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Proposed Taxonomy - Conditions of Children Presenting for Play Therapy

1 Introduction	4 Sources	7 Commonly Occurring Conditions - Alphabetic Listing
2 Improving PTI's Analytical Capabilities	5 Top Level Descriptors	8 How the Taxonomy is intended to work
3 How the Taxonomy has been developed	6 First and Second Levels	9 References
10 Other Conditions of Children Presenting for Play Therapy

1 Introduction

This proposal follows an article in the Autumn 2009 edition of ‘Play For Life’ which highlighted the Play Therapy profession’s need for a Taxonomy of Conditions. The first draft has now been reviewed by the PTI Research Advisory Board. It is now open to comments from PTI/PTIrl and other PTI affiliates’ members to provide a practitioner’s perspective. The closing date for comments is March 31st 2011.

After taking comments into account we will then submit a proposal to IBECPT seeking ratification. Once this is obtained the Taxonomy will be published, data capture forms, guides and procedures updated and the research database developed to use it. It is intended to make it a part of routine practice.

To recap, there are two main reasons for developing a Taxonomy of Conditions as an international standard.

To improve our analyses of clinical outcomes
To support our members who conduct special research studies by providing the means to use PTI’s recommended pragmatic psychology approach

Using an agreed international taxonomy of conditions will provide a greater degree of precision in answering the questions of ‘how well does play therapy work?’ and ‘which approaches work best?’

We believe that this will be a major step forward in increasing the play therapy evidence base and maintain PTI’s reputation for being the leading and most progressive organisation in our profession.

Please bear in mind that the Taxonomy is a classification method – not a diagnostic tool

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2 Improving PTI’s analytical capabilities

PTI is often asked about the effectiveness of play therapy for a special condition such as autistic spectrum, ADHD, anger management etc. At present we don’t have confident answers because up to now we haven’t classified our SDQ records in this way. All we can do is to refer the enquirer to books dealing with the condition. These are usually based on a small number of cases making it difficult to predict reliable, reproducible outcomes.

Fishman (2000) is also very clear that "standardised measures of patient typing and therapy outcomes are needed" because they are necessary to any cumulative foundation of a knowledge base. If every patient and every program is unique, nothing that is learned from one can inform work with another. If there are commonalties, it becomes possible to learn the nature of those commonalties. In the ‘Play for Life’ article we stated that the fundamental point about commonalties through standardisation is near and dear to our hearts. Hence the central position and importance of a standard taxonomy.

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3 How the Taxonomy has been developed

In developing the taxonomy three main criteria have been used:

Alignment with the Diagnostic and statistical manual of mental disorders (DSM IV), ICD 10 and other existing frameworks, where appropriate – although the Taxonomy is not a diagnostic tool, it is desirable that new ‘labels’ are not invented for their own sake and that as far as possible there is commonality with well known existing schemes.

It should be as short as possible whilst being consistent with the number of conditions that are likely to be met by practitioners working with children

Easy to use when writing up notes, for recording keeping and data entry

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4 Sources

Three main sources have been used:

A listing based upon the free text descriptions of conditions given with referral data for clients whose SDQ data is included in the PTI database of clinical outcomes. This produced a list of 70 conditions, many of which duplicated those from other sources. These are conditions as observed by referrers and parents and often described in lay terminology. They represent the ‘real world’. They are terms that Teachers, SENCOs and Social Workers tend to use.

The DSMIV – The section describing ‘Disorders usually first diagnosed in infancy, childhood or adolescence’ - This contained 218 conditions, many rarely occurring in play therapy referrals (about 110). These conditions have been precisely defined by psychiatrists over the course of many years. They represent the mental health professional’s view.

A list of conditions described in ‘Alphabet Kids’. This rather populist title conceals a very useful reference work. (A kind of ‘poor person’s DSM). It contains a list of over 120 conditions, of which 76 are relevant to play therapy. They represent the GP’s and parents’ view

Our first task was to merge and deduplicate items from these three sources, making slight adjustments to the wording of a few terms.

Then, in the interests of usability to group them in two ways – firstly by level of occurrence (common, occasional and rare) and secondly by main and sub domains.The first classification was undertaken on the basis of expert opinion. To have collected and used epidemiological data would, in our view, have taken too long and have been inconclusive because we have no data on the percentages referred to play therapy. Undoubtedly we will be reclassifying occurrence as our data grows.

The analysis at this stage resulted in:

Frequency	N
Common	70
Occasionally	67
Rare	133
	270

We concluded that the 70 commonly occurring conditions should form the main part of the Taxonomy, one that is used regularly, and the 200 others should be placed in a second part that may be consulted if and when needed. Subsequent editing has and will continue to reduce these numbers by a small amount.

The second task was to decide the number of levels needed.

The principles for a successful taxonomy design are ideally to:

Keep it broad, shallow, simple and elegant
Six to twelve top-level categories – we have kept to six
Two or three levels deep – we have chosen three levels

Another factor taken into account was the recognition that play therapy is delivered through a number of different service delivery channels such as education, social services, physical health care etc as well as mental health. Also that referrals come from parents, Teachers, Social Workers, Doctors etc and the words that they use will be different from, for example the DSM.

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5 Top Level Descriptors

The choice of our top level descriptors is:

1	Mental Health	Problems diagnosed as mental health conditions using the DSM or ICD classifications
2	Physical Health	Behaviour problems caused by, or leading to a physical health problem
3	Social/Family	Behaviour or conduct problems that emanate from family or other environments or have a social impact
4	Abuse & Trauma	Problems caused by other persons abusing or traumatising the child or those caused by traumatic events
5	Learning Difficulties	Problems that prevent a child reaching their full educational potential
6	Miscellaneous	Any others not covered by headings 1 to 5

These reflect the origin and/or main classification of conditions.

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6 First and Second Levels

The first and second levels combined are:

1	Mental Health
028	Depression and grief
040	Anxiety disorders
044	Impulse-control disorders not elsewhere classified
063	Personality Problems
064	Pervasive developmental disorders
071	SAS Separation Anxiety Disorder
085	Childhood Adjustment Disorder
2	Physical Health
034	Anorexia and Bulimia
036	Enuresis and Encopresis
076	Sleep disorders
3	Social/Family
004	Adjustment issues
028	Depression and grief
044	Behaviour/Conduct Problems
057	Parental Separation and Divorce Adjustment
069	Relationship problems
071	Attachment Issues
4	Abuse & Trauma
40	Abuse
41	Trauma
5	Learning Difficulties
051	Learning Disability
054	ODD Oppositional Defiant Disorder
083	Under Performance
6	Miscellaneous
055	Other disorders of infancy, childhood, or adolescence

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7 Commonly Occurring Conditions - Alphabetic Listing

Next is listed the complete list of commonly occurring conditions as specified in Part One of the Taxonomy, at the third level together with their top and second level descriptors. This is given in alphabetic order for ease of review.

124	Academic under achievement	Under Performance	Learning Difficulties
112	ADHD - Combined subtype - 314.01	Attention-deficit and disruptive behavior disorders	Learning Difficulties
113	ADHD - Difficulties in sustaining attention	Attention-deficit and disruptive behavior disorders	Learning Difficulties
114	ADHD - Disruptive Behavior Disorder	Attention-deficit and disruptive behavior disorders	Learning Difficulties
116	ADHD - Predominantly hyperactive-impulsive subtype - 314.01	Attention-deficit and disruptive behavior disorders	Learning Difficulties
117	ADHD - Predominantly inattentive subtype - 314.00	Attention-deficit and disruptive behavior disorders	Learning Difficulties
500	Adjustment Issue - General	Adjustment Issues	Social/Family
501	Adjustment Issue - With anxiety - 309.24	Adjustment Issues	Social/Family
502	Adjustment Issue - With disturbance of conduct - 309.3	Adjustment Issues	Social/Family
503	Adjustment Issue - With mixed anxiety and depressed mood - 309.28	Adjustment Issues	Social/Family
504	Adjustment Issue - With mixed disturbance of emotions and conduct - 309.4	Adjustment Issues	Social/Family
520	Aggression - including bullying	Behaviour/Conduct Problems	Social/Family
512	Anger	Behaviour/Conduct Problems	Social/Family
513	Antisocial behavior	Behaviour/Conduct Problems	Social/Family
200	Anxiety disorder	Anxiety disorders	Mental Health
250	Asperger’s Disorder - 299.80	Pervasive developmental disorders	Mental Health
510	Attachment Issues	Attachment Issues	Social/Family
110	Attention-Deficit Hyperactivity Disorder	Attention-deficit and disruptive behavior disorders	Learning Difficulties
251	Autistic disorder - 299.00	Pervasive developmental disorders	Mental Health
310	BED (Binge-Eating Disorder)	BED (Binge-Eating Disorder)	Physical Health
520	Bereavement Close Relatives	Bereavement / Loss	Social/Family
210	CAD Childhood Adjustment Disorder	Childhood Adjustment Disorder	Mental Health
220	CD Childhood Depression	Depression and grief	Mental Health
514	Child or adolescent antisocial behavior - V71.02	Behaviour/Conduct Problems	Social/Family
221	Diminished activity	Depression and grief	Mental Health
900	Disorder of infancy, childhood or adolescence NOS - 313.9	Other disorders of infancy, childhood, or adolescence	Miscellaneous
120	Dyslexia/Reading disorder - 315.00	Learning Disability	Learning Difficulties
001	Emotional abuse	Abuse	Abuse & Trauma
321	Encopresis	Enuresis and Encopresis	Physical Health
320	Enuresis	Enuresis and Encopresis	Physical Health
540	Family relationship difficulties	Parental Separation and Divorce Adjustment	Social/Family
201	Generalized anxiety disorder - 300.02	Anxiety disorders	Mental Health
240	Guilt	Personality Problems	Mental Health
223	Ideas of guilt and unworthiness	Depression and grief	Mental Health
118	Impulsiveness	Attention-deficit and disruptive behavior disorders	Learning Difficulties
230	Intermittent explosive disorder - 312.34	Impulse-control disorders not elsewhere classified	Mental Health
241	Lack of confidence	Personality Problems	Mental Health
242	Lack of self esteem	Personality Problems	Mental Health
224	Loss of interest and enjoyment	Depression and grief	Mental Health
515	Lying	Behaviour/Conduct Problems	Social/Family
226	Mild Depressive disorders - 296.31	Depression and grief	Mental Health
330	Nightmare disorder - 307.47	Sleep disorders	Physical Health
202	Nightmares	Anxiety Disorders	Mental Health
123	ODD Oppositional Defiant Disorder	ODD Oppositional Defiant Disorder	Learning Difficulties
119	Oppositional Defiant Disorder - 313.81	Attention-deficit and disruptive behavior disorders	Learning Difficulties
521	Other Loss	Bereavement / Loss	Social/Family
516	Parent-child relational problem - V61.20	Behaviour/Conduct Problems	Social/Family
115	Persistent over activity	Attention-deficit and disruptive behavior disorders	Learning Difficulties
002	Physical abuse	Abuse	Abuse & Trauma
125	Physical under performance	Under Performance	Learning Difficulties
517	Poor School Attendance	Behaviour/Conduct Problems	Social/Family
104	Posttraumatic stress disorder - 309.81	Trauma	Abuse & Trauma
511	RAD Reactive Attachment Disorder	Attachment Issues	Social/Family
901	Reactive attachment disorder of infancy or early childhood - 313.89	Other disorders of infancy, childhood, or adolescence	Miscellaneous
300	Recurrent compensatory inappropriate behaviour to prevent weight gain	Anorexia and Bulimia	Physical Health
530	Reduced concentration and attention	Depression and grief	Social/Family
225	Reduced self esteem	Depression and grief	Mental Health
550	Relational problem - general	Relationship problems	Social/Family
260	SAS Separation Anxiety Disorder	SAS Separation Anxiety Disorder	Mental Health
902	Separation anxiety disorder - 309.21	Other disorders of infancy, childhood, or adolescence	Miscellaneous
003	Sexual abuse	Abuse	Abuse & Trauma
243	Shyness	Personality Problems	Mental Health
551	Sibling relational problem - V61.8	Relationship problems	Social/Family
203	Social phobia - 300.23	Anxiety Disorders	Mental Health
126	Social relationships difficulties	Under Performance	Learning Difficulties
121	Temper tantrums	ODD Oppositional Defiant Disorder	Learning Difficulties
518	Unauthorised Absences	Behaviour/Conduct Problems	Social/Family
245	Withdrawn Personality	Personality Problems	Mental Health

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8 How the Taxonomy Is intended to work

After Members’ comments have been received we will carry out some practitioner testing.

Capturing the data

Members will be provided with a full Taxonomy and guidance notes.

Part 1 – Common Conditions

A listing by first and second level headings
An alphabetical listing

Part 2 – Other Conditions

A listing by first and second level headings
An alphabetical listing

The practitioner considers the condition specified by the referrer and enters the Taxonomy codes on the referral form, checking Part 1 of the taxonomy to find the unique number of the Taxonomy’s description that best matches the condition. (It is not normally the function of the practitioner to diagnose the problem). The top two levels may be used as pointers. It is envisaged that the over 90% of the unique numbers will be found this way.

If not, Part 2 may be used to find the unique number. either by means of the alphabetical listing or by using the top two levels.

In a few cases the referrer’s description may be too vague to identify the unique number at the third level. In these cases just use the second level number.

If, in the very unlikely event that an exact match cannot be found use the second or in the worst cases the top level number only.

The referral forms will be revised to accommodate this data similar to the following example:

Reasons for referral:

What are the reasons for concern? (If more than one - list in order of importance)

	Concern	Taxonomy Codes
	Concern	1st Level	2nd Level	3rd Level
1	Aggression – including bullying	3	044	520
2
3

Our database will allow up to three different conditions to be recorded for each case. Record the codes in order of priority or importance.

If during the course of the therapy episode the original condition appears to be incorrect, get confirmation that your Clinical Supervisor and the referrer agree that the code should be changed. Amend your referral form, with a note.

Entering the data

PTI will be responsible for entering the data into the clinical database.

Using the data

PTI will run a series of analysis that will show:

The incidence of referral of any condition, in total, by age, gender and ethnicity – this will enable us to build up a picture of the potential for using play therapy
The pre and post SDQ scores, bands and the change by condition – this will demonstrate the results through the clinical outcomes. (In some cases other appropriate psychometric instruments may be used.)
The activities in the playroom by type and condition – showing the activities that lead to the results, enabling us to investigate what changes are need

These research reports will provide answers to questions that have been lacking so far and on a scale that will be credible.

Practitioners will be encouraged to carry out the same analyses using their own data and compare results with the overall analyses.

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9 References

Robbie Woliver, Alphabet Kids - From ADD to Zellweger Syndrome, London, Jessica Kingsley Publishers Ltd,

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC:

Barlow, D. H., & Hersen, M. (1984). Single case experimental designs: Strategies for studyingbehaviourchange (2nd ed.). Elmsford, NY: Pergamon Press.

Fishman, D. B. (1999). The case for pragmatic psychology. New York: New York University Press.

Fishman, D. B. (2000, May 3). Transcending the efficacy versus effectiveness research debate: Proposal for a new, electronic "Journal of Pragmatic Case Studies." Prevention & Treatment, 3, Article 8. Available on the World Wide Web: http://journals.apa.org/prevention/volume3/pre0030008a.html.

Stricker, G. (1992). The relationship of research to clinical practice. American Psychologist, 47, 543–549.

Thomas, J.H. (2008) PTI’s Research Strategy and a Glimpse Into The Future, Play for Life, Winter 2008, PTUK Uckfield UK

Weiss, C. H. (Ed.). (1972). Evaluating social action programs. Boston: Allyn & Bacon.

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10 Other Conditions of Children Presenting for Play Therapy

(These are conditions that we expect will only be rarely encountered by our Members – say 1 in 50 cases)

1	*Mental Health*
3	*Anxiety disorders*
120	Acute stress disorder - 308.3
120	Agoraphobia without history of panic disorder - 300.22
120	Anxiety disorder due to... [indicate the general medical condition] - 293.89
120	Anxiety disorder NOS - 300.00
120	Panic disorder
120	Phobias
120	Specific phobia - 300.29
5	*Bipolar disorders*
122	Cyclothymic disorder - 301.13
122	Mild
122	Moderate
122	Mood disorder
122	Mood disorder due to... [indicate the general medical condition] - 293.83
122	Mood disorder NOS - 296.90
124	CBD Childhood Bipolar Disorder
6	*CA (Chlldhood Agoraphobia*
123	CA (Chlldhood Agoraphobia
126	Expressive language disorder - 315.31
126	Mixed receptive-expressive language disorder - 315.32
126	Phonological disorder - 315.39
126	Stuttering - 307.0
133	ERLD Expressive-Receptive Language Disorder
154	SPLD Semantic Pragmatic Language Disorder
7	*Depression and grief*
129	Bleak and pessimistic views of the future
129	Ideas of or acts of self harm or suicide
129	Increased amounts of fatigue
129	Depressive disorder NOS - 311
129	Dysthymic disorder - 300.4
129	Major depressive disorder
129	Major depressive disorder, recurrent
129	Major depressive disorder, single episode
129	Mild - 296 21
129	Moderate - 296.22
8	*Dissociative disorders*
131	Depersonalization disorder - 300.6
131	Dissociative amnesia - 300.12
131	Dissociative disorder NOS - 300.15
131	Dissociative fugue - 300.13
131	Dissociative identity disorder - 300.14
12	*Gender identity disorders*
135	In children - 302.6
13	*Impulse-control disorders not elsewhere classified*
137	Impulse-control disorder NOS - 312.30
137	Kleptomania - 312.32
137	Pathological gambling - 312.31
137	Pyromania - 312.33
137	Trichotillomania - 312.39
14	*LD Learning Disability*
138	APD Auditory Processing Disorder
138	Visual Perceptual.Visual Motor Deficit
15	*Mental Retardation*
139	Intellectual disability, severity unspecified - 319
139	Mild intellectual disability - 317
139	Moderate intellectual disability - 318.0
139	Profound intellectual disability - 318.2
139	Severe intellectual disability - 318.1
17	*DPD Dependent Personality Disorder*
132	DPD Dependent Personality Disorder
144	PD Panic Disorder
145	Avoidant personality disorder - 301.82
145	Borderline personality disorder - 301.83
145	Cluster A (odd or eccentric)
145	Cluster B (dramatic, emotional, or erratic)
145	Cluster C (anxious or fearful)
145	Dependent personality disorder - 301.6
145	Histrionic personality disorder - 301.50
145	Narcissistic personality disorder - 301.81
145	NOS
145	Obsessive-compulsive personality disorder - 301.4
146	Paranoid personality disorder - 301.0
146	Personality disorder not otherwise specified - 301.9
146	Schizoid personality disorder - 301.20
146	Schizotypal personality disorder - 301.20
146	Bi-polar
18	*Autistic Spectrum (ASD)*
121	Aspergers
121	Severe Autism
147	Childhood Disintegrative Disorder - 299.10
147	Pervasive Developmental Disorder NOS - 299.80
147	Rett's Disorder - 299.80
19	*COS Childhood-Onset Schizophrenia*
127	COS Childhood-Onset Schizophrenia
149	Brief psychotic disorder - 298.8
149	Catatonic type - 295.2
149	Delusional disorder - 297.1
149	Disorganized type - 295.1
149	Erotomanic subtype
149	Grandiose subtype
149	Jealous subtype
149	Mixed type
149	Paranoid type - 295.3
149	Persecutory subtype
150	Psychotic disorder due to... [indicate the general medical condition]
150	Psychotic disorder NOS - 298.9
150	Schizoaffective disorder - 295.7
150	Schizophrenia
150	Schizophreniform disorder - 295.4
150	Shared psychotic disorder - 297.3
150	Somatic subtype
150	Undifferentiated type - 295.9
150	With delusions - 293.81
150	With hallucinations - 293.82
22	*Tic disorders*
156	Chronic motor or vocal tic disorder - 307.22
156	Tic disorder NOS - 307.20
156	Tourette’s Disorder - 307.23
156	Transient tic disorder - 307.21
31	*SAD – Seasonal Affective Disorder*
148	SAD – Seasonal Affective Disorder
32	*PAPD Passive-Aggressive Personality Disorder*
143	PAPD Passive-Aggressive Personality Disorder
99	*CCS Clumsy Child Syndrome*
125	CCS Clumsy Child Syndrome
128	Delayed Development
130	DGS Developmental Gerstmann’s Syndrome
134	FXS Fragile X Syndrome
136	HS Hyperlexia Syndrome
140	MSDD Multisystem Developmental Disorder
141	Aggressive obsession
141	Checking and rechecking
141	Cleaning and Washing
141	Contamination
141	Counting
141	Hoarding and saving
141	Magical and superstitious thoughts
141	Need to know and remember
141	Ordering and arranging
141	Repeating rituals
142	Scrupulosity
142	Sexual obsession
142	Somatic
151	SID Sensory Integration Disorder
152	SLD Speech-Language Disorder
153	SMS Smith-Magenis Syndrome
157	WS Williams Syndrome
158	XXYS XXY Syndrome
2	Physical Health
9	*Anorexia and Bulimia*
170	Anorexia nervosa - 307.1
170	Binge eating. Irresistible craving for food
170	Bulimia nervosa - 307.51
170	Disturbance in the way body weight or shape is experienced
170	Intense fear of gaining weight or becoming fat
170	Refusal to maintain body weight
170	Rumination syndrome - 307.53
10	*Elimination disorders*
171	Encopresis
171	Enuresis (not due to a general medical condition) - 307.6
11	*Feeding and eating disorders of infancy or early childhood*
172	Feeding disorder of infancy or early childhood - 307.59
172	Pica - 307.52
16	*Motor skills disorders*
173	Developmental coordination disorder - 315.4
21	*Sleep disorders*
176	Breathing-related sleep disorder - 780.59
176	Circadian rhythm sleep disorder - 307.45
176	Dyssomnia NOS - 307.47
176	Hypersomnia type - 780.54
176	Insomnia type - 780.52
176	Mixed type - 780.59
176	Narcolepsy - 347
176	Other sleep disorders (edited)
176	Parasomnias
176	Primary hypersomnia - 307.44
177	Primary insomnia - 307.42
177	Primary sleep disorders
177	Sleep disorder due to... [indicate the general medical condition]
177	Sleep terror disorder - 307.46
177	Sleepwalking disorder - 307.46
37	*Physical Disabilities*
174	Birth defects
174	From accident
175	Headaches
175	Painful medical procedures
175	Recurrent abdominal pain
3	Social/Family
2	*Adjustment disorders*
179	With depressed mood - 309.0
6	*Communication disorders*
181	Communication disorder NOS - 307.9
181	Deafness
181	Mutism
181	Speech Difficulties
184	SM Selective Mutism
7	*Depression and grief*
182	Diminished appetite
182	Disturbed sleep
13	*Behaviour/Conduct Problems*
180	Severe destructiveness
180	Severe disobedience
180	Stealing
33	*Social Exclusion*
185	Social exclusion
36	*Drug Abuse*
183	Effects of witnessing drug abuse
183	Harmful substance abuse
183	Substance dependence
50	*Additional codes*
178	Acculturation problem - V62.4
178	Malingering - V65.2
178	Religious or spiritual problem- V62.89
4	Abuse & Trauma
3	*Abuse*
100	Neglect
100	Physical abuse of child - V61.21
100	Sexual
100	Posttraumatic stress disorder - 309.81
5	Learning Difficulties
4	*Attention-deficit and disruptive behavior disorders*
110	Adolescent onset - 312.82
14	*LD Learning Disability*
110	Dysgraphia
110	Dyspraxia
110	Language disorders
110	NLD Nonverbal Learning Disorder
110	Disorder of written expression - 315.2
110	Mathematics disorder - 315.1
34	*Under Performance*
110	Cultural
6	Miscellaneous
50	*Additional codes*
160	Acute akathisia - 333.99
160	Acute dystonia - 333.7
160	Adverse effects of medication NOS - 995.2
160	Age-related cognitive decline - 780.9
160	Borderline intellectual functioning - V62.89
160	Identity problem - 313.82
160	Medication-induced
160	Movement disorder
160	Neglect of child - V61.21
160	Noncompliance with treatment - V15.81
161	Postural tremor - 333.1
161	Psychological factors affecting medical condition - 316
161	Relational problem related to a mental disorder or general medical condition
161	Tardive dyskinesia - 333.82
161	Selective mutism - 313.23
161	Stereotypic movement disorder - 307.3

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