Table 2.

Recommendation Rating Systems and Definitions Used by National Guidelines Related to Pediatric Antipsychotic Use

Guidelines*	Rating System	Rating Definition†
		Strong/Highest Rating	Moderate Rating	Weak Rating	Not Endorsed‡
AACAP-AAA, AACAP-BP AACAP-ODD, AACAP-SZ	AACAP rating system§	Minimal standard/clinical standard: Rigorous/substantial empirical evidence (meta-analyses, systematic reviews, RCTs) and/or overwhelming clinical consensus; expected to apply more than 95% percent of the time	Clinical guideline: Strong empirical evidence (nonrandomized controlled trials, cohort or case-control studies), and/or strong clinical consensus; expected to apply in most cases (75% of the time)	Options: Acceptable but not required; there may be insufficient evidence to support higher recommendation (uncontrolled trials, case/series reports)	Not endorsed: Ineffective or contraindicated
CAMESA	GRADE29 system (includes SOR and SOE ratings)	SOR strong: 1A, 1B, 1C SOE high: 1A, 2A	SOE moderate: 2A	SOR weak: 2A, 2B, 3 SOE low: 1C, 2B, 3
PPWG	Adaptation of AACAP rating system	A: Well-controlled RCTs, large meta-analyses, or overwhelming clinical consensus	B: Empirical evidence (open trials, case series) or strong clinical consensus	C: Single case reports or no published reports, recommendation developed by expert consensus (informal)
T-MAY	Oxford Centre for EBM grading of evidence (A–D) system34 for SOE and separate SOR ratings	SOR very strong: ≥90% agreement SOE A: Consistent level 1 studies (eg, RCT)	SOR strong: 70–89% agreement SOE B: Consistent level 2 or 3 studies (eg, cohort or case control studies) or extrapolations from level 1 studies, B	SOR fair: 50–69% agreement SOE C: Level 4 studies (eg, case studies) or extrapolations from level 2 or 3 studies	SOR weak: <50% agreement SOE D: Level 5 evidence (eg, expert opinion without explicit critical appraisal) or troublingly inconsistent or inconclusive studies of any level

RCT indicates randomized controlled trial; SOE, strength of evidence; and SOR, strength of recommendation.

^*See Table 1 for full names.

^†To support comparisons of ratings across guidelines, ratings were grouped into the following categories: strong/highest, moderate, or weak.

^‡Most guidelines used a “strong” recommendation against rather than “not endorsed” to indicate that a practice should be avoided.

^§AACAP rating system is used for most AACAP guidelines.