Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood in Psychological Practice

Introduction

The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood — DC:0-5 [12] is a tool for the clinical assessment of mental health and the development of infants and young children, recognized by the international community of specialists among both scientists and practitioners [1; 5; 11]. Interest in this classification in the Russian Federation has risen since the release of its first version — DC:03 [11], which is reflected in a number of review publications [8; 9; 10].

The official translation of DC:0-5 into Russian and its printed edition were prepared within the framework of the “Mental Health and Early Intervention” project carried out by the Caritas Social School [3; 12]. The purpose of the translation and a number of other activities of the project was to familiarize a wide range of Russian specialists with the approach to diagnosing developmental disorders in infants and young children from the perspective of mental health. Mental health is considered as “a state in which a child develops the ability to form close and safe relationships, experience, express and regulate emotions, explore the environment and learn” [15, p. 6]. [15, с. 6].

Methods

The DC:0-5 tool describes the structure of the diagnosis based on a multidimensional analysis of the child’s development, relationships, and characteristics of life in different contexts. The analysis of child development is based on five axes [3, p. 110]. DC:0-5 considers infant and early childhood mental health as a multidisciplinary field, and therefore involves a comprehensive examination with the participation of different specialists with competencies in different areas. The developers of DC:05 recommend that the diagnostic process be conducted over five sessions. The diagnostic process includes interviews with family members, the observation of the child and caregivers, and the assessment of the child’s development. An important feature of the diagnostic approach offered by DC:0-5 is to maintain a focus on the quality of the child’s relationship with a caregiver and the extended caregiving environment. This approach also builds on ideas about the child’s functional capacity and ability to process information, which develop in interaction with others. In this way, the process of developmental diagnosis moves from assessing the child’s skills to determining the child’s level of functioning in the context of relationships, highlighting strengths and problem areas [13]. This allows us to determine the influence of different contexts on the occurrence of developmental and functioning disorders in the child: cultural (values, traditions, and beliefs of family members), relational context, psychosocial stressors, and physical health conditions and factors [8; 9; 10]. During the diagnostic period, the authors used methods of the expert assessment of development, including the assessment of the child’s adaptive behavior; the relationship between the child and a caregiver; the emotional state and behavior of adults.

Over a 12-month period, 48 families with children aged from 1 month to 4 years and 10 months applied to the Center. The analysis of the applications allowed us to identify the following typical categories of applications: health problems and concerns about the child’s disorders and developmental prospects; the presence of a symptom in the child; parents’ difficulties in interacting with the child; and difficulties in regulating emotional states.

Results

In the practical work on family support, two consecutive stages were determined: the diagnostic stage and the support stage. The systematized experience of conducting the diagnostic stage is described in the article.

The diagnostic stage was organized according to the algorithm for structuring information proposed in DC:05 [3], and included a telephone interview and face-toface diagnostic sessions with the family. Appointments were conducted by two specialists at the same time, and pairs were not assigned. This technology is widely used in the practice of family counseling and has, in our opinion, a number of important advantages: its use allows to reduce the subjectivity of assessment, to stay neutral, to distribute attention between family members more effectively, to discuss the experience with each other [2; 6; 7]. During the diagnostic stage we conducted: interviews with family members; the observation of the emotional state and behavior of the child and parents, as well as their interaction; aninvestigation of the results of medical examination and information from other specialists; a psychological examination. The stage was finalized with the preparation of a detailed diagnostic report with a list of recommendations.

The following is a case from the experience of the Child and Family Mental Health Center. The information is provided with the parents’ consent.

Case Description

At the time of referral, the boy A. was 2 years and 3 months old. A. practically did not speak, new situations caused him fear and anxiety. The meetings were attended by his mother O. and the son, and sometimes his father joined.

The family’s request was that the child’s speech development was lagging behind.

The following diagnostic assessment methods were used: interviews with parents, clinical observation; screening assessment of child development competencies; analysis of mother-child interaction. The following is a description of the results using the algorithm for structuring information according to DC:0-5.

Cultural aspects of the family. The mother’s age was 37 years, the father’s age was 30 years, the parents are Russian, have a higher education, were born and lived in a small town. The mother was the eldest in a large family, the father was the only child in the family. A.’s grandparents did not participate in his upbringing. O. describes the relationship with them as conflictual, their views on child-rearing differed. The parents sought help from specialists (doctors, psychologists, teachers).

Conditions and factors of the child’s physical health (Axis III). The pregnancy proceeded without peculiarities, the birth came on time, and A.’s condition was assessed as healthy. The mother described the birth as difficult (the pandemic period, she went to the wrong maternity hospital, she had severe perineal tears, bleeding and severe weakness after delivery for a long period of time, rough treatment by the maternity hospital staff, a lack of support from relatives). In the first months of life there were difficulties with breastfeeding, which resulted in poor weight gain. On the doctor’s recommendation, formula feeding was introduced, after which A. quickly gained excessive weight, which, in O.’s opinion, hindered his physical development (by 8 months of age,

A. could not turn over, and began crawling later). A neurologist recorded a delay in psychomotor development and prescribed rehabilitation. According to the assessment of an occupational therapist, at the time the family applied to the center, A.’s motor skills corresponded to the age norm.

Psychosocial stressors in the life of the child and family (Axis IV). The stressors included a number of factors mentioned by the mother in the childbirth history (see above for details), medical procedures during rehabilitation; the mother’s difficulties in recognizing the child’s needs, difficulties in regulating her own and the child’s emotional state; the isolation of herself and the child from socializing (on playgrounds, with close neighbors); and the presence in the parents’ experience of physical punishment, neglect, and violence in mastering discipline.

Child’s competencies (Axis V). A.’s developmental lag in the emotional sphere, speech and social communication was revealed, namely: he was cautious and constrained in expressing emotions, did not show anger, sadness, rarely smiled; the characteristic childish excitement during joy was not observed. In stressful situations, when, for example, the psychologist offered something, when the video camera appeared, the child froze, excessive tension rose in the body, activity stopped; A. began to communicate using gestures and mooing, did not answer questions, did not initiate communication. In the sphere of social and interpersonal relations, cognitive and motor development, competences appeared inconsistently. In kindergarten, interaction with children and participation in common activities with the teacher appeared; A. understood instructions and requests, but did not answer questions; he did not play independently, but played simple repetitive plots with an adult; “pretend” play appeared. A. walked independently, squatted, stood up. Due to high tension, A. did not demonstrate other motor skills.

Context of child and close adult relationships (Axis II).

The assessment of the child-mother relationship revealed a problem area on the part of O. She had a depressed emotional state, difficulty recognizing her son’s emotional needs and signals, and inappropriate responses to them for the child’s age and needs. O. had difficulty recognizing and regulating her intense unpleasant feelings (anger, rage). In the first year of her son’s life, it was difficult for her to organize the sleep mode, to participate in joint play and activities with the child, to ensure his physical safety. A.’s problem area was inhibition of activity and emotions. He could tolerate discomfort for a long time, froze, did not seek help, demonstrated excessive anxiety and fear. The characteristics listed above were categorized as risk factors that have an intensive impact on A.’s social and emotional development.

The data obtained during the diagnostic process made it possible to identify a number of protective factors. These included the parents’ ability to meet the child’s basic needs in nutrition, hygiene, clothing, housing and medical care, and to ensure the child’s physical safety. With his father,

A. was observed playing and doing household chores together, which brought joy to both of them. Together with psychologists, the parents were able to observe changes in their son’s condition and behavior, as well as to discuss and relate their experiences and emotional state to what was happening to A. The strength of the parents’ interaction was the distribution of roles (clear agreements on who was the primary caregiver, the distribution of time spent with the child, and the financial support of the family). Parents’ ways of conflict resolution and communication were of no concern. However, in the area of parental interaction, characteristics that can be attributed to risk factors were identified. Thus, there was inconsistency in the actions of the parental couple in the regulation of behavior and discipline regarding the child.

In accordance with the algorithm proposed by DC:05, the level of the adaptive functioning of the motherchild relationship was defined as “compromised to disturbed” (Level 3). The family was offered a support program including the psychological counseling of the mother-child pair.

Clinical disorders (Axis I). Analyzing the obtained data, we reflected on the presence of Developmental Language Disorder (10.6) and the Relationship Specific Disorder of Infancy and Early Childhood (80.1).

At the end of the diagnostic stage, a detailed report with recommendations was given to the family.

Conclusions

The experience of using the DC:0-5 diagnostic manual has shown that the proposed classification helps to structure the information obtained, creates a common language for the team of specialists, and allows to identify risk and protective factors that are important to consider when designing intervention programs for the infant or child and his or her family. The advantages of the diagnostic period are the opportunity to observe the child and family in different emotional states, in different compositions; to collect data from a variety of sources; to see the child’s potential and strengths; to reflect for a sufficient time on the child’s developmental situation and on the contribution of different factors to the difficulties encountered. This makes the formation of specialists’ perceptions of the child and his/her family more balanced, reasoned, complete and comprehensive. The data obtained in this way allows for the most complete formulation of the direction of an individual treatment program for the child and family.

At present, the authors continue to work on the description of cases from practice, the experience of work is analyzed and generalized. As a prospect for the further study of this topic, we plan to conduct a statistical analysis of the survey results obtained with a larger sample of families.