The APA published a variation of the ICD-6 mental disorders categories in 1952, as the first edition of the Diagnostic Statistical Manual of Mental Disorders (DSM), and it was first revised in 1967.⁷ Both of these editions were influenced predominantly by a psychoanalytic approach, and the term reaction was used for many of the disorders, more so in the first edition. For example, in 1967, what is now defined as attention-deficit/hyperactivity disorder (ADHD) was still labeled hyperkinetic reaction of childhood. The classificatory structure was organized with two poles: psychosis on the severe end, characterized by a disconnection with reality and typically manifested by hallucinations, delusions, and illogical thinking, and neurosis at the mild end, characterized by distortions of reality and typically manifested by anxiety and depression.

In 1980, when the DSM was revised to the third edition,⁸ the psychodynamic view was discarded, and a biomedical model became the principal approach. The system included explicit diagnostic criteria and a multiaxial system. The revised system tried to make a clear distinction between normal and abnormal. The revision of the third edition, DSM-III-R,⁹ was published in 1987 and was based on additional research and consensus. It was subsequently revised again in 1994 as the fourth edition (DSM-IV),¹⁰ in part to develop compatibility between the DSM system and the tenth edition of the International Classification of Diseases (ICD-10).¹¹ Additional revisions in the text were published in 2000 without any substantial changes in the disorder characteristics (DSM-IV-TR).¹²

ORGANIZATIONAL PLAN

The DSM-IV system has become the most well established and widely used of diagnostic classification systems in clinical practice with children with behavioral disorders. The DSM-IV system is divided into five axes to provide for the assessment of multiple domains of information. These axes are described as follows.

Axis I: Clinical Disorders and Other Conditions

The first axis consists of most of clinical mental disorders and other conditions that may be a focus of clinical attention. They are grouped into 16 major diagnostic classes. The first section is devoted to disorders usually first diagnosed in infancy, childhood, and adolescence (Table 6-1). Communication Disorders; Pervasive Developmental Disorders; Attention-Deficit and Disruptive Behavior Disorders; Feeding and Eating Disorders of Infancy or Early Childhood; Tic Disorders; Elimination Disorders; and Other Disorders of Infancy, Childhood, or Adolescence. However, some individuals with disorders that may be diagnosed during childhood (e.g., ADHD) may not present for clinical attention until adulthood. Moreover, it is not uncommon for the age at onset of many disorders in other sections (e.g., Major Depressive Disorder) to begin during childhood or adolescence. Significant controversy has arisen about when bipolar disorders are likely to manifest.¹³ Other diagnoses that are not specific to children but are applicable for children and adolescents include Anxiety, Mood Disorders, Eating Disorders, Somatoform Disorders, and Substance Use Disorders.

TABLE 6-1 DSM-IV Axis I Disorders

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence

Learning Disorders

Reading Disorder

Mathematics Disorder

Disorder of Written Expression

Learning Disorder NOS

Motor Skills Disorder

Developmental Coordination Disorder

Communication Disorders

Expressive Language Disorder

Mixed Receptive-Expressive Language Disorder

Phonological Disorder

Stuttering

Communication Disorder NOS

Pervasive Developmental Disorders

Autistic Disorder

Rett Disorder

Childhood Disintegrative Disorder

Asperger Disorder

Pervasive Developmental Disorder NOS

Attention-Deficit and Disruptive Behavior Disorders

Attention-Deficit/Hyperactivity Disorder

Predominantly Inattentive Type

Predominantly Hyperactive-Impulsive Type

Attention-Deficit/Hyperactivity Disorder NOS

Conduct Disorder

Childhood-Onset Type

Adolescent-Onset Type

Unspecified Onset

Oppositional Defiant Disorder

Disruptive Behavior Disorder NOS

Feeding and Eating Disorders of Infancy or Early Childhood

Pica

Rumination Disorder

Feeding Disorder of Infancy or Early Childhood

Tic Disorders

Tourette Disorder

Chronic Motor or Vocal Tic Disorder

Transient Tic Disorder

Tic Disorder NOS

Elimination Disorders

Encopresis

With Constipation and Overflow Incontinence

Without Constipation and Overflow Incontinence

Enuresis (Not Due to a General Medical Condition)

Other Disorders of Infancy, Childhood, or Adolescence

Separation Anxiety Disorder

Selective Mutism

Reactive Attachment Disorder

Stereotypic Movement Disorder

Specify if: With Self-Injurious Behavior Disorder of Infancy, Childhood

Delirium, Dementia, and Other Cognitive Disorders

Mental Disorders Due to a General Medical Condition not Otherwise Classified

Substance-Related Disorders

Schizophrenia and Other Psychotic Disorders

Mood Disorders

Major Depressive Disorder

Dysthymic Disorder

Bipolar Disorder

DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association); NOS, not otherwise specified.

International Classification of Diseases, 10th Edition (ICD-10)

HISTORY

A unified classification of diseases started in 1853 at the First International Statistical Congress. The Bertillon Classification of Causes of Death was a synthesis of English, German, and Swiss classifications that was general accepted internationally at the end of the 19th century and was accepted by the American, Canadian, and Mexican organizations in 1898. In 1929, a Mixed Commission made up of representatives of the International Statistical Institute and the Health Organization of the League of Nations developed the Fourth Revision of the International List of Causes of Death; this was revised as the fifth edition in 1938. A recognition that morbidity needed to be included started in the earlier 1900s, so that the fourth revision included further subdivisions to reflect morbid conditions that were not causes of death. The sixth edition, titled International Classification of Diseases, was entrusted to the Interim Commission of the World Health Organization in 1948.

In the early 1960s, the Mental Health Program of the World Health Organization worked to improve the diagnosis and classification of mental disorders. These activities resulted in major revisions in the mental disorders, classified in the eighth edition. In both the eighth and ninth revisions, like DSM-II, the system contained the divisions between neurotic and psychotic disorders. However, the 10th edition (ICD-10), published in 1992,¹¹ took a more atheoretical approach, similar to that of DSM-IV. The number of categories expanded from 30 in ICD-9 to 100 in ICD-10.

ORGANIZATIONAL PLAN

The mental disorders in ICD-10 are divided into ten categories: organic, including symptomatic, mental disorders (F00-09); mental and behavioral disorders caused by psychoactive substance use (F10-19); schizophrenia, schizotypal, and delusional disorders (F20-29); mood (affective) disorders (F30-39); neurotic, stress-related, and somatoform disorders (F40-49); behavioral syndromes associated with physiological disturbances and physical factors (F50-59); disorders of adult personality and behavior (F60-69); mental retardation (F70-79); disorders of psychological development (F80-89); and behavioral and emotional disorders with the onset usually occurring in childhood and adolescence (F90-98). The behavioral and emotional disorders with onset usually occurring in childhood and adolescence and the disorders of psychological development are presented in Table 6-2.

TABLE 6-2 ICD-10: Behavioral and Emotional Disorders with Onset Usually Occurring in Childhood and Adolescence and Disorders of Psychological Development

Behavioral and Emotional Disorders with Onset Usually Occurring in Childhood and Adolescence

Hyperkinetic Disorders

Disturbances of activity and attention

Hyperkinetic conduct disorder

Other hyperkinetic disorders

Hyperkinetic disorder, unspecified

Conduct Disorders

Conduct disorder confined to the family context

Unsocialized conduct disorder

Socialized conduct disorder

Oppositional defiant disorder

Other conduct disorders

Conduct disorder, unspecified

Mixed Disorders of Conduct and Emotions

Depressive conduct disorder

Other mixed disorders of conduct and emotions

Mixed disorder of conduct and emotions, unspecified

Emotional Disorders with Onset Specific to Childhood

Separation anxiety disorder of childhood

Phobic anxiety disorder of childhood

Social anxiety disorder of childhood

Sibling rivalry disorder

Other childhood emotional disorders

Childhood emotional disorder, unspecified

Disorders of Social Functioning with Onset Specific to Childhood and Adolescence

Elective mutism

Reactive attachment disorder of childhood

Disinhibited attachment disorder of childhood

Other childhood disorders of social functioning

Childhood disorders of social functioning, unspecified

Tic Disorders

Transient tic disorder

Chronic motor or vocal tic disorder

Combined vocal and multiple motor tic disorder [Tourette syndrome]

Other tic disorders

Tic disorder, unspecified

Other Behavioral and Emotional Disorders with Onset Usually Occurring in Childhood and Adolescence

Nonorganic enuresis

Nonorganic encopresis

Feeding disorder of infancy and childhood

Pica of infancy and childhood

Stereotyped movement disorders

Stuttering [stammering]

Cluttering

Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence

Unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence

Disorders of Psychological Development

Specific Developmental Disorders of Speech and Language

Specific speech articulation disorder

Expressive language disorder

Receptive language disorder

Acquired aphasia with epilepsy [Landau-Kleffner syndrome]

Other developmental disorders of speech and language

Developmental disorders of speech and language, unspecified

Specific Developmental Disorders of Scholastic Skills

Specific reading disorder

Specific spelling disorder

Specific disorder of arithmetical skills

Mixed disorder of scholastic skills

Other developmental disorders of scholastic skills

Developmental disorders of scholastic skills, unspecified

Specific Developmental Disorder of Motor Function

Mixed Specific Developmental Disorders

Pervasive Developmental Disorders

Childhood autism

Atypical autism

Rett syndrome

Other childhood disintegrative disorders

Overactive disorder associated with mental retardation and stereotyped movements

Asperger syndrome

Other pervasive developmental disorders

Pervasive developmental disorder, unspecified

Other Disorders of Psychological Development

Unspecified Disorders of Psychological Development

ICD-10, International Classification of Diseases, Tenth Edition (World Health Organization).

Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version

HISTORY

For many years, pediatricians were concerned that the DSM-IV was of limited the primary care setting for several critical reasons: (1) lack of a spectrum that characterizes issues at less than a disorder level; (2) limited developmental perspective; and (3) limited characterization of environmental factors of importance for prevention. On the basis of these concerns, there was an interest to develop a modified system that would address these deficiencies. The development process started in 1989 under the auspices of the National Institute of Mental Health, which sponsored two meetings between representatives of the four primary care disciplines of internal medicine, family practice, pediatrics, and obstetrics/gynecology and representatives from the APA who were responsible for the DSM-IV. Participants at those meetings concluded that primary care clinicians did not find the DSM system useful for their purposes and formulated the recommendation to develop a more user-friendly system for primary care clinicians.

For adult mental disorders, the APA assumed responsibility for the system development with consultants from the primary care participants at the meetings. To address the need for a more extensive, child-oriented system, the American Academy of Pediatrics took the lead by forming a task force. From the outset, the process was a collaborative effort among the American Academy of Pediatrics, the APA, and the American Psychological Association (primarily through the Society for Pediatric Psychology). Other organizations also participated, including the Society for Developmental and Behavioral Pediatrics, the American Academy of Child and Adolescent Psychiatry, the American Academy of Family Physicians, the Canadian Pediatric Society, the Zero to Three/National Center for Clinical Infant Programs, the Maternal and Child Health Bureau, and the National Institute of Mental Health. Funding was obtained from the Robert Wood Johnson Foundation, the Maternal and Child Health Bureau, and the American Academy of Pediatrics Friends of Children Fund.

The intent of the DSM-PC Child and Adolescent Version was to develop a system that would help primary care clinicians better identify psychosocial issues and conditions affecting their patients, so that they could provide interventions when appropriate and make referrals to mental health clinicians where needed. The development of a common language between general medical and mental health clinicians was essential in this process. At the outset of the project, several assumptions and directives concerning the construction of the system were made:

Children demonstrate symptoms that vary along a continuum from normal variations to mental disorders, and this continuum can be subgrouped into normal developmental variations, problems, and disorders.

Environment has an important effect on the mental health of children, and if stressful situations are addressed, more severe mental health problems can be prevented.

Children vary in how they respond to situations, depending on their age and development.

A useful system must remain compatible with existing systems, especially the DSM-IV.

The system must be clear, concise, and user friendly for primary care physicians.

The system must be based on objective information as much as possible, with consensus when this is not possible, and organized so that it can be verified or revised by subsequent research.

The project brought together experts from pediatrics, psychiatry, and psychology to develop the system. There were seven working groups. Each was chaired by a pediatrician and consisted of two additional pediatricians, one of whom was always a primary care physician; two child psychiatrists; and two child psychologists. An important part of the process was the collaborative dialog that developed in each of the working groups. This allowed the final system to have a broader perspective than occurs within any one discipline. After completion, the DSM-PC was reviewed by 171 professionals from the fields of primary care pediatrics, developmental-behavioral pediatrics, child psychiatry, child psychology, and child neurology.

ORGANIZATIONAL PLAN

The manual is divided into two major sections. The first section addresses the issue of a child’s environment, and the second section discusses a child’s manifestations of behavior. The preamble to the child’s environment “Situations Section” is provided to help the clinician describe and consider the effect of situations that present in practice and affect a child’s mental health. It also helps the clinician determine the potential consequences of an adverse situation and identify factors that may make a child more vulnerable or resilient and thus lessen or heighten the situation’s effect. The preamble is followed by a list of potentially adverse situations grouped by their nature, in which more common and/or well-researched situations are more specifically defined (Table 6-3). To help clinicians evaluate the effects of stressors, information concerning key risk and protective factors is provided. To help clinicians assess the effects of situations on the behavior of children, a table summarizes the common behavioral responses to stressful events for children of varying ages.

TABLE 6-3 DSM-PC Classification of Situations

Challenges to Primary Support Group

Challenges to Attachment Relationship

Death of a Parent or Other Family Member

Marital Discord/Divorce

Domestic Violence

DIFFERENTIAL DIAGNOSIS

The clusters also help the clinician develop a differential diagnosis. This component follows the spectrum component and is divided into two sections: alternative causes and comorbid and associated conditions. The differential diagnosis component begins with phenomena that could be alternative causes for the behaviors and is divided into three parts. The first part lists general medical conditions that could cause the child’s behavioral manifestations. The second part lists substances, legal and illegal, that may cause the behavioral manifestations. The third part lists other mental disorders that may manifest with similar behavioral symptoms and that, if present, should be coded in place of the disorder in the cluster. The comorbid section is organized similarly to the alternative causes section with only two parts: other mental disorders and general medical conditions that commonly co-occur with the disorder.

SEVERITY

Severity is somewhat addressed in the spectrum section of the child manifestations, because the decision about behavioral symptoms reflecting variation, problem, or disorder is a severity judgment. In addition, the system provides clinicians with general guidelines to characterize their patient’s overall functioning, describes the key elements that should help determine the severity of a child’s condition (symptoms, functioning, burden, suffering, and risk/protective factors), and suggests using the three categories mild, moderate, and severe to describe the severity.

HOW IS THE DSM-PC CURRENTLY BEING USED IN PRACTICE?

How the DSM-PC is currently being used in a range of settings is an important issue. To provide some preliminary information on this topic, Drotar and associates ¹⁶ surveyed two groups, each of whom would be expected to be more knowledgeable about the DSM-PC and more likely to use it than the average group of professionals: (1) the Ohio Chapter of the Society for Developmental and Behavioral Pediatrics (an interdisciplinary group of pediatricians, psychologists, and social workers) and (2) an interdisciplinary group consisting of the faculty trainers for DSM-PC. Professionals who reported using the DSM-PC were also asked to describe the advantages and disadvantages of the instrument. Most respondents believed that an advantage of the DSM-PC was its conceptualization of behavioral problems and the environmental contexts. Others reported that the developmental spectrum and the age-appropriate examples of symptom presentations were very useful and that the continuum of symptom severity and ability to label subsyndromal conditions was also an advantage. The primary disadvantage involved problems with reimbursement from third-party payers. Other disadvantages were lack of specificity or clarity of concepts outlined and an absence of guides to facilitate its use.¹⁶

CLINICAL APPLICATION: AN EXAMPLE FROM A PRIMARY CARE PRACTICE SETTING

To address the need for clinical application of the DSM-PC, Sturner and Howard ¹⁷ developed a computerized version of a parent inventory known as the Child Health and Development Interactive System (CHADIS). In the inventory, parents are asked to identify their level of concern (very, somewhat, or not at all concerned) among a list of general concerns derived from the “presenting complaint” section of the DSM-PC Child Manifestations section. If more than one concern is identified, the parent is asked to prioritize among them. The parent is then prompted to respond to an algorithm of questions related to the identified chief complaint. The parent continues through the series of questions until (1) criteria for a diagnostic level are not achieved or (2) all the questions necessary to make a DSM-PC diagnosis have been reached. A pilot and feasibility study conducted with 27 children from a pediatric practice indicated positive parental reactions to participating in visits in which the CHADIS application of the DSM-PC was used.¹⁷ In several studies, Sturner and colleagues described the utility of the CHADIS system in identifying children in primary care who have DSM-PC diagnoses.¹⁸^–²⁰

Sturner and colleagues ¹⁸ described the kinds of mental health problems documented by pediatricians during the course of child health supervision and the DSM-PC diagnoses made for the same children by the CHADIS. A convenience sample of inner-city children was seen by pediatricians for child health visits in two university-affiliated community pediatric clinics. After each visit, CHADIS/DSM-PC was administered to the child’s caregiver. Mental health diagnostic information documented on the clinic’s standard encounter forms was noted by two reliable coders. DSM-PC diagnoses were obtained from the CHADIS/DSM-PC. CHADIS/DSM-PC identified a “disorder” diagnosis in 27%, a “problem” in 28%, “developmental variation” in 21%, and no diagnosis for 23%. Pediatricians used a DSM-IV disorder label for 13% and informal diagnostic labels for another 10%.

INTERDISCIPLINARY USE

The DSM-PC can be a very useful tool for training psychologists and mental health professionals to understand the full range of clinical problems and environmental stressors among children when providing consultation to primary care physicians.^4,²¹ Because the DSM-PC emphasizes the concept of a continuum of behavioral problems, it can be used to teach undergraduate and graduate students concepts of child development and developmental psychopathology.⁵

USE IN TARGETING AND MONITORING INTERDISCIPLINARY COMMUNITY-BASED PREVENTIVE INTERVENTION FOR CHILDREN AT RISK

Because the DSM-PC contains nontechnical language and is not limited to profession-specific, diagnostic classification language such as that in the DSM-IV, it may be useful to a broad range of professional service providers for organizing and targeting interventions for children at risk of emotional disturbance or with early signs of emotional disturbance.

The DSM-PC also provides a method for community-based service providers to categorize the types of environmental situations or stressors that might be expected to affect treatment planning and prognosis for at-risk children.¹⁶ For example, some children may receive early intervention services in response to specific environmental stressors (e.g., domestic violence or problems in caregiving) that are readily categorized by the DSM-PC.

RESEARCH

To our knowledge, Sturner and colleagues ¹⁹ presented the first data on the validation of the DSM-PC, by using the previously described CHADIS/DSM-PC. Caregivers of children completed the CHADIS/DSM-PC and were assessed for DSM disorders through a computerized parent version of the Diagnostic Interview for Children and Adults (DICA),²² measures of child behavioral symptoms,²³ and competencies.²⁴

No child with a diagnosis of DSM-PC Developmental Variation was found to have a disorder according to the DICA, and only two children in the problem category were shown to have a disorder on the DICA. Only one child who received no DSM-PC diagnosis was shown to have a DICA disorder. These results also supported the DSM-PC’s theoretical definitions for both Developmental Variations and Problems. For example, when parents raised concerns about behaviors that fall into the developmental variation category, the child’s behaviors were within the range of expected behaviors for the age and rarely warranted a diagnosis of mental disorder. This finding provides empirical support for the clinical utility of the developmental variations category.

Sturner and colleagues ²⁰ also described, on the basis of DSM-PC categories, the 1-year stability of children’s mental health status and morbidity in preschool- and school-aged children seen for health supervision visits at one of two Baltimore City clinics. Total scores used to represent mental health status (1 for each variation, 2 for each problem, 3 for each disorder) demonstrated excellent stability, as shown by a correlation of 0.69. Children with DSM-PC category diagnoses continued to show similar levels of morbidity 1 year later, whereas most children who received a diagnosis of a disorder persisted with the disorder. Moreover, most children who received an initial diagnosis of a problem either sustained the problem diagnosis or worsened. The Problem category demonstrated a positive predictive value of 0.71 for Problem or Disorder categories 1 year later, which provided evidence for the predictive utility of the DSM-PC categories.

The research conducted by Sturner and colleagues concerning the clinical application and validity of the DSM-PC represents an important beginning concerning empirical validation of the DSM-PC. However, findings should be interpreted with caution because they have not yet been published in the peer-reviewed literature. For this reason, research on the DSM-PC needs to be extended by other investigators in other settings.

Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: Zero to Three (DC:03 and DC:03R)

HISTORY

Infants and young children present a particular challenge for diagnostic classification because of the rapid developmental change and fluidity of change during this developmental period. The DC:03 was developed to categorize the developmental and mental health problems of infants and young children for purposes of diagnosis and treatment planning by a wide range of practitioners. Expert, consensus-based categorizations of mental health and developmental disorders in the early years of life were developed by the Multidisciplinary Diagnostic Classification Task Force established by the Zero to Three National Center for Infants, Toddlers, and Families. This task force recognized that many infants and young children presented in practice situations with problems that could not be readily classified within the DSM-IV. The DC:03 was intended to complement and extend the DSM-IV as an initial guide for clinicians and researchers to facilitate clinical diagnosis, treatment planning, and research.²⁵

The revision of the DC:03, the DC:03R, was developed on the basis of clinical experience and the findings of the Task Force on Research Diagnostic Criteria: Infancy and Preschool.^26,²⁷ The DC:03R provides clearer, more operational criteria than the original version as shown in Table 6-5.

TABLE 6-5 DC:03R Axis I Disorders

Posttraumatic Stress Disorder

Deprivation/Maltreatment Disorder

Disorders of Affect

Prolonged Bereavement/Grief Reaction

Anxiety Disorders of Infancy and Early Childhood

Separation Anxiety Disorder

Specific Phobia

Social Anxiety Disorder (Social Phobia)

Generalized Anxiety Disorder

Anxiety Disorder NOS

Depression of Infancy and Early Childhood

Type I: Major Depression

Type II: Depressive Disorder NOS

Mixed Disorder of Emotional Expressiveness

Adjustment Disorder

Regulation Disorders of Sensory Processing

Hypersensitive

Type A: Fearful/Cautious

Type B: Negative Defiant

Hyposensitive/Underresponsive

Sensory Stimulation–Seeking/Impulsive

Sleep Behavior Disorder

Sleep-Onset Disorder (Protodyssomnia)

Night-Waking Disorder (Protodyssomnia)

Feeding Behavior Disorder

Feeding Disorder of State Regulation

Feeding Disorder of Caregiver-Infant Reciprocity

Infantile Anorexia

Sensory Food Aversions

Feeding Disorder Associated with Concurrent Medical Condition

Feeding Disorder Associated with Insults to the Gastrointestinal Tract

Disorders of Relating and Communicating

Multisystem Development Disorder (MSDD)

Other Disorders (DSM-IV-TR or ICD 10)

DC:03R, Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: Zero to Three revision (Zero to Three Revision Task Force); DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; ICD-10, International Classification of Diseases, Tenth Edition; NOS, not otherwise specified.

ORGANIZATIONAL PLAN

The DC:03R proposes a multiaxial classification system that included five axes, described as follows.

Axis I: Clinical Disorders

This axis includes the following categories: Posttraumatic Stress Disorder; Deprivation/Maltreatment Disorder; Disorders of Affect; Prolonged Bereavement/Grief Reaction; Anxiety Disorders of Infancy and Early Childhood; Depression of Infancy and Early Childhood; Mixed Disorder of Emotional Expressiveness; Adjustment Disorder; Regulation Disorders of Sensory Processing; Hypersensitive; Hyposensitive/Underresponsive; Sensory Stimulation–Seeking/Impulsive; Sleep Behavior Disorder; Sleep-Onset Disorder (Protodyssomnia) and Night-Waking Disorder (Protodyssomnia); Feeding Behavior Disorder; Disorders of Relating and Communication; Multisystem Developmental Disorder; and Other Disorders.

Axis II: Relationship Classification

Axis II characterizes the functional level of the relationships and interactions of infants and young children and their parents’ level of distress and conflict, adaptive flexibility, and the effect of the relationship on the child’s parents and family. Two instruments, the Parent-Infant Relationship Global Assessment Scale and the Relationships Problems Checklist, provide a guide to evaluating relationships.

Axis III: Medical and Developmental Disorders and Conditions

Axis III describes physical (including medical and neurological), mental health, and/or developmental diagnoses established from other diagnostic and classification systems, such as the DSM-IV and the ICD-9 or ICD-10, and from specific classifications used by speech/language pathologists, occupational therapists, physical therapists, and special educators, and the DSM-PC.

Axis IV: Psychosocial Stressors

Axis IV describes the nature and severity of psychosocial stress that are influencing disorders in infancy and early childhood. A specific instrument, the Psychological and Environmental Stressor Checklist,²⁶ provides a framework for identifying (1) the multiple sources of stress experienced by individual effects on the young child and the family and (2) the duration and effect of stressors.

Axis V: Emotional and Social Functioning

The fifth axis reflects the infant or young child’s emotional and social functioning in the context of interaction with caregivers and in relation to expectable patterns of development. Relevant dimensions of emotional and social functioning in the DC:03R include the following: (1) Attention and Regulation; (2) Forming Relationships, Mutual Engagement; (3) Intentional Two-way Communication; (4) Complex Gestures and Problem Solving; (5) Use of Symbols to communicate; and (6) Connecting Symbols Logically. For each of these, the clinician may rate the child’s functioning on the 6-point Capacities for Emotional and Social Functioning Rating Scale.²⁶

Appendix

The final section of DC:03R includes an appendix that presents an approach for prioritizing diagnostic classifications and planning interventions.

CLINICAL APPLICATION AND RESEARCH

Despite these potential advantages, the DC:03 has not been used extensively by either pediatricians or developmental-behavioral pediatricians in practice, in comparison with either the DSM-IV or the DSM-PC. Research on either the DC:03 or DC:03R has been very limited. Frankel and associates’²⁷ chart reviews of children aged newborn to 58 months described the range and frequency of presenting symptoms, relationships between symptoms and diagnoses, and comparisons of the DC:03 and DSM-IV. Presenting symptoms were categorized into five groups: (1) Sleep Disturbances; (2) Oppositional and Disruptive Behaviors; (3) Speech and Language/Cognitive Delays; (4) Anxiety and Fears; and (5) Relationship Problems. Findings demonstrated interrater reliability for diagnoses with the use of both diagnostic systems, evidence of diagnostic validity through regression analyses, and good concordance for diagnoses in which the DSM-IV and DC:03 overlap.²⁷

International Classification of Functioning, Disability, and Health for Children and Youth (ICF-CY)

ORGANIZATIONAL PLAN

Available DCSs focus primarily on the categorizations of symptoms rather than on children’s functioning. To address the need to describe child and adolescent functioning with a common nomenclature, the International Classification of Functioning, Disability, and Health (ICF) was developed for clinical practice, research, and policy development across disciplines and service systems.²⁸ Key dimensions of this system include (1) impairments in body functions and in structured activities; (2) activity limitations; and (3) participation, defined as involvement in a life situation. In addition, the system describes environmental factors (e.g., the physical, social, and attitudinal settings in which individuals conduct their lives) and personal factors that affect functioning. A version of the ICF for children and youths (ICF-CY) has been developed.²⁹ The ICF-CY includes more than 100 functional impairments and relevant codes that are applicable to DSM-IV, DSM-PC diagnostic categories, and the DC:03R. An example of the relevant dimensions and codes that are applicable to one disorder (ADHD) is shown in Table 6-6.

TABLE 6-6 Example of Dimensions and Codes from the ICF-CY for Attention-Deficit/Hyperactivity Disorder

APPLICATIONS OF CLINICAL CARE, RESEARCH, AND POLICY

Lollar and Simeonsson ³⁰ discussed potential applications of the ICF-CY for developmental and behavioral problems in clinical care in describing activity limitations and access to care, for policy to define gaps in service, and for research concerning the functioning of children and adolescents and training.

One of the most important potential clinical applications of the ICF involves the facilitation of a common language and framework for professionals about impairment in functioning, diagnosis and treatment planning, and changes in these parameters.³¹ This common language facilitates professionals’ abilities to understand aspects of functional status or dysfunction in diagnosis and management of developmental and behavioral problems. For example, with ADHD, medication treatment might focus on addressing the child’s impairment in attention. In contrast, a psychologist’s behavioral intervention might focus on control of behavior and social relations. The ICF-CY system also provides a language for parents and various professional disciplines with which to communicate about goals for intervention and response to intervention.

Other potential clinical applications of the ICF-CY include identification of activity limitations associated with specific conditions (e.g., difficulty carrying out multiple tasks in association with ADHD). Another example is identification of specific environmental factors (e.g., access to medical treatment) that can help or hinder necessary treatment (e.g., medication) that may be necessary to reduce functional impairments associated with conditions such as ADHD.

Finally, the ICF-CY system also can be used to describe and manage the variations in the functioning of children with specific diagnoses. This is important in view of the considerable variation in the functional status of children who have specific behavioral and/or developmental disorders ⁶ and the fact that such variation is often the focus of clinical attention. The clinical importance of functional status also highlights the need to better use measures of functioning³¹ in clinical practice. Finally, like the DSM-PC, the ICF-CY highlights the importance of including environmental factors in diagnosis and treatment planning.

Despite limited research on the ICF-CY system, emerging developments and opportunities ³² include measures of critical dimensions that focus on school participation³³ and assessment of activity limitations. For example, Fedeyko and Lollar³⁴ used the ICF-CY to organize prevalence rates of activity limitations from the National Health Interview Survey, 1994–1995. Learning limitations were found to have the highest prevalence (9.4%) among children 5 to 17 years of age, followed by communication (4.8%) and behavior limitations (4.6%). Field trials are under way in the United States, Europe, Africa, Asia, and Latin America to complete age-specific assessments of functional codes among different age groups (0 to 3, 4 to 6, 7 to 12, and 13 to 18).³⁰

Perhaps the most important future applications of the ICF-CY focus on policy. The ICF-CY provides a common language with which to describe interdisciplinary clinical care and research on functional differences in children and adolescents across a range of settings.³⁵ In addition, the ICF-CY can facilitate health care practitioners’, teachers’, and therapists’ communications about children’s functional status in response to psychological and medical interventions.³⁰ The ICF-CY is a method that can be used to facilitate interdisciplinary care, research, and training³¹ across a wide range of different populations of children with behavioral and developmental disorders, impairments that result from these disorders, and settings in which these disorders are treated.

For all the diagnoses of mental disorders, impairment is part of the diagnostic criteria. In addition, the DSM-PC categories of problems and normal variations are defined by the extent of impairment. For this reason, the application of the ICF-CY provides an opportunity to define the metric by which the extent of impairment can be measured across different DCSs. It provides a construct on which a generalizable system of measurement of functional impairment can be developed. To accomplish this goal, measures must be developed and applied to specific chronic conditions,³⁵ and modifications of the ICF-CY must be made in order to consider variations in the developmental levels of children and adolescents.