The aim of the study was to examine directly the extent to which ICD 10 hyperkinetic disorder and DSM IV attention deficit/hyperactivity disorder (ADHD) identify the same children with the same difficulties. Participants were elementary school children (n=409) aged 7-10 years. Diagnostic criteria for ICD 10 hyperkinetic disorder and DSM IV ADHD were applied. Four groups were identified: hyperkinetic disorder and ADHD (n=35), ADHD only (n=27), hyperkinetic disorder only (n=3), and children without any symptoms according to DSM IV and ICD 10 criteria (n=344). The kappa coefficient assessing the agreement between the DSM IV ADHD and ICD 10 hyperkinetic disorder was K=0.66; percent of agreement = 78%. The c2-test yielded c2=250.3 (df=1; p<0.001). The prevalence of DSM IV ADHD and ICD 10 hyperkinetic disorder was 15.16% and 9.3%, respectively. DSM IV was found to identify a broader group of children; however, there was a substantial overlap between the groups formed according to these criteria.Cilj ovoga rada bio je usporediti u kojoj mjeri kriteriji MKB 10 za hiperkinetski poremećaj i poremećaj pozornosti/ hiperaktivnosti (ADHD) prema kriterijima DSM IV prepoznaju istu djecu s istovrsnim smetnjama. Ispitanici su bila djeca osnovnoškolskog uzrasta starosti 7-10 godina (n=409). U analizi su primijenjeni dijagnostički kriteriji prema klasifikaciji MKB 10 za hiperkinetski poremećaj i kriteriji DSM IV za ADHD. Izdvojene su četiri skupine djece: hiperkinetski poremećajem i ADHD (n=35), samo ADHD (n=27), samo hiperkinetski poremećaj (n=3) i djeca bez simptoma prema kriterijima DSM IV i ICD 10 (n=344). Koeficijent podudarnosti između hiperkinetskog poremećaja MKB 10 i DSM IV ADHD bio je K=0.66; postotak podudarnosti 78%. c2-test pokazao je statistički značajan rezultat (c2=250.3; df=1; p<0.001). Prevalencija za ADHD prema DSM IV bila je 15.16%, a za MKB 10 hiperkinetski poremećaj 9.3%. Utvrđeno je da DSM IV identificira širu skupinu djece, međutim, nađeno je značajno preklapanje među prepoznatim skupinama djece uz ova dva različita kriterija

Dalibor Karlović

Danijel Buljan

Danijel Crnković

Marko Martinac

Zoran Zoričić

English

Karlović, Dalibor

Zoričić, Zoran

Buljan, Danijel

Crnković, Danijel

Martinac, Marko

Repository of the Sestre milosrdnice University Hospital Center

Podudarnost između poremećaja smanjene pozornosti / hiperaktivnosti (DSM IV ADHD) i hiperkinetskog poremećaja ICD 10 u uzorku hrvatske dječje populacije

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Karloviæ D. et al. Correspondence between DSM IV and ICD 10Acta clin Croat, Vol. 41, No. 4, 2002 323Acta clin Croat 2002; 41:323-326 Original Scientific PaperCORRESPONDENCE BETWEEN DSM IV ADHD ANDICD 10 HYPERKINETIC DISORDER IN CROATIAN SAMPLEDalibor Karloviæ, Zoran Zorièiæ, Danijel Buljan, Danijel Crnkoviæ, Marko MartinacUniversity Department of Psychiatry, Sestre milosrdnice University hospital, Zagreb, CroatiaSUMMARY  The aim of the study was to examine directly the extent to which ICD 10 hyperkineticdisorder and DSM IV attention deficit/hyperactivity disorder (ADHD) identify the same children with thesame difficulties. Participants were elementary school children (n=409) aged 7-10 years. Diagnostic crite-ria for ICD 10 hyperkinetic disorder and DSM IV ADHD were applied. Four groups were identified: hyper-kinetic disorder and ADHD (n=35), ADHD only (n=27), hyperkinetic disorder only (n=3), and childrenwithout any symptoms according to DSM IV and ICD 10 criteria (n=344). The kappa coefficient assessingthe agreement between the DSM IV ADHD and ICD 10 hyperkinetic disorder was K=0.66; percent ofagreement = 78%. The χ2-test yielded χ2=250.3 (df=1; p<0.001). The prevalence of DSM IV ADHD andICD 10 hyperkinetic disorder was 15.16% and 9.3%, respectively. DSM IV was found to identify a broadergroup of children, however, there was a substantial overlap between the groups formed according to thesecriteria.Key words: Attention deficit disorder with hyperactivity, diagnosis; Hyperactivity, diagnosis; Child behavior disorders,classification; Reference values; Child; CroatiaCorrespondence to: Dalibor Karloviæ, M.D., M.S., University Departmentof Psychiatry, Sestre milosrdnice University Hospital, Vinogradska c. 29,HR-10000 Zagreb, CroatiaReceived July 7, 2002, accepted in revised form September 12, 2002IntroductionHyperactive behavior was first described in 1932, af-ter a pandemic of encephalitis lethargy followed by an in-creased number of children presenting hyperactive andimpulsive behavior1. Most researchers believed that thisbehavioral pattern was caused by minimal cerebral dys-function/damage (MCD). The research and diagnosticmethods of the time failed to produce evidence for mini-mal cerebral damage2. Therefore, the classification systemsof behavior problems were more or less confined to descrip-tion of phenomenology2-4.International Classification of Diseases (ICD) is anofficial classification of the World Health Organization(WHO). In 1969, ICD 8 classified the disorder as a hyper-kinetic reaction of childhood5. ICD 9 classified the disor-der as a hyperkinetic syndrome6, and ICD 10 as a hyperk-inetic disorder7,8. According to DSM classification (officialclassification of the American Psychiatric Association) from1994, the disorder is classified as attention deficit/hyper-activity disorder (ADHD)9. The names used in prior ver-sions of DSM emphasize different conceptualization of thedisorder over years, from motor dysinhibition in DSM II(hyperkinetic reaction of childhood), inattention in DSMIII (ADD, attention deficit disorder) through both inat-tention and hyperactivity in DSM III R and DSM IV10.Also, while DSM III R considers ADHD to be a unitarydisorder such as hyperkinetic disorder in ICD 10, DSM IVconceptualized ADHD as having three subtypes: com-bined, predominantly inattentive, and predominantly hy-peractive-impulsive subtypes11. For both clinicians andresearchers, this evolution in diagnostic thinking has beenhelpful because of the improvements in reliability andvalidity of successive definitions, but confusing for uncer-tainty in generalizing one diagnostic system to another. Itremains an empirical question whether these two systemsof classification are in fact  identifying the same, or simi-lar, groups of children.Karloviæ D. et al. Correspondence between DSM IV and ICD 10324 Acta clin Croat, Vol. 41, No. 4, 2002Subjects and MethodsSubjectsThe ime Budiniæ elementary school from Zadar wasrandomly selected among all elementary schools in theRepublic of Croatia. The study included all children(N=409) of the 1st to 4th grade of this elementary school,aged 7 to 10 (mean±SD 8.6±1.4) years, of both sexes (194boys and 215 girls).Medical examinationThe first step was to distribute the Conners psychiat-ric rating scale for analysis of hyperkinetic/attention dis-order to teachers and parents (forms for parents with 48items and forms for teachers with 38 items)12. We used theConners rating scale as a screening test for attention/hy-peractivity child problem. Based on the Conners ratingscale, 131 children suspected for ADHD were singled outand observed by a medical doctor, who made a diagnosisof ADHD according to DSM IV criteria or of hyperkineticdisorder according to ICD 10 criteria. Children were iden-tified as DSM IV ADHD if the following criteria were met:1. Teachers report indicated that the child exhibited 6or more symptoms of inattention and/or 6 or moresymptoms of hyperactivity/impulsivity.2. Parents answers to the standardized questionnaire orclinical interview with the child indicated the symp-toms of inattention/hyperactivity/impulsivity to bewere present in more than one setting.3. The symptoms interfered with the childs functioning.Children were identified as hyperkinetic disorder ac-cording ICD 10 criteria if all of the following criteria weremet:1. Parents answers to the questionnaire pointed to a min-imum of 6 symptoms of inattention and 3 symptomsof hyperactivity.2. The symptoms of hyperactivity, impulsivity and atten-tion deficit were present at the time of observation.Statistical analysisConcordance between ICD 10 and DSM IV for thepresence/absence of the diagnosis of hyperkinetic disor-der/ADHD was tested by both percentage agreement andCohens kappa (K). If K was greater than 0.60 and percent-age agreement higher than 73%, diagnostic reliability wasconsidered appropriate. Mc Nemar c2­test for dependentsamples was used for analysis of correlation between DSMIV and ICD 10 diagnosis. Statistical significance was setat 1% (p<0.01). The prevalence of DSM IV ADHD andICD 10 hyperkinetic disorder was also calculated.ResultsOut of 409 children, 62 (15.6%) met DSM IV criteriafor ADHD, 35 children met the criteria for the hyperac-tive-impulsive/combined subtype, and 27 for the inatten-tive subtype. All children who met the criteria for the hy-peractive-impulsive/combined subtype ADHD accordingto DSM IV, met the criteria for hyperkinetic disorder ac-cording to ICD 10. None of these 27 children who met thecriteria for inattentive subtype ADHD met the criteria forICD 10 hyperkinetic disorder.ICD 10 classification was applied in the same sampleof 409 children, which showed 38 (9.3%) children (9.3%)to meet the criteria for ICD 10 hyperkinetic disorder only.Only three children who met the criteria for ICD 10 hy-perkinetic disorder did not meet the criteria for ADHDaccording to DSM IV.The χ2-test with Mc Nemar correction yielded a sta-tistically significant difference (χ2=250.3; df=1;p<0.001). Cohens kappa coefficient of agreement wasmoderate (percentage of agreement 78%; K=0.66). Theprevalence rate calculated from DSM IV was 15.16% forADHD, and from ICD 10 9.3% for hyperkinetic disorder.DiscussionThe results of this study suggested significant overlap-ping of cases identified by the ICD 10 and DSM IV diag-nostic systems. The majority of children with diagnosedhyperkinetic disorder also met the criteria for ADHD.However, the results also suggested the DSM IV criteriafor ADHD to identify a broader group of children than theICD 10 definition of hyperkinetic disorder. The childrenwho met the criteria for both hyperkinetic disorder andADHD represented an ADHD combined type or hyper-active impulsive type according to DSM IV. The smallnumber of children with the diagnosis of hyperkinetic dis-order alone prevented comparison of this group with ei-ther hyperkinetic, ADHD group or ADHD only group.These children presumably had  considerable problemswith inattention and overactivity but did not display therequired six symptoms of inattention or hyperactivity/impulsivity.However, literature reports from different countriesshow different prevalence rates of hyperkinetic disorderor ADHD, varying from 3% to 20%13,14. This suggests thatdifferences in the prevalence rates were not due to cross-national differences in the rate of behavioral phenomenabut rather to differences in diagnostic practice or concep-tualization of these behavioral patterns15-17.The DSM IV system, which has been developed inNorth America, is becoming increasingly popular as a di-Karloviæ D. et al. Correspondence between DSM IV and ICD 10Acta clin Croat, Vol. 41, No. 4, 2002 325agnostic system in other countries as well. It also appearsto be preferred by scientific journals for the presentationof research results. The ICD system continues to be usedin clinical practice in Europe, and is used worldwide formorbidity statistics recording. Until recently, the WHOand American Psychiatric Association (APA) descriptionsof childhood hyperactivity have differed in three key re-spects: the symptoms they emphasize, the importancethey place on symptom pervasiveness, and their treatmentof comorbid conditions9. The DSM IV appears to bring theWHO and APA systems for classifying childhood hyperac-tivity closer than they have been for almost three decades.The increased similarity between ICD 10 hyperkineticdisorder and ADHD is not accidental. There was a closeliaison between the working parties of the WHO and theAPA18,19. However, the definition of hyperkinetic disorderand the criteria for ADHD are not identical20.The ICD 10 definition of hyperkinetic disorder empha-sizes the presence of abnormal levels of inattention andoveractivity in home and school settings, together with thedirect observation of this inattention/overactivity7,9.Whereas DSM IV requires that symptoms must be presentin 2 or more settings, it does not require direct observa-tion of the symptoms by the clinician21-26.In conclusion, the study sample was not a representa-tive epidemiologic sample. However, it could be consid-ered representative of children referred for evaluation ofADHD, and offered useful insights into the similarities anddifferences between the children meeting the diagnosticcriteria for ADHD and those meeting the criteria for bothADHD and hyperkinetic disorder in this context.The imperfect overlap between the two diagnosticsystems has several implications:1. In countries in which the ICD 10 system is used in thediagnosis of mental disorders, children with significantproblems of hyperactivity or inattention but not bothmay go undiagnosed.2. The children diagnosed as hyperkinetic are likely tocorrespond to the ADHD combined type only but notto the inattentive or hyperactive-impulsive type. Con-versely, the results from studies including these threeADHD subtypes will not necessarily apply to childrenwith hyperkinetic disorder.3. Finally, as the ICD system is used worldwide for record-ing morbidity statistics, the recording of prevalencerates for hyperkinetic disorder is likely to be inflatedin the countries using DSM IV for clinical diagnosis.References1. HOHMAN LB. Post-encephalitic behaviour disorder in children.Johns Hopkins Hosp Bull 1932;33:89-97.2. WEISS G. Attention deficit hyperactivity disorder. In: LEWIS M,ed. Child and adolescent psychiatry. New York: Williams and WilkinsCo., 1991:544-62.3. CLEMENTS SD, PETERS JE. Minimal brain dysfunction in theschool-age child. Diagnosis and treatment. Arch Gen Psychiatry1962;6:185-97.4. LAUFER M, DENHOFF E. Hyperkinetic impulse disorder in chil-dren. J Pediatrics 1957:21:463-74.5. World Health Organization. Manual of the international statisticsof diseases, injuries, and causes of death. 8th Revision. Geneva: WorldHealth Organization, 1969.6. World Health Organization. Manual of the international statisticsof diseases, injuries, and causes of death. 9th Revision. Geneva: WorldHealth Organization, 1977.7. World Health Organization. Manual of the international statisticsof diseases, injuries, and causes of death. 10th Revision. Geneva:World Health Organization, 1991.8. TAYLOR E, SERGEANT J, DEPFNER M, GUNNING B, OVER-MEYER S, MOBIUS HI, EISERT HG. Clinical guidelines for hy-perkinetic disorder. European Society for Child and AdolescentPsychiatry. Eur Child Adolesc Psychiatry 1998;7:184-200.9. American Psychiatric Association. Diagnostic and statistical manu-al of mental disorders. 4th ed. Washington, DC: American Psychiat-ric Association Press, 1994.10. ARNOLD E, JENSEN P. Attention deficit disorder. In: KAPLANHI, SADOCK BJ, eds. Comprehensive textbook of psychiatry. Vol.II, 6th ed. Baltimore: Williams and Wilkins, 1995:2295-310.11. BIEDERMAN J, FARAONE S, WEBER W, RUSSELL R, RATERM, PARK KS. Correspondence between DSM III-R and DSM IVattention deficit/hyperactivity disorder. J Am Acad Child AdolescPsychiatry 1997;36:1682-7.12. CONNERS CK. Rating scales in attention deficit/hyperactivitydisorder: use in assessment and treatment monitoring. J Clin Psy-chiatry 1998;58 (Suppl 7):24-30.13. TAYLOR E, SANDERBERG S, THARLEY G, GILES S. The ep-idemiology of childhood hyperactivity: London: Oxford UniversityPress, 1991.14. KOCIJAN-HERCIGONJA D. Hiperaktivno dijete. Jastrebarsko:Naklada Slap, 1999.15. PRENDERGAST M, TAYLOR E, ROPOPORT JL, BARTKO J,DONNELLY M, ZAMETKIN A, ABEARU MB, DUNNG G, WIE-SELBERG HM. The diagnosis of childhood hyperactivity: a U.S.-U.K. cross-national study of DSM-III and ICD-9. J Child PsycholPsychiatry 1988;29:289-300.16. HOLBOROW P, BERRY P. A multinational, cross-cultural prospec-tive on hyperactivity. Am J Orthopsychiatry 1986;56:320-2.17. KARLOVIÆ D. Procjena poremeæaja panje sa hiperaktivnoæu udjece u obiteljima i kolama dvije urbane sredine. M. S. thesis, Schoolof medicine, Zagreb University School of Medicine, 2002.Karloviæ D. et al. Correspondence between DSM IV and ICD 10326 Acta clin Croat, Vol. 41, No. 4, 200218. SARTORIUS N, USTUN TB, KORTEN A, COOPER JE, VONDRIMMELEN J. Progress toward acheving a common language inpsychiatry, II: results from the international field trials of the ICD-10 diagnostic criteria for research for mental and behavioral disor-ders. Am J Psychiatry 1995;152:1427-37.19. Mc BURNETT K. Development of the DSM-IV: validity and rele-vance for school psychologists. School Psychol Rev 1996;25:259-73.20. VOLKMAR FR, SCHWAB-STONE M. Annotation: childhood dis-orders in DSM-IV. J Child Psychol Psychiatry 1996;37:779-84.21. CANTWELL D. Attention deficit disorder: a review of the past 10years. J Am Acad Child Adolesc Psychiatry 1996;35:978-87.22. THORLEY G. Hyperkinetic syndrome of childhood: clinical char-acteristics. Br J Psychiatry 1984;144:16-24.23. SCHWAB-STONE M, KENNETH E. Systems of clasification ICD10, DSM III-R, and DSM IV. In: LEWIS M, ed. Child and adoles-cent psychiatry. New York: Williams and Wilkins, 1991:422-34.24. TRIPP G, LUK S, SCHAUGBENCY EA, SINGH R. DSM IV andICD 10: a comparison of the correlates of ADHD and hyperkineticdisorder. J Am Acad Child Adolesc Psychiatry 1999;38:156-64.25. KARLOVIÆ D, BULJAN D, ZORIÈIÆ Z. Correspondence betweenDSM IV ADHD and ICD 10 hyperkinetic disorder in a Croatiansample. Neurol Croat 2002;51 (Suppl 1):92.  (abstract)26. KARLOVIÆ D, BULJAN D, ZORIÈIÆ Z, CRNKOVIÆ D, MAR-TINAC M, MARÈINKO D. Suvremene osnove klasifikacije, dijag-nostike, epidemiologije i etiologije poremeæaja panje  hiperak-tivnog poremeæaja. Socijalna Psihijatrija 2002;30:209-16.SaetakPODUDARNOST IZMEÐU POREMEÆAJA SMANJENE POZORNOSTI/HIPERAKTIVNOSTI (DSM IV ADHD) IHIPERKINETSKOG POREMEÆAJA ICD 10 U UZORKU HRVATSKE DJEÈJE POPULACIJED. Karloviæ, Z. Zorièiæ, D. Buljan, D. Crnkoviæ i M. MartinacCilj ovoga rada bio je usporediti u kojoj mjeri kriteriji MKB 10 za hiperkinetski poremeæaj i poremeæaj pozornosti/hiperaktivnosti (ADHD) prema kriterijima DSM IV prepoznaju istu djecu s istovrsnim smetnjama. Ispitanici su bila djecaosnovnokolskog uzrasta starosti 7-10 godina (n=409). U analizi su primijenjeni dijagnostièki kriteriji prema klasifikaciji MKB10 za hiperkinetski poremeæaj i kriteriji DSM IV za ADHD. Izdvojene su èetiri skupine djece: hiperkinetski poremeæajem iADHD (n=35), samo ADHD (n=27), samo hiperkinetski poremeæaj (n=3) i djeca bez simptoma prema kriterijima DSM IV iICD 10 (n=344). Koeficijent podudarnosti izmeðu hiperkinetskog poremeæaja MKB 10 i DSM IV ADHD bio je K=0.66; postotakpodudarnosti 78%. χ2-test pokazao je statistièki znaèajan rezultat (χ2=250.3; df=1; p<0.001). Prevalencija za ADHD premaDSM IV bila je 15.16%, a za MKB 10 hiperkinetski poremeæaj 9.3%. Utvrðeno je da DSM IV identificira iru skupinu djece,meðutim, naðeno je znaèajno preklapanje meðu prepoznatim skupinama djece uz ova dva razlièita kriterija.Kljuène rijeèi: Poremeæaj smanjene pozornosti s hiperaktivnoæu, dijagnostika; Hiperaktivnost, dijagnostika; Poremeæaji ponaanja u djece,klasifikacija; Referentne vrijednosti; Dijete; Hrvatska

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Podudarnost između poremećaja smanjene pozornosti / hiperaktivnosti (DSM IV ADHD) i hiperkinetskog poremećaja ICD 10 u uzorku hrvatske dječje populacije

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