Miri Keren, M.D. Geha Mental Health Infant Clinic, Director Assistant Professor Tel Aviv Univ. Sackler Medical School, Past WAIMH President

Transcription

1 Miri Keren, M.D. Geha Mental Health Infant Clinic, Director Assistant Professor Tel Aviv Univ. Sackler Medical School, Past WAIMH President ( )

2 Vignette 1 11 month-old baby girl, was referred by Well-Baby Community Center to our IMH Unit, because of extreme passivity and withdrawal, with delay in developmental milestones. Unusually, the father was the one who brought the baby to the first consultation session. She was the only child of a young couple in their late twenties. Mother is described as shy from ever. The marital relationship was good until Mother became pregnant. Since then, Father is extremely anxious about their baby (he had a history of losses in his family). Mother feels hurt and excluded: he does not see her anymore, all his attention has turned to the baby. She reacted by withdrawing from the baby.

3 Vignette 2 A., a 2 ½ year-old girl, referred because she persistently asks for food, at home and at kindergarten, and eats significantly more than her peers. Status: A., a chubby little girl with a sad expression, clings to her father, avoids her mother, looks vigilant and displays limited exploratory behavior. Normally developed with high verbal skills.

4 As a baby, A. had been perceived as a fussy baby, calmed down only by eating. She would drink the bottle as if I was starving her. A. also had sleep problems: would fall asleep very late in the evening, waiting for her father s return from work. Started kindergarten at the age of 2 years, with separation difficulties. A. started to ask for food all day long, became oppositional at home, while very compliant and shy at kindergarten.

5 The observed mother-child interaction revealed strong maternal ambivalence towards the child, mixed with guilt feelings. Mother had herself a binge eating disorder. A. showed alternating behaviors of avoidance and oppositionality. At the triadic level, the father took a mediating role between his wife and daughter, The overall family atmosphere during their interaction was sad and tense. 5

6 Diagnosis, Formulation, and Treatment plan Diagnosis is the identification and classification of specific infant/young child s disorders (Axis I). Formulation is the way in which the infant s clinical presentation is understood in the context of his/her risk and protective factors in his relationships, biology, developmental status, and social network. These contextual factors are mentioned on Axes II to V. Treatment plan is based on those risk and protective factors that are modifiable.

7 Introduction DC: 0-5 is the product of a 3 year plan ( ) for carrying out the revision and update of the DC 0-3R (Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Revised Edition, 2005). The plan included: Survey of DC 0-3 users around the world with multiplechoice and open-ended questions. Review of clinical and research literature of past 10 years Drafting and eliciting comments from clinical experts in specific areas. Connecting with various professional organizations.

8 Reflecting on the multidisciplinary nature of infant mental health, the Diagnostic Classification Revision Task Force members included individuals representing the professional disciplines of psychiatry, psychology, pediatrics, nursing, social work, and counseling. The main goals were: To make updates and changes to respond to unresolved issues in the DC 0-3R To capture new findings pertinent to the diagnosis and diagnostic formulation for infants/young children.

9 The core approach Beyond the first 3 years: the first 5 years. Two key principles: Assessment and diagnostic classification are guided by the awareness that all infants/young children have their own developmental progression and show individual differences in their motor, language, sensory, cognitive, affective, and interactive patterns. All infants/young children are participants in relationships, the most significant ones being those within the family. Families, in turn, participate in relationships within their larger communities and cultures.

10 Axis I: Primary Diagnosis General principles Disorders are clustered into sections that group similar disorders together, including Neurodevelopmental disorders, Sensory Processing Disorders, Anxiety Disorders, Mood Disorders, OC and related Disorders, Sleep, Eating, and Crying Disorders, Trauma, stress, and deprivation disorders, Relationship Disorders. New diagnoses in these categories include Early Atypical Autism Spectrum Disorder, Inhibition to Novelty Disorder, Disorder of Dysregulated Anger and Aggression of Early Childhood, Overeating Disorder, Relationship Specific Disorder of Infancy/Early childhood. Co-morbidity (on first axis) is in infants/young children, is not only possible, it is common. This approach replaced the hierarchical approach. Each disorder includes a diagnostic algorithm to clarify how the criteria are to be used in order to maximize inter rater reliability. Age limitations and duration criteria are included when appropriate. Distress or functional impairment is a must criteria for each disorder. Links to the corresponding DSM V and ICD 10 disorders are included in the text for each diagnosis

11 Axis II: Relational Context Rating of level of adaptation of dyadic caregiving relationships Rating of level of adaptation of triadic/family caregiving relationships, including co-parenting. Axis III: Physical health conditions and considerations Includes illustrative examples of medical conditions relevant to IMH Note: Developmental disorders, including global delay, is not anymore on Axis III Axis IV: Psychosocial Stressors: Same Checklist, with addition of categories and stressors Axis V: Developmental Competence Has been extensively revised

12 Distress and/or Functional impairment criteria Symptoms of the disorder, or accommodations made by the caregiver in response to the symptoms, significantly affect the young child s and family s functioning in 1 or more of the following: Cause distress to the young child Interfere with the young child s relationships Limit the child s participation in developmentally expected activities or routines Limit the family s participation in everyday activities or routines Limit the child s ability to learn and develop new skills or interfere with developmental progress

13 Incorporating cultural perspectives Cultural identity of the individual: cultural identity of child and caregivers Cultural conceptualizations of distress: cultural explanations of the child s presenting problem. Psychosocial stressors and cultural features of vulnerability and resilience: Cultural factors related to the child s psychosocial and caregiving environment. Cultural features of the relationship between the individual and the clinician. Overall cultural assessment for child s diagnosis and care.

14 Neurodevelopmental Disorders Common features: Onset in early childhood Delay or abnormality in functions strongly related to biological maturation of the CNS Generally steady course that does not involve remissions and relapses that are more typical of other mental disorders Are more common in boys Genetic factors are implicated though in complex ways, as well as neurotoxins, medical complications at birth and institutional rearing. Prevalence of 15% in industrialized countries. Treatable but not often curable, therefore early and intensive interventions are recommended.

15 Include: Autism Spectrum Disorder Early Atypical ASD (9 months-36 months) ADHD (at least 36 months old) Over-activity Disorder of Toddlerhood (24-36 months) Global Developmental Delay Developmental Language Disorder Developmental Coordination Disorder Other Neurodevelopmental Disorder of Infancy/Early Childhood

16 Early Atypical Autism Spectrum Disorder Characterizes severe social-communication abnormalities and restricted and repetitive symptoms in infants between 9-36 months old who have not met full criteria for ASD. Beyond 36 months, they should be evaluated for the DSM 5 Social Pragmatic Communication disorder. The diagnostic threshold requires 2 of the 3 socialcommunication symptoms and 1 of the 4 restrictive repetitive symptoms. These infants are considered to be at high risk for ASD

17 Sensory Processing Disorders This is about impairing responses to sensory stimuli that are independent of other psychopathological and neurodevelopmental conditions. The sensory abnormalities must occur in more than one context, may involve one or more sensory domains. Age: at least 6 months old. Duration: at least 3 months May co-occur with other axis I diagnoses except of ASD and ADHD. Only Over, Under and Other categories Difficulties in motor coordination are not included

18 Anxiety Disorders Separation Anxiety Disorder Social phobia Generalized anxiety disorder Selective mutism Inhibition to Novelty Disorder Other

19 Until recently, distressing anxiety in infants was considered either as a normative phase of development or a temperament style and risk for future anxiety disorders, depression or any other mental health pb. It is now clear that anxiety in infants and young children can reach distressing levels and cause impairment in functioning, in addition to increase the risk for later anxiety disorders and depression. Identifying clinically significant anxiety in infants is challenging. It is based on

20 Inhibition to Novelty Disorder Inhibition to novelty disorder defines extremes of behavioral inhibition that impairs the infant/young child s functioning. Behavioral inhibition is demonstrable in about 15% of toddlers. Though no formal data on prevalence of Inhibition to Novelty Disorder have been reported, it represents a small percentage of those with behavioral inhibition Children with this disorder are commonly referred to primary care providers and to infant mental health clinicians.

21 These infants and young children show an overall and pervasive difficulty to approach new situations, toys, activities and persons that causes distress and interferes with relationships and/or participation in developmentally expected activities and routines. This condition is therefore not only a risk factor disorder for later emerging anxiety disorders, such as Generalized Anxiety Disorder and Social Anxiety Disorder, but is actually causing dysfunction and warrants allocation of treatment resources.

22 Sleep, Eating, and Crying Disorders These define disturbances in basic physiological activities necessary for healthy development and even survival. Sleep, eating and crying problems are often the result of other disorders. The disorders defined here are primary rather than symptoms of other disorders. More likely to be present in the first year of life and are common in primary care settings. To be defined as a disorder, the criteria of impairment in functioning must be met. Careful attention to the question of relationship specificity of sleep, eating and crying symptoms must be given.

23 Changes Eating instead of Feeding term, as the emphasis is on the infant s eating behavior Differentiation between Eating disorder as the child s pervasive across contexts disorder versus as one of the symptoms of a Specific Caregiver- Child relationship disorder. Failure to Thrive is not an obligatory criteria. In contrast, impairment of functioning is. Addition of Over eating and Atypical eating behaviors categories. 23

24 Over- Eating Disorder All of the following criteria must be met: A. Infants/young children overeat or attempt to overeat by demonstrating each of the following: The young child persistently seeks excessive amounts of food during meals/feedings The young child repeatedly seeks or eats excessive amounts of food between mealtimes or scheduled feedings. A

25 Over- Eating Disorder (cont.) B. Young child is excessively preoccupied with food and eating, as manifest by at least TWO of the following: The child takes food from others, or forages from garbage bins. The child stuffs food in the cheeks when eating. The child talks repeatedly about food or food themes predominate in play 25

26 Over- Eating Disorder (cont.) C. The young child becomes distressed if prevented from engaging in behaviors in criterion A. D. The young child s behavior is not due to a condition that better accounts for the behaviors (e.g., food unavailability and hunger, medication side effects) E. The child's feeding behavior causes significant impairment as defined in the impairment criteria

27 Over-Eating Disorder (continued) Age: The diagnosis is not made in children less than 24 months old Duration: The symptoms must be present for more than 1 month Note: The symptoms must be present with more than one caregiver Specify: If weight is above the 95th percentile normal, this will be noted on Axis III.

28 Under Eating Disorder Criteria All of the following criteria must be met: A. The child consistently eats less than expected for his/her age. B. Child exhibits one or more of the following maladaptive eating behaviors: Consistent lack of interest in eating Fearful avoidance of eating. Difficulty regulating state during feedings (repeatedly falls asleep or becomes agitated). Eats only while asleep Failure to transition to solid foods Eating only when specific conditions imposed by child are fulfilled by caregivers (e.g., in front of television) Extremely picky and selective Poaching (prolonged maintenance of food in mouth without swallowing)

29 Under Eating Disorder Criteria C. The maladaptive eating behavior is not better explained by medical condition or medication side effect. D. The child's feeding behavior causes significant impairment as defined in the impairment criteria

30 Notes : Loss of weight, or lack of expected weight gain, is not mandatory for the diagnosis of under eating disorder, but if it occurs, this is noted on Axis III. The diagnosis of Under-eating disorder should be given under cautious whenever there is no loss of weight. 30

31 Trauma, Stress, and Deprivation disorders PTSD Adjustment disorder Complicated Grief disorder of infancy/early childhood (from 9 months of age, for at least 30 days) Reactive Attachment disorder Disinhibited Social Engagement disorder Other trauma, stress, and deprivation disorder of infancy/early childhood All these have an etiology that is specified in the diagnostic criteria, because the symptomatic behaviors, mostly unspecific, derive from the presence of stressors, traumas, or from the absence of stimulation and caregivers, or from the loss of a primary caregiving relationship

32 Relationship Specific Disorders Research on relationships between infants and their caregivers has shown that behaviors (symptomatic as well as normal) of infants may differ systematically with different caregivers, as well as different attachment patterns. Relationship Specific Disorder of Infancy/Early childhood describes persistent symptomatic behavior in the infant/young child that is limited to one caregiving relationship, and impairs the infant s functioning. Comorbidity with other Axis I diagnoses is possible

33 By focusing only on the child s symptomatic behavior, this diagnosis does not include infants who are only at risk for psychopathology, such as infants with disorganized attachment observed only during the SSP, or infants with psychiatrically ill parents, etc.. As a rule, only infants who meet the criteria for RSD, will receive this diagnosis on Axis I. In contrast, all the evaluated infants will have their relationship contexts (dyadic and family) characterized on Axis II.

34 Important note: There is no presumption with regard to the etiology of the Relationship Specific Disorder: it can arise from problems within the caregiver, the child, the unique fit between the two. Identification of these factors during the evaluation process is essential to the treatment plan, but is not part of the diagnostic criteria.

35 Diagnostic criteria for Relationship Specific Disorder of Early Childhood The child exhibits a persistent emotional or behavioral disturbance in the context of one particular relationship with one primary caregiver but not with other caregivers. Examples include (but are not limited to) the following: Aggression/oppositionality Fearfulness Self-endangering behavior Sleep or feeding or toileting refusal Role-inappropriate behavior with caregiver (e.g., oversolicitous or controlling behavior) Breath-holding spells 35

36 Examples of Classifying Axis I Relational Problems 36 month old lives alone with mom attends childcare oppositional behavior with mom oppositional behavior at childcare oppositional behavior in both settings NO RSD diagnosis, other Axis I diagnosis 24 month old lives alone with mom does not attend childcare sleep disorder, no signs of primary relationship problem NO RSD diagnosis 36

37 42 month old lives with both parents role inappropriate with mom fearful withdrawn with dad RSD with each parent 10 month old lives with both parents food refusal problem with mom No food refusal with dad RSD with Mother

38 38

39 Assessing Caregiving Ensuring physical safety Providing for basic needs (e.g., food, hygiene, clothing, housing, health care) Conveying psychological commitment to and emotional investment in the infant/young child Establishing structure and routines Recognizing and responding to the infant/young child s emotional needs and signals Providing comfort for distress Strength Not a Concern Concern 39

40 Socializing Disciplining Engaging in play and enjoyable activities Showing interest in the infant s/young child s individual experiences and perspectives Engaging in reflectiveness regarding the infant s/young child s developmental trajectory Incorporating the infant s/young child s point of view in developmentally appropriate ways Tolerating ambivalent feelings in the caregiver infant/young child relationship Strength Not a Concern Concer n

41 Assessing the Child s Contributions to the Relationship Child Characteristic Temperamental dispositions Sensory profile Physical appearance Physical health (from Axis III) Developmental status (from Axes I and V) Mental health (from Axis I) Learning style Contribution to Relationship Quality Strength Concern or strain? Not a strength or concern

42 Relational Context Summary Rating Scale Four levels of adaptation used as a summary rating: Level 1. Well-Adapted to Good Enough Relationships No clinical concern Level 2. Strained to Concerning Relationships Careful monitoring is definitely indicated and intervention may be required Level 3. Compromised to Disturbed Relationships Clearly in the clinical range and intervention is indicated Level 4. Disordered to Dangerous Relationships Intervention is not only required but urgently needed due to the severity of the relationship impairment 42

43 Dimensions of the Family Environment Dimensions Problem solving Conflict resolution Caregiving role allocation Caregiving communication: Instrumental Caregiving communication: Emotional Emotional investment Behavioral regulation and coordination Sibling harmony Strengt h Not a Concern Concern

44 Caregiving Environment Summary Rating Four levels of adaptation used as a summary rating: Level 1. Well-Adapted to Good Enough Caregiving Environment No clinical concern Level 2. Strained to Concerning Caregiving Environment Careful monitoring is definitely indicated and intervention may be required Level 3. Compromised to Disturbed Caregiving Environment Clearly in the clinical range and intervention is indicated Level 4. Disordered to Dangerous Caregiving Environment Intervention is not only required but urgently needed due to the severity of problems 44

45 Competency Domain Rating Summary Language- Table Competency Domain Rating Exceeds developmental expectations Functions at ageappropriate level Emotional Social- Language Social Communicati on Cognitive Movement & Physical Competencies are inconsistently present or emerging Not meeting developmental expectations (delay or deviance) ZERO TO THREE, 2016, p /7/

46 Vignette 1: DC 0-5 Diagnosis Axis I co-diagnoses: Inhibition to Novelty disorder Parent-Infant relationship disorder Axis II: Significant disturbance on dyadic and triadic level Axis III: Mild developmental delay due to hypo tonicity

47 Vignette 2: Axis I DC0-5 diagnoses Axis I co-morbid diagnoses: Overeating disorder (persistently asked for food, at home and at kindergarten, and ate significantly more than her peers). Relationship specific disorder of early childhood (Mother) with oppositional and sleep symptoms.

48 Case N., 1 year and 4 months- old, the only son of a young couple, was addressed to our IMH Unit by his pediatrician because of extremely frequent breath-holding spells. N. was born prematurely, and was diagnosed at birth with diaphragmatic hernia, that necessitated immediate surgery. He stayed at the NICU for three months because of convulsions and persistent respiratory problems, and was discharged with diagnoses of Broncho Pulmonary dysplasia and left hemiplegia due to cerebral palsy. N.'s feeding was poor from the beginning.

49 Mother herself was diagnosed with a mixed anorexia and bulimia eating disorder, in addition to childhood onset juvenile diabetes mellitus. Her eating disorder started shortly after her older brother committed suicide when she was 14 years old. N s pregnancy was accompanied with repeated hypoglycemic spells due to maternal unbalanced diabetes

50 The observation of the mother-child interaction revealed a highly ambivalent and tense relationship, while the breathholding spells were especially frequent at meal times. In contrast, at the day care, N. ate well and his breathholding spells appeared only during his first week there and resolved.

51 DC 0-5 Diagnoses Axis I: # Mother-Child Specific Relationship Disorder # Neurodevelopmental disorder: Mild Cerebral Palsy Axis II: Dyadic Relational context Level 3 Axis III: # Breath Holding Spells Axis IV: # Maternal Eating Behavior Disorder Axis V: Delay in domains of motor and language development