173
Psychiatrie Disorders in Children and Adolescents: Results of the ICD-IO Field Trial B. Blanz, H. Amorosa *, M. H. Schmidt Department ofChild Psychiatry (Director: Prof. Dr. Dr. M. H. Schmidt), Central Institute for Mental Health, Mannheim, FRG *Max-Planck-Institute for Psychiatry (Director: Prof. Dr. Dr. F. Holsboer), München, FRG
Of the numerous changes made in the e1assification of psychiatrie disorders in children and adolescents in ICD-IO the most important are described. In an evaluation ofthe revised scherne, 7 raters from 2 facilities e1assified 40 case histories with both ICD-IO and ICD-9 codes. For ICD-IO and 4 character codes the level of agreement was 56% (lCD-9: 60%). As expected, 3-character codes yielded better agreement (ICD-IO: 71 %; ICD-9: 72%). Withinfacility agreement was roughly the same for each. The lowest levels of agreement for a given category were for mixed disorders of conduct and emotions (F92) and depressive disorders (F31, F43). The reasons for this are discussed.
1.lntroduction
The International C1assification of Diseases, 10th Revision (ICD-IO WHO, 1987) contains three sections on the e1assification of psychiatrie disorders with onset specific to childhood or adolescence. Before we present data from a field study with this revised e1assification scherne, we discuss the main changes in ICD-I 0 as compared with its predecessor, ICD-9 (WHO, 1977) in the sections "Developmental Disorders" (F80- F89) and "Behavioural and Emotional Disorders" (F90- F99) (cf. Schmidt. 1987).
1.1 Developmentaldisorders (F80- F89 In ICD-I 0 specific developmental disorders (F80- F83) and pervasive developmental disorders (F85) have been combined into a common section. The onset in infancy or childhood, the e10se relationship of impaired functions to the maturation of the central nervous system, the stable course, and the involvement of genetic factors are all seen as common elements of these disorders. We welcome the introduction of Pharmacopsychiatry 23 (1990) 173-176 (Supplement) @ Georg Thieme Verlag Stuttgart· New York
Psychiatrissehe Störungen bei Kindern und Jugendlichen: Ergebnisse der I CD-l O-Feldstudie
Von den zahlreichen Veränderungen, die in der ICD-I 0 für die Klassifikation kinder- und jugendpsychiatrischer Störungen erfolgen, werden die wichtigsten beschrieben. In einer Erhebung mit dem revidierten System schätzten 7 Rater aus 2 Zentren 40 Fallgeschichten mit ICD10 und ICD-9 diagnostisch ein. Für die vierstelligen ICDIO-Kodierungen ergab sich eine Übereinstimmung von 56% (lCD-9: 60%). Wie erwartet ergaben sich bei den dreistelligen Kodierungen bessere Übereinstimmungen. Die diagnostische Übereinstimmung innerhalb der Zentren war jeweils gleich. Die niedrigsten Übereinstimmungswerte für einzelne Kategorien zeigten sich bei der gemischten Verhaltens- und emotionalen Störung (F92) und depressiven Störungen (F31, F43). Die Ursachen hierfür werden diskutiert.
the objective approach with operationalized definitions for the specific developmental disorders: One of the diagnostic criteria for specific developmental disorders of speech and language (F80) is "a language delay that is sufficiently severe to fall outside the 2 standard deviation limits" and one for scholastic skills (F81) is scholastic achievement that is weil below the average level expected for a child ofthat IQ level and chronological age.
1.2 Behavioural and emotional disorders with onset usually occurring in childhood andadolescence (F90- F99) Hyperkinetic disorders (F90) are characterized by "the combination of overactive poorly modulated behaviour with marked inattention and lack of persistent task involvement"; further, there must be "pervasiveness over situations and persistence over time." The diagnostic category hyperkinesis with developmental delay (lCD-9: 314.1) has been deleted.
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Summary
Pharmacopsychiatry 23 (1990) A new category is conduct disorder confined to the family context (F91.0). We welcome the inc1usion of this disorder under conduct disorders, and anticipate that this will increase the confidence with which diagnoses in this area are made. Previously, such disorders were often considered to be an expression of neurotic delinquency and were then coded under neurotic disorders (ICD-9: 300.8) or other or mixed disturbance of emotions specific to childhood and adolescence (ICD-9: 313.8). As before, no distinction is made in the category conduct disorders between aggressive and non-aggressive behaviour. This distinction was added to DSM-I1I, but deleted again in DSM-I1I-R (cf. Steinhausen, 1987). Another change is the separation of mixed disorder of conduct and emotions (F92) from conduct disorder (F91). A category has thus been created for mixed disorders that, not infrequently, in the past were (incorrectly) c1assified as emotional disorders to avoid c1assification as conduct disorder. The group "emotional disorder with onset specific to childhood" (F93) continues to be differentiated from the neurotic, stress-related and somatoform disorders (F40F49). The justifications for this are the more favourable outcome in children, the developmental aspects of the psychopathological phenomena observed, the open question as to whether the mental mechanisms involved are the same as in adults, and the less c1ear demarcation of the main symptoms into supposedly specific entities. The category "disturbance of emotions specific to childhood and adolescence with misery and unhappiness" (lCD-9: 313.1) has been deleted. Disorders previously coded there can now usually be c1assified as depressive episode, moderate severity (F31.I), as recurrent depressive disorder, current episode moderate severity (F33.I) or as dysthymia (F34.1). These categories are valid for all ages, which counteracts overuse of the term "depression in childhood." The restriction of the earlier category relationship problems (ICD-9: 313.3) to sibling rivalry disorder (F93.3) must be viewed critically because there is no longer a specific category available for the peer rivalry typical in childhood. In the group of disorders of social functioning with onset specific to childhood or adolescence (F94), an exception has been made and etiological factors are relevant for the codes F94.1 (reactive attachment disorder of childhood) and F94.2 (attachment disorder of childhood, disinhibition type); experience will show whether it is still possible to differentiate these disorders reliably from other ifthe past history is incomplete. The tic disorders (F95) have been subdivided into four categories corresponding to empirical findings and therapeutic experience. In addition to the tic disorders (F95), anorexia nervosa (F50.0) has also been separated from the category "other behavioural and emotional disorders with onset usually occurring during childhood or adolescence" (F98). This is because these disorders occur in adults as weil as children. Overall, ICD-IO has a more detailed structure and provides more careful descriptions of many disorders than its predecessor.
B. Blanz, H. Amorosa. M. H. Schmidt fable 1 Number of different categories used in ICD-10 and ICD-9 for the main diagnoses. (For each case only the most frequently coded diagnosis is included.)
4-character diagnoses 3-character diagnoses
ICD-10
ICD-9
20
16 9
15
Below we present the most interesting findings from a field study on the practicability and reliability of ICD10 for c1assifying psychiatric disorders in children and adolescents. 2. Materials and Methods Case histories served as the basis for the study. The case histories used were summary reports on 40 children and adoles· cents admitted consecutively to an inpatient unit: all identifying material had been deleted, as had any direct mention ofthe diagnosis or dia· gnoses, and all information on treatment. The histories were evaluated independently by 7 raters from 2 facilities - the Child and Adolescent Psychiatric Unit at the Central Institute for Mental Health, Mannhelm (Facility I) and the Child Psychiatry Department of the Max·Planck· Institute for Psychiatry, Munich (Facility 11). Diagnoses were made with both ICD·lO and ICD-9, which yielded 280 ratings with each scheme. (Multiaxial classification is now used in child and adolescent psychiatry, but for reasons of comparability only the findings for Axis One Clinical Psychiatric Syndrome, are discussed here.) Agreement was 'calculated as percentage agreement and as a weighted kappa coefficient.
3. Results
3.1 Main diagnoses The ICD-IO diagnosis made was developmental disorder (F8) in 4 cases, behavioural or emotional disorder (F9) in 28 cases, and some other category in 8 cases. Thus, 80'% of the cases were given a code specific to children or adolescents, and hence the goal of evaluating this group of categories was achieved. Table 1 shows the number of different diagnostic categories used by the raters for the main diagnosis. Only one diagnosis is inc1uded per case - the one coded most frequently. More categories can be coded in ICD-IO than. in ICD-9. Since chance agreement of diagnoses decreases wlth increasing numbers of diagnostic categories available, the wider range of diagnoses in ICD-I 0 must be taken into consideration when interpreting the measure of agreement.
3.2 Overall agreement When 4-character codes were used, 56 '% of the raters were in agreement about a given ICD-IO diagnosis (ICD-9: 60%). As expected, when 3-character codes were used agreement was better (lCD·IO: 71 %; ICD-9: 72'%). When both main and alternative diagnoses were considered, agreement was 64% for 4-character codes (ICD-9: 64'%) and 77% for 3-character codes (ICD-9: 76%). Consideration of additional diagnoses led to only a negligible increase in agreement, however.
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174
Psychiatrie Disorders in Children and Adolescents: Results 0/ the [CD-] 0 Field Trial
Pharmacopsychiatry 23 (1990)
Tlble 2 Weighted kappa coefficients lor the individual pairs 01
Tlble 4 Most common diagnoses with lowest interrater agree-
raters (3-character main diagnoses, ICD-10)
ment, other diagnoses coded for the cases involved, and number of raters who coded each category
1 2 3 4 5 6
2
3
4
5
6
7
0.60
0.39 0.35
0.63 0.54 0.34
0.61 0.55 0.44 0.50
0.62 0.64 0.43 0.52 0.51
0.57 0.56 0.31 0.53 0.53 0.46
Tlble 3 Agreement by diagnosis: Main diagnostic categories ranked according to the level 01 agreement among raters (3-character codes, ICD-10) No. 01 cases
Categories F20 F45 F94
F32 F85 F90 F98
F42 F91 F92 F43 F70 F31
Schizophrenia Somatolorm disorders Disorders of social functioning with onset specific to childhood or adolsescence Bipolar affective disorder 1 Pervasive developmental disorder 4 Hyperkinetic disorder 4 Other behavioural and emotional disorders with onset usually occurring during childhood 3 Obsessive-compulsive disorder 1 Conduct disorder 18 Mixed disorder of conduct and emotions 2 Reaction to severe stress and adjustment disorders 1 Mild mental retardation 2 Depressive episode 1 Total
Agreement in% 100 100
100 86 86 86
Most common diagnosis (No. of raters)
Other diagnoses No. of raters)
F92" (8)
F93 (2)
F43' (4)
F61 (3)
F70' , (6) F31' (3)
F35 (1)
F43 (1)
F91 (1)
F95 (1)
F85 (3)
F71 (2)
F41 (1)
F79 (1)
F93 (1)
F34 (2)
F33 (1)
F60 (1)
"2 subjects, 14 ratings '1 subject, 7 ratings
vided - it was not always possible to make a definitive diagnosis. However, the relatively low levels of agreement for the categories F92, F43, F70 and F31 also reflect problems in dif· ferentiating between these and other categories. A look at the other main diagnoses coded for the cases in these categories makes this c1ear (Table 4). 4, Discussion
76 71 67 57 57 43 43
40
3.3 Withinfacilityagreement For 4-character codes the agreement on the main diagnoses was 58 % at Facility I (lCD-9: 63 %) and 52 % at Facility 11 (lCD-9: 52 %). Agreement was higher at both facilities when 3-character codes were used: Facility I 70 % (ICD-9: 73 %) and Facility 11 68 % (lCD-9: 68 %).
3.4 Interrater agreement Table 2 shows interrater agreement for each combination of raters. Raters I to 4 were from Facility I, and raters 5 to 7 from Facility 11. The kappa coefficients are between 0.31 and 0.64. The 6 lowest kappa values are associated with rater 3. This rater had relatively little experience with multiaxial c1assification schemes. Clear "clusters" in the sense of higher agreement of raters from the same facility are not evident.
3.5 Agreement by diagnoses Agreement among the 7 raters on a given diagnostic category ranged from 43% to 100% (Table 3). This is due in part to the difference in the amount ofinformation pro-
The level of agreement on the main diagnoses can be regarded as good. In a reliability study on the c1assification of psychiatrie disorders in children and adolescents with ICD-9, Remschmidt et al. (1983) found agreement levels of 42 % and 43 % for 4-digit codes, and 54 % and 62 % for 3-digit codes (two coding trials each under different conditions). The fact that agreement was better in our study reflects familiarity with ICD-9: Six of our 7 raters used ICD-9 routinely in their c1inical work, whereas none of the raters in the Remschmidt et al. study did. Two things would lead us to expect somewhat better agreement with ICD-9 than with ICD-IO. First, ICD-IO has more diagnostic categories available, which reduces the Iikelihood of chance agreement. Second, 6 of the 7 raters used the ICD-9 routinely, but none ofthem had had any experience with ICD-IO. Routine use should improve agreement, as should in-house conferences on diagnosis, which should aso sure similar applications of a c1assification scheme. The fact that the level of agreement was roughly the same for the two c1assification schemes therefore indicates that ICD-IO is the more reliable ofthe two. We conclude that reliable coding ofpsychiatric disorders in children and adolescents is possible with the special categories of ICD-IO provided for that purpose. The frequently expressed wish for a further differentiation ofthese disorders has thus been achieved in ICD-IO. The appropriateness of the changes made is evident in the raters' behaviour: The raters used more different categories for the main diagnosis (only the most common diagnosis considered) when coding with ICD-IO than with ICD-9. The fact that the availability of additional diagnostic categories did not result in a marked decrease in the overall level of agreement speaks for the c1earness ofthe categories.
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Rater 1
175
Pharmacopsychiatry 23 (/990) Within-facility agreement at both facilities did not differ substantially from between-facility agreement, as the within-facility and interrater evaluations show. Hence, no facility-related tendencies to code in a particular way are evident. The descriptive approach to cIassification in both ICD-9 and ICD-l 0 appears to counteract any such tendencies. Differentiation between diagnostic categories was much mor difficult für some categories than for others. This was evident both in the analysis of agreement by diagn0sis and in the wriÜen commentaries from the raters. One ofthe problematic categories was mixed disorder of conduct and emotions (F92). There were problems, for instance, in differentiating between this category and conduct disorder (F91), emotional disorder with onset specific to childhood (F93), mood affective disorders (F30- F39) and neurotic, stress-related and somatoform disorders (F40- F49). Sometimes the individual components of the mixed disorder were also coded, primarily emotional disorder. Nevertheless, in the 2 cases where F92 was the most common diagnosis, 8 of the 14 ICD-l 0 ratings were F92, whereas for these same 2 cases only 4 of the 14 ICD-9 ratings were 3 I2.3 (mixed disturbance of conduct and emotions). These findings speak for the separation of this category from the other conduct disorders (F91), for this coding possibility apparently increases the acceptability of the conduct component of the diagnoses. There are also problems in cIassifying the disorders that were previously coded under 313.1 (disturbance of emotions specific to childhood). In ICD-IO the most relevant codes are F31.1 (depressive episode, moderate severity), F33.1 (recurrent depressive disorder, current episode moderate severity) and F34.1 (dysthymia). These categories differ not only in the severity ofthe disorder, but also in symptom duration. With regard to the latter criterion, the information available in the case histories used was incomplete. Under F31 the comment is made that "atypical presentations are particulady common in adolescence"; this statement reduces the cIarity of the diagnostic criteria. Although category F34.1 (dysthymia) has the lowest requirement as to severity, a duration of at least several years is required. As a result, this category, too, is only rarely appropriate for use in childhood and adolsescence. Taken together, all this must inevitably have a negative effect on the level of agreement in the coding of these disorders. The simplest solution would be to reduce the time criterion for childhood and adolescence in category F34.1. ICD-9 category 313.3 (disturbance of emotions specific to childhood) has been limited in ICD-I 0 to sibling rivalry disorder (F93.3). Because ofthis change there is no Ionger a category for disorders with excessive rivalry between peers in childhood. Inasmuch as it is known from general cIinical experience that such rivalries do exist, the category F93.3 should contain a statement that disorders with excessive rivalry between non-siblings should be coded under F93.8. In the past 313.3 was also used for disorders that suggest a passive contact disorder (because of lack of social competence); there is no corresponding category in ICD-IO, and it would therefore be helpful to have a statement under F93.2 (social sensitivity disorder) that such disorders should be coded under F94.8.
B. Blanz. H. Amorosa. M. H. Schmidt References American Psychiatrie Association: Diagnostic and statistical manual of mental disorders (3rd edition) (DSM-III). APA, Washington D. C. 1980 American Psychiatrie Association: Diagnostic and statistical manual of mental disorders (3rd edition, rcvised) (DSM-III-R) APA, Washington D. C. 1987 Remschmidt. H. M. Schmidt. D. Gäbe/: Erprobungs- und Reliabilitätsstudie zum multiaxialen Klassifikationsschema für psychiatrische Erkrankungen im Kindes- und Jugendalter. In: Multiaxiale Diagnostik in der Kinder- und Jugendpsychiatrie, ed. by H. Remschmidt, M. Schmidt. Verlag Hans Huber, Bern 1983,43-75 Schmidt. M. H: Klassifikation kinder- und jugend-psychiatrischer Störungsbilder iR der ICD-IO: Zum Stand der Diskussion. Z. Kinder-Jugendpsychiatr. 15 (\ 987) 208- 223 Steinhausen. H-C.: Ein Ausblick auf DSM-III-R. DSM-III-R: A look ahead. Z. Kinder-Jugendpsychiatr. 15 (\ 987) 224- 234 Wor/d Hea/th Organization: Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death, vols I and 11 (Ninth Revision). World Health Organization, Geneva 1977 Wor/d Hea/th Organization: ICD-I 0, 1987 Draft of Chapter V, Categories FOO- F99, Mental, Behavioural and Developmental Disorders. Clinical Descriptions and Diagnostic Guidelines. World Health Organization, Division of Mental Health, Geneva 1987 (MNH/MEP/87.1 Rev.1) Wor/d Hea/th Organization: ICD-IO, 1988 Draft of Chapter V, Categories FOO-F99, Mental, Behavioural and Developmental Disorders. Clinical Descriptions and Diagnostic Guidelines. World Health Organization, Division of Mental Health, Geneva 1988 (MNH/MEP/87.2 Rev.2)
Dr. B. B/anz
Kinder- und Jugendpsychiatrische Klinik im Zentralinstitut für Seelische Gesundheit Postfach D-6800 Mannheim
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176
Psychiatrie Disorders in Children and Adolescents: Results of the ICD-IO Field Trial B. Blanz, H. Amorosa *, M. H. Schmidt Department ofChild Psychiatry (Director: Prof. Dr. Dr. M. H. Schmidt), Central Institute for Mental Health, Mannheim, FRG *Max-Planck-Institute for Psychiatry (Director: Prof. Dr. Dr. F. Holsboer), München, FRG
Of the numerous changes made in the e1assification of psychiatrie disorders in children and adolescents in ICD-IO the most important are described. In an evaluation ofthe revised scherne, 7 raters from 2 facilities e1assified 40 case histories with both ICD-IO and ICD-9 codes. For ICD-IO and 4 character codes the level of agreement was 56% (lCD-9: 60%). As expected, 3-character codes yielded better agreement (ICD-IO: 71 %; ICD-9: 72%). Withinfacility agreement was roughly the same for each. The lowest levels of agreement for a given category were for mixed disorders of conduct and emotions (F92) and depressive disorders (F31, F43). The reasons for this are discussed.
1.lntroduction
The International C1assification of Diseases, 10th Revision (ICD-IO WHO, 1987) contains three sections on the e1assification of psychiatrie disorders with onset specific to childhood or adolescence. Before we present data from a field study with this revised e1assification scherne, we discuss the main changes in ICD-I 0 as compared with its predecessor, ICD-9 (WHO, 1977) in the sections "Developmental Disorders" (F80- F89) and "Behavioural and Emotional Disorders" (F90- F99) (cf. Schmidt. 1987).
1.1 Developmentaldisorders (F80- F89 In ICD-I 0 specific developmental disorders (F80- F83) and pervasive developmental disorders (F85) have been combined into a common section. The onset in infancy or childhood, the e10se relationship of impaired functions to the maturation of the central nervous system, the stable course, and the involvement of genetic factors are all seen as common elements of these disorders. We welcome the introduction of Pharmacopsychiatry 23 (1990) 173-176 (Supplement) @ Georg Thieme Verlag Stuttgart· New York
Psychiatrissehe Störungen bei Kindern und Jugendlichen: Ergebnisse der I CD-l O-Feldstudie
Von den zahlreichen Veränderungen, die in der ICD-I 0 für die Klassifikation kinder- und jugendpsychiatrischer Störungen erfolgen, werden die wichtigsten beschrieben. In einer Erhebung mit dem revidierten System schätzten 7 Rater aus 2 Zentren 40 Fallgeschichten mit ICD10 und ICD-9 diagnostisch ein. Für die vierstelligen ICDIO-Kodierungen ergab sich eine Übereinstimmung von 56% (lCD-9: 60%). Wie erwartet ergaben sich bei den dreistelligen Kodierungen bessere Übereinstimmungen. Die diagnostische Übereinstimmung innerhalb der Zentren war jeweils gleich. Die niedrigsten Übereinstimmungswerte für einzelne Kategorien zeigten sich bei der gemischten Verhaltens- und emotionalen Störung (F92) und depressiven Störungen (F31, F43). Die Ursachen hierfür werden diskutiert.
the objective approach with operationalized definitions for the specific developmental disorders: One of the diagnostic criteria for specific developmental disorders of speech and language (F80) is "a language delay that is sufficiently severe to fall outside the 2 standard deviation limits" and one for scholastic skills (F81) is scholastic achievement that is weil below the average level expected for a child ofthat IQ level and chronological age.
1.2 Behavioural and emotional disorders with onset usually occurring in childhood andadolescence (F90- F99) Hyperkinetic disorders (F90) are characterized by "the combination of overactive poorly modulated behaviour with marked inattention and lack of persistent task involvement"; further, there must be "pervasiveness over situations and persistence over time." The diagnostic category hyperkinesis with developmental delay (lCD-9: 314.1) has been deleted.
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Summary
Pharmacopsychiatry 23 (1990) A new category is conduct disorder confined to the family context (F91.0). We welcome the inc1usion of this disorder under conduct disorders, and anticipate that this will increase the confidence with which diagnoses in this area are made. Previously, such disorders were often considered to be an expression of neurotic delinquency and were then coded under neurotic disorders (ICD-9: 300.8) or other or mixed disturbance of emotions specific to childhood and adolescence (ICD-9: 313.8). As before, no distinction is made in the category conduct disorders between aggressive and non-aggressive behaviour. This distinction was added to DSM-I1I, but deleted again in DSM-I1I-R (cf. Steinhausen, 1987). Another change is the separation of mixed disorder of conduct and emotions (F92) from conduct disorder (F91). A category has thus been created for mixed disorders that, not infrequently, in the past were (incorrectly) c1assified as emotional disorders to avoid c1assification as conduct disorder. The group "emotional disorder with onset specific to childhood" (F93) continues to be differentiated from the neurotic, stress-related and somatoform disorders (F40F49). The justifications for this are the more favourable outcome in children, the developmental aspects of the psychopathological phenomena observed, the open question as to whether the mental mechanisms involved are the same as in adults, and the less c1ear demarcation of the main symptoms into supposedly specific entities. The category "disturbance of emotions specific to childhood and adolescence with misery and unhappiness" (lCD-9: 313.1) has been deleted. Disorders previously coded there can now usually be c1assified as depressive episode, moderate severity (F31.I), as recurrent depressive disorder, current episode moderate severity (F33.I) or as dysthymia (F34.1). These categories are valid for all ages, which counteracts overuse of the term "depression in childhood." The restriction of the earlier category relationship problems (ICD-9: 313.3) to sibling rivalry disorder (F93.3) must be viewed critically because there is no longer a specific category available for the peer rivalry typical in childhood. In the group of disorders of social functioning with onset specific to childhood or adolescence (F94), an exception has been made and etiological factors are relevant for the codes F94.1 (reactive attachment disorder of childhood) and F94.2 (attachment disorder of childhood, disinhibition type); experience will show whether it is still possible to differentiate these disorders reliably from other ifthe past history is incomplete. The tic disorders (F95) have been subdivided into four categories corresponding to empirical findings and therapeutic experience. In addition to the tic disorders (F95), anorexia nervosa (F50.0) has also been separated from the category "other behavioural and emotional disorders with onset usually occurring during childhood or adolescence" (F98). This is because these disorders occur in adults as weil as children. Overall, ICD-IO has a more detailed structure and provides more careful descriptions of many disorders than its predecessor.
B. Blanz, H. Amorosa. M. H. Schmidt fable 1 Number of different categories used in ICD-10 and ICD-9 for the main diagnoses. (For each case only the most frequently coded diagnosis is included.)
4-character diagnoses 3-character diagnoses
ICD-10
ICD-9
20
16 9
15
Below we present the most interesting findings from a field study on the practicability and reliability of ICD10 for c1assifying psychiatric disorders in children and adolescents. 2. Materials and Methods Case histories served as the basis for the study. The case histories used were summary reports on 40 children and adoles· cents admitted consecutively to an inpatient unit: all identifying material had been deleted, as had any direct mention ofthe diagnosis or dia· gnoses, and all information on treatment. The histories were evaluated independently by 7 raters from 2 facilities - the Child and Adolescent Psychiatric Unit at the Central Institute for Mental Health, Mannhelm (Facility I) and the Child Psychiatry Department of the Max·Planck· Institute for Psychiatry, Munich (Facility 11). Diagnoses were made with both ICD·lO and ICD-9, which yielded 280 ratings with each scheme. (Multiaxial classification is now used in child and adolescent psychiatry, but for reasons of comparability only the findings for Axis One Clinical Psychiatric Syndrome, are discussed here.) Agreement was 'calculated as percentage agreement and as a weighted kappa coefficient.
3. Results
3.1 Main diagnoses The ICD-IO diagnosis made was developmental disorder (F8) in 4 cases, behavioural or emotional disorder (F9) in 28 cases, and some other category in 8 cases. Thus, 80'% of the cases were given a code specific to children or adolescents, and hence the goal of evaluating this group of categories was achieved. Table 1 shows the number of different diagnostic categories used by the raters for the main diagnosis. Only one diagnosis is inc1uded per case - the one coded most frequently. More categories can be coded in ICD-IO than. in ICD-9. Since chance agreement of diagnoses decreases wlth increasing numbers of diagnostic categories available, the wider range of diagnoses in ICD-I 0 must be taken into consideration when interpreting the measure of agreement.
3.2 Overall agreement When 4-character codes were used, 56 '% of the raters were in agreement about a given ICD-IO diagnosis (ICD-9: 60%). As expected, when 3-character codes were used agreement was better (lCD·IO: 71 %; ICD-9: 72'%). When both main and alternative diagnoses were considered, agreement was 64% for 4-character codes (ICD-9: 64'%) and 77% for 3-character codes (ICD-9: 76%). Consideration of additional diagnoses led to only a negligible increase in agreement, however.
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174
Psychiatrie Disorders in Children and Adolescents: Results 0/ the [CD-] 0 Field Trial
Pharmacopsychiatry 23 (1990)
Tlble 2 Weighted kappa coefficients lor the individual pairs 01
Tlble 4 Most common diagnoses with lowest interrater agree-
raters (3-character main diagnoses, ICD-10)
ment, other diagnoses coded for the cases involved, and number of raters who coded each category
1 2 3 4 5 6
2
3
4
5
6
7
0.60
0.39 0.35
0.63 0.54 0.34
0.61 0.55 0.44 0.50
0.62 0.64 0.43 0.52 0.51
0.57 0.56 0.31 0.53 0.53 0.46
Tlble 3 Agreement by diagnosis: Main diagnostic categories ranked according to the level 01 agreement among raters (3-character codes, ICD-10) No. 01 cases
Categories F20 F45 F94
F32 F85 F90 F98
F42 F91 F92 F43 F70 F31
Schizophrenia Somatolorm disorders Disorders of social functioning with onset specific to childhood or adolsescence Bipolar affective disorder 1 Pervasive developmental disorder 4 Hyperkinetic disorder 4 Other behavioural and emotional disorders with onset usually occurring during childhood 3 Obsessive-compulsive disorder 1 Conduct disorder 18 Mixed disorder of conduct and emotions 2 Reaction to severe stress and adjustment disorders 1 Mild mental retardation 2 Depressive episode 1 Total
Agreement in% 100 100
100 86 86 86
Most common diagnosis (No. of raters)
Other diagnoses No. of raters)
F92" (8)
F93 (2)
F43' (4)
F61 (3)
F70' , (6) F31' (3)
F35 (1)
F43 (1)
F91 (1)
F95 (1)
F85 (3)
F71 (2)
F41 (1)
F79 (1)
F93 (1)
F34 (2)
F33 (1)
F60 (1)
"2 subjects, 14 ratings '1 subject, 7 ratings
vided - it was not always possible to make a definitive diagnosis. However, the relatively low levels of agreement for the categories F92, F43, F70 and F31 also reflect problems in dif· ferentiating between these and other categories. A look at the other main diagnoses coded for the cases in these categories makes this c1ear (Table 4). 4, Discussion
76 71 67 57 57 43 43
40
3.3 Withinfacilityagreement For 4-character codes the agreement on the main diagnoses was 58 % at Facility I (lCD-9: 63 %) and 52 % at Facility 11 (lCD-9: 52 %). Agreement was higher at both facilities when 3-character codes were used: Facility I 70 % (ICD-9: 73 %) and Facility 11 68 % (lCD-9: 68 %).
3.4 Interrater agreement Table 2 shows interrater agreement for each combination of raters. Raters I to 4 were from Facility I, and raters 5 to 7 from Facility 11. The kappa coefficients are between 0.31 and 0.64. The 6 lowest kappa values are associated with rater 3. This rater had relatively little experience with multiaxial c1assification schemes. Clear "clusters" in the sense of higher agreement of raters from the same facility are not evident.
3.5 Agreement by diagnoses Agreement among the 7 raters on a given diagnostic category ranged from 43% to 100% (Table 3). This is due in part to the difference in the amount ofinformation pro-
The level of agreement on the main diagnoses can be regarded as good. In a reliability study on the c1assification of psychiatrie disorders in children and adolescents with ICD-9, Remschmidt et al. (1983) found agreement levels of 42 % and 43 % for 4-digit codes, and 54 % and 62 % for 3-digit codes (two coding trials each under different conditions). The fact that agreement was better in our study reflects familiarity with ICD-9: Six of our 7 raters used ICD-9 routinely in their c1inical work, whereas none of the raters in the Remschmidt et al. study did. Two things would lead us to expect somewhat better agreement with ICD-9 than with ICD-IO. First, ICD-IO has more diagnostic categories available, which reduces the Iikelihood of chance agreement. Second, 6 of the 7 raters used the ICD-9 routinely, but none ofthem had had any experience with ICD-IO. Routine use should improve agreement, as should in-house conferences on diagnosis, which should aso sure similar applications of a c1assification scheme. The fact that the level of agreement was roughly the same for the two c1assification schemes therefore indicates that ICD-IO is the more reliable ofthe two. We conclude that reliable coding ofpsychiatric disorders in children and adolescents is possible with the special categories of ICD-IO provided for that purpose. The frequently expressed wish for a further differentiation ofthese disorders has thus been achieved in ICD-IO. The appropriateness of the changes made is evident in the raters' behaviour: The raters used more different categories for the main diagnosis (only the most common diagnosis considered) when coding with ICD-IO than with ICD-9. The fact that the availability of additional diagnostic categories did not result in a marked decrease in the overall level of agreement speaks for the c1earness ofthe categories.
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Pharmacopsychiatry 23 (/990) Within-facility agreement at both facilities did not differ substantially from between-facility agreement, as the within-facility and interrater evaluations show. Hence, no facility-related tendencies to code in a particular way are evident. The descriptive approach to cIassification in both ICD-9 and ICD-l 0 appears to counteract any such tendencies. Differentiation between diagnostic categories was much mor difficult für some categories than for others. This was evident both in the analysis of agreement by diagn0sis and in the wriÜen commentaries from the raters. One ofthe problematic categories was mixed disorder of conduct and emotions (F92). There were problems, for instance, in differentiating between this category and conduct disorder (F91), emotional disorder with onset specific to childhood (F93), mood affective disorders (F30- F39) and neurotic, stress-related and somatoform disorders (F40- F49). Sometimes the individual components of the mixed disorder were also coded, primarily emotional disorder. Nevertheless, in the 2 cases where F92 was the most common diagnosis, 8 of the 14 ICD-l 0 ratings were F92, whereas for these same 2 cases only 4 of the 14 ICD-9 ratings were 3 I2.3 (mixed disturbance of conduct and emotions). These findings speak for the separation of this category from the other conduct disorders (F91), for this coding possibility apparently increases the acceptability of the conduct component of the diagnoses. There are also problems in cIassifying the disorders that were previously coded under 313.1 (disturbance of emotions specific to childhood). In ICD-IO the most relevant codes are F31.1 (depressive episode, moderate severity), F33.1 (recurrent depressive disorder, current episode moderate severity) and F34.1 (dysthymia). These categories differ not only in the severity ofthe disorder, but also in symptom duration. With regard to the latter criterion, the information available in the case histories used was incomplete. Under F31 the comment is made that "atypical presentations are particulady common in adolescence"; this statement reduces the cIarity of the diagnostic criteria. Although category F34.1 (dysthymia) has the lowest requirement as to severity, a duration of at least several years is required. As a result, this category, too, is only rarely appropriate for use in childhood and adolsescence. Taken together, all this must inevitably have a negative effect on the level of agreement in the coding of these disorders. The simplest solution would be to reduce the time criterion for childhood and adolescence in category F34.1. ICD-9 category 313.3 (disturbance of emotions specific to childhood) has been limited in ICD-I 0 to sibling rivalry disorder (F93.3). Because ofthis change there is no Ionger a category for disorders with excessive rivalry between peers in childhood. Inasmuch as it is known from general cIinical experience that such rivalries do exist, the category F93.3 should contain a statement that disorders with excessive rivalry between non-siblings should be coded under F93.8. In the past 313.3 was also used for disorders that suggest a passive contact disorder (because of lack of social competence); there is no corresponding category in ICD-IO, and it would therefore be helpful to have a statement under F93.2 (social sensitivity disorder) that such disorders should be coded under F94.8.
B. Blanz. H. Amorosa. M. H. Schmidt References American Psychiatrie Association: Diagnostic and statistical manual of mental disorders (3rd edition) (DSM-III). APA, Washington D. C. 1980 American Psychiatrie Association: Diagnostic and statistical manual of mental disorders (3rd edition, rcvised) (DSM-III-R) APA, Washington D. C. 1987 Remschmidt. H. M. Schmidt. D. Gäbe/: Erprobungs- und Reliabilitätsstudie zum multiaxialen Klassifikationsschema für psychiatrische Erkrankungen im Kindes- und Jugendalter. In: Multiaxiale Diagnostik in der Kinder- und Jugendpsychiatrie, ed. by H. Remschmidt, M. Schmidt. Verlag Hans Huber, Bern 1983,43-75 Schmidt. M. H: Klassifikation kinder- und jugend-psychiatrischer Störungsbilder iR der ICD-IO: Zum Stand der Diskussion. Z. Kinder-Jugendpsychiatr. 15 (\ 987) 208- 223 Steinhausen. H-C.: Ein Ausblick auf DSM-III-R. DSM-III-R: A look ahead. Z. Kinder-Jugendpsychiatr. 15 (\ 987) 224- 234 Wor/d Hea/th Organization: Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death, vols I and 11 (Ninth Revision). World Health Organization, Geneva 1977 Wor/d Hea/th Organization: ICD-I 0, 1987 Draft of Chapter V, Categories FOO- F99, Mental, Behavioural and Developmental Disorders. Clinical Descriptions and Diagnostic Guidelines. World Health Organization, Division of Mental Health, Geneva 1987 (MNH/MEP/87.1 Rev.1) Wor/d Hea/th Organization: ICD-IO, 1988 Draft of Chapter V, Categories FOO-F99, Mental, Behavioural and Developmental Disorders. Clinical Descriptions and Diagnostic Guidelines. World Health Organization, Division of Mental Health, Geneva 1988 (MNH/MEP/87.2 Rev.2)
Dr. B. B/anz
Kinder- und Jugendpsychiatrische Klinik im Zentralinstitut für Seelische Gesundheit Postfach D-6800 Mannheim
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