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30 Sep 2021

Robles R et al. Psychiatr Serv 2021; Epub ahead of print

The International Classification of Diseases 11th Revision (ICD-11) clinical guidelines for mental and behavioural disorders (First MB et al, 2015) must be tested in clinical settings to guarantee their usefulness and applicability worldwide. Some high-priority changes in the conceptualisation of the ICD-11 classification of child and adolescent disorders have been made, and there is a need to evaluate whether the diagnostic guidelines work in Mexico. Therefore, this study aimed to establish the interrater reliability and clinical utility of the ICD‑11 guidelines for mood, anxiety and fear-related disorders, ADHD, and disruptive behavioural disorder (DBD) among children and adolescents.

In this cross-sectional study, children and adolescents aged 6–17 years seeking mental health services at two specialised settings in Mexico City were interviewed between March and December 2017. All participants were interviewed by two psychiatrists, an interviewer and an observer, who independently established a diagnosis for each participant, and evaluated the clinical utility of the guidelines with each participant.

In total, 25 clinicians (10 interviewers and 15 observers) participated in this study. The study population included 52 participants, with a mean (standard deviation [SD]) age of 11.9 (3.2) years, and the majority were male (n=33, 63%). There were 21 (40%) children (aged 6–11 years) and 31 (60%) adolescents (aged 12–17 years) in the clinical sample. There were eight diagnoses that were the most frequently assigned main diagnoses, including: ADHD, combined presentation (interviewer: n=28, 54%; observer: n=31, 60%); oppositional defiant disorder with chronic irritability-anger (interviewer: n=9, 17%; observer: n=9, 17%); specific phobia (interviewer: n=8, 15%; observer: n=4, 8%); dysthymic disorder (interviewer: n=7, 14%; observer: n=6, 12%); separation anxiety disorder (interviewer: n=7, 14%; observer: n=6, 12%); posttraumatic generalised anxiety disorder (interviewer: n=7, 14%; observer: n=5, 10%); stress disorder (interviewer: n=5, 10%; observer: n=4, 8%); and adjustment disorder (interviewer: n=5, 10%; observer: n=2, 4%).

ICD-11 diagnostic guidelines for disruptive behavioural disorders in childhood and adolescence showed strong interrater reliability (κ>0.8), particularly for oppositional defiant disorder with chronic irritability-anger. ICD-11 diagnostic guidelines for mood, anxiety and fear-related disorders and for ADHD demonstrated moderate interrater reliability (κ=0.46–0.53) between clinicians evaluating children and adolescents. Over 80% of clinicians reported that the guidelines were clear, easy to use and accurate; that the guidelines and qualifiers were useful in helping to communicate with patients, select treatments and determine patients’ prognoses; and that descriptions of developmental presentations were useful as applied to the patient.

This study had a few limitations. Firstly, the experience of the psychiatrists was not equal, with some having more years of experience than others. Additionally, κ values and clinical utility perceptions were obtained from clinicians who underwent a 4-hour training session prior, highlighting the changes proposed in the diagnostic guidelines with the aim to harmonise diagnostic decision-making. The authors noted that this process may have sensitised clinicians to the diagnostic criteria and guideline rationale. The study was also limited by the small sample size of children aged 6–11 years in that it could not be determined whether there were differences between interrater reliability indices for clinicians evaluating children versus those for adolescents. Furthermore, the study was based at specialised centres, which limited the generalisability of the results.

The authors concluded that the use of ICD-11–based diagnostic guidelines for assessments of mood disorders, anxiety and fear-related disorders, ADHD, and DBD among children and adolescents in this study had moderate interrater reliability. Definitions of these disorders were perceived as useful for selecting treatment and determining patients’ prognoses when applied to children and adolescents.

Read more about the reliability and clinical utility of ICD-11 guidelines here

Disclaimer: the views expressed here are the views of the author(s) and not those of Takeda.

First MB, Reed GM, Hyman SE, et al. The development of the ICD-11 clinical descriptions and diagnostic guidelines for mental and behavioural disorders. World Psychiatry 2015; 14: 82-90.

World Health Organization. ICD-11: International Classification of Diseases 11th Revision. 2019. Available at: Accessed October 2021.

Robles R, de la Peña FR, Medina-Mora ME, et al. ICD-11 guidelines for mental and behavioral disorders of children and adolescents: reliability and clinical utility. Psychiatr Serv 2021; Epub ahead of print.

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