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Chapter: Essentials of Psychiatry: Diagnostic Classification in Infancy and Early Childhood

Overview of the Classification System - Infancy and Early Childhood

DC:0–3 proposes a provisional multiaxial classification system.

Overview of the Classification System


DC:0–3 proposes a provisional multiaxial classification system. We refer to the classification system as provisional because it is assumed that categories may change as more knowledge accumu-lates. The diagnostic framework consists of the following

The axes in this system are not intended to be entirely symmetrical with such other systems as DSM-IV and the In-ternational Statistical Classifi cation of Diseases and Related Health Problems, 10th Revision (ICD-10) because this system, in dealing with infants and young children, focuses on devel-opmental issues. Dynamic processes, such as relationship and developmentally based conceptualizations of adaptive patterns (i.e., functional–emotional developmental level), are therefore of central importance.


Use of the system will provide the psychiatrist with a “di-agnostic profile” of an infant or toddler. Such a diagnostic pro-file focuses the psychiatrist’s attention on the various factors that are contributing to the infant’s difficulties as well as on areas in which intervention may be needed.



Axis I: Primary Diagnoses


The following are the Axis I primary diagnoses that have thus far been suggested:

100. Traumatic Stress Disorder


A continuum of symptoms related to a single event, a series of connected traumatic events, or chronic enduring stress.


a)        Reexperiencing of the trauma, as evidenced by

i)          post traumatic play

ii)       recurrent recollections of the traumatic event outside play

iii)     repeated nightmares

iv)     distress at reminders of the trauma

v)       flashbacks or dissociation

b)       Numbing of responsiveness or interference with develop-mental momentum

i)          increased social withdrawal

ii)       restricted range of affect

iii)     temporary loss of previously acquired developmental skills

iv)     a decrease in play

c)        Symptoms of increased arousal

i)          night terrors

ii)       difficulty going to sleep

iii)     repeated night waking

iv)     significant attentional difficulties

v)       hypervigilance

vi)     exaggerated startle response

d)       Symptoms not present before

i)          aggression toward peers, adults, or animals

ii)       separation anxiety

iii)     fear of toileting alone

iv)     fear of the dark

v)       other new fears

vi)     self-defeating behavior or masochistic provocativeness

vii)  sexual and aggressive behaviors

viii)         other nonverbal reactions (e.g., somatic symptoms, mo-tor reenactment, skin stigmas, pain, or posturing)


200. Disorders of Affect


Focuses on the infant’s experience and on symptoms that are a general feature of the child’s functioning rather than specific to a situation or relationship.


201. Anxiety Disorders of Infancy and Early Childhood


Levels of anxiety or fear, beyond expectable reactions to normal developmental challenges.


e)        Multiple or specific fears


i)          Excessive separation or stranger anxiety


ii)       Excessive anxiety or panic without clear precipitant


iii)     Excessive inhibition or constriction of behavior


iv)     Lack of development of basic ego functions


v)       Agitation, uncontrollable crying or screaming, sleeping and eating disturbances, recklessness, and other behaviors Criterion: Should persist for at least 2 weeks and interfere with appropriate functioning.


202. Mood Disorder: Prolonged Bereavement–Grief Reaction


vi)     Possible crying, calling and searching for the absent par-ent, refusing comfort


vii)  Emotional withdrawal, with lethargy, sad facial expres-sion, and lack of interest in age-appropriate activities


viii)         Eating and sleeping possibly disrupted


ix)     Regression in developmental milestones


x)       Constricted affective range


xi)     Detachment


xii)  Sensitivity to any reminder of the caregiver


203.Mood Disorder: Depression of Infancy and Early Childhood


Pattern of depressed or irritable mood with diminished interest or pleasure in developmentally appropriate activities, diminished capacity to protest, excessive whining, and diminished social interactions and initiative. Disturbances in sleep or eating. Criterion: At least 2 weeks.


204. Mixed Disorder of Emotional Expressiveness


Ongoing difficulty expressing developmentally appropriate emotions.


i)          The absence or near-absence of one or more specific types of affects


ii)       Constricted range of emotional expression


iii)     Disturbed intensity


iv)     Reversal of affect or inappropriate affect


205. Childhood Gender Identity Disorder


2.        Becomes manifest during the sensitive period of gender identity development (between approximately 2 and 4 years).

i)          A strong and persistent cross-sex identification


ii)       repeatedly states desire to be, or insistence that he or she is, the opposite sex


iii)     in boys, preference for cross-dressing or simulating fe-male attire; in girls, insistence on wearing stereotypical masculine clothing


iv)     strong and persistent preferences for cross-sex roles in fan-tasy play or persistent fantasies of being the opposite sex


v)       intense desire to participate in the games and pastimes of the opposite sex


vi)     strong preference for playmates of the opposite sex


b)       Persistent discomfort with one’s assigned sex or sense of inappropriateness in that role


c)        Absence of nonpsychiatric medical condition


206. Reactive Attachment Deprivation–Maltreatment Disorder of Infancy


i)          Persistent parental neglect or abuse, of a physical or psy-chological nature, undermines the child’s basic sense of security and attachment.


ii)       Frequent changes in, or the inconsistent availability of, the primary caregiver.


iii)     Other environmental compromises that prevent stable attachments.


300. Adjustment Disorder


3.        Mild, transient situational disturbances related to a clear environmental event and lasting no longer than 4 months.


400. Regulatory Disorders


Difficulties in regulating physiological, sensory, attentional, motor, or affective processes and in organizing a calm, alert, or affectively positive state. Observe at least one sensory, sensory–motor, or processing difficulty from the following list, in addition to behavioral symptoms.


i)          Overreactivity or underreactivity to loud or high- or low-pitched noises


ii)       Overreactivity or underreactivity to bright lights or new and striking visual images


iii)     Tactile defensiveness or oral hypersensitivity


iv)     Oral–motor difficulties or incoordination influenced by poor muscle tone and oral-tactile hypersensitivity


v)       Underreactivity to touch or pain


vi)     Gravitational insecurity


vii)  Underreactivity or overreactivity to odors


viii)         Underreactivity or overreactivity to temperature


ix)     Poor muscle tone and muscle stability


x)       Qualitative deficits in motor planning skills


xi)     Qualitative deficits in ability to modulate motor activity


xii)  Qualitative deficits in fine motor skills


xiii)         Qualitative deficits in auditory–verbal processing


xiv)         Qualitative deficits in articulation capacities


xv)  Qualitative deficits in visual–spatial processing capacities


xvi)         Qualitative deficits in capacity to attend and focus


401. Type I: Hypersensitive

b)       Fearful and cautious


i)          Behavioral patterns: excessive cautiousness, inhibition, or fearfulness


ii)       Motor and sensory patterns: overreactivity to touch, loud noises, or bright lights


c)        Negative and defiant


i)          Behavioral patterns: negativistic, stubborn, controlling and defiant; difficulty in making transitions; prefers repetition to change


ii)       Motor and sensory patterns: overreactivity to touch and sound; intact visual–spatial capacities; compromised auditory processing capacity; good muscle tone and motor planning ability; shows some delay in fine motor coordination


402. Type II: Underreactive

d)       Withdrawn and difficult to engage


i)          Behavioral patterns: seeming disinterest in relation-ships; limited exploratory activity or flexibility in play; appears apathetic, easily exhausted and withdrawn


ii)       Motor and sensory patterns: underreactivity to sounds and movement in space; either overreactive or underre-active to touch; intact visual–spatial processing capaci-ties, but auditory–verbal processing difficulties; poor motor quality and motor planning


e)        Self-absorbed


i)          Behavioral patterns: creative and imaginative, with a ten-dency to tune into her or his own sensations, thoughts, and emotions


ii)       Motor and sensory patterns: decreased auditory–verbal processing capacities


403. Type III: Motorically Disorganized, Impulsive Mixed sensory reactivity and motor processing difficulties. Some appear more aggressive, fearless and destructive; others appear more impulsive and fearful.


i)          Behavioral patterns: high activity, seeking contact and stimulation through deep pressure; appears to lack caution


ii)       Motor and sensory patterns: sensory underreactivity and motor discharge


404. Type IV: Other


500. Sleep Behavior Disorder


Only presenting problem; younger than 3 years of age; no accompanying sensory reactivity or sensory processing difficulties. Difficulty in initiating or maintaining sleep; may also have problems in calming themselves and dealing with transitions from one stage of arousal to another.



600. Eating Behavior Disorder


Shows difficulties in establishing regular feeding patterns with adequate or appropriate food intake. Absence of general regulatory difficulties or interpersonal precipitants (e.g., separation, negativism, trauma).


700. Disorders of Relating and Communicating


i)          DSM-IV conceptualization pervasive developmental dis-order, or


ii)       Multisystem developmental disorder


·           Multisystem Developmental Disorder


i)          Significant impairment in, but not complete lack of, the ability to form and maintain an emotional and social rela-tionship with primary caregiver


ii)       Significant impairment in forming, maintaining, or devel-oping communication


iii)     Significant dysfunction in auditory processing


iv)     Significant dysfunction in the processing of other sensa-tions and in motor planning


701. Pattern A


These children are aimless and unrelated most of the time, with severe difficulty in motor planning, so that even simple intentional gestures are difficult.


702. Pattern B


These children are intermittently related and capable, some of the time, of simple intentional gestures.


703. Pattern C


These children evidence a more consistent sense of relatedness, even when they are avoidantor rigid


Axis II: Relationship Disorder Classification


The diagnostic system also includes an Axis II for relationships classification. Three aspects of a relationship are considered: 1) behavioral quality of the interaction, 2) affective tone, and 3) psy-chological involvement. The types of relationship problems are as follows:


901. Overinvolved Relationship


Physical or psychological overinvolvement.


i.               Parent interferes with infant’s goals and desires


ii.               Overcontrols


iii.               Makes developmentally inappropriate demands


iv.               Infant appears diffuse, unfocused and undifferentiated


v.               Displays submissive, overly compliant behaviors


vi.               May lack motor skills or language expressiveness


902. Underinvolved Relationship


Sporadic or infrequent genuine involvement.


i.               Parent insensitive or unresponsive


ii.               Lack of consistency between expressed attitudes about in-fant and quality of actual interactions


iii.               Ignores, rejects, or fails to comfort


iv.               Does not reflect infant’s internal feeling states


v.               Does not adequately protect


vi.               Interactions underregulated


vii.               Parent and infant appear to be disengaged


viii.               Infant appears physically or psychologically uncared for


ix.               Delayed or precocious in motor and language skills


903. Anxious–Tense Relationship


Tense, constricted with little sense of relaxed enjoyment or mutuality.


i.               Parent is overprotective and oversensitive


ii.               Awkward or tense handling


iii.               Some verbally and emotionally negative interactions


iv.               Poor temperamental fit between parent and child


v.               Infant compliant or anxious


904. Angry–Hostile Relationship


Harsh and abrupt, often lacking in emotional reciprocity.


i.               Parent insensitive to infant’s cues


ii.               Handling is abrupt


iii.               Infant frightened, anxious, inhibited, impulsive, or dif-fusely aggressive


iv.               Defiant or resistant behavior


v.               Demanding or aggressive behaviors


vi.               Fearful, vigilant and avoidant behaviors


vii.               Tendency toward concrete behavior


905. Mixed Relationship


Combination of the features described above.


906. Abusive Relationships


a)        Verbally abusive relationship.


i)          Intended to severely belittle, blame, attack, overcontrol and reject the infant or toddler


ii)       Reactions vary from constriction and vigilance to se-vere acting-out behaviors


b)       Physically abusive relationship.


i)          Physically harms by slapping, spanking, hitting, pinch-ing, biting, kicking, physical restraint, isolation


ii)       Denies food, medical care, or opportunity to rest


iii)     May include verbal and emotional abuse or sexual abuse


c)        Sexually abusive relationship.


i)          Parent engages in sexually seductive and overstimulat-ing behavior – coercing or forcing child to touch par-ent sexually, accept sexual touching, or observe others’ sexual behaviors


ii)       Young child may evidence sexually driven behaviors such as exhibiting himself or herself or trying to look at or touch other children


iii)     May include verbal and emotional abuse or physical abuse


Axis III: Medical and Developmental Diagnoses


On Axis III, one indicates any coexisting physical (including medical and neurological), mental health, or developmental dis-orders. DSM-IV, ICD-9 or ICD-10 for the primary care setting classifications are used. Occupational therapy, physical therapy, special education and other designations are specified.


Axis IV: Psychosocial Stressors


On Axis IV, one identifies (1) the source of stress (e.g., abduction, adoption, loss of parent, natural disaster, parent’s illness), (2) se-verity (mild to catastrophic), (3) duration (acute to enduring), and (4) overall impact (none, mild, moderate, severe)



Axis V: Functional–Emotional Developmental Level


Axis V profiles the child’s functional and emotional developmen-tal level. It involves the following.


A. Essential processes or capacities


1.        Mutual attention: ability of dyad to attend to one another


2.        Mutual engagement: joint emotional involvement


3.        Interactive intentionality and reciprocity: ability for cause-and-effect interaction; infant signals and re-sponds purposefully


4.        Representational–affective communication: language and play communicate emotional themes


5.        Representational elaboration: pretend play and sym-bolic communication that go beyond basic needs and deal with more complex intentions, wishes, or feelings


6.        Representational differentiation I: pretend play and symbolic communication in which ideas are logically related; knows what is real and unreal


7.        Representational differentiation II: complex pretend play; three or more ideas are logically connected and informed by concepts of causality, time and space


B. Functional–Emotional Developmental Level Summary, which documents the child’s achievement


1.        Has fully reached expected levels


2.        At expected level but with constrictions – not full range of affect; not at this level under stress; only with certain caregivers or with exceptional support


3.        Not at expected level but has achieved all prior levels


4.        Not at current expected level but some prior levels


5.        Has not mastered any prior levels


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