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The State of Minnesota is recommending that clinicians serving children under the age of five use the DC:0-3R Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: Revised Edition developed by Zero to Three(2005). This process requires that clinicians use a cultural and developmental lens when evaluating a child’s clinical needs and status, partner with a child’s primary caregivers in order to obtain accurate information about the child’s and family’s functioning and observe the child in his/her natural settings with his/her various caregivers.

NAME OF CHILD:          DATE OF DA SESSIONS:    

          DATE OF REPORT:

DATE OF BIRTH:          CHRONOLOGICAL AGE:  

Parents and Caregivers Engaged in Assessment:  

  

Reason for Referral

Caregivers Greatest Areas of Concern

Sources of Data Information and Dates

• Observations (include all sites where child was observed and information about the child’s strengths and struggles in those sites with the various individuals involved)

• Interview (include information on the child’s development, cultural influences- including any family spiritual beliefs, family illness history, child’s current living situation, the child’s/family’s basic needs status, the child’s experience with the early learning system (education or child care), history of mental health treatment and history of trauma)

• Documentation (medical reports, child protection reports, previous developmental assessments, police reports etc.)

• Assessment Data (include an assessment of current risk and protective factors with the family andinformation from developmental and psychological assessment tools etc.)
  

DIAGNOSTIC IMPRESSION

The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 0-3R, 2005) provides a developmentally based approach to the classification of mental illness and developmental difficulties experienced by children during the first four years of life. This framework uses a 5-multiaxial system for clinical formulation to draw attention to those factors contribution to the child’s difficulties, adaptive strengths, and areas of functioning in which intervention may be needed. The axes are:

Axis I    Clinical Disorders based on symptoms exhibited by the infant or child

Axis II    Relationship Classification describes the quality of the caregiver-child

Axis III   Medical and Developmental Disorders and Conditions records conditions classified

by other systems.

Axis IV    Psychosocial Stressors describes psychosocial stressors as experienced by infant/child.   

Axis V    Emotional and Social Functioning reflects infant/child’s emotional and social capacities in the context       of interactions with important caregivers as compared with specific developmental stages.

  

Axis I    Clinical Disorders based on symptoms exhibited by the infant or child

Primary:   _____________

Based on the following symptoms and history:

Secondary:   _______________

Based on the following symptoms and history:

Additional Considerations: ________________________________________________

Axis II  Relationship Classification describes the quality of the caregiver-child (the identified caregivers are only those who are responsible for the child’s care and wellbeing- childcare providers are not considered).

Relationship A.

Child with   ___________________________

Parent-Infant Relationship Global Assessment Score _______________________________  

Qualities of Relationship   ______________________________________________________

As evidenced by:

Behavioral Quality of Interaction

Affective Tone:

Psychological Involvement:

Relationship B.

Child with   ___________________________

Parent-Infant Relationship Global Assessment Score _______________________________  

Qualities of Relationship   ______________________________________________________

As evidenced by:

Behavioral Quality of Interaction

Affective Tone:

Psychological Involvement:

Axis III   Medical and Developmental Disorders and Conditions records conditions classified

by other systems.

Diagnosis          As recorded by:

Axis IV  Psychosocial Stressors describes psychosocial stressors as experienced by infant/child.   

Psychosocial Stressor    Age   Duration     Intensity      Caregiver

  Of Child            Availability

____________________________________________________________________________

LEVEL OF PSYCHOSOCIAL STESSORS FOR INFANT/CHILD ___________________________

Axis V  Emotional and Social Functioning reflects infant/child’s emotional and social capacities in the context of interactions with important caregivers as compared developmental stages when these capacities typically occur. The clinician should use a rating of not applicable if the child is younger than the typical age at which the capacity may emerge. (See below for the ratings).

CAPACTITIES FOR EMOTIONAL AND SOCIAL FUNCTIONING RATING SCALE

CAPACITY      TYPICAL FUNCTIONAL  FUNCTIONAL   FUNCTIONAL FUNCTIONAL

        AGE RATING    RATING   RATING   RATING

        FIRST    CAREGIVER A  CAREGIVER B   CAREGIVER C   EXAMINER            OBSERVED

ATTENTION & REGULATION	0-3 MOS
FORMING RELATIONSHIPS/MUTUAL ENGAGEMENT	3-6 MOS
INTENTIONAL TWO-WAY COMMUNICATION	4-10 MOS
COMPLEX GESTURES AND PROBLEM SOLVING	10-18 MOS
USE OF SYMBOLS TO EXPRESS THOUGHTS/FEELINGS	18-30 MOS
CONNECTING SYMBOLS LOGICALLY/ABSTRACT THINKING	30-48 MOS

CAREGIVER A ___________________________________

CAREGIVER B ___________________________________

CAREGIVER C ___________________________________

FUNCTIONING RATING

SCORE  DESCRIPTOR

1     Age appropriate under all conditions/full range of affect

2    Age appropriate, vulnerable to stress, constricted range of affect or both

3    Immature; has capacity but not at age level

4    Functions inconsistently unless special structure or sensorimotor support is available

5    Barely evidences this capacity

6    Has not achieved this level

N/A    Not applicable. Child is below the age level

DC0-3R SUMMARY        DSM-IV/ICD-9/10 CROSSWALK – USED FOR BILLING

Axis I  

  

Axis II    

Axis III   

Axis IV  

Axis V    

ECSII SCORING WORKSHEET

ã2009 American Academy of Child and Adolescent Psychiatry

Name of child ___________________________________ Rater(s)__________________________________________

Date of ECSII rating ___________________ Rater’s judgment of SI Level needed prior to ECSII rating ____________

Explanation if final disposition differs from ECSII SI Level _________________________________________________

STEP 1

DOMAIN

Score

Anchor Points Met / Comments (with justification from data)

I. Degree of Safety

II. Caregiving Relationships

III. Caregiving Environment

--------

A. Strengths/protective factors

B. Stressors/vulnerabilities

IV. Functional/Developmental Status

V. Impact of Medical, Develop. or Emot/ Behav. Problems

TOTAL SCORE on I-V

STEP 2

Preliminary SI Level by Total Score on Domains I-V

Total score

6-8

9-12

13-17

18-22

23-26

27-30

SI Level

0

1

2

3

4

5

STEP 3

Application of Independent Criteria

ECSII Domain

I. Degree of Safety

II. Child-Caregiver Relationships

IV. Functional/ Devel. Status

If Score is

5

5

5

Action

Moves to Level 5

Moves up 1 Level*

Moves up 1 Level*

(*only 1 level raised if Domains II and IV are both rated 5)

STEP 4

ECSII SERVICE INTENSITY LEVEL

STEP 5

SERVICES PROFILE SCORES

(A) Child Involvement

(A) Involvement

(B) Fit

(C) Effectiveness

(A) Caregiver Involvement

(** Consider one SI level increase if sum of three Service Profile scores = 12 or above)

  

Explanation if final disposition differs from the ECSII-derived SI Level: ______________________________

_________________________________________________________________________________________

SUMMARY of CASE CONCEPUALIZATION INCLUDING THE ECSII INFORMATION (please refer to the Minnesota Outpatient Rule for more information on requirements):

RECOMMENDATIONS FOR INTERVENTION

DC:0-3R™ SIGNATURES

Provider
Signature	Printed Name	Credentials	Date
Provider rendering diagnosis [if different than above]
Signature	Printed Name	Credentials	Date
Supervisor [if applicable]
Signature	Printed Name	Credentials	Date