miri keren, m.d. - tau · miri keren, m.d. introduction dc: 0-5 is the product of a 3 year plan...

Miri Keren, M.D.

Introduction� DC: 0-5 is the product of a 3 year plan (2013-2016) 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 20.000 DC 0-3 users around the world with

multiple-choice 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.

� 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.

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.

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.

The Five Axes� Same axial structure than in DC 0-3R, but different definition of each axis:

� Axis I: � 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

� 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

Distress and/or Functional

impairment criteria� Symptoms of the disorder, or accomodations 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

Incorporating cultural perspectives in the

mental health assessment of infants/young

children � 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.

Neurodevelopmental Disorders� Common features:

� Onset in early childhood� Delay or abnormality in functions strongly related to

biological maturation of the CNS� Generally staedy 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.

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

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 social-communication symptoms and 1 of the 4 restrictive repetitive symptoms.

� These infants are considered to be at high risk for ASD

Diagnostic algorithm for EAASD� At least 2 out of 3 social-communication + 1 repetitive and

restrictive criteria must be met, in addition to the impairment criterion:� A. Social- communication symptoms:

� 1. Limited or atypical social responsivity, such as at least one of those:� Atypical social approach

� Reduced or limited ability to engage in reciprocal social games/activities (peek- a -boo)

� Reduced or limited ability to initiate joint attention to shred interest or emotions, or to seek information about objects of interest

� Restricted responses to social interaction, or rare, restricted initiation of social interaction

� 2. Deficits in non verbal social-communication behaviors, such as at least one of:� Lack or restricted integration of non verbal and verbal behaviors

� Atypical use of eye contact and turning away from others in social contexts

� Difficulty understanding or using non verbal communication (gestures)

� Restricted range of facial expressions

� 3. Peer interaction difficulties as evidenced by at least one of the following:� Problems adapting behavior to social demands

� Difficulties engaging in spontaneous pretend or imaginative play

� Limited or lack of interest in peers and in playing with other infants/young children

� B. Symptoms in criterion A are not better explained by sensory impairments (vision, hearing, or other major sensory deficit), not the child meets criteria for ASD.

� C. One of the following repetitive/restrictive behaviors:1. Stereotyped or repetitive babbling or speech. Motor movements, or use of

objects

2. Rigidly maintains routines and resist change, shows distress in transitions, or ritualized use of odd, idiosyncratic verbal sentences or nonverbal behaviors.

3. Highly circumscribed specific unusual interests

4. Atypical responsivity to sensory inputs

� D. Impairment in functioning

� Age: 9-36 months

� Specify presence of global delay, language delay, genetic condition, sensory processing abormalities

Over-activity Disorder of Toddlerhood

� Pervasive, extreme, persistent, developmentally inappropriate hyperactivity and impulsivity , in young children,

� that impair their functioning,

� are present in at least two different physical settings or within two different relationships,

� Age range: between 24 to 36 months

� Duration: at least 6 months

Diagnostic algorithm for OADTALL of the following criteria must be met:

� A. The young child presents at least 6 symptoms from the following:� 1. Frequently squirms or fidgets when expected to be still

� Usually gets up or ties to from seat during activities

� Often climbs on furniture or on inappropriate objects

� Makes more noise than others and has difficulty to play quietly.

� Often shows excessive motor activity and nondirected energy

� Usually talks too much

� Has difficulty to wait for turn

� B. Behaviors meeting criteria A. must be excessive when compared with developmentally and culturally expected norms

� C. Symptoms must be present in at least 2 contexts or within two different relationships

� D. Criteria of impairment must be met

� Age: 24-36 months

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

Anxiety Disorders� Separation Anxiety Disorder

� Social phobia

� Generalized anxiety disorder

� Selective mutism

� Inhibition to Novelty Disorder

� Other

� 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

Slow-to-warm-up

temperament� All young children show a fear response when

confronted by frightening or very unusual situations. They will respond by staying close to their parents, and exhibit facial expressions of fear, crying and a refusal to investigate and approach.

� Takes time to approach new stimuli/situations but by the end of the hour, does it!

� This child is perfectly happy and well adjusted, but he needs to proceed with new activities and interactions with new people at his own deliberate pace.

� Does not cause impairment as long as there is goodness of fit, therefore is not considered as pathological.

Behavioral Inhibition� Children with BI show patterns of dysregulated

behavior. They show fear responses even in situations that are not threatening and at times their fearful behavior and levels of distress are extreme and continue long after the threat has been removed.

� They are fussy, react strongly to any changes such as being undressed, are difficult to calm, react strongly to strangers or new situations.

� They also are very sensitive to being wet, hungry, or in discomfort. These infants become easily over-aroused and distressed when there is a lot going on around them.

� Compared with their peers, BI children may experience more social rejection, interpret ambiguous social encounters as particularly rejecting, more vigorously tend to avoid social stressors, and more often respond to social rejection with attributions of internal failures and avoidant coping;

� BI is a risk factor for later anxiety disorders, including social phobia and selective mutism.

The need for a diagnostic

category

� 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.

� 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.

Diagnostic Algorithm

All of the following A B C criteria must be met:

A. The infant/young child exhibits a pattern of fearful behavior in the presence of novel/unfamiliar objects (e.g., toys), people, and/or situations. The infant/young child almost always:

1. Freezes or withdraws (e.g., stops vocalizing, avoids eye contact) and/or attempts to distance himself/herself from the novel object, person or experience by hiding or seeking the caregiver.2. Displays marked, persistent, and pervasive negative affect.

B. The inhibited behavior is not better explained as a trauma or stress-related symptom as in PTSD or Adjustment Disorder and is not simply a phobic reaction to specific stimuli.

.C. Symptoms of the disorder, or caregiver accommodations in response to the

symptoms, significantly impact the young child’s and/or family’s functioning in one or

more of the following ways:

1. Cause distress to the child;

2. Interfere with the child’s relationships;

3. Limit the child’s participation in developmentally expected activities or routines;

4. Limit the family’s participation in everyday activities or routines; or

5. Limit the child’s ability to learn and develop new skills, or interfere with

developmental progress.

� Age: The child must be younger than 24 months of age. Beyond 24 months, the

disorder is not diagnosed since young children who remain symptomatic after this

age seem to display symptoms of other anxiety disorders (e.g., Generalized Anxiety

Disorder, Social Anxiety Disorder).

� Duration: Symptoms of the disorder must be present for at least one month.

The relational aspects of

anxiety disorders in infancy

� Kiel (2011): Not all parents respond to their children's

fearfulness with protective behavior, suggesting

moderating influences on the relation between fearful

temperament and protective parenting; it has been

theorized that some parents are particularly attuned to

their temperamentally fearful children's wariness and

therefore likely to respond with over protection when

they anticipate such displays;

� Gartstein (2010): Maternal depression accounted for change in fearfulness, with more frequent and more severe maternal symptoms leading to greater increases in infant fear and increases in fearfulness leading to more problematic toddler anxiety;

� The clinical implication of these two studies, as illustrated by our case, is the need to work on the parent-infant relationship ANYWAY.

Clinical vignette� 11 month-old baby girl, was referred by Well-Baby

Community Center to our IMH Unit, because of “extreme passivity and 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.

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

Outcome of multimodal treatmentFollow-up session at three years of age:

Well developed and functional, but still very

shy child. Has two friends at kindergarten

and plays only with them. Took time to open

up to kindergarten teacher. Tends to speak

very low in strangers’ presence. Does not like

birthday parties.

Parents are doing well and their relationship is stable. No signs of parent- child relationship disorder anymore.

Conclusion� The essential feature of Inhibition to Novelty Disorder is that

infants and young children exhibit a pattern of fearful behavior

in the face of new people or situations that is not better explained

by a traumatic or frightening event.

� This fear and inhibition are extreme and associated with

impairments in the infant/young child and/or family’s

functioning. The main functional consequence of the disorder is

the restriction of the infant's exploratory behavior and learning

through new experiences and resistance to efforts to encourage exploration.

� We hope the insertion of this new diagnostic category will

encourage further research in this field of very early-onset anxiety conditions.

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.

Sleep disorders� Sleep Onset disorder (from 6 months of age)

� Night waking disorder (from 8 months of age)

� Partial Arousal Sleep disorder (from 12 months of age)

� Nightmare Disorder of Early Childhood (from 12 months old)

DC 0-3R Diagnostic Classification of Feeding

Disorders in Infancy

� Feeding Disorder of State Regulation (onset during the newborn period).

� Feeding Disorder of Reciprocity (onset between 2 and 6 months of age).

� Infantile Anorexia (onset during transition to spoon and self-feeding).

� Sensory Food Aversions (onset during the introduction of baby or table food).

� Feeding Disorder Associated with Concurrent Medical Condition (onset at anytime)

� Post-traumatic Feeding Disorder (onset at anytime)

12/7/2016Copyright © 2016 ZERO TO THREE. All rights reserved. 41

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.


Impairment of Functioning Criteria

� Symptoms of the disorder (or caregiver accommodations in response to the symptoms) impact significantly the child and/or family functioning in one or more of the following ways:

� cause distress to the child, and/or to family;

� interfere with the child’s relationships;

� limits the child’s participation in developmentally-expected activities or routines and/or the family’s participation in everyday activities or routines;

� failure to follow age appropriate growth trajectories

Over- Eating Disorder A

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.


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


Over- Eating Disorder (cont.) .CThe young child becomes distressed if prevented from engaging in behaviors in criterion A.

.DThe 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)

.EThe child's feeding behavior causes significant impairment as defined in the impairment criteria


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 .


Vignette

� 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.


� 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.


� 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.


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.


Under Eating Disorder CriteriaAll 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)


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


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.


Vignette

� 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.


� 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


� The observation of the mother-child interaction revealed a highly ambivalent and tense relationship, while the breath-holding spells were especially frequent at meal times.

� In contrast, at the day care, N. ate well and his breath-holding spells appeared only during his first week there and resolved.


Axis I DC 0-5 Diagnosis

� Specific Mother-Child Relationship Disorder (as manifested by symptoms of breath-holding spells and eating difficulties only in the context of the mother-child interaction.)

Note: No diagnosis of Eating Disorder


Atypical Eating disorders

ALL THE THREE following criteria must be present:

A. The infant /young child exhibits a pattern of abnormal eating behaviors that includes AT LEAST ONE of the following:

� Hoarding – the child hides food in unusual places (e.g., in the bed, in a desk drawer).

� Pica – habitual eating of nonnutritive substances.

� Rumination – a pattern of regurgitating and re-swallowing food.


Atypical Eating disorders

B. The infant’s/young child’s abnormal eating behavior is not better explained by a medical condition or medication side effect.

C. The infant’s/young child's atypical eating behavior causes significant impairment as defined in the impairment criteria

Note: One should mention on Axis III, the presence of medical complications, such as dental caries and anemia as a consequence of these atypical feeding behaviors.


Excessive Crying DisorderAll the following criteria must be met:

� A. The infant cries at least 3 hours a day, 3 or more days a week, for at least 3 weeks

� B. Crying is not better explained by a medical condition

� C. Symptoms cause significant impairment

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

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

Relationship Specificity� There is considerable evidence that infants/young

children may construct different kinds of relationships with different caregivers.

64

Relationship quality between mother and child

Relationship quality between father and child

� 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.

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.

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., over-solicitous or controlling behavior)

67

Relationship Specific Disorder of Early Childhood

� Exclusion criterion: The child’s symptoms are expressed in more than one caregiving relationship.

� The child’s emotional and behavioral disturbances involve significant and persistent distress for the child and/or place the child at substantially increased risk for developmental compromise.

� Specify: Caregiver with whom symptomatology is manifest.


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

12/7/2016 69

� 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

Considerations about the RSD Diagnosis

Contributions

� Inclusion in Axis I legitimizes the relationship focus of best-practices intervention

� Anchor in child’s symptomatology obviates the need for new relational vocabulary.

� Broad net of possible manifestations: No specific symptoms or behaviors are required for diagnosis

Drawbacks

� Concrete diagnostic quandaries when there is only one primary parent figure or caregiver

� Asymptomatic children in disordered parent-child relationships are not eligible for diagnosis, although the maladaptive family context can be described in Axis II

71

Unanswered question awaiting clinical input and research:

Will this diagnosis influence and improve assessment and treatment?

72

Contextualizing normality and psychopathology

“There is no such thing as an infant, meaning, of course,

that whenever one finds an infant one finds maternal care,

and without maternal care there would be no infant.”

Winnicott

“One of the most important changes in developmental

research in the past 25 years is the discovery and

exploration of context.”

Sameroff

74

What Caregiver and Infant/Young Child

Bring to their Relationship

�Dimensions of Caregiving

�Infant/Young Child Contributions

�Ratings

�Strength

�Not a concern

�Concern


Dimensions of Caregiving

76

ZERO TO THREE, 2016, p. 140

Three overarching caregiving dimensions:

Knowing and valuing child as unique

Emotionally available

Comfortable and completely in charge

• Monitoring, reading cues, responding effectively

• Overlaps with emotional availability

• Setting aside one’s needs to meet child’s needs

Assessing Dimensions of Caregiving

StrengthNot a

ConcernConcern

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

Copyright © 2016 ZERO TO THREE. All rights reserved. 7712/7/2016

(Continued)

StrengthNot a

ConcernConcer

n

Socializing

Disciplining

Engaging in play and enjoyable activities

Showing interest in the infant’s/young child’s individual experiences and perspectivesEngaging in reflectiveness regarding the infant’s/young child’s developmental trajectoryIncorporating the infant’s/young child’s point of view in developmentally appropriate waysTolerating ambivalent feelings in the caregiver–infant/young child relationship


Assessing the Child’s Contributions

to the RelationshipChild Characteristic Contribution to Relationship Quality

StrengthConcern or

strain?

Not a strength or

concern

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


Relational Context Summary Rating Scale

Four levels of adaptation used as a summary rating:

Level 1. Well-Adapted to Good Enough RelationshipsNo clinical concern

Level 2. Strained to Concerning RelationshipsCareful 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 RelationshipsIntervention is not only required but urgently needed due to the severity of the relationship impairment


Dimensions of the Caregiving

Environment

81

DimensionsStrengt

hNot a

ConcernConcern

Problem solving

Conflict resolution

Caregiving role allocation

Caregiving communication: Instrumental

Caregiving communication: Emotional

Emotional investment

Behavioral regulation and coordination

Sibling harmony

Copyright © 2016 ZERO TO THREE. All rights reserved.12/7/2016

Caregiving Environment Summary RatingFour levels of adaptation used as a summary rating:� Level 1. Well-Adapted to Good Enough Caregiving

EnvironmentNo clinical concern

� Level 2. Strained to Concerning Caregiving EnvironmentCareful 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


Level 1: Well-Adapted to

Good-Enough Caregiving

Environment� Relationships among the caregivers function adequately or

better� ups and downs may be evident

� conflicts are not characteristic

� strains adequately repaired

� Caregivers� have a solid repertoire of problem-solving strategies

� have a mutually satisfying allocation of caregiving roles

� collaborate adequately with each other in coparenting

� Infant/young child typically shows comfort and ease in interacting with the different caregivers

83


Copyright © 2016 ZERO TO THREE. All rights reserved.12/7/2016

Level 2: Strained to Concerning

Caregiving Environment� Relationships show

� Some worrisome patterns of interaction regarding upbringing of the infant/young child

� Signs of conflict, insufficient communication and coordination

� The infant/young child

� Experiences distress about how to negotiate interactions with the different caregivers

� May show preferences that spark conflict among them

84Copyright © 2016 ZERO TO THREE. All rights reserved.12/7/2016

Level 2: Strained to Concerning

Caregiving Environment

(continued)� Concern about the caregivers’

� misalignment of expectations

� coordinated emotional availability with the infant/young child

� responding to needs for comfort and protection

� age-appropriate socialization

� willingness to engage in play and exploration

� Some important adaptive qualities are present in the relationship


Level 3: Compromised to

Disturbed Caregiving Environment� Relationships at this level are fraught with

� inappropriate levels of risk to safety,

� significant conflict,

� insufficient or irregular engagement, or

� significant imbalance.

� The infant’s/young child’s social and emotional trajectory has become or is at risk of being compromised.


Level 3: Compromised to

Disturbed Caregiving Environment� Problems with the caregivers’

� role allocation

� emotional availability and the infant’s/young child’s emotional regulation, or

� mutual support in responding to the infant’s/young child’s

� needs for comfort and protection

� age-appropriate socialization

� willingness to engage in play and exploration


Level 4: Disordered to Dangerous

Caregiving Environment� An unquestionable urgency about intervening to

address serious and potentially dangerous relationship conflicts

� Relationship pathology among caregivers is severe and pervasive

� Significant impairments in

� provision of adequate protection,

� responsive caregiving,

� age-appropriate socialization, or

� support for exploration and learning




(continued)� The relationships are fraught with significant overt

conflict, insufficient engagement, or significant role reversal.

� These relationship disturbances seriously compromise the infant’s/young child’s development.

� These relationship disturbances threaten the infant’s/young child’s physical or psychological safety.




(continued)� Mandated reporting should be considered BUT may or

may not be indicated with this rating.

� If the infant’s/young child’s safety is threatened and the infant/young child is in potential danger, the clinician must consider reporting to child protective services.

� Prior history of maltreatment does NOT automatically lead to a Level 4 rating.


.


Revising Axis V

� Maintain a focus on understanding children’s mental health in the context of their developmental capacities;

� Make the axis more accessible to clinicians working across multiple theoretical orientations;

� Provide an approach that allows clinicians to describe multiple domains of development as well as capture whether children were developing evenly or unevenly across developmental areas.


Axis V: Developmental Concepts

� Emotional and social capacities are present at birth and serve as the foundation for all development.

� The infant/young child makes use of earlier capacities to reach higher levels of functioning. In this process, new capacities emerge.

� Understanding how an infant/young child integrates competencies across and within domains is necessary for clinical formulation.


Developmental Competency and Milestones

Rating Table

The clinician rates the infant’s/young child’s functioning in five developmental domains:

� Emotional

� Social-Relational

� Language-Social communication

� Cognitive

� Motor and Physical


Competency Domain Rating Summary Table


Competency Domain Rating

EmotionalSocial-

Language

Language-Social

Communication

CognitiveMovement &

Physical

Exceeds developmental expectations

Functions at age-appropriate level

Competencies are inconsistently present or emerging

Not meeting developmental expectations (delay or deviance)


Developmental Competency Domain Rating

Rate individual behaviors in the age or mental age range as follows:

1 = Fully present

2 = Inconsistently present or emerging

3 = Absent


Kiw

i S

tree

t S

tud

ios


Axis V:

Developmental Competency Overview

The five domains are rated independently

� capacities develop in an integrated fashion

� capacities emerge within interactions with important caregivers

Axis V ratings are designed

� to inform clinical and diagnostic formulation

� as an aid in capturing developmental capacities

� NOT as a replacement for other modes of developmental assessment


miri keren, m.d. - tau · miri keren, m.d. introduction dc: 0-5 is the product of a 3 year plan...

Documents