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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:
1Mental Health
028Depression and grief
040Anxiety disorders
044Impulse-control disorders not elsewhere classified
063Personality Problems
064Pervasive developmental disorders
071SAS Separation Anxiety Disorder
085Childhood Adjustment Disorder
2Physical Health
034Anorexia and Bulimia
036Enuresis and Encopresis
076Sleep disorders
3Social/Family
004Adjustment issues
028Depression and grief
044Behaviour/Conduct Problems
057Parental Separation and Divorce Adjustment
069Relationship problems
071Attachment Issues
4Abuse & Trauma
40Abuse
41Trauma
5Learning Difficulties
051Learning Disability
054ODD Oppositional Defiant Disorder
083Under Performance
6Miscellaneous
055Other 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.
124Academic under achievementUnder PerformanceLearning Difficulties
112ADHD - Combined subtype - 314.01Attention-deficit and disruptive behavior disordersLearning Difficulties
113ADHD - Difficulties in sustaining attentionAttention-deficit and disruptive behavior disordersLearning Difficulties
114ADHD - Disruptive Behavior DisorderAttention-deficit and disruptive behavior disordersLearning Difficulties
116ADHD - Predominantly hyperactive-impulsive subtype - 314.01Attention-deficit and disruptive behavior disordersLearning Difficulties
117ADHD - Predominantly inattentive subtype - 314.00Attention-deficit and disruptive behavior disordersLearning Difficulties
500Adjustment Issue - GeneralAdjustment IssuesSocial/Family
501Adjustment Issue - With anxiety - 309.24Adjustment IssuesSocial/Family
502Adjustment Issue - With disturbance of conduct - 309.3Adjustment IssuesSocial/Family
503Adjustment Issue - With mixed anxiety and depressed mood - 309.28Adjustment IssuesSocial/Family
504Adjustment Issue - With mixed disturbance of emotions and conduct - 309.4Adjustment IssuesSocial/Family
520Aggression - including bullyingBehaviour/Conduct ProblemsSocial/Family
512AngerBehaviour/Conduct ProblemsSocial/Family
513Antisocial behaviorBehaviour/Conduct ProblemsSocial/Family
200Anxiety disorderAnxiety disordersMental Health
250Asperger’s Disorder - 299.80Pervasive developmental disordersMental Health
510Attachment IssuesAttachment IssuesSocial/Family
110Attention-Deficit Hyperactivity DisorderAttention-deficit and disruptive behavior disordersLearning Difficulties
251Autistic disorder - 299.00Pervasive developmental disordersMental Health
310BED (Binge-Eating Disorder)BED (Binge-Eating Disorder)Physical Health
520Bereavement Close RelativesBereavement / LossSocial/Family
210CAD Childhood Adjustment DisorderChildhood Adjustment DisorderMental Health
220CD Childhood DepressionDepression and griefMental Health
514Child or adolescent antisocial behavior - V71.02Behaviour/Conduct ProblemsSocial/Family
221Diminished activityDepression and griefMental Health
900Disorder of infancy, childhood or adolescence NOS - 313.9Other disorders of infancy, childhood, or adolescenceMiscellaneous
120Dyslexia/Reading disorder - 315.00Learning DisabilityLearning Difficulties
001Emotional abuseAbuseAbuse & Trauma
321EncopresisEnuresis and EncopresisPhysical Health
320EnuresisEnuresis and EncopresisPhysical Health
540Family relationship difficultiesParental Separation and Divorce AdjustmentSocial/Family
201Generalized anxiety disorder - 300.02Anxiety disordersMental Health
240GuiltPersonality ProblemsMental Health
223Ideas of guilt and unworthinessDepression and griefMental Health
118ImpulsivenessAttention-deficit and disruptive behavior disordersLearning Difficulties
230Intermittent explosive disorder - 312.34Impulse-control disorders not elsewhere classifiedMental Health
241Lack of confidencePersonality ProblemsMental Health
242Lack of self esteemPersonality ProblemsMental Health
224Loss of interest and enjoymentDepression and griefMental Health
515LyingBehaviour/Conduct ProblemsSocial/Family
226Mild Depressive disorders - 296.31Depression and griefMental Health
330Nightmare disorder - 307.47Sleep disordersPhysical Health
202NightmaresAnxiety DisordersMental Health
123ODD Oppositional Defiant DisorderODD Oppositional Defiant DisorderLearning Difficulties
119Oppositional Defiant Disorder - 313.81Attention-deficit and disruptive behavior disordersLearning Difficulties
521Other LossBereavement / LossSocial/Family
516Parent-child relational problem - V61.20Behaviour/Conduct ProblemsSocial/Family
115Persistent over activityAttention-deficit and disruptive behavior disordersLearning Difficulties
002Physical abuseAbuseAbuse & Trauma
125Physical under performanceUnder PerformanceLearning Difficulties
517Poor School AttendanceBehaviour/Conduct ProblemsSocial/Family
104Posttraumatic stress disorder - 309.81TraumaAbuse & Trauma
511RAD Reactive Attachment DisorderAttachment IssuesSocial/Family
901Reactive attachment disorder of infancy or early childhood - 313.89Other disorders of infancy, childhood, or adolescenceMiscellaneous
300Recurrent compensatory inappropriate behaviour to prevent weight gainAnorexia and BulimiaPhysical Health
530Reduced concentration and attentionDepression and griefSocial/Family
225Reduced self esteemDepression and griefMental Health
550Relational problem - generalRelationship problemsSocial/Family
260SAS Separation Anxiety DisorderSAS Separation Anxiety DisorderMental Health
902Separation anxiety disorder - 309.21Other disorders of infancy, childhood, or adolescenceMiscellaneous
003Sexual abuseAbuseAbuse & Trauma
243ShynessPersonality ProblemsMental Health
551Sibling relational problem - V61.8Relationship problemsSocial/Family
203Social phobia - 300.23Anxiety DisordersMental Health
126Social relationships difficultiesUnder PerformanceLearning Difficulties
121Temper tantrumsODD Oppositional Defiant DisorderLearning Difficulties
518Unauthorised AbsencesBehaviour/Conduct ProblemsSocial/Family
245Withdrawn PersonalityPersonality ProblemsMental 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
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)
1Mental Health
3Anxiety disorders
120Acute stress disorder - 308.3
120Agoraphobia without history of panic disorder - 300.22
120Anxiety disorder due to... [indicate the general medical condition] - 293.89
120Anxiety disorder NOS - 300.00
120Panic disorder
120Phobias
120Specific phobia - 300.29
5Bipolar disorders
122Cyclothymic disorder - 301.13
122Mild
122Moderate
122Mood disorder
122Mood disorder due to... [indicate the general medical condition] - 293.83
122Mood disorder NOS - 296.90
124CBD Childhood Bipolar Disorder
6CA (Chlldhood Agoraphobia
123CA (Chlldhood Agoraphobia
126Expressive language disorder - 315.31
126Mixed receptive-expressive language disorder - 315.32
126Phonological disorder - 315.39
126Stuttering - 307.0
133ERLD Expressive-Receptive Language Disorder
154SPLD Semantic Pragmatic Language Disorder
7Depression and grief
129Bleak and pessimistic views of the future
129Ideas of or acts of self harm or suicide
129Increased amounts of fatigue
129Depressive disorder NOS - 311
129Dysthymic disorder - 300.4
129Major depressive disorder
129Major depressive disorder, recurrent
129Major depressive disorder, single episode
129Mild - 296 21
129Moderate - 296.22
8Dissociative disorders
131Depersonalization disorder - 300.6
131Dissociative amnesia - 300.12
131Dissociative disorder NOS - 300.15
131Dissociative fugue - 300.13
131Dissociative identity disorder - 300.14
12Gender identity disorders
135In children - 302.6
13Impulse-control disorders not elsewhere classified
137Impulse-control disorder NOS - 312.30
137Kleptomania - 312.32
137Pathological gambling - 312.31
137Pyromania - 312.33
137Trichotillomania - 312.39
14LD Learning Disability
138APD Auditory Processing Disorder
138Visual Perceptual.Visual Motor Deficit
15Mental Retardation
139Intellectual disability, severity unspecified - 319
139Mild intellectual disability - 317
139Moderate intellectual disability - 318.0
139Profound intellectual disability - 318.2
139Severe intellectual disability - 318.1
17DPD Dependent Personality Disorder
132DPD Dependent Personality Disorder
144PD Panic Disorder
145Avoidant personality disorder - 301.82
145Borderline personality disorder - 301.83
145Cluster A (odd or eccentric)
145Cluster B (dramatic, emotional, or erratic)
145Cluster C (anxious or fearful)
145Dependent personality disorder - 301.6
145Histrionic personality disorder - 301.50
145Narcissistic personality disorder - 301.81
145NOS
145Obsessive-compulsive personality disorder - 301.4
146Paranoid personality disorder - 301.0
146Personality disorder not otherwise specified - 301.9
146Schizoid personality disorder - 301.20
146Schizotypal personality disorder - 301.20
146Bi-polar
18Autistic Spectrum (ASD)
121Aspergers
121Severe Autism
147Childhood Disintegrative Disorder - 299.10
147Pervasive Developmental Disorder NOS - 299.80
147Rett's Disorder - 299.80
19COS Childhood-Onset Schizophrenia
127COS Childhood-Onset Schizophrenia
149Brief psychotic disorder - 298.8
149Catatonic type - 295.2
149Delusional disorder - 297.1
149Disorganized type - 295.1
149Erotomanic subtype
149Grandiose subtype
149Jealous subtype
149Mixed type
149Paranoid type - 295.3
149Persecutory subtype
150Psychotic disorder due to... [indicate the general medical condition]
150Psychotic disorder NOS - 298.9
150Schizoaffective disorder - 295.7
150Schizophrenia
150Schizophreniform disorder - 295.4
150Shared psychotic disorder - 297.3
150Somatic subtype
150Undifferentiated type - 295.9
150With delusions - 293.81
150With hallucinations - 293.82
22Tic disorders
156Chronic motor or vocal tic disorder - 307.22
156Tic disorder NOS - 307.20
156Tourette’s Disorder - 307.23
156Transient tic disorder - 307.21
31SAD – Seasonal Affective Disorder
148SAD – Seasonal Affective Disorder
32PAPD Passive-Aggressive Personality Disorder
143PAPD Passive-Aggressive Personality Disorder
99CCS Clumsy Child Syndrome
125CCS Clumsy Child Syndrome
128Delayed Development
130DGS Developmental Gerstmann’s Syndrome
134FXS Fragile X Syndrome
136HS Hyperlexia Syndrome
140MSDD Multisystem Developmental Disorder
141Aggressive obsession
141Checking and rechecking
141Cleaning and Washing
141Contamination
141Counting
141Hoarding and saving
141Magical and superstitious thoughts
141Need to know and remember
141Ordering and arranging
141Repeating rituals
142Scrupulosity
142Sexual obsession
142Somatic
151SID Sensory Integration Disorder
152SLD Speech-Language Disorder
153SMS Smith-Magenis Syndrome
157WS Williams Syndrome
158XXYS XXY Syndrome
2Physical Health
9Anorexia and Bulimia
170Anorexia nervosa - 307.1
170Binge eating. Irresistible craving for food
170Bulimia nervosa - 307.51
170Disturbance in the way body weight or shape is experienced
170Intense fear of gaining weight or becoming fat
170Refusal to maintain body weight
170Rumination syndrome - 307.53
10Elimination disorders
171Encopresis
171Enuresis (not due to a general medical condition) - 307.6
11Feeding and eating disorders of infancy or early childhood
172Feeding disorder of infancy or early childhood - 307.59
172Pica - 307.52
16Motor skills disorders
173Developmental coordination disorder - 315.4
21Sleep disorders
176Breathing-related sleep disorder - 780.59
176Circadian rhythm sleep disorder - 307.45
176Dyssomnia NOS - 307.47
176Hypersomnia type - 780.54
176Insomnia type - 780.52
176Mixed type - 780.59
176Narcolepsy - 347
176Other sleep disorders (edited)
176Parasomnias
176Primary hypersomnia - 307.44
177Primary insomnia - 307.42
177Primary sleep disorders
177Sleep disorder due to... [indicate the general medical condition]
177Sleep terror disorder - 307.46
177Sleepwalking disorder - 307.46
37Physical Disabilities
174Birth defects
174From accident
175Headaches
175Painful medical procedures
175Recurrent abdominal pain
3Social/Family
2Adjustment disorders
179With depressed mood - 309.0
6Communication disorders
181Communication disorder NOS - 307.9
181Deafness
181Mutism
181Speech Difficulties
184SM Selective Mutism
7Depression and grief
182Diminished appetite
182Disturbed sleep
13Behaviour/Conduct Problems
180Severe destructiveness
180Severe disobedience
180Stealing
33Social Exclusion
185Social exclusion
36Drug Abuse
183Effects of witnessing drug abuse
183Harmful substance abuse
183Substance dependence
50Additional codes
178Acculturation problem - V62.4
178Malingering - V65.2
178Religious or spiritual problem- V62.89
4Abuse & Trauma
3Abuse
100Neglect
100Physical abuse of child - V61.21
100Sexual
100Posttraumatic stress disorder - 309.81
5Learning Difficulties
4Attention-deficit and disruptive behavior disorders
110Adolescent onset - 312.82
14LD Learning Disability
110Dysgraphia
110Dyspraxia
110Language disorders
110NLD Nonverbal Learning Disorder
110Disorder of written expression - 315.2
110Mathematics disorder - 315.1
34Under Performance
110Cultural
6Miscellaneous
50Additional codes
160Acute akathisia - 333.99
160Acute dystonia - 333.7
160Adverse effects of medication NOS - 995.2
160Age-related cognitive decline - 780.9
160Borderline intellectual functioning - V62.89
160Identity problem - 313.82
160Medication-induced
160Movement disorder
160Neglect of child - V61.21
160Noncompliance with treatment - V15.81
161Postural tremor - 333.1
161Psychological factors affecting medical condition - 316
161Relational problem related to a mental disorder or general medical condition
161Tardive dyskinesia - 333.82
161Selective mutism - 313.23
161 Stereotypic movement disorder - 307.3

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