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Diagnostic Classification Manual for Infants/Toddlers DC: 0-3, Revised (Zero to Three, 2005) Mindy Kronenberg, Ph.D. Go to http://www.zerotothree.org/child-development/early-childhoodmental-health/diagnostic-classification-of-mental-health-anddevelopmental-disorders-of-infancy-and-early-childhood-revised.html for DC 0-3R forms and checklists Adapted the Colorado DC:0-3 ToT (2004 and 2005), in conjunction with the Irving Harris Program in Child Development and Infant Mental Health and Project BLOOM, University of Colorado Health Sciences Center. Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD 1 Purpose of the DC:0-3R To provide a developmentally sensitive diagnostic tool for diagnosing young children To consider the impact of relationships To complement the DSM-IV for young children – both use a multi-axial framework to allow for examination of the various areas that may influence the clinical presentation Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD Diagnostic Classification Development by Zero To Three: National Center for Infants, Toddlers and Families 1987-2003 1990-2003 1994 1997 2003-2005 20032005 Diagnostic Classification Task Force convened Task Force expanded Diagnostic Classification: 0-3 published DC: 0-3 Casebook published DC: 0-3R Task Force convened DC: 0-3 Training Task Force Diagnostic Classification: 0-3R released Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD Diagnostic Classification: 0-3R Requires multiple sessions over time (3-5 minimum) before completing diagnosis Assesses vulnerabilities, difficulties, strengths, and adaptations in such major development areas as: social interactions emotional regulation developmental maturation Considers the impact on the child of the family unit, the community and the culture Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD Diagnostic Classification: 0-3R The goal of diagnosis is to obtain a complete understanding of the infant, in the context of his/her family Diagnosis is an ongoing process The diagnostic process leads to the development of a comprehensive prevention and/or treatment plan Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD Diagnostic Classification Manual for Infants/Toddlers DSM-IV DC: 0-3R Axis I Clinical Disorders, Other conditions that may be the focus of clinical attention Primary Diagnosis Axis II Personality D/O, Mental Retardation Relationship D/O Classification Axis III General Medical Conditions Medical & Developmental D/O & conditions Axis IV Psychosocial & Environmental Problems Psychosocial Stressors Axis V Global Assessment of Functioning Functional Emotional Developmental Level 6 Axis I Diagnoses 100. Posttraumatic Stress Disorder 150. Deprivation/Maltreatment Disorder 200. Disorders of Affect 210. Prolonged Bereavement/Grief Reaction 220. Anxiety Disorders of Infancy and Early Childhood Separation Anxiety Disorder Specific Phobia Social Anxiety Disorder (Social Phobia) Generalized Anxiety Disorder Anxiety Disorder Not Otherwise Specified (NOS) 230. Depression of Infancy and Early Childhood 221. 222. 223. 224. 225. 230. Major Depression 231. Depressive Disorder NOS 240. Mixed Disorder of Emotional Expressiveness Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD Axis I Diagnoses 300. Adjustment Disorder 400. Regulation Disorders of Sensory Processing 410. Hypersensitive 411. Type A: Fearful/Cautious 412. Type B: Negative/Defiant 420. Hyposensitive/Underresponsive 430. Sensory Stimulation-Seeking/Impulsive Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD Axis I Diagnoses 500. Sleep Behavior Disorder 510. Sleep-Onset Disorder 520. Night-Waking Disorder 600. Feeding Behavior Disorder 601. Feeding Disorder of State Regulation 602. Feeding Disorder of Caregiver-Infant Reciprocity 603. Infantile Anorexia 604. Sensory Food Aversions 605. Feeding Disorder Associated with Concurrent Medical Condition 606. Feeding Disorder Associated with Insults to the Gastrointestinal Tract Axis I Diagnoses 700. Disorders of Relating and Communicating 710. Multisystem Developmental Disorder (alternative for PDD-NOS for children under 2 years) 800. Other Disorders (DSM-IV-TR or ICD 10) Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD DC: 0-3R DIAGNOSTIC GUIDELINES - AXIS I: CLINICAL DISORDERS Answer all the questions (1-11). [See Appendix A, page 66]. More than one primary diagnosis may often be appropriate. All diagnoses that meet specific criteria should be used. Yes 1. Is there a clear stress condition or traumatic event? No 2. Has the child lost a primary caregiver? No Yes 3. Are there clear constitutionally or individually based sensory, motor, processing, organizational or integration difficulty? No 4. 5. 100. Posttraumatic Stress Disorder [p 15] 210. Prolonged Bereavement/Grief Reaction [p 19 ] Yes 400. Regulation Disorders of Sensory Processing [p 28] Are the presenting problems mild, of short duration (less than 4 months) and associated with a clear environmental event or person? No Yes 300. Adjustment Disorder [p 28] Are there difficulties in the regulation of affects? Yes Yes 200. Disorders of Affect [p 19] 700. Disorders of Relating and Communicating [p 38] No 6. Are there severe difficulties in relating and communicating that involve a chronic pattern of maladaptation? No 7. Is the only difficulty the caring or parental relationship? No 8. 9. Does the difficulty occur only in a certain situation or in relation to a particular person? No No Is there evidence of seriously inadequate physical, psychological and emotional care? 10. Are feeding and sleep behavior problems present? No No No 11. Are there other mental health-related classifications not found in DC:0-3R that are found in DSM-TR or ICD 10? No Record Diagnoses Go to Axis II Reconsider Adjustment Disorder (#4) or Relationship Disorder (#7) Yes Yes 150. Deprivation/Maltreatment Disorder [p 17] [Note: Use Axis II for current caregiving relationships] other caregiving 500. Sleep Behavior Disorder [p 34] relationship concerns 600. Yes 220. Anxiety Disorders of Infancy and Early Childhood [p 20] 221. Separation Anxiety Disorder [p 21] 222. Specific Phobia [p 23] 223. Social Anxiety Disorder [p 23] 224. Generalized Anxiety Disorder [p 24] 225. Anxiety Disorder NOS [p 25] 230. Depression of Infancy and Early Childhood [p 25] 231. Type I: Major Depression [p 26] 232. Type II: Depressive Disorder NOS [p 27] 240. Mixed Disorder of Emotional Expressiveness [p 27] Axis II: Relationship Classification [p 41] Yes Yes 410. Hypersensitive [p 29] 411. Type A: Fearful/Cautious [p 30] 412. Type B: Negative/Defiant [p 32] 420. Hyposensitive/Underresponsive [p 32] 430. Sensory Stimulation-Seeking/Impulsive [p 33] 800. Othe 800. Feeding Behavior Disorder [p 35] Other Disorders (DSM-IV-TR or ICD 10) [p 40] [Number(s) in parentheses is the source page number(s) in the manual.] Note: Use DSM-IV-TR, Pervasive Developmental Disorders for children 2 years and above. 710. Multisystem Developmental Disorder can be used for children under 2 years) [p 39] 510. Sleep Onset Disorder [p 35] 511. Night Waking [p 35] Subcategories of Feeding Behavior Disorder 601. Feeding Disorder of State Regulation [p 36] 602. Feeding Disorder of Caregiver-Infant Reciprocity [p 36] 603. Infantile Anorexia [p 36] 604. Sensory Food Aversions [p 37] 605. Feeding Disorder Associated with Concurrent Medical Condition [p 37] 606. Feeding Disorder Associated with Insults to the Gastrointestinal Tract [p 37] Adapted from ZERO TO THREE. (2005). Diagnostic classification of mental health and developmental disorders of infancy and early childhood: Revised edition (DC:0-3R). Washington, DC: ZERO TO THREE Press. Adapted from ZERO TO THREE /National Center for Infants, Toddlers, and Families. 2005. Diagnostic Classification: 0-3R; Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood Revised. [Wright & Northcutt (2005)] Axis II: Relationship Classification Assesses the parent-infant relationship and includes consideration of: Overall functional level of both the child and the parent Level of distress in both the child and the parent Adaptive flexibility of both the child and the parent Level of conflict and resolution between the child and the parent Effect of the quality of the relationship on the child’s developmental progress Two tools for evaluating relationship classification PIR-GAS Score Relationship Problems Check List Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD Axis II: Relationship Classification Parent-Infant Relationship Global Assessment Scale (PIR-GAS) Used to assess the quality of infant-parent relationship Typically completed after multiple clinical evaluations Relationship problems may or may not occur with symptomatic behaviors Assess the intensity, frequency, and duration of difficulties Similar to the DSM-IV-TR’s Global Assessment of Functioning scale 100-81=Adapted relationship 80-41 = Features of a disordered relationship 40-0 = Disordered relationship Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD Axis II: Relationship Classification Relationship Problems Check List (RPCL) Used to document problems or lack of problems in a relationship, recording the extent of certain features of a parent-infant relationship (include abuse and neglect) and rates them on behavioral quality, affective tone, and psychological involvement Overinvolved Underinvolved Anxious/Tense Angry/Hostile Abusive Verbally Abusive Physically Abusive Sexually Abusive DC: 0-3R DIAGNOSTIC GUIDELINES – AXIS II: RELATIONSHIP CLASSIFICATION Assess the relationship between primary caregiver(s) and the infant or young child. Primary caregivers may be biological, foster, and adoptive parent(s), as well as grandparents, members of the extended family, and caregivers outside the family. Consider multiple aspects of the relationship dynamic including the child and parent’s overall functional level, level of distress, adaptive flexibility, and level of conflict and resolution between both the child and parent and the effect of the quality of the relationship on the child’s developmental progress. A relationship disorder is specific to a relationship and symptoms may derive from conditions within the infant, from within the caregiver, from the unique “fit” between the infant and caregiver, from the larger social context or from a combination of these factors. When relationship difficulties are apparent, assess the intensity, frequency, and duration of the difficulties. PIR-GAS IsYes the relationship characterized by: Adapte mutual enjoyment without significant stress for each partner Theorrelationship is pattern that protects and promotes the developmental progress of both partners Yes The relationship is 91-100 Well Adapted [p 43] Is the relationship: functioning less than optimally, Thepattern transient, or relationship has The relationship Thedevelopmental progress relationship has ca n proceed, but may be temporarily interrupted Adapted No Diagnosis 81-90 Adapted [p 43] ***** No AXIS II DIAGNOSIS Remember to complete the Relationship Problems Checklist [p 46] 71-80 Perturbed [p 43] Yes The relationship has 61-70 Significantly Perturbed [p 44] Features of a Disorder Relationship Quality 51-60 Distressed [p 44] Overinvolved [p 46] 41-50 Disturbed [p 44] No Is the relationship marked by: rigidly maladaptive interactions, distress in one or both partners, Disordered developmental progress of the child is influenced adversely, or documented neglect or abuse that affects child’s physical Yesand emotional development ***** Underinvolved [p 47] 31-40 Disordered [p 44] Yes 21-30 Severely Disordered [p 44] Anxious/Tense [p 48] Disordered Angry/Hostile [p 49] The relationship is 11-20 Grossly Impaired [p 45] Abusive [p 50] 1-10 Documented Maltreatment [p 45] Verbally [p 50] Physically [p 51] Sexually [p 51] [Number(s) in parentheses is the source page number(s) in the manual.]0-3R; Diagnostic Adapted from ZERO TO THREE /National Center for Infants, Toddlers, and Families. 2005. Diagnostic Classification: Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood Revised. [Northcutt & Wright (2005)] Axis III Medical and Developmental Disorders and Conditions Indicate any coexisting physical (including medical and neurological) and/or developmental diagnoses made using other diagnostic and classification systems Many psychiatric symptoms can be caused by medical illnesses. Pediatric or other medical evaluation is highly recommended. Some examples include: Mood disorder symptoms = Endocrine disorders Abrupt onset irritability, motor dyscoordination, restlessness = Heavy metal toxicity. 16 Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD Axis IV: Psychosocial Stressors Provides a framework for identifying and evaluating psychosocial and environmental stressors that may influence the presentation, course, treatment, and prevention of mental health symptoms and disorders in young children Recognition that the impact of stressors depends on: Severity, intensity and duration, and predictability Developmental level of child Buffering capacity of caregiving adults Includes a Psychosocial and Environmental Checklist Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD Axis V: Emotional and Social Functioning Indicates the developmental level at which the infant organizes affective, interactive, communicative, cognitive, motor, and sensory experiences, as reflected by the infant’s functioning Assessment is based on observations of infants interacting with parent(s) or significant caretaker Rates the quality of the child’s play based on essential processes or capacities Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD Axis V: Emotional and Social Functioning Capacities for Emotional and Social Functioning Rating Scale: Attention and regulation (birth – 3 mos.) Forming relationships or mutual engagement (3 – 6 mos.) Intentional two-way communication (4 – 10 mos.) Complex gestures and problem solving (10 – 18 mos.) Use of symbols to express thoughts and feelings (18 – 30 mos.) Connecting symbols logically and abstract thinking (30 – 48 mos.) Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD DC: 0-3R DIAGNOSTIC GUIDELINES - AXIS V: EMOTIONAL AND SOCIAL FUNCTIONING Observe the quality of the infant or young child’s play with each of the significant people in his or her life then choose the rating that best fits the child’s functioning with respect to each of the capacities listed below in interaction with each caregiver. Primary caregivers may be biological, foster, and adoptive parent(s), as well as grandparents, members of the extended family, and caregivers outside the family. Functioning Rating (1-6, n/a) for Each Caregiver Emotional and Social Functioning Capacities Attention and regulation [p 63] [typically observable between birth to 3 months] From: Does the infant notice and attend to what is going on in the world through all the senses? To: Does the infant stay sufficiently regulated to attend and interact, without over- or under- reacting to external or internal stimuli? Forming relationships/mutual engagement [p 63] [typically observable between 3 and 6 months] From: Does the infant develop a relationship with an emotionally available caregiver for soothing, security, and pleasure? To: Is the child able to experience the full range of positive and negative emotions while remaining engaged in a relationship? Intentional two-way communication [p 63] [typically observable between 4 to 10 months] From: Does the infant use simple gestures, including purposeful demonstrations of affect, to start reciprocal “conversations’? To: Does the young child use a more complex sequence of gestures? Complex gestures and problem solving [p 63] [typically observable between 10 and 18 months] From: Has the toddler learned how to use emerging motor skills and language to get what he needs or wants? To: Does the young child use words as well as gestures for communication and problem solving? Use of symbols to express thoughts and feelings [p 63] [typically observable between 18 and 30 months] From: Does the child begin to use play and language to express thoughts, ideas, and feelings through symbols? To: Does the child project her own feelings onto the characters and actions of her imaginative play? Connecting symbols logically; abstract thinking [p 63] [typically observable between 30 and 48 months] From: Does the child connect and elaborate sequences of ideas logically and use logically interconnected ideas in conversation? To: Does the child understand abstract concepts, reflect on feelings, and articulate lessons that he has learned from an experience? A B C D E F G [Number(s) in parentheses is the source page number(s) in the manual.] Rating 1 2 3 4 5 6 n/a Functioning Rating for Each Capacity Description [p 62] Age appropriate under all conditions and with full range of affects Age appropriate but vulnerable to stress or constricted range of affect or both Immature; has the capacity but not at an age appropriate level Functions inconsistently unless special structure or sensorimotor support is available Barely evidences this capacity Has not achieved this level Not applicable. Child is below the age level typically expected to have achieved. Caregiver List Name Relationship A B C D E F G Adapted from ZERO TO THREE /National Center for Infants, Toddlers, and Families. 2005. Diagnostic Classification: 0-3R; Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood Revised. [Wright & Northcutt (2005)] Conceptual Crosswalk Between DC-03R and DSM IV Herbert C. Quay, PhD Harris Institute for Infant Mental Health Training Florida State University Center for Prevention and Early Intervention Policy (Rev. 1/06) DC-03R DSM-IV Axis I 100 Posttraumatic Stress Disorder 308.3 Acute Stress Disorder 309.81 Posttraumatic Stress Disorder 150 Deprivation/Maltreatment Disorder: Emotionally withdrawn or Inhibited Indiscriminant or disinhibited Disorders of Affect Prolonged Bereavement/Grief Reaction Separation Anxiety Disorder Specific Phobia Social Anxiety Disorder (Social Phobia) Generalized Anxiety Disorder Anxiety Disorder NOS Depression of Infancy and Early Childhood Type I- Major Depression 313.89 Reactive Attachment Disorder of Infancy or Early Childhood: Inhibited type Disinhibited type 200 210 212 222 223 224 225 230 231 240 300 Type II- Depressive Disorder NOS Mixed Disorder of Emotional Expressiveness Adjustment Disorder 296.90 V 62.82 309.21 300.29 300.23 Mood Disorder NOS Bereavement Separation Anxiety Disorder Specific Phobia Social Phobia 300.02 300.00 Generalized Anxiety Disorder Anxiety Disorder NOS 296.2 300.4 Major Depressive Disorder Single Episode Dysthymic Disorder (2 yr. Duration) 311 Depressive Disorder NOS 309.0- Adjustment Disorder 309.9 DC-03R 400 410 411 412 Regulation Disorders of Sensory Processing Hypersensitive Type A- Fearful/Control Type B- Negative/Defiant 420 Hyposensitive/Under-responsive 430 Sensory Stimulation-Seeking/ Impulsive 500 510 Sleep Behavior Disorders* Sleep-Onset Disorder (Sleep onset protodyssomnia) Night-Waking Disorder (Night Waking Protodyssomnia) Feeding Behavior Disorders Feeding Disorder of State Regulation Feeding Disorder of CaregiverInfant Reciprocity Infantile Anorexia 520 600 601 602 603 604 Sensory Food Aversion 605 Feeding Disorder Associated with Concurrent Medical Condition Feeding Disorder Associated with Insult to the Gastrointestional Tract 606 DSM-IV 312.9 300 313.81 309.21 314.00 Disruptive Behavior Disorder NOS Anxiety Disorder NOS Oppositional Defiant Disorder Attention Deficit Disorder, Predominantly Inattentive 314.9 ADHD NOS 314.01 Attention Deficit Disorder, Predominately Hyperactive/Impulsive 314.9 ADHD NOS 307.42 Primary Insomnia 307.47 Dyssomnia NOS 307.47 Dyssomnia NOS 307.49 Feeding Disorder of Infancy or Early Childhood 307.49 Feeding Disorder of Infancy or Early Childhood 307.49 Feeding Disorder of Infancy or Early Childhood 307.49 Feeding Disorder of Infancy or Early Childhood 307.49 Feeding Disorder of Infancy or Early Childhood 307.49 Feeding Disorder of Infancy or Early Childhood 1 DC-03R 700 712 Disorders of Relating and Communicating Multisystem Developmental Disorder (MDD) ** DSM-IV 299.00 299.80 299.10 299.80 299.80 Autistic Disorder Rett’s Disorder Childhood Disintegration Disorder Asperger’s Disorder PDD, NOS V61.20 V61.21 V61.20 V61.20 V61.20 V61.21 V61.21 Parent-Child Relational Problem Neglect of Child Parent-Child Relational Problem Parent-Child Relational Problem Parent-Child Relational Problem Physical Abuse of Child Sexual Abuse of Child Axis II Overinvolved Undervolved Anxious/Tense Angry/Hostile Verbally Abusive Physically Abusive Sexually Abusive *If criteria are met for a DSM-IV Sleep Disorder, it should be coded on Axis I as an 800 diagnosis **If criteria are met for a DSM-IV Pervasive Developmental Disorder, it should be coded on Axis I as an 800 diagnosis Herbert C. Quay, PhD Harris Institute for Infant Mental Health Training Florida State University Center for Prevention and Early Intervention Policy (Rev. 1/06). DC:0-3R Summary Developmentally informed Axis I describes clinical symptoms and disorders found in young children Axis II highlights relational concerns Axis III provides a place for medical and/or developmental diagnoses derived using other systems Axis IV examines the impact of psychosocial stressors Axis V looks at the child’s emotional and social functioning Copyright 2006, the FSU CPEIP and Robert J. Harmon, MD