|Year : 2018 | Volume
| Issue : 5 | Page : 63-67
Childhood disorders in international classification of diseases and related health Problems-11 and their relationship to diagnostic and statistical manual of mental Disorders-5 and international classification of diseases and related health Problems-10
Shoba Srinath1, Preeti Jacob1, Preeti Kandasamy2, Sowmya Bhaskaran3
1 Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Tamil Nadu, India
3 Department of Psychiatry, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
|Date of Web Publication||20-Nov-2018|
Dr. Shoba Srinath
Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Disorders in latest editions of the classificatory systems ICD-11 and DSM-5 have been categorised from a developmental lifespan perspective which is step in the right direction. Other laudatory features include highlighting developmental presentations, grouping neurodevelopmental disorders and including new diagnoses such as Complex PTSD and Prolonged Grief Disorder among others. However, conditions such as Conduct Disorder confined to the family context and Mixed Neurodevelopmental Disorder have been eliminated from the new classificatory system. These changes which have special clinical relevance especially from the Indian context have been reviewed and discussed below.
Keywords: Childhood disorders, Diagnostic and Statistical Manual of Mental Disorders-5, International Classification of Diseases and Related Health Problems-11
|How to cite this article:|
Srinath S, Jacob P, Kandasamy P, Bhaskaran S. Childhood disorders in international classification of diseases and related health Problems-11 and their relationship to diagnostic and statistical manual of mental Disorders-5 and international classification of diseases and related health Problems-10. Indian J Soc Psychiatry 2018;34, Suppl S1:63-7
|How to cite this URL:|
Srinath S, Jacob P, Kandasamy P, Bhaskaran S. Childhood disorders in international classification of diseases and related health Problems-11 and their relationship to diagnostic and statistical manual of mental Disorders-5 and international classification of diseases and related health Problems-10. Indian J Soc Psychiatry [serial online] 2018 [cited 2019 Apr 19];34, Suppl S1:63-7. Available from: http://www.indjsp.org/text.asp?2018/34/5/63/245831
| Introduction|| |
The eleventh revision of the International Classification of Diseases and Related Health Problems (ICD) is currently underway by the World Health Organization (WHO) and will be made available by 2018 (www.who.int/classifications/icd/whoresponseicd11.pdf? ua = 1). Meanwhile, the beta draft of the chapter on mental and behavioral disorders in the 11th revision of the (ICD) is available for contributions and comments (http://apps.who. int/classifications/icd11/browse/l-m/en). This is one such commentary on childhood disorders in the 11th revision of the ICD when compared to the previous revision in what is most assuredly a mammoth undertaking. A critique of all the mental, behavioral, and neurodevelopmental disorders of childhood were not possible due to space constraints and this is a limitation. We have selected a few disorders that have special relevance from a sociocultural perspective, particularly with respect to their clinical utility and have highlighted them here.
Both the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the ICD have always followed a descriptive categorical approach despite the limitations of this type of classification. However, the categorical approach also has a number of advantages in both the clinical sphere and with respect to our understanding and research into psychiatric disorders. The ICD and DSM classificatory systems have some significant differences in their conceptualization of certain disorders. This lack of concordance between the two major classificatory systems across diagnoses has always been a source of ire and frustration for practitioners and researchers worldwide. Keeping this in mind, the American Psychiatric Association and the WHO have strived hard to achieve conceptual and item-wise disorder-specific congruence between their respective classificatory systems., Both classificatory systems (ICD-11 and DSM-5) have now taken a developmental lifespan approach and have, thereby drastically reduced the number of classified disorders. This has been achieved by inclusion of additional features and subcategorization to account for the clinical heterogeneity and developmental presentations.
A discussion on the broad categorization of disorders relevant to children and based on the authors' clinical experience and research involvement from teaching hospitals in India is presented below.
| Neurodevelopmental Disorders|| |
A welcome change in both the latest revisions of the classificatory systems is that they have combined all neurodevelopmental disorders into one big cluster. Attention-deficit hyperactivity disorder (ADHD), stereotypic movement disorder, and tic disorders have been recognized as neurodevelopmental disorders and have rightly found a place under this section. This change reflects our current conceptual understanding of these disorders from shared genetic and environmental risk factors affecting neural and biological characteristics and ultimately the phenotypes that they represent.,, Given the familial nature of enuresis and its obvious comorbidity with other neurodevelopmental disorders, a case can be made for the inclusion of this condition under the rubric of neurodevelopmental disorders as well.,
Based on the current understanding of neurodevelopmental disorders, the omission of mixed specific developmental disorders (F83) as a category from the latest revision of the ICD is abstruse. DSM-5 has a category called other specified neurodevelopmental disorder (F315.8) and an unspecified neurodevelopmental disorder (315.9) which corresponds to F88 and F89 in the 10th revision and to other neurodevelopmental disorder in the 11th revision of the ICD. The “unspecified” and the “other” categories nevertheless are not equivalent to the “mixed” category. “Mixed” presentations are accommodated under “other specified neurodevelopmental disorder” (315.8) in DSM-5, which includes presentations with sociooccupational dysfunction/impairment that does not meet the criteria for specific neurodevelopment disorders. A separate category with mixed presentation with combination of symptoms from different disorders is not delineated. This is suboptimal because mixed presentations need further assessment, intervention, and follow-up. The “unspecified” category also does not cover these presentations well because it is meant for situations where there is insufficient information to make a more specific diagnosis. While there is a place for strict categories both in clinical practice and research, our experience often times is that children with neurodevelopmental symptoms, especially early on, do not neatly fall into these categories. This has been described in the concept known as “early symptomatic syndromes eliciting neurodevelopmental clinical examinations” (ESSENCE). While comorbid diagnoses are allowed in both classificatory systems now, some cases do not meet criteria for specific disorders and have an admixture of symptoms from different neurodevelopmental disorders. Delineation of “mixed neurodevelopmental disorder” would help the clinician appreciate that there is an assortment of difficulties and impairments in the child that requires holistic and continual assessment and management over the lifespan. ICD-10 included a category of “mixed specific developmental disorders”-“this is an ill-defined, inadequately conceptualized (but necessary) residual category of disorders.….” With the recognition of ESSENCE the need for “mixed specific developmental disorders” category is greater than earlier. We suggest that while specifying this category, the classificatory system should mention that it is a temporary diagnosis requiring reassessment and that it should be reserved for children below 5 years of age. The diagnosis would also help the clinician to focus on the neurodevelopmental disorder as well as other subthreshold symptoms suggestive of related disorders (e.g., ADHD and ASD) with regard to evaluation, interventions, referral, and follow-up.
| Anxiety and Fear-Related Disorders|| |
The DSM-5 and ICD-11 have espoused a developmental lifespan approach to the disorders classified under this section with the inclusion of separation anxiety disorder and selective mutism. Both revisions have given “anxiety and fear related disorders” their due by classifying them as an independent grouping, unlike their previous editions. Other laudatory features are the inclusion of developmental presentations under each category and discussions about boundaries with normal development and differential diagnosis to enable better clinical judgment. Both classificatory systems have allowed for comorbid diagnosis, both across anxiety disorders and with depression, in keeping with our current conceptual understanding of these conditions. However, a qualifier for social anxiety, namely “performance only,” has not been recorded in the beta version of ICD-11. This is an important qualifier in the Indian context, given that “board examinations” which take place at the age of 16 and 18 years (Secondary and Higher Secondary School Examinations) are a common cause of anxiety, especially in adolescents; either because of undue pressure from parents and teachers or internalization of such expectations on the part of the adolescents. Many adolescents have a range of psychiatric and psychological problems at this juncture, including school refusal, depression, suicidal ideation/attempt, and debilitating anxiety., The qualifier “performance only” under social anxiety disorder would help clinicians in formulating targeted intervention for both the adolescents and their family.
| Disorders Specifically Associated with Stress|| |
There is a change in the title of the grouping from “reaction to severe stress and adjustment disorders” in ICD-10 to “disorders specifically associated with stress” in ICD-11. An identifiable stressor is necessary for the diagnosis of disorders specifically associated with stress, and the classification of disorders in this grouping is based on the nature, pattern, and duration of the symptoms that arise in response to the stressful event. The change of title, in our opinion, has important implications for our understanding of the disorders listed under this section as well as our understanding of stress. The latest revision of the ICD has taken into account that not all stress needs to be life-threatening and horrific and less severe psychosocial stress (life events) can also lead to psychological symptoms and disorders. At the same time, ICD-11 has conceptualized acute stress reaction as a normal response to recent overwhelming stressor and has included it under the category of “factors influencing health status and contact with services,” so as to not pathologize what is essentially a transient state occurring in the immediate aftermath of an acute stressful event, but which may still require clinical attention.
As with other disorders in ICD-11, developmental presentations have been included in this section as well which is praiseworthy. In fact, for a condition such as posttraumatic stress disorder, ICD-11 has acknowledged what is known in the literature that children may not present like adults due to their “emerging cognitive capacities and limited verbal abilities” and may thus find it difficult to report internal states.
Complex posttraumatic stress disorder (complex PTSD) is a new diagnosis in this grouping. This diagnosis is a combination of PTSD and ICD-10 category of “enduring personality change after catastrophic experience (F62.0)” as the latter did not garner adequate clinical and scientific interest. Children are more vulnerable to this disorder than adults and thus the previous practice of undermining the importance of prolonged stress in early childhood because it was difficult to diagnosis “enduring personality change after catastrophic experience” in childhood was not appropriate. This diagnosis is not present in DSM-5. Complex PTSD is envisaged as a disorder that occurs in the wake of an event or a series of events that are horrific, life-threatening, and are often times repetitive and prolonged, where the person feels escape is difficult. This is especially relevant given that children are often the target of severe and significant violence and human rights violations including sexual violence, trafficking, and other such heinous crimes.,,
Prolonged grief disorder has been given the status of an independent disorder in ICD-11, while its counterpart in DSM-5, persistent complex bereavement disorder has been placed under the section of “conditions for future study.” With respect to children, ICD-11 has discussed the boundaries of normal bereavement and prolonged grief disorder with developmental presentations and expressions of grief, including other relevant psychological and psychosocial factors such as the nature and intensity of child's relationship with the deceased (e.g., loss of primary caregiver) and the contextual factors such as change in social environment, family communication, and caregivers' coping with the loss among others; issues that are pertinent to the clinical situation.
In ICD-10, attachment disorders were classified under the section of “Disorders of social functioning with onset specific to childhood and adolescence” (F94). Research over the last decade has established that exposure to chronic stress in the form of severe social neglect and grossly inadequate caregiving specifically in the early developmental period is necessary for attachment disorders to occur and both DSM-5 and ICD-11 have taken cognizance of the accumulating literature in this area and these two disorders have been aptly classified under this section.
Finally, with respect to adjustment disorders, this is a diagnosis, that is, frequently used in the clinical setting despite its diagnostic criteria being unclear and the lack of epidemiological and other research in this area. The lack of precise criteria for adjustment disorders in ICD-10 resulted in conflation with other disorders and the excessive use of psychotropic agents. The diagnostic guidelines for adjustment disorders in the ICD-11 have been made more specific, especially delineating the boundary with normality and other mental and behavioral disorders. This will certainly prevent this diagnosis from being misused as a wastebasket diagnosis for subthreshold symptoms. However, ICD-11 beta version does not have any qualifiers in the section on adjustment disorders as opposed to DSM-5. In our experience, qualifiers such as “with mixed anxiety and depressed mood” or “with mixed disturbance of emotions and conduct” have considerable clinical utility as the management differs and ICD-11 should consider adding these qualifiers. In addition, regression is a frequently occurring symptom complex in children and adolescents, and while it is mentioned in the developmental presentation of the disorder, a qualifier “with regression” would have considerable clinical relevance.
| Disruptive Behavior and Dissocial Disorders|| |
A number of important issues have been noted with regard to disruptive and dissocial disorders in ICD-11 and DSM-5. First, there is no stated age cutoff, and while there was not one even in the previous revisions, these disorders were coded under the section on “disorders of childhood and adolescence” (F90–98)., It is now clear that conduct disorder (CD) under the category of “disruptive behaviors and dissocial disorders” can persist the past developmental periods of childhood and adolescence.
Oppositional defiant disorder (ODD) (F 91.3) was seen as a subtype of CD in ICD-10. The disorders are considered separate in ICD-11 based on low rates of conversion from ODD to CD; and the findings suggesting that ODD mostly predicted emotional outcomes and CD, predicted behavioral outcomes. Research in the past decade has also shown that the “irritable” dimension of ODD was predictive of depression and many patients with ODD also had a family history of mood disorders. Only the headstrong and the hurtful dimensions of ODD were predictive of ADHD and nonaggressive/aggressive CD., The 11th revision of the ICD reflects this understanding of ODD and we feel that these qualifiers will have substantial usefulness in the clinical setting. DSM-5 also recognizes angry/irritable mood as a core symptom of ODD but does not include it as a specifier. On the other hand, DSM-5 has a category called disruptive mood dysregulation disorder (DMDD) (296.99). This diagnosis is not available in ICD-11. The ICD-11 category of “ODD with chronic irritability and anger” is the closest counterpart of DSM-5 DMDD. We feel this lack of concordance between the two classificatory systems is a cause for concern. While, there is some support for (DMDD) as a diagnostic entity, whether it will actually reduce the rates of diagnosis of bipolar disorder in children and adolescents remains to be seen. Furthermore, the lack of global evidence on DMDD makes its inclusion in ICD-11 difficult. It is therefore understandable that ICD-11 has been circumspect and has included “chronic irritability” as a qualifier under ODD because of its public health and clinical utility.
CD confined to the family context (F 91.0) has been removed from the beta draft of ICD-11. This was an extremely important diagnostic entity in India, both from a clinical and sociocultural perspective. In fact, CD in the family context was the most common diagnosis in a file review on CD from India. India is undergoing massive changes in terms of urbanization and globalization where there is a constant struggle between old and new values and this is very evident in the realm of parenting. Indian families are mostly patriarchal and the parenting style continues to be authoritarian for most part. Parents of boys are indulgent and punitive even though these two styles seem contradictory. Often parents have unrealistic expectations regarding academic success and achievement resulting in a number of psychiatric and psychological disturbances including CD confined to the family context. A study done on parenting dimensions and externalizing behaviors in the Indian context showed that there was a significant correlation between punitive, physically coercive, and verbally hostile parenting that predicted externalizing behaviors in children. Indian as well as Western research has shown that familial factors such as inconsistent disciplining, overinvolvement, marital conflict, discordant intrafamilial relations, lack of parental supervision/control, presence of parental mental disorder, and anomalous family situations; are associated with CD.,,, As the symptoms of CD are mostly present in the family context, this is an important diagnosis from the perspective of intervention. ICD-11 must reconsider retaining this diagnostic category as it is extremely relevant in the present Indian context.
| Other Considerations – Multiaxial Classification|| |
Multiaxial systems help circumvent problem of false dichotomies, wherein clinicians have to choose between two diagnoses as it provides a means to record the main clinical picture and other dimensional features. Given the ease of use, multiaxial classification is considered the norm in child psychiatry and it is hoped that like ICD-10 (https://www.bookdepository.com/Multiaxial-Classification-Child-Adolescent-Psychiatric-Disorders-World-Health-Organization-WHO/9780521 581332), the 11th revision will also incorporate a similar version. In ICD-11 beta draft, “Factors influencing health status or contact with health services” compensate to an extent in this regard.
| Conclusions|| |
No classificatory system is perfect. However, both DSM-5 and ICD-11 are in keeping with our current conceptual understanding of mental and behavioral disorders. Classificatory systems are meant to ease communication between professionals and with clients so that appropriate clinical interventions can be instituted. In this regard, the congruence between ICD-11 and DSM-5 will aid in their greater global acceptance and applicability. This will help in establishing comparability of research findings across countries. But as with all categorical systems in a dimensional world, there are always problems when people do not neatly fall into categories and thus the continued need for “mixed” categories. The aim of classificatory systems must be that more people use it across a multitude of settings and across cultures, and therefore, these factors must be paid attention to for greater applicability. There are certain diagnostic categories that are particularly useful in specific countries or cultures. Since ICD is a global classificatory system, it must retain these diagnostic categories. Multiaxial classificatory systems have tremendous clinical utility and allow a more holistic conceptualization of the child and family factors and hopefully, a system like that in ICD-10 for children and adolescents will be incorporated in ICD-11. Overall, ICD-11 brings greater clarity regarding the presentation of all disorders seen in children and adolescents, and there is hope that it will improve recognition of these disorders across various health-care settings.
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