Proposed Taxonomy

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.

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

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.

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.

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.

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.

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

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.

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.

(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