Proposed Taxonomy  

Proposed Taxonomy - Conditions of Children Presenting for Play Therapy  

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/PTUK Research Advisory Board. It is now open to comments from PTI/PTUK/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.  

  1. To improve our analyses of clinical outcomes
  2. 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  

Improving PTI/PTUK's Analytical Capabilities

PTI/PTUK 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 commonalities, it becomes possible to learn the nature of those commonalities. In the ‘Play for Life’ article we stated that the fundamental point about commonalities through standardisation is near and dear to our hearts. Hence the central position and importance of a standard taxonomy. 

How the Taxonomy has been developed

In developing the taxonomy three main criteria have been used:  

  1. 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.  
  2. 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.  
  3. Easy to use when writing up notes, for recording keeping and data entry.  


Sources

Three main sources have been used:  

  1. A listing based upon the free text descriptions of conditions given with referral data for clients whose SDQ data is included in the PTUK 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.  
  2. 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 professionals’ view.  
  3. 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 reduplicate 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.  

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.                               

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 

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 behaviour disorders
Learning Difficulties
113
ADHD - Difficulties in sustaining attention
Attention-deficit and disruptive behaviour disorders
Learning Difficulties
114
ADHD - Disruptive Behaviour Disorder
Attention-deficit and disruptive behaviour disorders
Learning Difficulties
116
ADHD - Predominantly hyperactive-impulsive subtype - 314.01
Attention-deficit and disruptive behaviour disorders
Learning Difficulties
117
ADHD - Predominantly inattentive subtype - 314.00
Attention-deficit and disruptive behaviour 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 behaviour
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 behaviour 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 behaviour - 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 behaviour 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 behaviour 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 behaviour 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

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
1st Level Taxonomy Codes
2nd Level Taxonomy Codes
3rd Level Taxonomy Codes
1
Aggression – including bullying
3
44
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/PTUK will be responsible for entering the data into the clinical database.                      

Using the data                  

PTI/PTUK 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.                              

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 studying behaviour change (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.                         

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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