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The DC:0-3R Multi-Axial System

Axis I
Axis II
Axis III
Axis IV
Axis V

Axis I: Primary Diagnosis

Decision Tree
[127 KB  Icon_pdf]

Axis I provides diagnostic classifications for characterizing the primary or most prominent features of the presenting concerns. The classifications describe the individual infant or child's functioning.

Primary Diagnoses:

100 Traumatic Stress Disorder
200 Disorders of Affect
300 Adjustment Disorder
400 Regulatory Disorder
500 Sleep Behavior Disorder
600 Eating Behavior Disorder
700 Disorders of Relating and Communicatin 

Axis II: Relationship Classification

Decision Tree
[ 135 KB Icon_pdf]

Axis II reflects a basic premise in the field of infant mental health that infants and young children are developing in the context of their primary emotional relationships, and that the quality of these relationships has a profound influence in shaping the child's developmental course towards mental health or disorder.

Understanding the quality of the infant parent relationship, then, is an important part of developing a diagnostic profile for infants and young children. Clinicians can be assisted in systematically understanding the meaning of behaviors within the young child's primary relationship(s). Interventions can then be formulated and focused on both individual and relationship levels.

Axis II is intended to diagnose the presence of a clinical problem in the child's relationship with the primary caregiver, usually the parent. When a disorder exists, it is specific to a relationship, meaning that the child's behavioral disturbances while interacting with one caregiver are not observed in the child's relationships with other caregivers. If the relationship disorder does not affect the child's functioning in other domains, then a diagnosis would be given only on Axis II.

Relationship disorders include several patterns. Each highlights a relational pattern that includes descriptors of behavior, affect, and psychological involvement for the caregiver and the child.

901 Overinvolved
902 Underinvolved
903 Anxious/Tense
904 Angry/Hostile
905 Mixed Relationship Disorder
906 Abusive (verbal, physical, sexual)  


Axis III: Medical and Developmental Disorders or Conditions

This axis is used to note any physical (including medical and neurological), mental health, and/or developmental diagnosis made using other diagnostic and classification systems.

Medical disorders of infants and young children also involve developmental difficulty. Such relevant medical conditions would be listed under Axis III. Such conditions are not treated as an alternative diagnosis, but as a co-existing problem.

If a DSM diagnosis is related to a primary diagnosis under the DC:0-3 system it should be listed under Axis III.

Axis IV: Psychosocial Stressors

This axis helps clinicians take into account various forms and severity of psychosocial stress that are influencing factors in a variety of disorders in infancy and early childhood.

In considering the impact of direct and indirect psychosocial stress on infants and young children, it is useful to think in terms of the child's loss of basic safety, security, and comfort - that is, the protective, supportive "envelope" that should constitute an infant's immediate caregiving environment.

The ultimate impact of a stressful event or enduring stress depends upon three factors:

  • Severity of the stressor
  • The developmental level of the child
  • The availability and capacity of adults to serve as protective buffers
  • The purpose of the stress index is to identify sources of stress, their severity, and their duration (acute or enduring) with respect to the individual infant or young child.

The overall impact is summarized by a 7-point scale ranging from a rating of 1, indicating no obvious effects, to a rating of 7 for stressors that significantly derail developmental functioning and adaptation.


Axis V: Functional Emotional Developmental Level 

Decision Tree
[ 108 KB Icon_pdf ]

The assessment of a young child's functional level should be based on observations of the child in interaction with each parent and with other significant caregivers. The levels achieved in interactions with the clinician, as the child becomes increasingly comfortable through the course of the evaluation, should also be noted.

Essential domains of functioning:

  • Mutual attention (all ages)
  • Mutual engagement (readily observable at 3-6 mo.)
  • Interactive intentionality and reciprocity (readily observable at 6-8 mo.)
  • Representational/affective communication (+18 mo.)
  • Representational elaboration (+30 mo.)
  • Representational differentiation I (+36 mo.)
  • Representational differentiation II (+42 mo.)

Axis V provides a 5-point scale that summarizes the child's overall functional emotional developmental level. This summary is based primarily on direct observation of and interaction with the child, but it is also important to ask about the child's functioning at home, other salient settings, and other times. The summary level is based on the child's most optimal functioning even if this level is not consistent with all caregivers.

1 - Has fully reached expected levels

2 - At expected level but with constrictions (several examples)

3 - Has not achieved current expected level, but has achieved all prior levels

4 - Has not achieved current expected level but has achieved some prior levels (indicate which)

5 - Has not mastered any prior level




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