Download Handout 1 - Hempstead & Associates

IDEA Eligibilities and
DSM-IV-TR Diagnoses
Separate but Equal?
Ellen M. Frye, Ed.D.
TEDA Conference
April 8, 2011
Houston, do we have a problem?
Current issues impacting
the 2 nosologies:
Differences between diagnosis
And disability determination
Who determines category?
Purpose of category?
What is the outcome?
Avenues to intervention?
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Types of mental health professionals
(Kline & Silver, 2004)
and school equivalents
Psychiatrist
•School:
Psychologist
•Psychologist
Social worker
•Social worker
Psychiatric nurse
•Nurses
Mental health counselor
Instrumentation- Clinical interview to
examine all systems to include family
history to examine genetic links, familial
patterns… Implications for educational
model???
•Counselors
•Diagnosticians
•IQ tests, achievement,
CBM. Social history,
observations, behaviors,
Inherent problems to the 2 systems of
classification:
What is the impact on:
Parents
Confusion, mixed messages
Child/student
Who is going to help me, do I understand what I need?
Service delivery
Medication, therapy, education accommodations?
Service provider
Who will deliver service?
Is it an educational implication or clinical?
Coordination of services education vs. clinical?
Diagnostic systemsSchool versus Mental Health
• Definitions mandated by IDEA
• Service delivery mandated by
IDEA
• Data supplied by teacher,
parents, psychometric
instruments
• Category of disability
contributes to determination
of appropriate services and
placement into special
education class.
• Definition based upon
psychiatric model – DSM-IV
• Service delivery transferred to
schools
• Data based upon clinical
interview and other possible
informants- parent, student
and possibly teacher.
• Psychometric instruments not
mandatory
• Disability definition not
educationally based but
services dependent upon
school
• Allows for 3rd-party financial
reimbursement from
insurance companies & other
sources
History of DSM-IV-TR
• DSM-I published in 1952 by APA
– Correlated diagnoses with International
Classification of Diseases (ICD) published by
World Health Organization (WHO)
– Based on military diagnoses of WWII veterans
– Did not include diagnoses for children
• DSM-II (1968)
– Coordinated with 8th revision of ICD
– Included ‘Behavior Disorders of Childhood &
Adolescence’
History of DSM-IV-TR
• DSM-III (1980) & DSM-III-R (1987)
– Previous DSMs were short pamphlets or small
notebooks
– DSM-III included first multi-axial system
– Expanded systematic description of categories
– Explicit diagnostic criteria, including lists of
symptoms
– Used field trials for proposed diagnostic
revisions
History of DSM-IV-TR
• DSM-IV (1994)
– Great efforts made to base changes on empirical
evidence rather than psychiatric opinion
– Revisions based on literature reviews, reanalyses of existing data sets, and field trials
History of DSM-IV-TR
• DSM-IV-TR (2000)
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Corrected any factual errors identified in DSM-IV
Reviewed DSM-IV text to make sure it was up-to-date
Made changes to reflect new information
Made improvements to enhance ‘educational value’ of
DSM-IV (not necessarily for use in public schools)
– Updated ICD-9 codes that had changed since DSM-IV
1996 coding update
– All changes proposed had to be supported by empirical
data
History of IDEA eligibilities
• PL 94-142—Education of the Handicapped
Act (EHA) signed by President Ford in 1975
– Defined fewer eligibilities than we have now
• What are now ‘impairments’ were ‘handicaps’
• Autism originally included under ED
• TBI added later
• Re-authorized several times, most recently
in 2004 as Individuals with Disabilities
Education & Improvement Act (IDEIA)
IDEA Eligibilities with DSM-IV-TR
diagnoses
• Specific Learning Disability
• Mental Retardation
• Autism
• Emotional Disturbance
• Other Health Impairment
• Speech Impairment
• Honorable mention-Developmental Coordination d/o
Mental Retardation
• IDEA—300.8(c)(6)
Mental retardation means significantly
subaverage general intellectual
functioning, existing concurrently with
deficits in adaptive behavior and
manifested during the developmental
period, that adversely affects a child’s
educational performance.
Mental Retardation
• DSM-IV-TR
Significantly subaverage intellectual functioning: an IQ of 70
or below on an individually administered IQ test
Concurrent deficits or impairments in present adaptive
functioning in at least 2 of following areas: communication,
self-care, home-living, social/interpersonal skills, use of
community resources, self-direction, functional academic
skills, work, leisure, health, & safety
Onset before age 18 years
No changes anticipated for DSM-V
Speech Impairment
• IDEA—300.8(c)(11)
–Speech or language impairment
means a communication disorder,
such as stuttering, impaired
articulation, a language impairment,
or a voice impairment, that adversely
affects a child’s educational
performance.
Speech Impairment
• DSM-IV-TR—Communication Disorder
– Expressive Language Disorder
– Mixed Receptive-Expressive Language Disorder
– Phonological Disorder (formerly Developmental
Articulation Disorder)
– Stuttering
– Communication Disorder Not Otherwise
Specified
– No change anticipated for DSM-V
Developmental Coordination d/o
• Marked impairment in developmental motor coordination
• Not due to medical condition (eg. CP, md) and not due to
pdd.
• Delays in achieving milestones
– Walking crawling, sitting
– Puzzles, building models, etc.
– No anticipated change for DSM-V
• IDEA equivalent
– Orthopedically impaired
– OHI
– SLD- handwriting/fine motor (OT?)
Specific Learning Disability
• IDEA—300.8 (c)(10)(i)
– General. Specific learning disability means a
disorder in one or more of the basic
psychological processes involved in
understanding or in using language, spoken or
written, that may manifest itself in the imperfect
ability to listen, think, speak, read, write, spell,
or to do mathematical calculations, including
conditions such as perceptual disabilities, brain
injury, minimal brain dysfunction, dyslexia, and
developmental aphasia.
Specific Learning Disability--IDEA
• 300.309.(a)The group described in § 300.306 may
determine that a child has a specific learning disability, as
defined in § 300.8(c)(10), if —
(1) The child does not achieve adequately for the child’s
age or to meet State-approved grade-level standards in one
or more of the following areas, when provided with learning
experiences and instruction appropriate for the child ’ s age
or State-approved grade-level standards:
(i) Oral expression.
(ii) Listening comprehension.
(iii) Written expression.
(iv) Basic reading skill.
(v) Reading fluency skills.
(vi) Reading comprehension.
(vii) Mathematics calculation.
(viii) Mathematics problem solving.
Specific Learning Disability--IDEA
• (a) The group described in § 300.306 may
determine that a child has a specific learning
disability, as defined in § 300.8(c)(10), if —
...
(2)
(i) The child does not make sufficient progress
to meet age or State approved grade-level
standards in one or more of the areas identified in
paragraph (a)(1) of this section when using a
process based on the child’s response to scientific,
research-based intervention; or
Specific Learning Disability-IDEA
• (a) The group described in § 300.306 may determine that a
child has a specific learning disability, as defined in §
300.8(c)(10), if —
...
(2)
...
(ii) The child exhibits a pattern of strengths and
weaknesses in performance, achievement, or both, relative
to age, State-approved grade level standards, or intellectual
development, that is determined by the group to be
relevant to the identification of a specific learning disability,
using appropriate assessments, consistent with §§ 300.304
and 300.305; and
Specific Learning Disability
• DSM-IV-TR—Learning Disorders
• Diagnosed when “the individual’s achievement on
individually administered, standardized tests in
reading, mathematics, or written expression is
substantially below that expected for age,
schooling, and level of intelligence”
• Learning problems significantly “interfere with
academic achievement or activities of daily living
that require reading, mathematical or writing skills”
• Variety of statistical approaches can be used to
determine if discrepancy is significant
• ‘substantially below’ usually defined as 2 standard
deviations…unless
Specific Learning Disability-continued
• “A smaller discrepancy between
achievement and IQ is sometimes used,
especially in cases where an individual’s
performance on an IQ test may have been
compromised by an associated disorder in
cognitive processing, a comorbid mental
disorder, or general medical condition, or the
individual’s ethnic or cultural background.”
(DSM-IV-TR, 2000, pg. 49)
Specific Learning Disability in DSM IV TR
• DSM-IV-TR gives criteria for
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Reading Disorder
Mathematics Disorder
Disorder of Written Expression
Learning Disorder Not Otherwise Specified
• DSM-V proposed changes
– No changes for Reading Disorder and Mathematics
Disorder
– Disorder of Written Expression and LD-NOS to be
“subsumed under other Diagnoses (no DSM-V criteria
proposed)”
Other Health Impairment
• IDEA 300.8(c)(9)
• Other health impairment means having limited strength,
vitality, or alertness, including a heightened alertness to
environmental stimuli, that results in limited alertness with
respect to the educational environment, that —
(i) Is due to chronic or acute health problems such as
asthma, attention deficit disorder or attention deficit
hyperactivity disorder, diabetes, epilepsy, a heart condition,
hemophilia, lead poisoning, leukemia, nephritis, rheumatic
fever, sickle cell anemia, and Tourette syndrome; and
(ii) Adversely affects a child’s educational
performance.
* OSEP to determine on a case by case basis.
Other Health Impairment
• DSM-IV-TR has no specific diagnoses for
other health impairment
• Diagnoses which have been used under OHI
umbrella include
– Attention Deficit/Hyperactivity Disorder
– Central Auditory Processing Disorder
– Several rare genetic disorders
– Seizure disorder
– AIDS (Grice, 2002)-not consistent nationwide
Autism
• IDEA—300.8 (c)(1)(i)
– Autism means a developmental disability
significantly affecting verbal and nonverbal
communication and social interaction, generally
evident before age three, that adversely affects
a child’s educational performance. Other
characteristics often associated with autism are
engagement in repetitive activities and
stereotyped movements, resistance to
environmental change or change in daily
routines, and unusual responses to sensory
experiences.
Autism
• IDEA—300.8 (c )(1)(ii-iii)
– (ii) Autism does not apply if a child’s educational
performance is adversely affected primarily
because the child has an emotional disturbance,
as defined in paragraph (c)(4) of this section.
– (iii) A child who manifests the characteristics of
autism after age three could be identified as
having autism if the criteria in paragraph
(c)(1)(i) of this section are satisfied
• Became separate eligibility with 1997 IDEA
amendments
Autism
• DSM-IV-TR
• Pervasive Developmental Disorder—characterized
by severe & pervasive impairment in several areas
of development: reciprocal social interaction skills,
communication skills, or the presence of
stereotyped behavior, interests, and activities
• Includes Autistic Disorder, Rett’s Disorder,
Childhood Disintegrative Disorder, and Pervasive
Developmental Disorder Not Otherwise Specified
Autistic Disorder
• A. Total of 6 or more items from (1), (2), & (3)
with at least 2 from (1) and 1 from (2) & (3)
• (1)qualitative impairment in social interaction, as
manifested by at least 2 of:
– Marked impairment in use of multiple nonverbal
behaviors such as eye-to-eye gaze, facial expression,
body postures, & gestures to regulate social interaction
– Failure to develop peer relationships appropriate to
developmental level
– Lack of spontaneous seeking to share enjoyment,
interests, or achievements with other people
– Lack of social or emotional reciprocity
Autistic Disorder
• (2)qualititative impairments in communication as
manifested by at least 2 of the following
– Delay in, or total lack of, the development of spoken
language
– In individuals with adequate speech, marked impairment
in the ability to initiate or sustain a conversation with
others
– Stereotyped & repetitive use of language or idiosyncratic
language
– Lack of varied, spontaneous make-believe play or social
imitative play appropriate to developmental level
Autistic Disorder
• (3)restricted repetitive & stereotyped patterns
of behavior, interests, and activities, as
manifested by at least 1 of the following
– Encompassing preoccupation with 1 or more
stereotyped & restricted patterns of interest that is
abnormal either in intensity or focus
– Apparently inflexible adherence to specific,
nonfunctional routines or rituals
– Stereotyped & repetitive motor mannerisms
– Persistent preoccupation with parts of objects
Autistic Disorder
• B. Delays or abnormal functioning in at
least 1 of the following areas, with onset
prior to age 3 years: (1) social interaction,
(2) language as used in social
communication, or (3) symbolic or
imaginative play
• C. The disturbance is not better accounted
for by Rett’s Disorder or Childhood
Disintegrative Disorder
Asperger’s Disorder
• Severe & sustained impairment in social
interaction
• Restricted repetitive patterns of behavior,
interests & activities
• Clinically significant impairment in social,
occupational, or other areas of function
• No delays in language acquisition
• No delay in cognitive development
• Criteria not met for other PDD or
schizophrenia
PDD-NOS
• Severe & pervasive impairment in
development of reciprocal social interaction
associated with impairment in either verbal
or nonverbal communication skills or with
presence of stereotyped behavior, interests,
and activities
• Criteria not met for specific PDD,
schizophrenia, schizotypal personality
disorder, or avoidant personality disorder
• Includes ‘atypical autism’
Proposed DSM-V Changes for PDD/Autism
• Rett’s Disorder—possible removal, no DSMV criteria proposed
• Autistic Disorder—no change from DSM-IV
• Childhood Disintegrative Disorder,
Asperger’s Disorder, PDD/NOS—to be
“subsumed under other diagnoses (no DSMV criteria proposed)”
Asperger’s Disorder? & PDD-NOS
• IDEA definition
**LD of honorable mention**
Nonverbal Learning Disorder (NVLD)
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A subtype of learning disability.
Includes 20% of learning disabled students
Differential diagnosis can be confusing.
Many children do not receive adequate
intervention.
Franz, 2000
Emotional Disturbance
• IDEA—300.8 (c)(4)(i)
• Emotional disturbance means a condition exhibiting one or
more of the following characteristics over a long period of
time and to a marked degree that adversely affects a
child ’s educational performance:
(A) An inability to learn that cannot be explained by
intellectual, sensory, or health factors.
(B) An inability to build or maintain satisfactory
interpersonal relationships with peers and teachers.
(C) Inappropriate types of behavior or feelings under
normal circumstances.
(D) A general pervasive mood of unhappiness or
depression.
(E) A tendency to develop physical symptoms or
fears associated with personal or school problems.
Emotional Disturbance
• IDEA 300.8 (c)(4)(ii)
• Emotional disturbance includes
schizophrenia. The term does not apply to
children who are socially maladjusted,
unless it is determined that they have an
emotional disturbance under paragraph
(c)(4)(i) of this section.
• Social maladjustment exclusion interpreted
as referring to oppositional defiant disorder
& conduct disorder
Emotional Disturbance
• No specific diagnosis of ‘emotional
disturbance’ in DSM-IV-TR
• School psychologists usually will provide a
DSM-IV diagnoses for students identified
with ED
• Diagnoses include depression, adjustment
disorders, anxiety disorders
No Proposed Changes for DSM-V
• Attention Deficit/Hyperactivity Disorder
• Attention Deficit/Hyperactivity DisorderNOS
• Oppositional Defiant Disorder
• Conduct Disorder
• Disruptive Behavior Disorder-NOS
Conduct disorder/
Oppositional Defiant Disorder
Def. DSM-IV-TR
Repetitive and persistent pattern of
behavior…basic rights of others or major age
appropriate societal norms or rules are violated to
include:
•Aggression to people and animals
•Destruction of property
•Deceitfulness or theft
•Serious violation of rules
Search for educational interventions
• Not referenced for IDEA services
• No specific reference for category but many
references to comorbidity with another sped.
Category…LD? ADHD? Bipolar?
• Anti-social personality d/o in making (Weiner,
2009)
• No sped for “bad kids?”
• What is definition of ED?????
• Does “exclusionary” practice impact dx?
Comparisons between IDEA & DSM IV
• DSM IV criteria are weakest & least
relevant in areas where school
psychology & IDEA are strongest
– Mental retardation
– Learning disabilities
• DSM IV strong in criteria for ADHD
which is not defined in IDEA
(McBurnett, 1996)
Are we doing it wrong or just
differently?
Problems with using DSM IV in schools
• Designed for different purposes
– IDEA determines need for educational services
– DSM IV determines eligibility for 3rd party
reimbursement for psychological services
• Confusion for parents, clinical psychologists,
& school psychologists
– especially with diagnoses of autism where, for
IDEA purposes, symptoms must affect
educational functioning (Dahle, 2003)
Problems with using DSM IV in schools
• DSM IV TR includes lengthy list of
psychiatric conditions, but short list of
academic conditions (Wodrich, Pfeiffer, &
Landau, 2008)
– Limited precision in defining academic problems
– Being diagnosed with a DSM IV TR learning
disorder gives no advantages over IDEA
eligibilities
Problems with using DSM IV in schools
• DSM IV includes a very limited list of school-based
symptoms in psychiatric disorders (Wodrich,
Pfeiffer, & Landau, 2008)
– Diagnoses from DSM IV TR are not based on
information from teachers, classroom observations, or
information from school records
– Appears that a child’s functioning in school is irrelevant
to diagnostic process
• DSM IV diagnoses do not lead to or suggest
treatment methods or educational programming
(McBurnett, 1996)
Problems with using DSM IV in schools
• DSM IV criteria & explanations say very little
about requirements to learn & retain basic
academic skills, complete work, & follow
teacher’s directions
– DSM IV mentions school functioning very rarely
• DSM IV does not include many cultural &
racial/ethnic influences in criteria (except
LD!)
Recommendations for DSM-V
• Clarify what is a ‘psychiatric disorder’ & what
is not; possibly delete diagnoses for
conditions that are more educational than
psychological
– Do speech/language disorders and learning
disabilities need to be included in DSM-V?
– Many medical conditions (such as epilepsy) have
never been included in any version of DSM
Recommendations for DSM-V
• Work with educational professionals &
organizations (such as AAMR & ACLD) to
clarify other diagnoses
– Is it possible to develop common criteria for
PDD/Autism, MR, LD, SI?
• Supplement section on disorders of infancy,
childhood & adolescence with guidelines to
inform psychologists on how to used schoolbased information (Wodrich, Pfeiffer, &
Landau, 2008)
Recommendations for DSM-V
• Increase list of academic conditions to
include disorders that cause school failure
(Wodrich, Pfeiffer, Landau, 2008)
• Create parallel diagnostic criteria for IDEA
eligibilities; acknowledge that eligibility
criteria may differ from state to state
• Consider school-based behavior in criteria
for appropriate psychiatric conditions
– could facilitate school-based mental health
services
In the meantime…
• Comprehensive review of
– All systems- home, school, clinical
– Available measurements to include psychological,
sociological, medical, academic…
– History of impairments and school dysfunction (where
applicable)
• Interdisciplinary collaboration
– School personnel to confer with clinical regarding dx.
and application to school setting.
• Conference call, parent report, written log and/or feedback.
• Share RTI type observations with clinician.
For further info contact:
[email protected]
[email protected]
.edu