Diagnosing Infants and Young Children Using the 2005 Revision of DC: 0-3R0. Infant/Young Child in Context. Ecosystemic Assessment

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1 Diagnosing Infants and Young Children Using the 2005 Revision of DC: 0-3R0 Jean M. Thomas, M.D., M.S.W. Children s s National Medical Center The George Washington University Medical Center Karen Frankel, Ph.D. Harris Program in Child Development and Infant Mental Health University of Colorado Denver School of Medicine 2009 Karen Frankel, PhD, Jean Thomas, MD, Reprints with permission only. Infant/Young Child in Context There is no such thing as a baby. Child Parent(s) and family Other important people Community Culture (Winnicott, 1965) Ecosystemic Assessment Developmentally attuned Relationally focused Family-centered Strength-based Contextually grounded

2 Purpose of Assessment To find a shared view To guide treatment To determine the need for additional services To communicate with other professionals Diagnostic Classification: 0-3R0 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Revised ZERO TO THREE National Center for Infants, Toddlers, and Families DC: 0-3R: 0 A Minor Revision To provide needed specifications and clarifications (operationalization( operationalization) ) in order to facilitate reliability among clinicians and set a new platform for advancing the evidence-based evolution of the system To improve the clinical usefulness of the system by enhancing its utility for clinical case formulation

3 Key Changes: DC: 0-3R0 Operationalizes criteria Supports comorbidity Increases the utility of diagnostic criteria and the assessment of all 5 axes Links the DC: classification system to other classifications of psychiatric disorders: DSM-IV (1994), RDC: PA (2003), APA (2007), DSM-V V (2012?) Diagnostic Classification: : 0-3R0 Multiaxial Framework Axis I: Axis II: Axis III: Axis IV: Axis V: Clinical Disorders Relationship Classification Medical & Developmental Disorders & Conditions Psychosocial Stressors Emotional & Social Functioning Axis I: Clinical Disorders 100 Posttraumatic Stress Disorder 150 Deprivation Maltreatment Disorder 200 Disorders of Affect 300 Adjustment Disorder 400 Regulation Disorders of Sensory Processing 500 Sleep Behavior Disorders 600 Feeding Behavior Disorders 700 Disorders of Relating and Communicating 800 Other Disorders

4 Axis I: 100 Posttraumatic Stress Disorder Exposure to Trauma Re-experiencing experiencing (at least 1) Numbing of responsiveness (at least 1) Increased arousal (at least 2) Associated features: Temporary loss of previously acquired skills 100 Posttraumatic Stress Disorder A single traumatic event, a series of events, or enduring stress. Experienced or witnessed, actual or threatened, death or serious injury to child or others, or a threat to the psychological or physical integrity of child or others Re-experiencing experiencing of traumatic event Posttraumatic play Recurrent recollections Repeated nightmares Physiological distress at reminder of event Recurrent flashbacks or dissociation

5 Numbing of responsiveness Social withdrawal Constricted range of affect Diminished interest Avoidance of activities, places or people that arouse recollection Increased arousal Sleep difficulties with Falling asleep Repeated waking Concentration difficulties Hypervigilance Exaggerated startle response Increased irritability, outbursts of anger or fussiness, tantrums 150 Deprivation/Maltreatment Disorder Persistent and severe parental neglect or documented physical or psychological abuse Frequent changes in or inconsistent availability of primary caregiver Serious neglect

6 Emotionally withdrawn or inhibited pattern Rarely seeks comfort in distress Minimal response to offered comfort Limited positive affect and excessive irritability, sadness, or fear Reduced social reciprocity Indiscriminate or Disinhibited Pattern Overly familiar behavior Failure to check back with adult caregivers after venturing away Willingness to go off with strangers 200 Disorders of Affect 210 Prolonged Bereavement / Grief Reaction 220 Anxiety Disorders 230 Depression 240 Mixed Disorder of Emotional Expressiveness

7 210 Prolonged Bereavement/ Grief Reaction Cries or calls for absent caregiver Refuses others attempts to comfort Withdraws emotionally Lethargy Disrupted eating Disrupted sleep Loss of previously attained skills Marked disturbance with reminder of loss 220 Anxiety Disorders Challenges identifying anxiety disorders Developmentally expected anxiety or fear vs. anxiety disorder Anxious temperament vs. anxiety disorder Limited verbal and cognitive capacities Common Characteristics of Anxiety Disorders Distress in, or avoidance of, activities or settings associated with fear Pervasive 2 or more everyday activities 2 or more relationships Uncontrollable Impairs functioning Persistence over time Often family history

8 Specific Anxiety Disorders 221 Separation Anxiety 222 Specific Phobia 223 Social Anxiety Disorder 224 Generalized Anxiety Disorder 225 Anxiety Disorder, NOS 230 Depression of Infancy and Early Childhood Change from child s s baseline mood Depressed or irritable mood, uncoupled with upsetting events most of the day, more days than not,, for at least 2 weeks Occurring in more than 1 activity and in more than 1 relationship Distress, impaired functioning, impeded development 231 Major Depression (Type I) & Depression NOS (Type II) Depressed or irritable mood Diminished pleasure or interest Significant weight loss or gain Insomnia/hypersomnia Psychomotor agitation/retardation Fatigue, loss of energy Feelings of worthlessness/guilt Poor concentration Themes of death or suicide, or attempts at self harm

9 240 Mixed Disorder of Emotional Expressiveness Absence of 2 or more developmentally appropriate affects Disturbed intensity of emotional expression, reversed affect, or affect inappropriate to situation 300 Adjustment Disorder An environmental stressor event is clear Disturbance appears within 1 month Affective Behavioral Persists more than 2 weeks Less than 4 months duration 400 Regulation Disorders of Sensory Processing Observed across settings & within multiple relationships Involves sensory, motor, or processing difficulties, and specific behavior patterns Sensory stimuli touch, sight, sound, taste, smell, sensation of movement in space, awareness of one s body position in space

10 410 Hypersensitive 411 Type A: Fearful / Cautious 412 Type B: Negative Defiant 420 Hyposensitive/Underresponsive Sensory Patterns: Under-reactivity reactivity Motor Patterns: Poor motor planning Behavior Patterns: Limited exploration 430 Sensory Stimulation-Seeking Seeking / Impulsive Sensory Patterns: Seeks stimulation Motor Patterns: Active, impulsive Behavior Patterns: Disorganized

11 500 Sleep Behavior Disorders When sleep is the only presenting problem 510 Sleep-Onset Disorder 520 Night-Waking Disorder 600 Feeding Behavior Disorders Difficulty establishing regular feeding patterns Difficulties in gaining and/or maintaining a healthy weight 600 Feeding Behavior Disorders 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 Gastrointrestinal Tract

12 700 Disorders of Relating and Communicating Pervasive Developmental Disorders (PDD) (DSM-IV IV-TR) 710 Multisystem Developmental Disorder (MSDD) (may use for children under 2 years) Four areas of difficulty may change with development: Relatedness, Communications, Affect, Sensory processing DC: 0-3R Diagnostic Guidelines 1. If there is a clear trauma, first consider Posttraumatic Stress Disorder (100) 2. If the child has lost a primary caregiver and meets criteria for Bereavement Disorder (210), prioritize this over other diagnoses DC:0-3R Diagnostic Guidelines-2 3. If there is a clear constitutionally or individually based sensory, motor, processing, or organizational difficulty associated with maladaptive behavior, consider Regulation Disorders of Sensory Processing (400)

13 DC:0-3R Diagnostic Guidelines-3 4. If the problems are mild, less than 4 months duration, and associated with clear stressors, consider Adjustment Disorder (300) 5. If there is no constitutionally or individually- based vulnerability, no associated significant stress or trauma, and symptoms are not mild, not of short duration, consider Disorders of Affect (200) DC:0-3R Diagnostic Guidelines-4 6. If difficulties with social relatedness and communication are extreme and recognizable in their own right, prioritize Disorders of Relating and Communicating (700). These take precedence over Regulation Disorders of Sensory Processing and Posttraumatic Stress Disorder. DC:0-3R Diagnostic Guidelines-5 7. If the only difficulty involves a caring or parental relationship, and there are no symptoms independent of that relationship, do not use Axis I. Use Axis II Relationship Classification 8. Reserve Deprivation/Maltreatment Disorder for seriously inadequate physical, psychological, and emotional care. Use Axis II: Relationship Classification for other concerns about a caregiving relationship.

14 DC:0-3R Diagnostic Guidelines-6 9. When feeding or sleep behavior disorders are present, assess the underlying basis for these difficulties, which may be problems in their own right or part of other diagnostic categories. 10. DC:0-3R specifies that more than one Axis I Clinical Diagnosis may often be appropriate. The order of the diagnoses listed is significant. Diagnostic Classification: 0-3R0 AXIS II: RELATIONSHIP CLASSIFICATION Axis II: Relationship Classification Three aspects of a relationship: Behavioral quality of the interaction Affective tone Psychological involvement All relationships are rated using the above three aspects

15 Axis II: Relationship Classification When assessing the parent-infant relationship, need to consider multiple aspects: Overall functional level of child and parent Level of distress Adaptive flexibility Level of conflict and resolution Effect of the quality of the relationship on child s s developmental progress Axis II: Relationship Classification Infants often have relationships with more than one caregiver. mother baby daycare provider father Axis II: Relationship Classification Two tools to determine Relationship Classifications Parent-Infant Relationship Global Assessment Scale (PIR-GAS) Relationship Problems Checklist (RPCL)

16 Axis II: Relationship Classification Parent-Infant Relationship Global Assessment Scale (PIR-GAS) Assesses quality of infant-parent relationship Typically completed after multiple visits Relationship problems may or may not occur with symptomatic behaviors Assesses the intensity, frequency, and duration of difficulties Need not know etiology of relationship problem to use scale Axis II: Relationship Classification PIR-GAS Well Adapted: : functioning exceptionally well Adapted: : functioning well; no significant stress; reciprocal and adaptive; conflicts do not persist and are resolved; promotes developmental progress Perturbed: : less than optimal but with adaptive flexibility; transient distress up to a few weeks; disturbance in one domain, developmental progress not impeded Axis II: Relationship Classification Two tools to determine Relationship Classifications Parent-Infant Relationship Global Assessment Scale (PIR-GAS) Relationship Problems Checklist (RPCL)

17 Axis II: Relationship Classification Relationship Problems Check List (RPCL) Documents problems or lack of problems Records the extent of certain features (include abuse and neglect) Rates relationships on behavioral quality, affective tone, and psychological involvement Descriptive features of relationship qualities are not intended as criteria,, but as guidelines for description Axis II: Relationship Classification Over involved Under involved Anxious/Tense Angry/Hostile Abusive Verbally Abusive Physically Abusive Sexually Abusive Over involved Physical or psychological over involvement BEHAVIORAL QUALITY Parent Interferes with infant s s goals & desires Dominates Makes developmentally inappropriate demands Infant Appears diffuse, unfocused, or undifferentiated Displays submissive, overly compliant behaviors or defiant behaviors Lacks motor skills &/or language expression

18 Over involved Physical or psychological over involvement AFFECTIVE TONE Parent s s anxiety/depression/anger leads to inconsistency with infant Infant passively or actively expresses anger and whines Infant s s range of affective expression is very constricted PSYCHOLOGICAL INVOLVEMENT Parent romanticizes or eroticizes infant Parent does not see infant as a separate individual with own needs and uniqueness Infant clings to parent & resists separation Angry/Hostile Harsh & abrupt, often lacking emotional reciprocity BEHAVIORAL QUALITY Parent Insensitive to infant cues Abruptly handles infant Taunts or teases infant Infant Inhibited, impulsive, or diffusely aggressive Defiant or resistant Demanding or aggressive Fearful, anxious, vigilant, or avoidant Tendency towards concrete behavior rather than imagination Angry/Hostile Harsh & abrupt, often lacking emotional reciprocity AFFECTIVE TONE Hostile or angry edge Tense Lack of enjoyment or enthusiasm Child s affect may be constricted PSYCHOLOGICAL INVOLVEMENT Parent views dependence as demanding Parent s resentment may relate to current stressors or own relationship history

19 Axis II: Relationship Classification Relationship Problems Checklist (RPCL) Relationship Quality Overinvolved Underinvolved Anxious / Tense Angry / Hostile Verbally Abusive Physically Abusive Sexually Abusive No Evidence Some Evidence; Needs further investigation Jean Thomas, MD & Karen Frankel PhD, Reprints with permission only Substantial Evidence 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 AXIS II DIAGNOSIS Is Yes the relationship characterized by: Adapte mutual enjoyment without significant stress for each partner The or relationship is pattern that protects and promotes the developmental progress of both partners No Is the relationship: functioning less than optimally, The pattern relationship transient, has or The relationship The developmental relationship progress has ca n proceed, but may be temporarily interrupted 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 Yes and emotional development Yes The relationship is Yes The relationship has Yes The relationship is Well Adapted [p 43] Adapted No Diagnosis Adapted [p 43] * * * * * Remember to complete the Relationship Problems Checklist [p 46] * * * * * Perturbed [p 43] Significantly Perturbed [p 44] Features of a Disorder Relationship Quality Distressed [p 44] Overinvolved [p 46] Disturbed [p 44] Underinvolved [p 47] Disordered [p 44] Anxious/Tense [p 48] Severely Disordered [p 44] Disordered Angry/Hostile [p 49] Grossly Impaired [p 45] Abusive [p 50] 1-10 Documented Maltreatment Verbally [p 50] Physically [p 51] Sexually [p 51] [p 45] [Number(s) in parentheses is the source page number(s) in the manual.] Adapted from ZERO TO THREE /National Center for Infants, Toddlers, and Families Diagnostic Classification: 0-3R; Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood Revised. [Northcutt & Wright (2005)] Jean Thomas, MD Karen Frankel PhD, Reprints with permission only Axis III: Medical & Developmental Disorders & Conditions Physical, medical, neurological, developmental diagnoses from other diagnostic systems, including those used by primary health providers speech/language pathologists occupational therapists physical therapists special educators

20 Axis III: Medical & Developmental Disorders & Conditions (2) Development is the unfolding of biological potential within a specific, ever evolving caregiving context. Medical and developmental conditions are significant risk factors that increase vulnerability to psychiatric symptoms. Medical and development difficulties require appropriate detailed assessment. Axis IV: Psychosocial Stressors Severity of stressor Duration Suddenness of initial stress Frequency Unpredictability of recurrence Developmental level of child Chronological age Social emotional history Biological vulnerability to stress Capacity of caregiver to Act as buffer Help child understand Cope with stressor Axis IV: Psychosocial Stressors (2) Assess the child for potential loss of basic safety, sense of security, and comfort. Assess the adequacy of the protective, supportive envelope that the caregiving environment provides. The stressors may be acute or enduring.

21 Diagnostic Classification: 0-3R0 AXIS V: EMOTIONAL AND SOCIAL FUNCTIONING Axis V: Emotional and Social Functioning Reflects child s s emotional and social functioning with important caregivers, in relation to expectable patterns of development Capacities for Emotional and Social Functioning Rating Scale: Attention and regulation (birth 3 mos.) Mutual engagement (3 6 mos.) Intentional two-way way communication (4 10 mos.) Complex gestures & problem solving (10 18 mos.) Symbols express thoughts & feelings (18 30 mos.) Connecting symbols, abstract thinking (30 48 mos.) Axis V: Emotional and Social Functioning Observe the play & interaction with each caregiver Rate each of the capacities: 1. Functions at age level; full range of affect 2. At age level, but is vulnerable to stress or has constricted range of affect 3. Functions immaturely; has capacity but not at age level 4. Functions inconsistently or intermittently unless special structure/support is provided 5. Barely demonstrates capacity, even with support 6. Has not achieve capacity

22 Attention and regulation (birth 3 mos.) Notices and attends Uses all sense Stays sufficiently regulated to interact Mutual engagement (3 6 mos.) Infant develops a relationship with an emotionally available caregiver Experiences soothing, security and pleasure Can experience full range of emotions Intentional 2-way 2 Communication Conversations with gestures &affect

23 Complex gestures & problem-solving (10-18mos) 18mos) Toddler uses emerging motor and language skills to express thoughts & ideas Express needs or wants Single gestures become sequences Use of Symbols (18-30 mos.) Imaginative play and language Expressing thoughts and feelings Elementary role-playing Can be real-life life or stories, tv,, videos Can project own feelings into play Connecting Symbols & Abstract Thinking (30-48 mos.) Elaborate pretend sequences logically Conversations about daily events Stories with beginning, middle and end Understand abstract concepts Reflect on feelings

24 Axis V: Emotional and Social Functioning Observe the play & interaction with each caregiver Rate each of the capacities: 1. Functions at age level; full range of affect 2. At age level, but is vulnerable to stress or has constricted range of affect 3. Functions immaturely; has capacity but not at age level 4. Functions inconsistently or intermittently unless special structure/support is provided 5. Barely demonstrates capacity, even with support 6. Has not achieve capacity Closing the Circle: Infant-Toddler Mental Health Services Focus on relationships Pay attention to the unique characteristics of each relational partner Develop therapeutic relationships with this in mind