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Relational Context and Relational Psychopathology in Early Childhood: An Illustration of the DC:0–5 Approach

Dec 8, 2021

Julie A. Larrieu and Charles H. Zeanah, Tulane University School of Medicine

Abstract

DC:0–5™: Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood* (ZERO TO THREE, 2016) emphasizes the centrality of relationships for young children’s development and psychopathology. The authors share the story of a young child and his mother to illustrate the use of DC:0–5, with an emphasis on how ratings of the primary caregiving relationships and the caregiving environment are used in the assessment process to create a treatment plan for the child and family.*

As a nosology of early childhood disorders, DC:0–5™: Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0–5, ZERO TO THREE, 2016) emphasizes the centrality of relationships for young children’s development and psychopathology by devoting an entire axis to the caregiving context. DC:0–5 features the explicit statement that understanding the relationship context “should be included in every assessment of infants/young children” (p. 139). Also explicit is that the relationship between caregiving relationships and child psychopathology is bidirectional and that disturbances in the caregiving relationship may arise largely from within the child or the caregiver or from the fit between the two (ZERO TO THREE, 2016).

Though a relationship axis was included in Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0–3, ZERO TO THREE, 1994), in DC:0–5, Axis II is substantially revised. First, there is a characterization of the young child’s relationship with one or more primary caregivers, and a characterization of the broader caregiving environment. Both primary caregiving relationships and the caregiving environment are to be formally rated using a four-point anchored scale of level of adaptive qualities. Each level includes a range of adaptive functioning: well-adapted to good-enough, strained to concerning, compromised to disturbed, and disordered to dangerous. The scales are ordinal (but not continuous) in that Level 1 is assumed to include the majority of young child–caregiver relationships, designating those that are not in need of clinical focus.

To aid in the clinical assessment of the young child’s primary caregiving relationships, the clinician is encouraged to rate 14 separate dimensions of caregiving as “strength,” “not a concern,” or “concern.” Similar ratings are encouraged for seven different child characteristics that call attention to the child’s contribution to the relationship (see Tables 1 and 2, p. 14). The clinician is encouraged also to complete similar ratings of eight dimensions of the broader caregiving environment (see Table 3, p. 15).

Another significant change in DC:0–5 is the inclusion of a relationship disorder on Axis I. Building on a large body of research documenting that infants and young children may construct qualitatively different relationships with different adult caregivers and on clinical case reports of relationship specific psychopathology (Zeanah & Lieberman, 2016), the new rela- tionship specific disorder of infancy/early childhood identifies symptomatic behavior in the young child that is restricted to one relationship. As with other disorders in DC:0–5, functional impairment is required to emphasize that the diagnosis is made to identify nontrivial emotional or behavioral disturbances. If diagnostic criteria for relationship specific disorder are met, then the primary caregiving relationship adaptation on Axis II must be rated at Level 3 or 4.

Photo: shutterstock/Tony Stoc

Both primary caregiving relationships and the caregiving environment are to be formally rated using a four-point anchored scale of level of adaptive qualities.

Table 1. Dimensions of Caregiving

Table 2. Infant’s/Young Child’s Contributions to the Relationship

Table 3. Dimensions of the Caregiving Environment

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