Overview of the Classification System - Infancy and Early Childhood

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