Download Copyright 2006, the FSU CPEIP and Robert J

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