DC:0-3R Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood REVISED EDITION DISTRIBUYE EN CHILEThe DC:0-3R Revision Task Force Helen Link Egger Emily Fenichel Antoine Guedeney Brian K. Wise Harry H. Wright Robert N. Emde, Chair ES Poses Ey DC:0-3R / Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood REVISED EDITION ZERO TO THREE Washington, D.C.‘Tallftce orders (800) 899-4801; Fax: (202) 638-0851 Wie: hap /wwewerotothree.org Roowadowaki, KArtand Des ‘composition: Seven Worldwide Publ Cover desig “Text design [Library of Congress Catalogingin-Publiation Daca ‘of mental health and developmental disorders of infancy hood : DC!O3R Rev. and early pcm. Ret ed. of Diagnostic classification, 03, BN 0.943657-003 {REE materials, please , Danvers, MA 01925; phone, (978) 750-400; ak wowcopyrightcom, “The information com book is protected by copyright. Thi ‘the DC.O-3R four-digit codes, may be wed. ‘purposes only and may not be repr eds Th any format, including electronically, without the express written e TO THREE. 10987654 ISBN-15:978-0943657:905 ISBN-10- 0949657.903 Printed in the United States of America 2 meta ZERO TO THREE. (2005). Diggastc clsifcation of mental hath and deop doors of infancy ond ery dldood: Revd ein (DC0-3R). Washington. DC: ‘ZERO TO THREE Press Axi Table of Contents Acknowledgments Introduction ‘The Origins of DC.0-8 The Usefulness of DC:0-8 and the Need for Revision ‘The Diag ‘A Summary of Changes in DC:0-3R ‘The Future of DC:0-3R Clinical Disorders 100. Posttraumatic Stress Disorder 150, Deprivation /Maltreatment Disorder 200. Disorders of Affect 210. Prolonged Bereavement/Grief Reaction 220. Anxiety Disorders of Infancy and Early Childhood 221. Separation Anxiety Disorder 222. Specific Phobia 238 jsorder (Social Phobia) 224 od Anxiety Disorder 225, Anxiety Disorder NOS. 280. Depression of Infancy and Early Childhood 281. Type I: Major Depression 282, Type Il: Depressive Disorder NOS 240. Mixed Disorder of Emotional Expressiveness 300. Adjustment Disorder 400. Regulation Disorders of Sensory ProcessingAxis I: Axis 1M: Axis IV: Axis V: 410. Hypersensitive 411. Type A: Feai 412, Type B: Negati 420, Hyposensitive /Underresponsive 430, Sensory Stimulation Secking Impulsive 500. Sleep Behavior Disorder 510. Sleep-Onset Disorder (Protodyssomnia) 520, Night Waking Disorder (Protodyssomnia) 600, Feeding Behavior Disorder 700. Disorders of Relating and Communicating 710, Multisystem Developmental Disorder (MSDD) 800, Other Disorders (DSMIV TR or ICD 10) Relationship Classification ‘The PIRGAS and the RPCL ‘The Parent-nfant Relationship Global Assessment Scale Relationship Problems Check! Rel ship Qualities scriptive Feat ‘Medical and Developmental Disorders and Conditions Psychosocial Stressors ‘The Psychological and Environmental Stressor Checklist Emotional and Social Functioning Rating Capacities for Emotional and Social Functioning, Capacities for Emotional and Social F Rating Seale Appendix A: Prioritizing Diagnostic Classification and Planning Intervention (Choosing a Primary Diagnostic Category Appendix B: The Process of Revising DC:0-3 ‘Appendix C: ZERO TO THREE Diagnostic Classification Task Force References “Acknowledgments The Revision Task Force acknowledges with thanks the help given us by the global community of infant mental health clinicians and researchers who responded to our requests for information and feedback about DC0-3, reflected the fruits of a decade of experience. These hundreds respondents are cited refes t majority of contributions that we reviewed. A future publication will provide an overview of citations and the muchappreciated evidence that backs up our revs ‘We are grateful to everyone who responded to the Revision Task Force’s ‘wo surveys in 2003. Respondents included practicing clinicians from a range of ds , those engaged in research and administration in the infant mental health Feld, ‘Anumber of groups provided crucial information or feedback that guid- ced our efforts. A group of occupational therapists, chaired by Lucy ded our work on Regulation Disorders of Sensory ing. A group of ans experienced with Posttraumatic Stress Disorder, chaired by Neil Boris, helped to shape our efforts on that classification, Rot Jean Thomas provided guidance from the perspective of trai ‘rs in the use of DC0-8. An independent working group, chaired by Michael Scheeringa and generously supported by the American Academy of Child and Adolescent Psychiatry (AACAP), developed the Research Diag: nostic Criteria, Preschool Age (RDO-PA Task Force on Research Diagnostic Griteria: Infancy and Preschool, 2003) subsequently published by AACAP, that informed our approach and contributed substantially to a number of ‘included in DC0-BR. We are grateful for the evidence-based is group that allows us to link our classification system to the pre- school ages. As documented in our introduction, swo members of DC.0-SR Revision Task Force had been members of the RDC-PA group, ‘A number of individuals deserve special acknowledgment for th structive contributions at key points. Serena Wieder provided her perspe tives for disorders of regulation and Axis V as: revaluation of her views on the role ofpeo-3n classification in general. Ci and Charles Zeanah generous [As we moved closer to agreed to review our document and offer detailed suggestions. We are grate: final version of our revision, several experts \d coordinated our efforts. icude to the original task group that Greenspan DG.0-3R goes forward because of The Revision Task Force Helen Link Egger 1 Harry H. Weight Robert N. Emde, Chair Introduction ZERO TO THREE's Diagnostic Clas Developmental Disorders of Infancy and Barly 1994, was designed to address the Mental Disorders of the American Prychiatic ional Classification of Diseases of the World He: te to adaptive and ing of individual differences in infan ton system, provides a revision that updates crit pora areas of persistent ambiguity, new knowledge from clinical exper The Origins of DC:0-3 the field of infant development and mental jans and researchers from infant ‘mental health cen ‘and Europe. Members of the group systematically analyzed case reports from participating centers, ntified recurring patterns of behavioral problems, and described cate~ gories of disorders. The process was an open one, in which opinions were sought from a variety of disciplines.DeO-IR ‘Through expert consensus, an of diagnostic categories ‘emerged. Task Force members recogni given the limitatic infant mental health knowledge, diagnostic categories in the new clasifica- tion system could only be descriptive—that is, representative of meaningful symptom patterns. Sometimes categorical descriptions included associated ‘events (eg., between a traumatic event and a group of symptoms) or devel features (e.g, between sensory oF motor pi a group of seen at a particular stage of early development), The result was a scheme based on five axes Axis IV: Peychosocial Suessors ‘+ Axis II: Medical and Developmental Disorders and Conditions * Axis V: Functional Emotional Develo} Invany scientic enterprise, but particularly in & new Ted a healthy ten slon-exists. between the desire 10 analyze findings from syster ‘esearch before offering even intial conceptual ‘isseminate preliminary conceptualizations so thet they can serve as @ basis for collecting systematic data, which can lead to more empirically based efforts... The development of DC:0-3 represents an impor- tnt fist step: the presentation of expert, consensus-based categorize. f mental health and developmental disorder Need for Revision Glinicians who address the mental health needs of infants and your dren welcomed DC0-8 shed in Dutch, Fr ‘and Spanish, Limited-" by Posttraumatic Stress Disorder (eg, avoidance Separation Anxiety Disorder (e.g. ice of school/daycare), or Social Phobia (e.g, avoidance of interact 6. The dis bance lasts for AT LEAST 4 MONTHS. 223. Social Anxiety Disorder (Social Phobia) ‘The diagnosis of Social Anxiety Disorder requires that ALL st of the follow: ing criteria be met: 1. The child exhibits marked and persistent fear of one or more social or performance liar people or possible scrutiny by others. The child must show this fear with both Peers and adults. Social or performance situations that evoke fear young children include play dates with peers, large family gatherings, birthday partes, religious ceremonies, or “circle time” at child care or preschool,ot work or heat, ean cross the boundary. The volume of a closed syste ge DCO-3R 2, Exposure to the feared social situation ‘ety in the child, who may express anxiety by panic, crying, tant freeting, people. ging, or shrinking from social situations with unfamiliar td avoids the feared social or performance situation(s) or ‘with intense anxiety or: young children from the feare tress. Parents often protect very 's avoidance, anxious anticipatio interferes significantly with the c the child's expected development. distress in the feared sit functioning and/or The fear or avoidance is not better accounted for by other disorders, including Pervasive Developmental Disorder, Separation Anxiety Disorder, Simple Phobia, or other anxiety orders. 6. The disturbance lass for AT LEAST 4 MONTHS, 224. Generalized Anxiety Disorder “The diagnosis of Generalized Anxiety Disorder requires that aL SEVEN of the following criteria be met: 1. The child experiences excessive anxiety and worry more days than not for at Least 6 MONTHS. 2, The child finds it very difficult o control the anxiety or worry (e.g. the child may repeatedly ask a parent for reassurance). 3. The anxiety and/or worry occurs during TWO OR MORE activities or set- tings or within Two OR MORE relationships. 4. The anxiety and worry are associated with ONE (OR MORE) of the Follow: ing ix symptoms: (a) Restlessness ot feeling “keyed up” or “on edge.” () Fatigabiliy, (€) Difficulty concentrating, ( (©) Muscle tension. (H Sleep disturbance (difficulty falling or staying asleep or restless, ‘unsatisfying sleep). 5. The focus ofthe anxiety or worry isnot better accounted for by the DSMAIV-TR diagnostic category of Obsessive-Compulsive Disorder (eg, fear of dirt or needing ritualized reassurance from a parent), Posttraumatic Stress Disorder, Separation Anxiety Disorder (e.g., anxi- ety about separation from a caregiver), or Social Phobia (e.g, worry about social interactions). jertability or antrumming. invariably provokes anxi- Axis | Clinica Duondos 6. The anai , worry, oF physical symptoms interfere significantly with the child's functioning and or the child’s expected development. 7."The disturbance is not due to the direct physiologic effect of a sub- stance (e.g. asthma medication or steroids) and does not occur exclu sively during a Pervasive Developmental Disorder. 225, Anxiety Disorder Not Otherwise Specified (NOS) ‘This category includes symptoms of prominent anxiety or phobic avoidance that cause severe distress and/or interfere significantly with functional psy chosocial or developmental adaptation, Symptoms do not fully meet the cri- teria for any specific anxiety disorder, but the anxieyy or fear of concern must ‘meet ALL FIVE general characteristics for anxiety disorders described in the beginning of this sect In infants, agitation and/or ing, sleeping and eating disturbance separation ity, uncontrollable erying or scream- ble and. pervasive ess oF social anxiety (particularly inthe context of a family history of anxiety disorders or depr tean early onset ans ‘+ When trauma is evident or has been reported, and the onset of the child's difficulties follows the trauma, the diagnosis of Post ication disorder should be considered. 230. Depression of Infancy and Early Childhood ‘The eriteria for depres have the verbal or cog experi ‘To diagnose a depressive disorder in a very young child, the clinician bserve ALL FIVE of these general characteristics: 1. The disturbed affect and pattern of behavior should represent a change from the child's baseline mood and behavior. 2. The depressed irritable mood or anhedonia must be persistent and, at least some of the time, uncoupled from s: or upsetting experiences,ot work or heat, can crs the boundary. The volume ofa closed 59 Deo-3R (€4g, watching a sad television show, being punished). “Pe ‘means being PRESENT FOR MOST OF THE DAY, MORE DAYS THAN NOT, OVER A PERIOD OF AT LEAST 2 WEEKS, 5. Symptoms should be pervasive, occurring in more than one activity oF setting and in more than one relationship. If depresive symptoms ‘occur only within one relationship, a diagnosis under Axis I ship Classification should be considered, iptoms should be causing the child clear distress, impairing func- joning, or impeding development. iNces are not due to a general medical condition (e ) or the direct effect ofa substance (e.g,, medicatio 231. Type I: Major Depression Depression requires that AVE of the following symp- be preset most of the day, more days than not for ATLEAST 2 WEEKS INGLUDE ONE. OF THE FIRST TWO SYMPTOMS: 1. Depressed or irritable mood most of the di mood most of the day, more days than not, as indicated by either the ehil port or observations made by ) is fun”) change of more than 5% of body Tease or increase in appetite, oF or hypersomnia. 5. Pychomot agitation or retardation that is observable by others (not ‘merely childs subjective feelings of restlessness or being “slowed town"). 6. Fatigue or loss of energy: 17. Evidence of feelings of worthlessness oF inapy Propriate guilt in play (e.g, Punitive actions and play) 's direct expr 9. Recurrent allusions to or themes of death or hharm. The child may demonstrate these sympt Activites, play, or potentially lethal behaviors. through thoughts, of em 232. Type It: Depressive Disorder NOS ‘The diagnosis of Type Il: Deprestive Disorder NOS requ 0 ype the presence of “DIRE OR FOUR OF THE NINE svUPTOMS described for Type I: Major Depression. above. Symptoms must be present for a MINIMUM OF 2 WEEKS, The diagnosis requires the presence of AT LEAST ONE of the first two symptoms. Associated Feature: When toms of Major Dept Disorder NOS are observed in the presence of significant psychosocial/ ian should note these circumstances of Infancy as. alternative Disorder NOS in the presence of significant 240. Mixed Disorder of Emotional Expressiveness “Mixed Disorder of Emotional Expressiveness is characterized by a child’s culty in expressing a developmentally appropriate range and intensity 1 Over AT LEAST A 2-WEEK PERIOD. The pattern is pervasive, across multiple types of affect, and represents a change from the child's previous functioning. ‘The diagnosis requires the presence of AT LEAST ONE OF THE FIRST TWO SxMPTOMS listed below AND interference with ageappropriate functioning (third symptom below). When & delays, the affective expression is inappropriate to the ch Criteria ae: ‘exhibits developmental ‘the disturbance in developmental level 1. The absence or nearabsence of Two OR MORE specific affects (eg, pleasure, anger, sadness, and excitement) that are expectable given the child's age. The child’s difficulty in using lan- guage or play to express emotions supports this classification. The cli- nician may observe a notable absence of age-expectable fears, con- cers, or anxieties, sch as fears of separation or bodily harm, that serve adaptive functioning. ar‘of work or heat, can cross the boundary, The volume of a closed 55 COIR turbed intensity of affect, reversed affect oF affect inappropriate to turbed intensity of emotional expression, such as anger or blandness and apathy, ) Reversal of affect or affect inappropriate tothe situation, such, ness" or laughing with apparent bravado when negative emotions, such as fear or remorse, would be appropriate. 5. Interference with appropriate functioning, narsts of 300. Adjustment Disorder iustment Disorder should be considered for any wan isturbances that (1) do not meet the criteria for other Axis ‘has Posttraumatic Stress Disorder or Prolonged rief Reaction), (2) are not merely an exacerbs ‘The infant or young child may exhibit affective symptoms (appearing, for ex for example, opposi i tantrums, or regression 8. Symptoms do not me ders of Affe 4. Symptoms persist for MORE THAN 2 WEEKS. 400. Regulation Disorders of Sensory Processing ders of Sensory Processing are constitutionally based respons mull, The diagnosis of Regulation Disorders of Sensory a child's dificulties in regulating emotions and behaviors tosensory stimulation that lead ¢o impair and functioning. The patterns of behavior that are char- acteristic ofthis disorder are manifest (1) across settings and (2) within muli- Proces Axis 1 Clinical Dierders Every child has specific ways of respon rent. Some children have difficulty processing sensory input and regul their responses. Diffical may interfere with a child’ ity and, more speci age-appropriate activities, Caregivers moderate a child's behavioral responses to sensory input. Caregivers who are attuned to the child's patterns of behavior can amelio- regulation regulating responses social and emotional development and , with the child's ability to participate in nal responses to sensory stimuli and caregiver not characteristic ofa child, the elinician should ications. For example: and “willful” behavior ma; arse from coercive parenting (Axis ‘+ Negative and “willl” behavior may reflect a primary di ‘order, such as Oppositional Defiant Disorder (DSM is mot specifically associated with sensory processi tive behavior + Fearfulness, as described in Type A: Hypersensitivity Regulation Disorder (described below), may reflect an Anxiety Disorder. Regulation Disorders of Sensory Proces orders (eg., Type may co-occur with other dis: , sensory, and motor Although there is broad consensus concet cations, specific ave not been i this tage of our knowledge. 410: Hypersensitive Infants or toddlers who are hypersens fe t0 sensory stimuli experience behaviors include 3, unfamiliar smells and tastes, roughJRE" ot workor hear, can cross the boundary. The volume of a closed syst DCo-IR ‘An infant oF young child wi sensitivity to various stimuli il behavior: a regulation disorder arising from hyper ‘one of two characteristic patterns of ‘+ Type B: Negative/Defiant. Children with either patern of behavior avoid or demonstrate aversive reactions to sensory stimuli. In other words, fearful/cautious infants young children and negative/defiant infants and young children have same underlying pattern of hyper ‘even though behavioral patterns differ, Hypersensitive chil sensory input. They are easily overwhelmed by ¢ part of everyday life,and they tend sensory stiml perience considerable ‘calm and alert in the the end of the day), A: Fearful/Cautious Hyper- with Anxiety Disorders and that Type B: "Negative Defiant Hypersensitivity may co-occur with disruptive behavior dis- orders such as Oppos Defiant Disorder. 444: Type A: Fearful/Cautious 1. Sensory Reactivity Patterns (@) These patterns are characterized by overreactivity to sensory stimuli, including light touch, loud noises, bright lights, unfamiliar smells and tastes, rough textures, or movement in space. Example: A toddler be able to tolerate rough‘andcumble play or swinging. An infant may signal distress when placed in a supine position or shifted in position (particularly if te head is tipped bac (©) Responses to + Fearfulness © Gaying. + "Freezing" nsory stimuli may include: Asis] 1 Clinical Disorders sa + Auempted escape from the stimulus, + Increased distract ‘+ Aggression, + Angry outbursts, including tantrums, + Excessive startle reactions, + Motoric agitation, *+ Restricted tolerance for variety in food textures, tastes, and ty and aversion to sensory ‘experience in manipulating or interacting resulting in functional deficits in motor development. Motor patterns, which vary among children, may include: Difficulties postural control and tone, (©) Difficulty in fine motor coordination (often associated with play and experience with toys and other objects that have been limited by the child’s hypersensitivity). with motor planning, Less exploration than expected forage. and fearfulness. In addition to these patterns, the behavior patterns of {infants with Type A: Hypersensitivity may include: (a) Restricted range of exploration. (b) Limited assertiveness cress when routines change. (@) Fear and clinginess in new situations, ‘The behavior patterns of toddlers and preschcolers with Type A: Hypersen- sitivigy may also include: (a) Excessive fears or worries or both ) yess in response to new people, places, or abjects in the envi (6) Distractbilty by sensory stimuli (2) Impulsiviy when overloaded by sensory stimuli (@) Frequent periods of irritability and tearfulness. (© Limited ability to selfsoothe (e.g, difficulty returning to sleep after waking).the boundary. The volume of a closed lof work of heat can Deso-an slow engageme: Negative/Defiant ty patterns are identical to those of Type A. se described in Type A: ‘Type B, however, are different from those in TThe child with Negative /Defiant Hypersensitivity tends to avoid or be slow to engage in new experiences and, in general, is aggressive only 1 of infants and young children With Type B: Negative/Deflant Hyperse include: ) Negativstic behavior (eg in an infant, persistent fussiness; in a (oddler or preschool to parenal requests or frequent angry outbursts, including tantrums). (©) Control ) Defiance (d) Preference for repetition, absence of change, and, if change is nec: cssary, change at a slow pace. ) Difficul (D Compulsiveness and perfectionism, reflexive negative resp jte of what is requested or expected) ting to changes in routines or plans. () Avoidance or slow engagement in new experierices or sensations, 420: Hyposensitive/Underresponsive sive Disorder, and (8) the child's withdrawal anxiety disorder, such as Social Anxiety Disorder. Sensory Reactivity Patterns Underreac unds, movement, smell, Limited exploration, Restricted play repertoire Search for specific sensory i ities, such as swinging or j Lethargy. (©) Poor motor planning and cl body schema—a consequence of prioceptive input. 3. Behavioral (@) Apparent lack of inter challenging gam ing properties of objects, or engaging in social interactions. () Apathetic appearance. Fatigabiliy Withdrawal from stimuli \e above symptoms, infants with Hyposensitive/ Underresponsive Regulation Disorder may appear delayed or depressed, « Prachools with the disorder may “tune out” from conversation and may reveal only a imaginative play ited range of ideas and fantasies in everyday behavior or ny 430: Sensory Stimulation-Seeking/Impulsive Infants, odalrs, and young children who seek ou sensory stimulation, ike Children who are hypovenve, require highinteniy, fequent, and/or tomg-duradon senor input before they are abl overpond, Unlike hypore take cldren, tht inka oem and preschoolers ately seek 0 Inthe nce for high lees of ensory input much more ofthe ume an play developing cilren. This pace of sensory aod motor reset ttuy be ssociated vith Attention Deict Hyperacivy Disorder (DSMIV- ‘TR, paula the hyperactive impulsive pe o combined ope1 work or heat, can cross the boundary. The volume of a closed 5 DCo-3R 1. Sensory Reactivity Patterns 2) Craving for highvintensity sensory stimul, Such a craving may lead to destructive or high-risk behaviors ) High need for motor discharge. i, (©) Accident proneness without clumsiness. (@) Disfuse impul 8, Behavioral patterns High activity levels. ecking constant contact with people and objects. {) Seeking stimulation through deep pressure. (@) Recklessness : (6) Disorganized behavior a a consequence of sensory stimolation. ition to the symptoms above, infants may also seek or crave sensory nulation. Ina to the symptoms above, preschoolers may also be + Excitable, + Aggressive «Intrusive « Daring and reckless, risking accidents and injuries. «+ Preoceupied with aggressive themes in pretend play. [Not infrequently, the sensory stimulation seeking chi for physical contact with people or objects Jeads to des re invusion into others’ physical space, or hitting without apparent provos Gon, Children and adults may mistake the sensory stimulatonseeking Child's excitability for aggression. Once others react aggressively to the child, the child may begin to behave aggressively with intention. 500. Sleep Behavior Disorder ‘are common during the first year of life. They are associated fions and medical problems. The clinician should not sleep problem is primarily due to dis. ment problems, Posttraumatic Stress disorder. leep Behavior Disordaris reserved for two types of rear after 12 months of age, when stable sleep patterns typ- wring the recommendations of the RDC-PA (2003), we «intervention and/or rem ‘Axis 1 Clinical Diserders (800, *Orher") in DC-O-3R. ‘The supplemental clasifications in DCO-SR are: + Sleep Onset Protodyssomnia—Disorders of initiating sleep. ‘+ Night Waking Protodyssomnia—Disorders of maintaining sleep (e.g. ‘waking up during the night, with difficulty returning to sleep) 510. Sleep-Onset Disorder (Sleep-Onset Protodyssomnia) Sleep-onset problems are reflected in the time i takes a child to fall the child’s need for the parent and/or "Ps in the room until she falls asleep, 1 with the parent (i.c., the parent leaves the room and comes back in response to bids from the child), ‘The diagnosis of Sleep-Onset Disorder requires that there be significant difficulty falling asleep for AT LEAST 4 WEEKS, with five to seven episodes per week, ‘The child must be 12 months of age or older. 520. Night: Waking Disorder (Night-Waking Protodyssomnia) Nightwaking problems are reflected in awakenings the parental bed. ing Disorder requires that wakenings be present for aT LEAST 4 WEEKS les per week. id must be 12 months of age or older. 3 require parental A diagnosis of Night in nighttis ificant difficulty wale five to 1 600. Feeding Behavior Disorder ‘The diagnosis of Feeding Behavior Disorder, the symptoms of which may become evident at different stages of infancy and early childhood, should be considered when an infant or young child has difficulty establis! feeding patterns—that is, when the child does not reg in accordance with physiological feelings of hunger or fullness. If these8 cof work or heat, can cfoss the boundary. The volume of a lose E Deon «i 1e absence of tants such as separation, negativsm, a primary feeding disorder. Specific feeding disorders of infancy and early childhood such as pica land rumination are described in DSMAV-TR. As in the RDCPA, criteria are listed here for six subeategories of Feeding Behavior Disorder. ger and/or interpersonal precipi- a, the clinician should cons 601. Feeding Disorder of State Regulation ‘The diagnosis of Feeding Disorder of State Regulation requires that AL ing feeding(e.g., the infant is too sleepy, oo agitated, and/or too distressed 0 feed) @) Feeding diiculiess the newborn period. (8). The infant fails to gain weight or loses weight. 2. Feeding Disorder of Caregiver-Infant Reciprocity liagnosis of Feeding Disorder of Caregiver-Infant Reciprocity requires TAREE of the following criteria be met ling) with the primary caregiver during feeding. infant or young child shows significant growth deficiency. \y and lack of relatedness are not due solely to 1 physical disorder or a pervasive developmental disorder. 603. Infantile Anorexia ‘The diagnosis of Infantile Anorexia requi ing child refuses to eat adequate amounts of food 1 month, @)_ Onset ofthe food refus: (8) The infant or young. interest in food bu tion with caregiver, or both. (4). The child shows signi ant growth deficiency. ©) The food refusal does not follow a waumatic event, (©The fo0d refusal is not due to an underlying medical illness. Axis 604. Sensory Food Aversions “The diagnosis of Sensory Food Aversions requires that ALL FOUR of the fol- another, may eat carrots but refuse green bear ‘but refuse baby food). eats without refusal causes spe oral motor development, 605. Feeding Disorder Associated with Concurrent Medical Condition Feeding Disorder Associated with Concurrent Medical that al POUR of the following criteria be met: (A) The child fails to gain adequate weight or may even lose weight + 606. Feeding Disorder Associated with Insults to the Gastrointestinal Tract ‘The diagnosis of Feeding Disorder Associated with Insults to the Gastrointestinal Tract requi (Q) Food refusal follows a major aversive event or repeated noxious insults to the oropharynx or gastr al tract (eg, choking, ertion of nasogustric or endotracheal tubes, suctioning) that Wigger intense distress in the infant or ‘young child. ALL FOUR ofthe following criteria be met: @) The infant or young: the las consistent refusal to eat takes one of ing forms: (a) The infant or young child refu may accept food offered by spo0 the bottle but the child may‘of work or heat, can cross the boundary. The volume of & losea sy Doom sly refuse to drink from the bottle when awake, she nk from the bottle when sleepy or asleep.) infant or young child refuses solid food but may accept the bottle (©) The child refuses all oral feedings, (8) Reminders ofthe traumatic event(s) cause distres, as manifested by one or more of the following: (@) The infant shows anticipatory ress when positioned for feeding. (®) The infant or young. cly when a caregiver approaches with a bo © nfant or young child shows intense resistance to swallow: ing food placed in her mouth, iO ‘The food refusal poses an acute or long-term threat to the child's ‘Note: This diagnosis should not be used when a young child's fe problem is primarily due to Disorders of Affect, Adjustment Diso Posttraumatic Stress Disorder, Deprivation/Maltreatment Disorder, or a Relator not use Feeding ian can indicate the lowever, if a feeding distur difficulties continues after ies have been resolved, the diagnosis of Feeding order may be appropriate 700. Disorders of Relating and Communicating ‘This group of disorders i first evident disorders involve severe difficuldes in relating and communicating, come bined with difficulties in the regulation of physiological, sensory, attentional, ‘motor, cognitive, somatic, and affective processes. In DSMAV-TR, Disorders of Relating and Communicating are referred to 4 Pervasive Developmental Disorders. They include Autistic Disorder, Childhood Disintegrative Disorder, Asperger's Disorder, Rhet's Disorder, and Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS), A growing body of clinical evidence suggests being diagnosed with Pervasive Developmental infancy and early childhood. These iren who are currently corder present a range of Axis 1 Gling isles relationship patterns, differences in affect regulation, and a variety of pro- cessing and cognitive difficulties. Until recently, only children with the most severe types of di relating and communicating were described as evidencing Autistic Disorder. An expanded diagnostic framework has now ‘emerged, with Autistic Disorder now seen at one of a group of disorders that have characteristics in common but are distinguished from one another by variations in severity of symptoms across various developmental domains. Autistic Disorder can be diagnosed as early as 2 years of age. DCO-BR includes tem Developmental Disorder (MSDD) that -d to some children under 2 years of age. MSDD is based on a knowledge, the features of MSD are = 710. Multisystem Developmental Disorder (MSDD) Some clinicians may prefer to use the diagnosis of MSDD rather than PDD- NOS for infants or toddlers less years old who have the fol characteristics: + Significant impairment in the abi to engage in an emotional and social relationship with a primary caregive avoidant or aimless but may evidence subtle, or relate quite warmly intermittent) + Signific ‘+ Significant dysfunction in the processing of visual, auditory, tactile, pro- ing hyperreactivity and * Significant dysfunction in motor (sequencing movements) Infants and toddlers diagnos may change as development prog est the range of observable behaviors: D have four areas of dificulry (ors for each area sug.