First of all, I have to say that the invitation to provide some thoughts on this comprehensive review of diagnoses and classification of child mental disorders written by Professor Rutter (Rutter, 2011) was an unexpected honor. At 17 years of age, I did my first fellowship in Child Psychiatry during the summer vacation after my first year of medical school. My mentor at that time and now colleague, Professor Zavaschi, gave me as a first introductory reading on child nosology a paper by Professor Rutter and colleagues on the multiaxial classification of child psychiatric disorders, published in Psychological Medicine some years earlier. Never in my wildest dreams would I have imagined a chance to discuss a paper on child nosology by Professor Rutter almost 30 years later in such a prestigious outlet as the Journal of Child Psychology and Psychiatry. Second, I have to confess the difficulty of the task! Nobody in our field has such close and extensive experience of child psychiatric nosology issues as Professor Rutter. His profound intimacy with both the conceptualization and the problems of our current classification systems – DSM-IV and ICD-10 – quickly becomes clear to the readers of his paper.

It is important to bear in mind that almost 85% of the world’s youth live in developing countries in Asia, Africa and Latin America (United Nations website: In the more conservative estimates, the prevalence of mental disorders in children and adolescents in these countries is at least as high as those in developed countries. So, issues related to child psychiatric nosology matter a lot for child mental health professionals working in these countries.

According to the World Health Organization (WHO), at least two child psychiatrists should work full-time for every 60,000 children and adolescents in the population (Belfer, 2008). Most of the countries in the developing world are a very long way from reaching this threshold. Family doctors, pediatricians, psychologists or general psychiatrists are caring for the majority of children in need of mental health services in primary health care centers in those areas.

Thus, three aspects discussed by Professor Rutter regarding the new classification systems deserve immediate attention in this context. First, the proposal to have a classification for mental disorders specifically created for use in primary care in ICD-11 that expands the embryonic classification in ICD-10 (only four diagnoses). Like DSM-IV, it seems that DSM-V will continue to be a unitary document. Second, the proposal to radically decrease the number of unneeded and unused diagnoses of mental disorders in both classification systems. Third, the plan to implement a real and extensive harmonization between ICD-11 and DSM-V. Recently, First (2009) documented that only one diagnosis is identical in both DSM-IV and ICD-10 despite the existence of a harmonization committee during the development of these classification systems. If implemented, the first two modifications will make diagnoses of the main relevant child mental disorders a potential reality in the hands of child mental health workers in primary care centers in developing countries, decreasing the extreme complexity of using classification systems for mental disorders in these environments. Something that has never happened so far! The third modification might allow communication between the few isolated research centers in developing countries that use DSM nomenclature and the clinical world around them which officially uses ICD nomenclature in the majority of these countries. Additionally, the use of two classification systems imposes both difficulties in interpreting cross-cultural studies and a logistic problem of needing training in different systems.

Another point of intense debate is the adequacy and utility of the multiaxial system for the conceptualization of mental disorders. I cannot agree more with Professor Rutter that it would be a backward step to force child psychiatrists around the world to conceptualize child mental disorders in a uniaxial system as proposed by the WHO, even though the rest of the manual is solely uniaxial. It is a clear impoverishment not to use a specific Axis to present potential environmental risk factors that might be important in the conceptualization of caseness in the era of gene × environment interaction and epigenetics. Moreover, this strategy poses a special problem for the majority of child mental health disorders in developing countries, where the quality of the environment is crucial in shaping the expression of biological vulnerability to the disorder.

Despite recent investigations documenting a more similar prevalence rate worldwide for some mental disorders than expected in the past (see Canino, Polanczyk, Bauermeister, Rohde, & Frick, 2010; Polanczyk, Horta, Lima, Biederman, & Rohde, 2007), we are far from solving the conflict between a more universalist vision of child psychopathology and a relativist one (see Canino & Alegria, 2008). Cultural aspects can influence the phenotypic presentation of mental health problems in several ways, for example by defining and creating specific sources of distress and impairment or determining the way people interpret and value the symptoms. So, as discussed by Professor Rutter, classification systems need to be constructed in a flexible way, allowing at least that culturally determined nuances of phenotypic presentation can be integrated.

On the other hand, there are some proposed modifications that might lead to difficulties and challenges in the applicability of these classification systems in developing countries. The inclusion of a more dimensional perspective in the diagnostic criteria and the conceptualization of impairment outside of the diagnostic criteria clearly put the conceptualization of disorders in psychiatry closer to those in other medical specialties. However, these strategies, added to allowing diagnoses of subthreshold cases with impairment, carry the potential of exploding prevalence rates of mental disorders in developing countries due to the extremely low level and intensity of training of those mental health workers in charge of detecting mental disorders in primary care settings. This is not to say that we should not move in this direction, but that we need to think carefully about approaches to implementing these modifications.

One of the major criticisms of the DSM-IV/ICD-10 classifications was that the criteria proposed did not take into account a development perspective. So, deleting specific sections for child mental disorders, such as the DSM-IV ‘Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence’ or the ICD-10 ‘Behavioural and emotional disorders with onset usually occurring in childhood and adolescence (F90-F98)’, in favor of including a developmental perspective for all diagnoses is very appealing. However, if only the exclusion occurs and we do not have sufficient power to guarantee the careful inclusion of a developmental perspective in the systems, we may do more harm than good. A drastic modification such as this one carries the risk of making children with mental disorders first detected in infancy and the preschool years even more orphans of the diagnostic systems. In addition, we might decrease the awareness of, and interest in, child mental health by general mental health workers and policymakers from developing countries if the ‘spotlight is turned off’ from child mental disorders in the classification systems.

Although much more can be learned and highlighted from this dense exploration by Professor Rutter of the limitations, challenges and potentialities of the classification systems for child mental disorders, I would like to end by quoting Martin Fischer – a German-American physician and writer: ‘Diagnosis is not the end but the beginning of practice’. I hope our readers will have the same pleasure that I experienced through reading Professor Rutter’s manuscript!

Correspondence to

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Luis Augusto Rohde, Federal University of Rio Grande do Sul, Hospital de Clinicas de Porto Alegre, Av. Ramiro Barcelos 2350 – room: 2201A, Porto Alegre – RS – Brazil – 90035/003; Tel (Fax): + 55 51 33213946; Email:


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  3. References