Illinois DC: 0-3 R Crosswalk Manual Molly Romer Witten, Ph.D., Tanya Anderson, M.D., Karen Freel, Ph.D. Committee Co-Chairs: Susan Berger, Ph.D., Joyce Hopkins, Ph.D., and Char Slezak, Ph.D.
DC: 0-3 R CROSSWALK COMMITTEE AND REVIEWERS Co-Chairs: Tanya Anderson Molly Romer Witten Sub-Committee Leaders: Joyce Hopkins, Axis I Susan Berger, Axis II Char Slezak, Axis III & IV Molly Romer Witten, Axis V Committee Members: Adjoa Blalock Cheryl Pratt Ann Cutler Karen Freel Karen Gouze Stephanie Hanko Jennifer McKenna Lynn Liston Nikki Lively Margret Nickels Deborah Saunders Illinois Reviewers: Patty Beck Anita Berry Janice Connolly Mitch Davenport Gaylord Gieseke Liz Glasgow Jackie Haas Gene Liebler Sally Mondino Jewell Oats Carrie Ray Nancy Segall Joyce Webber Heidi Wilken Non-Illinois Reviewers: Donna Weston Beth Limberg
Background The creation of a crosswalk linking the Diagnostic Classification of Mental Health and Development Disorders in Infancy and Early Childhood - Revised (DC: 0-3R) and traditional mental health diagnostic codes was a joint effort between the Illinois Children s Mental Health Partnership and the Illinois Association of Infant Mental Health (ILAIMH). Both the Partnership and the ILAIMH, through statewide and regional discussions and participation in various committees, realized that one of the most pressing issues in mental health treatment involved strengthening and expanding the capacity of clinical professionals to work with very young children and their families. Strengthening and expanding the clinical workforce requires a multi-pronged effort that includes training and information on accurate and appropriate diagnoses for young children that will guide suitable interventions. Zero To Three s revised, developmentally based diagnostic manual, Diagnostic Classification of Mental Health and Development Disorders in Infancy and Early Childhood - Revised (DC: 0-3R), was developed and revised for the population of infants and young children. The DC: 0-3R not only guides the clinician in observing and describing the behaviors and relationship issues that lead to an accurate diagnosis but it recognizes that the diagnosis is most valuable for informing the therapeutic work with the child and family. The DC: 0-3R is dynamic in that it recognizes that growth and change is central in this population and so diagnoses need not be static but can continue to guide and inform the clinician in their work with the family. DC: 0-3 R diagnoses, however, are not currently reimbursable through Medicaid and most insurance companies a large barrier to wider use of this important diagnostic approach and system. Medicaid and insurance companies recognize either the standard psychiatric diagnoses found in Diagnostic and Statistical Manual of Mental Disorders (DSM- IV TR Fourth Edition, Text Revision) or the International Classification of Diseases (IDC -9) codes. Neither classification system has codes that reflect the driving force of development in infant and toddler diagnosis. A small handful of states have developed a crosswalk between the appropriate 0-3 codes found in the DC: 0-3 R manual with DSM-IV TR or ICD-9 codes. A crosswalk for Illinois that could build upon other crosswalks already developed was needed. In the summer of 2007, a Committee of diagnosticians and clinical providers led by Drs. Molly Romer Witten, a certified Zero to Three Trainer on DC: 0-3 R and Tanya Anderson, Deputy Clinical Director, Department of Mental Health, Children and Adolescent Services, met to create a crosswalk between DC: 0-3R and DSM-IV TR and ICD- 9 codes. The Committee divided up into 4 Sub- Committees, each tackling the development of crosswalks with both the DSM- IVand ICD-9 codes for one or more of the Axes in the DC: 0-3 R. Ably led by Joyce Hopkins, Susan Berger, Char Slezak and Molly Romer Witten, the Sub- 1
Committees each created draft crosswalks for their respective Axes to bring back to the whole group for discussion. Through this discussion with the whole Committee, each Sub-Committee made changes to their drafts as needed. Each full Committee meeting was attended by representatives from the Illinois Department of Healthcare and Family Services (Illinois Medicaid agency), to provide consultation on reimbursable Medicaid codes in Illinois. In the fall of 2007, various Illinois stakeholders in the diagnosis and intervention of very young children met to review the crosswalk and to provide input into a final product. After their review the crosswalk was sent to two national experts in DC: 0-3R for review and comment. The crosswalk contained in this manual is therefore the result of a variety of Illinois clinicians, stakeholders and providers as well as national experts. Drs. Romer-Witten and Anderson, the entire Committee and the reviewers hope you find the crosswalk useful in your important work with infants, young children and their families. 2
Introduction The purpose of this manual is threefold. The first purpose is to provide a straightforward strategy for providing accurate, insurance reimbursable diagnoses for developmental and mental conditions of infancy and early childhood. This task is not an easy one because the DSM has no theoretical or developmental infrastructure as the DC: 0-3R does. The DSM uses a descriptive design meant to capture the behavioral range of any given diagnostic category. The DC: 0-3R however provides both a theoretical basis for diagnosis, and inclusion of strategic developmental phenomena that are affected when an infant or young child experiences emotional stress, cognitive delay, or ineffective motor capacity. The second purpose is to demonstrate how issues and disorders that first occur during the first three years of life may transform along a continuum into those conditions that we diagnose and treat in older children, adolescents and adults. Documentation of the thinking process that went into understanding how to use the DSM diagnoses in a developmentally informed way constitutes the third purpose of the manual. While these aims overlap, it is important to consider them independently, as the details within each objective clarify and expand our understanding of the function of diagnosis during infancy and early childhood. The organization of this manual follows from the crosswalk itself. We present the rationale used in constructing each axis. When necessary we follow the reasoning with an example to illustrate the dynamic range of diagnosis within each axis, and where appropriate, the additional or alternative diagnostic criteria necessary for diagnosis of a specific condition. In creating the crosswalk, the committee wanted to capture the complexity of diagnosis during the first three years of life and emphasize that diagnosis during infancy and early childhood has a primary intervention planning function, not a predictive function. However, as we explored the issues in greater depth we realized that although an interim measure, the crosswalk nevertheless provides further clarification regarding the theoretical basis for understanding the ineffective or dysfunctional developmental and mental behavior patterns that occur during infancy and early childhood. This bridge between older diagnostic codes still in use (DSM IV and ICD 9 and ICD 10) and the emerging diagnostic code for infants and young children (DC: 0-3R) is necessarily a temporary aid until public policies catch up to clinical recommendations, based on research results. So, this crosswalk which sets up a path from established ideas and diagnostic practices to current thinking is meant to function as a vehicle for moving the spheres of documentation for insurance, clinical practice, and public policy into alignment with each other. As the research evidence and clinical understanding regarding the needs and processes of development in infants and young children inform policy, permanent changes rendered into statewide policy, will definitively supersede this crosswalk. For the interim, explanation of the theoretical underpinnings of the crosswalk can help shed light on needed policy across a range of potential 3
issues such as etiology, prognosis, and intervention planning. As well as providing the impetus to bring change to the manner in which diagnosis is taught in educational institutions responsible for training infant mental health workers, this bridge offers understanding to the broader community of mental health clinicians. Additionally, it encourages administrators to consider adoption of new standards of intervention planning for all individuals receiving a developmental, mental health or emotionally focused diagnosis. 4
Axis I Primary Clinical Conditions: To quote the explanation in the DC: 0-3R, The DC: 0-3R [continues the intention to] complement[s] the existing approaches to diagnostic classification of mental health and developmental disorders of infancy and early childhood. The original DC: 0-3 responded to the failure of the DSM system to include (1) sufficient coverage of syndromes of early childhood that needed clinical attention or (2) sufficient consideration of developmental features of early disorders. Each Axis I diagnosis during infancy and early childhood can transform into a variety of more organized and observable disorders in the future. Hence, there is not a one to one correspondence from the DC: 0-3R to the DSM and ICD systems. For each Axis I diagnosis in the DC: 0-3R we suggest a range of possible DSM and/or ICD diagnoses. This detail is necessary to capture the developmental quality of diagnosis during the 0-3 year age range, as well as scope of intervention and intervention planning possibilities. Additionally, V codes, those codes in the DSM system that reflect interpersonal distress not clearly located within an individual, may signal specific diagnostic categories in the DC: 0-3R. When this is the case, the V codes are presented in bold italics beneath the appropriate Axis I code in the DC: 0-3R system. In this way the diagnosis represents our best idea of how a set of behaviors develops into a developmental or mental disorder of infancy and early childhood. For 100 Traumatic Stress Disorder in the DC: 0-3R code, both posttraumatic stress disorders (PTSD) as well as abuse and neglect diagnoses reflect the range of conditions that a child may experience. Many interpersonal and relational issues can also contribute significantly to the creation of a traumatic stress disorder. The specific issues that occur with the existence of a Deprivation/ Maltreatment Disorder in the DC: 0-3R requires that it constitute its own type of traumatic stress disorder. Often it corresponds to the older and somewhat misleading diagnosis of Reactive attachment Disorder of Infancy and Early Childhood in the DSM system. 200 Disorders of Affect in the DC: 0-3R explains a group of issues that does not have a corresponding diagnostic category in the DSM system. Therefore we interpreted the developmental quality by choosing the diagnostic codes for those issues that most closely reflect the constriction of affect, the effect on the child s functioning, and the lack of range interpersonal capacities. Disorders of Affect need to be differentiated from those issues that result in observable and describable anxious states, or which result in clearly identifiable depressed state and restriction and/or flattening of affect, and /or are limited to the shorter duration of an adjustment disorder. Disorders reflective of problematic levels of anxiety constitute the code 220, Anxiety Disorders of Infancy and Early Childhood. There is adequate correspondence between problematic states of anxiety in infancy and those found in later childhood and adolescence to use DSM codes when appropriate. 5
Superficially, the same can be said for 230 Depression of Infancy and Early Childhood, and various types of Major Depressive Disorder, Dysthymic disorder and Depressive disorder, NOS. However, there is much disagreement regarding whether an infant or young child can experience a major depression. One question that research has revealed is whether the infant s experience of depression takes an analogous form as in later development given our improving understanding of the developmental emergence of neurotransmitters in the brain during infancy. For example, the cholinergic system begins to function only after 13 months of age, so any depression occurring prior to that time would have to be qualitatively different than after the physiological shift that involves emergence of the acetylcholine sensitive neurotransmitter system. While clinicians can observe somber muted functioning in babies prior to age one, we do not yet understand if this condition produces analogous behavior to the clear-cut sadness that accompanies loss or grieving for an absent caregiver, or the heightened irritability of an agitated depression expressed in toddler behavior. 240 Mixed Disorder of Emotional Expressiveness is a new diagnostic code reflecting disturbed affect that is reserved for children less than 3 years of age. It does not have an equivalent in the DSM system. This diagnosis reflects the child s difficulty showing an expanding range of affects and emotions. The appropriate DSM code that can be used is 296.90 Mood Disorder NOS. Diagnosis of the DC: 0-3R code 300 Adjustment Disorder corresponds to the same 309.XX in the DSM system. The duration criteria and the severity criteria are specific however to the 0-3 age range. 400 Regulatory Disorders of Sensory Processing has no equivalent category of disorder in the DSM IV system. Therefore those disorders that demonstrate the characteristics of the disorder, or provide a descriptive identification are included as comparable diagnoses to use in the crosswalk. For example 411 Hypersensitive Type A is represented by only one DSM diagnosis. However, 411 Hypersensitive Type B in the DC: 0-3R is represented by two or more diagnoses in the DSM system. 420 Hyposensitive/under-responsive has no equivalent diagnosis and hence the DSM diagnosis 313.9 Disorder of Infancy, Childhood, or Adolescence NOS is used. (There will be a later discussion of using this diagnosis for other somatic issues on Axis III) Some caution is needed in moving from 430 Sensory Stimulation-Seeking to a DSM diagnosis. While it is inappropriate to use Oppositional Defiant Disorder (ODD), Attention Deficit Disorder (ADD) or Attention Deficit/Hyperactive Disorder (ADHD) for children under two years of age, current research suggests that it may be used for child beginning at ages over two years. The determining factor is how the clinician constructs the intervention plan. Since medication is a regular feature of the intervention for ODD, ADD or ADHD, this diagnosis may be theoretically correct, but not appropriate given the high degree of hesitancy among prescribing professionals to use medication as the first component of intervention, as occurs with older children. There is widespread reticence to 6
providing psychotropic medication for children less than three years. Hence, using the corresponding DSM diagnosis for ODD, ADD or ADHD may be misleading for insurers. Intervention planning will necessarily focus on more behavioral approaches to alter the high level of activity or distractibility rather than relying on medication as a first intervention. And, it often is the case that the surface behavior of distractibility or hyperactivity can be the referral concern for a number of different underlying disorders, not just ODD, ADD, and ADHD. 500 Sleep Behavior Disorders and 600 Eating Behavior Disorders are DC: 0-3R Axis I diagnoses to be used when the presenting behavioral issues involve only sleeping or eating. These disorders correspond to existing diagnoses in the DSM and the ICD systems; however there are variants unique to the 0-3 age group. Frequently sleeping and eating disorders are accompanied by disorders of affect, regulatory disorders, adjustment disorders, underlying relationship issues, as well as primary medical disorders such as GERD, in the case of eating disorders, and epilepsy, in the case of sleeping disorders. When the presenting problem is indeed only a sleep issue, and the DSM codes* do not describe the behavioral issues sufficiently to accurately provide for intervention planning, the use of 313.9 Disorder of Infancy, Childhood, or Adolescence Not Otherwise Specified may be necessary in order to add characteristics of the sleep issues individual to the specific infant or toddler. When the presenting problem is indeed only an eating issue, and the DSM codes of 307.1 Anorexia Nervosa and 307.51 Bulimia Nervosa, do not cover the issues specified in the DC: 0-3R, 307.50 Eating Disorder Not Otherwise Specified can be used with additional descriptors that indicate the nature of the early childhood specific eating disorder. 700 Disorders of Relating and Communicating, the last diagnostic category in Axis I of the DC: 0-3R has no equivalent in the DSM system. As a result, the range of DSM codes that appropriately describes both 700 Disorders of Relating and Communicating as well as 710, Multisystem Developmental Disorder (MSDD) more specifically come from many different categories of disorder. MSDD is reserved for children at least two years old but not yet three years of age. This specificity is necessary for two reasons. First, the only way a baby can demonstrate distress involves relating, communicating and movement. When these behaviors are taken as the disorder, rather than as a signal of some more complex emotional or developmental dilemma, the intervention plan may omit central issues of resolution such as developmental apraxia or relational issues. Secondly, often, disorders of relating and communicating are equated with autism spectrum disorders beyond age three, and there is consensus in the field to delay this diagnosis prior to age three. * including Dyssomnias, 307.42 Primary Insomnia, 307.44 Primary Hypersomnia, 347.00 Narcolepsy, 780.57 Breathing- Related Sleep Disorder, 327.xx Circadian Rhythm Sleep Disorder (formerly Sleep-Wake Schedule Disorder), 307.47 Dyssomnia Not Otherwise Specified, Parasomnias, 307.47 Nightmare Disorder (formerly Dream Anxiety Disorder), 307.46 Sleep Terror Disorder, 307.46 Sleepwalking Disorder, 307.47 Parasomnia Not Otherwise Specified, Sleep Disorders Related to Another Mental Disorder, 327.02 Insomnia Related to Another Mental Disorder; 327.15 Hypersomnia Related to Another Mental Disorder, Other Sleep Disorders, 327.XX. Sleep Disorder Due to a General Medical Condition 7
Illinois' Crosswalk for DC: 0-3R to DSM-IV TR to ICD-9-DM Axis I DC: 0-3R 100. Postraumatic Stress Disorder V61.9, V61.20, V61.80, V71.02, V62.3, V62.4, V62.89, V62.82 *(see note) 150. Deprivation/Maltreatment Disorder V61.9, V61.20, V61.21, V62.3 DSM-IV TR 309.81 Postraumatic Stress Disorder V61.21 Physical Abuse, Neglect 313.89 Reactive Attachment Disorder of Infancy or Early Childhood V61.20 Parent-Child Problem V61.21 Physical Abuse, Neglect ICD-9-CM 308.3 Other acute reactions to stress 309.81 Prolonged post-traumatic stress disorder 995.52 Child Neglect 995.54 Child Abuse, Physical 995.53 Child Sexual Abuse 995.51 Child Emotional/Pyschological Abuse 308.4 Mixed disorders as reaction to stress 308.9 Unspecified acute reaction to stress 313.89 Other or mixed emotional disturbances of childhood or adolescence Other - (Reactive Attachment Disorder) 200. Disorders of Affect 210. Prolonged Bereavement/Grief Reaction V61.21, V61.20, V62.3, V62.89 309.0 Adjustment Disorder/Depressed Mood 309.28 Adjustment Disorder/Mixed Anxiety & Depressed Mood 309.4 Adjustment Disorder/Mixed Disturbance of Emotions & Conduct 309.9 Unspecified V62.82 Bereavement 309.0 Brief depressive reaction 309.1 Prolonged depressive reaction Illinois' Crosswalk for DC: 0-3R to DSM-IV TR to ICD-9-DM Axis I DC: 0-3R DSM-IV TR ICD-9-CM 220. Anxiety Disorders of Infancy & Early Childhood 221. Separation Anxiety Disorder 309.21 Separation Anxiety Disorder 309.21 Separation Anxiety Disorder V61.20, V65.2, V62.4, V62.3,V62.82 222. Specific Phobia 223. Social Anxiety Disorder (Social Phobia) 224. Generalized Anxiety Disorder V61.21 Parent-Child Problem 300.02 Specific Phobia 300.23 Social Phobia 300.02 Generalized Anxiety Disorder 300.29 Other Isolated or Specific Phobias V61.20, V61.8, V62.82, V62.3, V62.4 (Sp Phobia) 300.23 Social Phobia V62.3 V62.4 313.82 V71.02V71.02(Soc Anx Dis.) 300.02 Generalized Anxiety Disorder V61.20, V61.8, V62.3, V62.82, 313.20 225. Anxiety Disorder NOS 300.00 Anxiety Disorder NOS 300.0 Anxiety State, Unspecified 230. Depression of Infancy & Early Childhood 231. Type I: Major Depression 296.2 Major Depressive Disorder, single episode 296.2 Major Depressive Disorder, single episode V61.20, V62.82, V62.4, V62.3, V 61.9, 296.3 Major Depressive Disorder, recurrent 296.3 Major Depressive Disorder, recurrent V61.21, 313.82 episodes episodes 301.1 Prolonged Depressive Disorder 232. Type II: Depressive Disorder NOS 300.4 Dysthymic Disorder 311 Depressive Disorder NOS 311 Depressive Disorder NOS 240. Mixed Disorder of Emotional Expressiveness V61.20, V62.82, V62.4, V61.9, V61.21 313.82 296.90 Mood Disorder NOS 313.8 Other or Mixed Emotional Disturbances of Childhood or Adolescence 313.9 Unspecified Emotional Disturbance of Childhood or Adolescence 300. Adjustment Disorder 309.0 Adjustment Disorder w/depressed Mood 309.0 Adjustment Disorder with Depressed Mood V61.20, V65.20, V62.82, V62.4, V62.3 313.82 309.24 Adjustment Disorder w/anxiety 309.28 Adjustment Disorder/Mixed Anxiety & Depressed Mood 309.2 Adjustment Disorder w/predominant Disturbance of Other Emotions (range from 309.21-309.29) 309.3 Adjustment Disorder w/disturbance of 309.3 Adjustment Disorder w/disturbance of Conduct Conduct 309.4 Adjustment Disorder/Mixed Disturbance of Emotions & Conduct 309.4 Adjustment Disorder/Mixed Disturbance of Emotions & Conduct 309.8 Other Specified Adjustment Reactions (range from 309.81-309.89) 8
Illinois' Crosswalk for DC: 0-3R to DSM-IV TR to ICD-9-DM Axis I DC: 0-3R DSM-IV TR ICD-9-CM 400. Regulation Disorders of Sensory Processing 410. Hypersensitive 411. Type A: Fearful/Cautious 300.00 Anxiety Disorder NOS 313.21 Sensitivity/Shyness Disorder of Childhood V61.20, V62.3 313.22 Introverted Disorder of Childhood 412. Type B: Negative Defiant 313.81 Oppositional Defiant Disorder 313.81 Oppositional Defiant Disorder V61.20, V65.20, V62.3 (Specifier: only after 2 years of age); code with sensory disorder on Axis III 312.9 Disruptive Behavior Disorder NOS; code with sensory disorder on Axis III 420. Hyposensitive/Underresponsive 313.0 Disorder of Infancy, Childhood, or 313.0 Unspecified Emotional Disturbance of V61.20 V62.3 Adolescence NOS Childhood 430. Sensory Stimulation-Seeking 314.01 Attention-Deficit/Hyperactivity Disorder, 314. Hyperkinetic Syndrome of Impulsive V61.20 Combined Type or Predominantly Childhood (range of diagnosis from 314.0 - Hyper-Active Impulsive Type 314.9) (specifier: only after 3 yrs. of age) 500. Sleep Behavior Disorder 510. Sleep-Onset Disorder (Protodyssomnia) 307.42 Primary Insomnia 307.41 Transient Disorder of Initiating or V61.20 Maintaining Sleep 307.42 Persistent Disorder of Initiating or Maintaining Sleep 520. Night-Walking Disorder (Protodyssomnia) 307.45 Dyssomnia NOS 307.41 Transient Disorder of Initiating or V61.20, V62.82, V62.4, V61.9, V61.21 327.31 Circadian Rhythm Sleep Disorder, Maintaining Sleep Delayed Sleep Phase Type 307.42 Persistent Disorder of Initiating or Maintaining Sleep 307.46 Sleep Arousal Disorder 307.47 Other Dysfunction of Sleep Stages or Arousal from Sleep Illinois' Crosswalk for DC: 0-3R to DSM-IV TR to ICD-9-DM Axis I DC: 0-3R DSM-IV TR ICD-9-CM 600. Feeding Behavior Disorder 601. Feeding Disorder of State Regulation 307.50 Eating Disorder unspecified V61.20, V61.21, V62.82, V62.4 602. Feeding Disorder of Caregiver-Infant 307.59 Other (Feeding disorder of infancy or (Feeding Disorder - State Reg) Reciprocity early childhood of non-organic origin V61.20, V61.21, V62.82, V62.4 603. Infantile Anorexia 307.5 Other and unspecified disorders of eating (Feeding - Cargiver-Infant Rec) 604. Sensory Food Aversions V.61.20, V62.82 605. Feeding Disorder associated with Infantile Anorexia concurrent Medical Condition V61.9 606. Feeding Disorder associated with Insults Sensory Food Aversions to Gastro-Instestinal Tract V61.9 Feeding - Gastro Intestinal Tract V62.89, V61.9 Feeding _ Medical Condition 700. Disorder of Relating and Communicating 710. Multisystem Developmental Disorder 307.9 Communication Disorder NOS (MSDD) 299.80 Pervasive Developmental Disorder NOS V 61.20, V62.3, V61.8 299.0 Childhood Disintegrative Disorder (Note: Specify Funcational Emotional Capacity on Axix V) 299. Pervasive Developmental Disorders (range from 299.0-299.9) 315.9 Developmental Disorder NOS * While not currently reimbursable, V codes are included since the relational focus of many if not most of the V codes are salient to a diagnosis in infancy and early childhood. This appliesto all V codes in thiscrosswalk. 9
Axis II Relationship and Interaction Disorders: Axis II in the DC: 0-3R does not correspond to a specific axis in the DSM. While some V codes do reflect the intent to assess the quality of the relationship between a baby and a caregiver, V codes are not usually reimbursable. The rationale for not reimbursing relational disorders is that there is no indication of intra-individual dysfunction that would permit a focus of intervention planning on the needs of one specific individual. However during infancy and early childhood intervention of relationship disorders prevents future intra-individual disorders. Creating a strategy for reimbursement constitutes primary prevention of future lifelong disability just as intervention of strep throat prevents enlargement of the heart with attendant later disability. Since the point of the DC: 0-3R is to describe issues that require therapeutic action, for children less than three years of age, relationship disorders are often the focus of intervention planning and intervention. Hence the diagnostic category needs to be reimbursable. For Axis II, relational disorders of any degree of severity, a psychosocial stressor must, by definition, also be present. When a relationship disorder or an interaction disorder seems to be the diagnosis of choice in the DC: 0-3R system, the very least that can be used in the DSM system is the diagnosis of 309.XX Adjustment disorder (to the psychosocial stressor). If the relational disorder is of longer duration than permitted under the criteria of adjustment disorder, the diagnostician will look for observable changes in affect, in level of anxiety, in range and flexibility of mood, as well as possible regulatory issues, as well as sleep and eating issues. All of these diagnoses correspond to appropriate DSM diagnostic categories; the diagnosis that is chosen will be the diagnosis that constitutes the focus of intervention planning and intervention. Axis II disorders in the DC: 0-3R do not correspond to any DSM Axis II diagnosis. Specifically the DSM Axis II diagnoses reflect developmental or personality disorders. For children under three, all diagnosis reflects disturbance in developmental process. The DSM Axis II becomes useless when looking at the issues for a child under three years of age. Use of the conditions that reflect how the young child reacts to the relational dysfunction with a caregiver offers an appropriate and developmentally adequate DSM solution. For example, the diagnostician might ask, does the relationship disorder create anxiety in the child, flattened affect or otherwise attenuated affect in the child, or depressed mood for the child? The answer will determine the focus of intervention planning and intervention, and the intervention organization will require the specific DSM diagnosis offered. Since all intervention prior to age three requires parental/caregiver involvement, the focus of intervention will necessarily include the family system or care giving system of the baby as well as the child him/herself. 10
Illinois' Crosswalk for DC: 0-3R to DSM-IV TR to ICD-9-DM Axis II ForAxis II, relational disorders of any degree of severity, a psychosocialstressoris also present RefertoAxisIV to find the relevantpsychosocialstressor(s) andfollow the crosswalk for AxisIV 11
Axis III Medical Conditions that affect the Primary Diagnosis: Axis III is the same within both the DC: 0-3R and DSM diagnostic schemas. However, there are a number of primary clinical conditions in the DC: 0-3R schema that also needs to be coded on Axis III, as they require medical intervention planning and active medical intervention. Diagnosis of physiological state regulation, such as 400 Regulatory Disorders of Sensory Processing, 500, 510, 520 Disorders of Sleep, and 600 Disorders of Feeding, can become a range of ICD-9-CM diagnosis including fussy baby, excessive crying, sensitivity, shyness, or social withdrawal, or anxiety. A diagnosis of 420 Hyposensitive/Under-responsive RDSP may, when appropriate, be coded on the DSM as 787.X disorders of elimination including diarrhea, encopresis, chronic constipation, and reflux. Diagnoses of motor apraxia, dyspraxia, and disorders of language, speech production, or prosody, and communication pragmatics will also be coded on Axis III. The diagnosis needs to reflect the characteristics of the child s functioning that will be the focus of intervention planning and intervention. Illinois' Crosswalk for DC: 0-3R to DSM-IV TR to ICD-9-DM Axis III DC: 0-3R DSM-IV TR ICD-9-CM 400. Regulation Disorder of Sensory 780.91 Fussy Baby Processing 780.92 Excessive Crying of Infant 780.95 Excessive Crying of Child Adolescent or Adult 314.01 Hyperkinisia, Simple Disturbance of Activity & Attention 313.2 Sensitivity, Shyness & Social Withdrawal 313.21 Shyness, Introverted Disorder of Childhood 293.84 Anxiety associated with Physical Condition 307.9 Other & Unspecified special symptoms or Syndromes NOS 410. Hypersensitive Regulation Disorder 313.81 ODD 312.9 Disruptive Behavior Disorder NOS 309.21 Separation Anxiety Disorder 313.23 Selective Mutism 313.9 Disorder of Infancy NOS 420. Hypsosensitive/Underresponsive 307.6 Enuresis (not due to a medical condition) 787.6 With Constipation & Overflow Incontinence 314.00 ADHD 787.7 Without Constipation & Overflow 307.6 Enuresis (not due to a medical condition) Incontinence 430. Sensory Stimulation Seeking/Impulsive 314.01 ADHD 314.9 ADHD NOS 307.3 Stereotypic Behaviors 309.21 Separation Anxiety Disorder 500. Sleep Disorder 307.42 Primary Dysomnia 600. Feeding Disorder 307.59 Feeding Problem, Non-Organic Origin 779.3 Improper Feeding-Newborn 995.52 Nutrition, lack of care 994.2 Nutrition, lack of food 12
Axis IV Psychosocial Stressors: All the stressors in the DC: 0-3R indicate at the very least an adjustment disorder on Axis I, as the child has to adjust to some environmental or interpersonal stressor that affects his or her functioning. Use the decision tree for Axis I Primary Diagnoses* and the severity rating to determine the appropriate diagnosis. While V codes may be appropriate to use, and have been listed in the Crosswalk, an Axis I diagnosis must be used in order to obtain reimbursement for intervention. *The decision tree for Axis I is available through participation in practitioner training provided by Zero To Three/ILAIMH DC: 0-3R Training. Illinois Crosswalk for DC: 0-3R to DSM-IV TR to ICD-9-DM The Psychosocial and Environmental Stressor Checklist Axis IV Rate the severity on a scale of 0 to 4 with 0 being minimal and 4 being severe The severity may suggest a diagnosis ie, adjustment disorder vs PTSD All the stressors indicate an adjustment disorder at the least, as a child is having to adjust to some environmental stressor. Adjustment Disorder Diagnosis: 309.9 Unspecified 309.24 With Anxiety 309 With Depressed Mood 309.3 With Disturbance of conduct 309.28 With Mixed Anxiety and Depressed Mood 309.4 With Mixed Disturbance of Emotions and Conduct All V-codes may also be used - unless superseded by a diagnosis - V15.81 Noncompliance w/ Treatment V61.1 Partner Relational Problem (Physical/Sexual Abuse of Adult) V61.20 Parent-Child Relational Problem V61.21 Child Neglect, Physical/Sexual Abuse of Child V61.8 Sibling Relational Problem Relational Problem Related to a Mental Disorder or General Medical Condition V62.2 Occupational Problem V62.3 Academic Problem V62.4 Acculturation Problem V62.81 Relational Problems V62.82 Bereavement V62.89 Borderline IQ; Phase of Life Problem; Religious/Spiritual Problem V65.2 Malingering V71.01 Adult Anti Social Behavior V71.02 Child or Adolescent Antisocial Behavior The Psychosocial and Emotional Stressor Checklist follows: 13
Illinois' Crosswalk for DC: 0-3R to DSM-IV TR to ICD-9-DM Axis IV DC: 0-3R DSM-IV TR 300. Adjustment Disorder ICD-9-CM V Code 300. Adjustment Disorder 309.0 Adjustment Disorder w/depressed Mood 309.24 Adjustment Disorder w/anxiety 309.28 Adjustment Disorder w/mixed Anxiety & Depressed Mood 309.3 Adjustment Disorder w/disturbance of Conduct 309.4 Adjustment Disorder w/mixed Disturbance of Emotions & Conduct 309.0 Adjustment Disorder with Depressed Mood V61.20, V65.20, V62.82, V62.4, V62.3 309.2 Adjustment Disorder w/predominant 313.82 Disturbance of Other Emotions (range from 309.21-309.29) 309.3 Adjustment Disorder w/disturbance of Conduct 309.4 Adjustment Disorder w/mixed Disturbance of Emotions & Conduct 309.8 Other Specified Adjustment Reactions (range from 309.81-309.89) 14
Axis V Functional Emotional Developmental Capacities: Functional emotional developmental capacities (FEDL) are based on the child s optimal functioning even if the child cannot demonstrate this level with all caregivers or in all environments. Functional capacities are age dependent in that we would not expect a nonverbal child of 6 months to demonstrate elaborate shared problem solving. The emphasis belongs on the strengths that the child brings to their functional behavior, given their age. Each FEDL represents a coping strategy that the child uses in order to function independently by the age of 36-42 months. The assessment of the FEDLs requires that the diagnostician actively evaluate developmental level simultaneously with observing and assessing functional capacities. Level I: Attention and Regulation: The diagnostician will look for indications that the child has interest in human relatedness. Disorders at Level I include disorders of global functioning, medical disorders that prevent or limit the child s capacity for human relatedness. The DSM diagnoses that meet the criteria of this assessment in the DC: 0-3R constitutes the most severe issues of development during infancy and early childhood. The intervention planning and intervention will necessarily be intense and prolonged, as the child is at risk for life long delay without intense and comprehensive intervention. Level II: Forming Relationships/Mutual Engagement: The diagnostician will evaluate whether the child finds satisfaction during human interaction and whether the child can sustain interest and interaction with an interested caregiver. Disorders that disrupt the pleasures that occur during interaction will be the focus of the DSM diagnosis. The diagnostician is cautioned to use developmentally appropriate DSM diagnoses. For example, while a two year old may be oppositional, it cannot constitute a pathological state since it is a normal task of development during the second year to learn how to use the concept NO in an interpersonal context. Often in the learning process, the child will become demanding and oppositional to an inappropriate extent, in testing the limits of the concept. While the parent may complain about the toddler s oppositional behavior, it may be more appropriate to explore the possibility of a relational or interaction disorder at this developmental level. DSM diagnoses in which the child seems to intentionally avoid human interaction, cannot commit to engagement but tries to interact, or experiences engagement as unbearably uncomfortable can include mood disorders, depressive disorders, oppositional defiant disorder, and bipolar disorder. Level III: Intentional two-way communication/interactive Reciprocity: The diagnostician will evaluate whether the child can sustain a back and forth interaction, both gesturally and when age appropriate verbally, through a range of affects. Disorders that disrupt or prevent the child from engaging in back and forth communication, disorders that demonstrate rigid scripting or rigid expectations for stylized interaction might include Asperger s syndrome, Obsessive Compulsive Disorder, Disruptive Behavior Disorder, NOS, and 15
Selective Mutism. Again, it is important to emphasize that the diagnostician is creating a diagnosis for the purposes of intervention planning and intervention. Therefore the DSM diagnosis used will be the focus of psychotherapeutic and psycho-educational intervention. Level IV: Complex Gestures, Communication and Interpersonal Problem Solving: The diagnostician will evaluate whether the child demonstrates facial expressions, gestural communication, robust emotional cues as to his/her internal state, or whether the child s functioning becomes flat in the face of affectively intense reciprocal interaction. DSM diagnoses will reflect a lack of capacity to follow through on communication of emotional state, or lack of communication around ideas, thoughts, feelings, or fantasies. These diagnoses can include Tic Disorders, Tourette s syndrome, and communication disorders of all types, developmental coordination disorders, and apraxia. The diagnostician is cautioned to use developmentally appropriate DSM diagnoses. For example, a nine-month-old baby does not typically walk independently. However this lack of functional capacity is developmental in nature and does not reflect an apraxic condition. Level V: Use of Symbols to Express Thoughts/Feelings/Ideas in Representational Play: The diagnostician will evaluate whether the child demonstrates pretend play, imaginative play, expansion of scripts into novel fantasy play. Any disorder that interferes with or prevents the child from representing their ideas thoughts, feelings, or fantasies in mutually satisfying play with another person reflects difficulty at this FEDL. DSM diagnoses might include mental retardation, and other physiologically based developmental delay in motor functioning, speech production, or cognitive capacity. Level VI: Connecting Symbols Logically/Abstract Thinking/Shared Emotional Problem Solving: The diagnostician will evaluate whether the child demonstrates the capacity for argument without disconnecting, negotiations, compromise, and the emerging capacity to come up with a novel solution that incorporates both his/her own idea as well as the play partner s idea. DSM diagnoses will reflect a lack of capacity for persisting at thinking through emotional dilemmas while staying related to the person with whom the difference of opinion exists. DSM diagnoses of anxiety disorders that reduce interactive reciprocity are the chief source of interactive disruption at this level. 16
Illinois' Crosswalk for DC: 0-3R to DSM-IV TR to ICD-9-DM Axis V DC: 0-3R FEDL Level 1: Shared Attention Level II: Mutual Engagement Level III: Interactive Reciprocity DSM Axis I DX ICD-9, ICD-10, DX Axis III DX Disorders of Global Functioning Medical Disorders preventing or limiting capacity for Relatedness 742.9 Static Encephalopathy 299.80 PDD 299. ASD 299.10 Childhood Disintegrative Disorder 300.02 Anxiety Disorders (severe) 300.00 Anxiety NOS, Anaclitic Depression 348.1 Brain Damage Disorders that disrupt the pleasure that occurs during related interaction in which the child cannot commit to engagement, or cannot experience engagement as pleasurable. 296.0X Bipolar Disorders 296.2X Mood Disorders 296.3X Mood Disorders 311. Depressive Disorder NOS 313.81 Oppositional Defiant Disorder Behaviors consistent with personality disorders in adults that disrupt or prevent the child from engaging in back & forth communication 299.80 Asperger's Syndrome 300.3 Obsessive Compulsive Disorder 312.9 Disruptive Behavior Disorder NOS 313.23 Selective Mutism V Code All V codes may also be used - unless superceded by an Axis I Diagnosis All V codes may also be used - unless Use descriptors provided by the various superceded by an Axis I Diagnosis DSM codes to indicate severity of V62.82 Bereavement age-delayed behavior V61.1 Partner Relational Problem 1 - Age appropriate capacity (Physical/Sexual Abuse of Adult2 - Age appropriate capacity but V61.20 Parent-Child Relational Problem V61.8 Sibling Relational Problem V61.9 Relational Problem related to a Mental Disorder or General Medical Condition Severity of Functional Delay Use descriptors provided by the various DSM codes to indicate severity of age-delayed behavior vulnerable to stress with constricted range of affect or both 3 - Funcationally delayed; some capacity but not age appropriate 4 - Inconsistent or intermittent capacity or only with support 5 - Barely shows capacity 6 - Has not achieved this capacity All V codes may also be used - unless Use descriptors provided by the various superceded by an Axis I Diagnosis DSM codes to indicate severity of age-delayed behavior 1 - Age appropriate capacity 2 - Age appropriate capacity but vulnerable to stress with constricted range of affect or both 3 - Funcationally delayed; some capacity but not age appropriate 4 - Inconsistent or intermittent capacity or only with support 5 - Barely shows capacity 6 - Has not achieved this capacity 17
DC: 0-3R Level IV: Complex Communication Level V: Representational Play Level VI: Shared Emotional Problem Solving Illinois' Crosswalk for DC: 0-3R to DSM-IV TRto ICD-9-DM Axis V DSM Axis I DX V Code Behaviors and disorders that prevent or interrupt a child's attempts to communicate their ideas, thoughts, feelings or fantasies 307.20 Tic Disorder NOS 307.21 Transient Tic Disorder 307.22 Chronic Motor or Vocal Tic Disorder 307.23 Tourette's Syndrome 307.9 Communication Disorder NOS 314.9 ADHD NOS 315.31 Expressive Language Disorder 315.32 Mixed Receptive-Expressive Language Disorder 315.39 Phonological Disorder 315.4 Developmental Coordination Disorder 784.69 Apraxia Any disorder which interferes with or prevents the infant or young child from representing their ideas, thoughts, feelings or fantasies in mutually satisfying play with another person 317. Mild Mental Retardation 318.X Mental Retardation Any disorder that reflects the child's lack of capacity for finding novel solutions to emotional dilemmas while relating to anotehr person 300.02 Anxiety Disorders 300.00 Anxiety NOS 300.23 Social Phobia (Social Anxiety Disorder) 309.21 Separation Axiety Disorder All V codes may also be used - unless superceded by an Axis I Diagnosis All V codes may also be used - unless superceded by an Axis I Diagnosis All V codes may also be used - unless superceded by an Axis I Diagnosis Severity of Functional Delay Use descriptors provided by the various DSM codes to indicate severity of age-delayed behavior 1 - Age appropriate capacity 2 - Age appropriate capacity but vulnerable to stress with constricted range of affect or both 3 - Funcationally delayed; some capacity but not age appropriate 4 - Inconsistent or intermittent capacity or only with support 5 - Barely shows capacity 6 - Has not achieved this capacity Use descriptors provided by the various DSM codes to indicate severity of age-delayed behavior Rate severity of the developmental delay using modifiers Notes and Advice: 1) Axis V encompasses global developmental states that represent the child's changing and thus functional capacity to integrate both internal states with external contextual conditions 2) The DSM Axis V notation inadequately illustrates or articulates the complexity of a child's developmental process. However, where the child's functioning meets criteria, diagnosing a DSM Axis I diagnosis is appropriate to capture the lack of age appropriate behavior. 3) Essentially in using Axis V, the diagnotician asks the following question, "Given that this baby or young child has an internally imposed limit in organizing at a given level of emotional development, what behaviors does he/she use to accommodate to their own inadequate mastery of the interactive processes inherent in age appropriate functioning? 4) Axis V provides information about how a child copes and thus in determining which DSM codes to apply. The diagnotician will want to use the following data: - Observable behaviors that function to signal the child's incomplete mastery - Observable behaviors that constitute a disruption or interference with flexible stable age appropriate functioning. 18
Final Thoughts: The primary use of the crosswalk is to create a developmentally informed diagnosis for children under the age of three years, using a tool originally created to be a detailed, two-dimensional, nosology. There was no attempt at communicating the dynamical and emergent nature of developmental process, nor the specific understanding of complex interplay among the basic factors influencing functioning: environment, physiology and learning capacity in the motivation behind the DSM format. The function of such a nosology was and continues to be a shorthand method for sharing information between professionals who become intimately involved in the intervention and resolution of painful emotional and developmental issues on one hand, and those responsible for deciding issues of funding for intervention. This crosswalk continues and extends that goal for understanding, diagnosing and addressing the first difficult mental and emotional dilemmas of life. 19