children and 20% of
nonautistic children had verbal comprehension within
normal limits for their age. All seven of the children with
Asperger’s Syndrome were included in the autistic group
with normal verbal comprehension.
The percentage of autistic and nonautistic children show-
ing various autistic features is given in Fig. 1. It can be
seen, not surprisingly, that the presence of all autistic
features was very much more common in the autistic
group, although a considerable number of children
eventually diagnosed as nonautistic also showed each
feature. A similar proportion of children were found to be
clumsy (defined as a deficit in gross and fine motor skills
sufficiently severe to warrant referral to physiotherapy}occupational therapy) in each group (24% of autistic
children and 19% of nonautistic children).
Finally, a similar and high proportion in each group (60%
of autistic children and 62% of nonautistic children) were
found to have significant behaviour problems. Families in
both groups reported aggressive}destructive behaviour or
temper tantrums most frequently, followed by overactive
behaviour and sleep problems. Anxious behaviour and
mood swings were mentioned only by families in the
nonautistic group, whereas lack of a sense of danger,
smearing, self-injurious behaviour, fussy eating, and
screaming were mentioned only by families of autistic
children.
Figure 2 shows the percentage of autistic and nonautistic
children who had medical and}or neurological problems.
Child Psychology & Psychiatry Review Volume 3, No. 3, 1998122
Original Article : An Autism Assessment Service II
100
80
60
40
20
0Deviantspeech
Abnormalnonverbal
communication
Abnormalsocial
behaviour
Repetitivebehaviour
Abnormaladaptationto change
Stereotypies Absent/limitedsymbolic play
Abnormalpre-
occupations
Autistic
Nonautistic
Figure 1. Percentage of autistic and nonautistic children showing various autistic features
% o
f ch
ildre
n
Autistic
Nonautistic
50
40
30
20
10
0
% o
f ch
ildre
n
Problems inpregnancy
Labourproblems
Perinatalproblems
Epilepsy AbnormalEEG
Chromosomeabnormality
Othermedical
problems
Figure 2. Percentage of autistic and nonautistic children with medical and/or neurological problems
It can be seen that a quarter to a third of the mothers of
autistic children had problems during pregnancy and}or
labour and}or the child had problems in the perinatal
period, as well as a variety of other medical problems.
These included squint, hearing difficulties, hemiplegia,
cystinuria, and food allergies. Other medical problems
tended to be more common in the nonautistic group and
included polydactyly, delayed visual maturation, hydro-
nephritis, ureteric obstruction, cleft lip, growth hormone
deficiency, and hydrocephalus.
None of the children in the autistic group had any
Child Psychology & Psychiatry Review Volume 3, No. 3, 1998 123
Original Article : An Autism Assessment Service II
Epilepsy
Abnormal EEG
Other medical/neurologicalproblems
60
50
40
30
20
10
0
% o
f ch
ildre
n
Normal Intelligence Mild LearningDisability
Moderate/severeLearning Disability
Figure 3. Association between intellectual level and medical/neurological problems in autistic group
chromosome abnormality, including Fragile X, whereas
chromosome abnormalities were found amongst 12% of
children in the nonautistic group, mainly translocations of
unknown significance, with no cases of Fragile X. In the
group of children seen since this analysis, one has been
found to have a chromosomal complement of 47, XXY
(Klinefelter’s Syndrome). He was not autistic, but had
some social relationship and early language difficulties.
Table 2 indicates that 58% of the children in our autistic
sample showed varying degrees of learning disability. The
data were re-examined in order to ascertain whether the
degree of learning disability differentiated between autistic
individuals in terms of other characteristics. It was found
that a higher proportion of autistic children with moderate
or severe learning difficulties had epilepsy (20%) and}or
an abnormal EEG (27%) than autistic children with mild
learning difficulties (6% and 19% respectively) or of
normal intelligence (0% and 14% respectively). Children
with moderate or severe learning difficulties were also
more likely to have other medical problems (53%, cf.
30% of autistic children with mild learning difficulties and
20% of those with normal intelligence). The relevant data
is shown in Fig. 3.
Both speech and symbolic play were much more likely to
be absent or severely limited amongst autistic children
who had moderate or severe learning difficulties. Amongst
the other features considered, repetitive use of objects was
more likely to be found amongst autistic children with
learning disabilities (LD) (93% moderate}severe LD;
93% mild LD; 45% normal intelligence), as were stereo-
typies (87% moderate}severe LD; 69% mild LD; 52%
normal intelligence). On the other hand, abnormal pre-
occupations and circumscribed interests were found far
less frequently amongst autistic children with moderate or
severe learning difficulties (7% moderate}severe LD;
55% mild LD; 58% normal intelligence).
Over half of the autistic children and two thirds of the
nonautistic children gave a family history of significant
medical}psychiatric problems or learning disability in
first- or second-degree relatives. Families in both groups
often reported more than one problem. The type of
problems reported may be divided into psychiatric (e.g.
depression, schizophrenia), developmental}learning dis-
ability (including developmental delay, language delay}disorder, dyslexia), medical}neurological problems (in-
cluding epilepsy, Alzheimer’s disease, spina bifida, cleft
lip, multiple sclerosis) and autistic spectrum disorders
(autism}Asperger’s Syndrome). The percentage of
problems of each type reported in the family histories of
children in the autistic and nonautistic groups is shown in
Fig. 4. It can be seen that, whereas a third of families in
each group with a significant family history reported
developmental}learning difficulties, there was a tendency
for more families in the autistic group to give a history of
psychiatric problems, particularly affective disorder, and
more families in the nonautistic group to give a history of
medical}neurological problems.
Two families in the autistic group and one in the
Child Psychology & Psychiatry Review Volume 3, No. 3, 1998124
Original Article : An Autism Assessment Service II
Autistic
Nonautistic
60
50
40
30
20
10
0
% o
f re
spo
nd
ents
Psychiatric Developmental/learningdisability
Medical/neurological
Autism/Aspergersyndrome
Figure 4. Percentage of respondents in autistic and nonautistic groups giving family history ofdifferent types of problem
nonautistic group gave a history of an autistic spectrum
disorder in a close relative. In addition, four families were
seen in which more than one family member were assessed.
In three cases, these were sibling pairs ; in the fourth, a
sibling and a cousin.
The most common referral route to our service was found
to be via a hospital paediatrician or a community
paediatrician. A further 45% of referrals came from GPs
and these included cases identified by other nonmedical
personnel (e.g. health visitor, clinical}educational psy-
chologist) who recommended referral, which must be via
a medical route.
Nearly three quarters of the children referred were already
in special educational provision at the time of their
assessment. The vast majority were in schools for children
with moderate or severe learning disabilities or specialist
preschool provision and there was no difference between
children eventually diagnosed as autistic or nonautistic in
distribution across the various types of provision. Only
four children (7%) in the autistic sample were attending
an educational placement specifically designated for
autistic children at the time of their assessment.
Discussion
It is perhaps not surprising that over two thirds of the
children referred to our service were diagnosed as autistic,
given that all the referrals had already had a diagnosis of
autism considered. This is consistent with the finding of
Gillberg et al. (1990) that 75% of children referred with
suspected autism before the age of 3 years had the
diagnosis confirmed after that age. The majority of our
referrals were of children below the age of 8 years. This
suggests that service providers need to have particular
expertise in the assessment of children in this younger age
range.
The children diagnosed with Asperger’s Syndrome were
all over the age of 6 years and typically presented with
major difficulties in handling social situations at school.
The 43% considered to be clumsy was higher than the
proportion of other children in the autistic group thought
to be clumsy (21%). This is consistentwith the observation
that Asperger’s children are often clumsy, although this is
not an obligatory feature when making the diagnosis
according to ICD-10 criteria (e.g. Ehlers & Gillberg,
1993).
The majority of children not diagnosed as autistic showed
behavioural features characteristic of autism, explaining
why they were referred and underlying the need for
expertise amongst the assessment team in deciding com-
plex diagnostic issues. The younger children tended to
present with a combination of language delay}disorder
Child Psychology & Psychiatry Review Volume 3, No. 3, 1998 125
Original Article : An Autism Assessment Service II
and behaviour problems and often posed significant
management difficulties at home and}or school. A rela-
tively high proportion of older children presented with a
severe learning disability and we suspect that in some of
these cases the parents may have been hoping for a
diagnostic label of autism, believing this to be more
acceptable than a disability of unknown origin. In all cases
thorough assessment was helpful in clarifying the nature
of the child’s difficulties and in providing general pointers
in the direction of behavioural management and likely
educational needs. Feedback from parents indicated that
they also found the assessment helpful (cf. Moore et al.,
1998).
The male}female ratio of 5±9 to 1 amongst the autistic
children in our sample is high but not inconsistent with the
ratio of 5±7 to 1 found by Steffenburg and Gillberg (1986)
for ‘Kanner autism type cases ’. It is known that the
preponderance of males is greater in the case of children
with an IQ in the normal range (cf. Bailey, Phillips, &
Rutter, 1996) and this is consistent with the observation
that a greater proportion of children in our autistic sample
had normal intelligence than the one quarter expected on
the basis of epidemiological studies (Rutter, 1979). This
then appears to represent a referral bias to our service.
Two possible explanations are that some children with a
learning disability and autism already have their needs
catered for by specialist educational provision and}or that
the management difficulties posed by autistic children of
normal intelligence are sufficiently worrying to prompt
referral.
The finding that the quality of spoken language and
communication skills differentiated the autistic and non-
autistic children is consistent with the many studies
highlighting the deviant communication features charac-
teristic of autism (cf. Bailey et al., 1996), and supports our
inclusion of a SALT in our core assessment team. We
believe that the SALT is better able than other pro-
fessionals to provide a detailed analysis of the child’s
semantic, syntactic, and pragmatic language skills as well
as nonverbal communication, and that the quality and
comprehensiveness of our assessments has improved as a
result.
Our finding that other medical conditions, including
chromosome abnormalities, tended to occur less fre-
quently in the autistic group is consistent with the
observations of Rutter et al. (1994) that this association is
less strong than originally proposed, although unfortu-
nately we are not able to provide a detailed categorisation
of conditions on the basis of the data available. However,
our data provide strong support for Rutter et al.’s (1994)
contention that known medical conditions are much more
common when autism is accompanied by severe retar-
dation (cf. Fig. 3). The fact that we found no cases of
Fragile X in the autistic group is probably not of
significance, since recent estimates put the rate of co-
occurrence as low as 2±5% (Bailey et al., 1993; Piven et al.,
1991).
Obstetric complications were reported in up to one third
of our mothers of autistic children. The weight of evidence
suggests that these complications derive from a genetically
abnormal foetus rather than that the complications result
in environmental risk (Bolton et al., 1994; Bailey et al.,
1996). This is a point that can sometimes be usefully
explored with parents in the feedback session, since several
mothers have longstanding concerns about the possible
effects of difficulties during pregnancy on the subsequent
development of their child.
Our finding that there was an increased incidence of
affective disorder amongst the families of autistic children
has been reported in several other studies (Bolton et al.,
1995; DeLong, 1994; Piven et al., 1990; Smalley,
McCracken, & Tanguay, 1995). As yet it is not clear
whether this association is genetically mediated, or
whether it might be a reflection of the stresses associated
with rearing an autistic child (Bailey et al., 1996).
The fact that we found evidence of autism and}or autistic-
like conditions occurring amongst the close relatives of
children in our autistic group is consistentwith the findings
of many studies (summarised in Bailey et al., 1996) that
there is a significantly increased risk of both autism and a
range of similar social and cognitive abnormalities oc-
curring amongst the siblings of autistic children. This is an
important point to bear in mind when counselling parents
on the genetic implications of receiving a diagnosis of
autism for their child.
We believe that the main benefits of providing a diagnostic
service include clarifying the nature of the child’s diffi-
culties and specifying current strengths and weaknesses,
providing information and an opportunity for informed
discussion about genetic implications and prognosis, and
highlighting likely educational needs and strategies for
behaviour management. Since we are an assessment
service we are restricted in the extent to which we can
implement the latter.
A future aim is to forge closer links between our service
and community-based treatment services for local chil-
dren, in particular drawing on the skills of the clinical
psychologist and SALT to implement behavioural pro-
grammes (cf. Clements, 1987; Howlin & Rutter, 1987;
Lovaas, 1987). This is particularly relevant in view of the
large number of children presenting for assessment with
behaviour problems. Good links with the local education
service are also essential and we are fortunate that
TEACCH programmes (Treatment and Education of
Autistic and Related Communication-Handicapped Chil-
dren; Schopler & Reichler, 1979; Schopler, Reichler, &
Lansing, 1980) are being implemented in an increasing
number of schools in Hampshire.
A second aim involves the need to update our assessment
protocol in the light of current developments. A recent
refinement is the inclusion of a range of executive function
tasks in the psychological assessment, following the
Child Psychology & Psychiatry Review Volume 3, No. 3, 1998126
Original Article : An Autism Assessment Service II
suggestion that autistic children may exhibit difficulties in
high-level planning and control of behaviour (e.g. Hughes,
Russell, & Robbins, 1994; Ozonoff, Pennington, &
Rogers, 1991). Finally, we have recently forged stronger
links with our local child development centre and we are
offering assessment to younger preschool children, in view
of the findings that diagnosis is possible earlier than
supposed in the past (e.g. Baron-Cohen, Allen, & Gillberg,
1992; Dahlgren & Gillberg, 1989; Gillberg et al., 1990;
Lord, 1995) and that there are significant advantages to
early intervention (e.g. Greenspan, 1992; Lovaas, 1987).
References
American Psychiatric Association. (1994). Diagnostic and stat-
istical manual of mental disorders (4th edn.–DSM-IV).
Washington, DC: Author
Bailey, A., Bolton, P., Butler, L., Le Couteur, A., Murphy, M.,
Scott, S., Webb, T., & Rutter, M. (1993). Prevalence of the
Fragile X anomaly amongst autistic twins and singletons.
Journal of Child Psychology and Psychiatry, 34, 673–688.
Bailey, A., Phillips, W., & Rutter, M. (1996). Autism: Towards
an integration of clinical genetic neuropsychological and
neurobiological perspectives. Journal of Child Psychology and
Psychiatry, 37, 89–126.
Baron-Cohen, S., Allen, J., & Gillberg, C. (1992). Can autism be
detected at 18 months? The needle, the haystack and the
CHAT. British Journal of Psychiatry, 138, 839–843.
Bolton, P., Macdonald, H., Pickles, A., Rios, P., Goode, S. L.,
Crowson, M., Bailey, A., & Rutter, M. (1994). A case-control
family history study of autism. Journal of Child Psychology and
Psychiatry, 35, 877–900.
Bolton, P., Pickles, A., Murphy, M., & Rutter, M. (1995).
Autism, affective and other psychiatric disorders : Patterns of
familial aggregation. Cited in A. Bailey, W. Phillips, & M.
Rutter (1996). Autism: Towards an integration of clinical
genetic neuropsychological and neurobiological perspectives.
Journal of Child Psychology and Psychiatry, 37, 89–126.
Clements, J. (1987). Severe learning disability and psychological
handicap. Chichester, U.K.: Wiley.
Dahlgren, S., & Gillberg, C. (1989). Symptoms in the first two
years of life : A preliminary population study of infantile
autism. European Archives of Psychiatry and Neurological
Sciences, 238, 169–174.
DeLong, R. (1994). Children with autistic spectrum disorder and
a family history of affective disorder. Developmental Medicine
and Child Neurology, 36, 674–687.
Ehlers, S., & Gillberg, C. (1993). The epidemiology of Asperger’s
Syndrome: A total population study. Journal of Child Psy-
chology and Psychiatry, 34, 1327–1350.
Gillberg, C., Ehlers, S., Schaumann, H., Jakobson, G., Dahlgren,
S., Lindblom, R., Bagenholm, A., Tjuus, T., & Blidner, E.
(1990). Autism under 3 years : A clinical study of 28 cases
referred for autistic symptoms in infancy. Journal of Child
Psychology and Psychiatry, 31, 921–934.
Greenspan, S. (1992). Infancy and early childhood: The practice of
clinical assessment and intervention with emotional and de-
velopmental challenges. Madison, CT: International Uni-
versities Press.
Howlin, P., & Rutter, M. (1987). Treatment of autistic children.
Chichester, U.K.: Wiley.
Hughes, C., Russell, J., & Robbins, T. (1994). Evidence for
executive dysfunction in autism. Neuropsychologia, 32,
477–492.
Kanner, L. (1943). Autistic disturbances of affective contact.
Nervous Child, 2, 217–250.
Le Couteur, A., Rutter, M., Lord, C., Rios, P., Robertson, S.,
Holdgate, M., & Mclennan, J. (1989). Autism Diagnostic
Interview: A standardised investigator-based instrument.
Journal of Autism and Developmental Disorders, 19, 363–387.
Lord, C. (1995). Follow-up of 2-year-olds referred for possible
autism. Journal of Child Psychology and Psychiatry, 36,
1365–1382.
Lovaas, O. (1987). Behavioural treatment and normal edu-
cational and intellectual functioning in young autistic children.
Journal of Consulting and Clinical Psychology, 55, 3–9.
Moore, V., Titcomb. J., Cronk, E., Goodson, S., & Rolles, C.
(1998). Developing an autism assessment service I : Procedures,
priorities and pitfalls over the first 5 years. Child Psychology
and Psychiatry Review, 3, 116–120.
Ozonoff, S., Pennington, B., & Rogers, S. (1991). Executive
function deficits in high functioning autistic children: Re-
lationship to theory of mind. Journal of Child Psychology and
Psychiatry, 32, 1081–1106.
Piven, J., Gayle, J., Chase, J., Fink, B., Landa, R., Wzorek, M.,
& Folstein, S. (1990). A family history study of neuro-
psychiatric disorders in the adult siblings of autistic individuals.
Journal of American Academy of Child and Adolescent Psy-
chiatry, 29, 177–183.
Piven, J., Gayle, J., Landa, R., Wzorek, M., & Folstein, S. (1991).
The prevalence of the Fragile X in a sample of autistic
individuals diagnosed using a standardised interview. Journal
of the American Academy of Child and Adolescent Psychiatry,
30, 825–830.
Rutter, M. (1979). Language, cognition and autism. In R.
Katzman (Ed.), Congenital and acquired cognitive disorders.
New York: Raven Press.
Rutter, M., Bailey, A., Bolton, P., & Le Couteur, A. (1994).
Autism and known medical conditions: Myth and substance.
Journal of Child Psychology and Psychiatry, 35, 311–322.
Schopler, E., & Reichler, R. (1979). Individual assessment and
treatment of autistic and developmentally disabled children, Vol.
1: Psychoeducational profile (2nd Edn.). Austin, TX: Pro-Ed.
Schopler, E., Reichler, R., & Lansing, M. (1980). Individual
assessment and treatment of autistic and developmentally dis-
abled children, Vol. 2: Teaching strategies for parents and
professionals. Dallas, TX: Pro-Ed.
Smalley, S., McCracken, J., & Tanguay, P. (1995). Autism,
affective disorders and social phobia. American Journal of
Medical Genetics (Neuropsychiatric Genetics), 60, 19–26.
Steffenburg, S., & Gillberg, C. (1986). Autism and autistic-like
conditions in Swedish rural and urban areas: A population
study. British Journal of Psychiatry, 149, 81–87.
World Health Organisation. (1993). International classification of
diseases (ICD-10). Geneva: Author.
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