I am not even remotely a mental health professional. I majored in English Literature and went on to become an attorney. However, in my special education law practice in Connecticut, I brush up against psychologists and psychiatrists every day, and rely on them to let me know what, if any, disabilities my clients have, and how they need to be addressed. Therefore, I need to have at least a working knowledge of the DSM-IV, which is the current version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
One of the most complicated concepts to explain to my clients is that there is a real difference between the medical model and the educational model of intervention.
Very often, parents of children with disabilities will say to me: “I don’t understand why the school district won’t give her an IEP, she has been diagnosed with (insert diagnosis).” It seems like it should be simple: you get a diagnosis from a doctor and you then get a special education plan that addresses the diagnosis. It doesn’t work that way. Having a diagnosed disability under the DSM does not necessarily translate into eligibility under the IDEA.
Medical “diagnosis” is different from special education “eligibility.”
The IDEA 2004 includes ten different eligibility categories: “mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance (referred to in this title as ’emotional disturbance’), orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities.” 20 USC 1401 (3)(A)(i) Many states have additional eligibility categories under their own special education laws. Having one of these identified disabilities does not automatically entitle a student to an IEP; it must be demonstrated that a student falls into one of these categories AND that they require special education and related services.
Many children and adolescents meet criteria under the DSM-IV for a particular diagnosis, but this does not necessarily mean that they are entitled to, or require, an IEP.
Most of my clients are students who have already been found eligible for special education and related services under the IDEA. However, many are children who have been diagnosed with a disability, but their school district does not believe that their disability justifies identification as a special education student. We routinely try to resolve these disputes by bringing in mutually agreed upon outside psychologists or psychiatrists to inform us as to whether or not a student’s diagnosis is accurate, and if so, whether it rises to the level of requiring special education services.
The DSM-V will be the next edition of the manual which mental health professionals rely upon to issue diagnoses.
Just as when the DSM-IV replaced the DSM-III, I fully expected that there would be some “fall out” when the new edition came out. Nuance in the descriptions old disorders, definitions of new disorders, re-categorization of both, or new ways of assessing them will become fodder for analysis by attorneys like me, and my opposing counsel who represent schools. We will clamor again, as we have before, to bring in expert witnesses to tell us what this new subsection means, or doesn’t, and why there is an “and” instead of an “or” listed at the end of a description of symptoms. Sounds like fun, right?
It is all part of the usual ebb and flow of adjusting to a new DSM when you practice special education law.
I was, therefore, surprised, and quite concerned, to read this recent article in the Psychiatric Times, which raises significant questions about the methodology which is going into the generation of the DSM-V, including an overall lack of transparency in the process. The author talks of a “paradigm shift” in the DSM-V which, according to him, is not supported by the scientific evidence. Descriptions of new categories of “subthreshold” disorders in the DSM-V as “reckless” with the potential result of the “medicalization of normality” abound, and one is left with the strong impression that the new DSM-V is headed for disaster as it adds everything short of “road rage” to the new Manual. The article contemplates the effects on not just doctors and patients, but virtually everyone else, from the pharamaceutical industry to insurance companies.
He should have added “special education” to the list.
Now granted, the article is just one man’s opinion; but it just so happens to be the opinion of the man who headed up the last DSM Task Force. So I am guessing he has some idea what he’s talking about. And while I would be willing to bet that my opposing counsel would think that I would be “all for” diagnosing more students, thereby justifying more special education eligibility determinations, I am actually quite worried about this purported “softening” of DSM criteria.
If the DSM-V is issued amid controversy and skepticism, a backlash against special education eligibility is inevitable.
I can just see it now. I’ll walk in to an IEP meeting with an evaluation from a psychiatrist of unquestionable prestige and experience. The report will contain a DSM-V diagnosis, perhaps a diagnosis which has a changed word or two in the category. And instead of focusing on what the child needs, we’re going to be treated with a host of excuses as to why the diagnosis doesn’t really mean what is says, because the DSM-V has all sorts of critics, etc., etc. etc.
And school districts will have yet another delay tactic in their already vast arsenal of delay tactics.
I urge the American Psychiatric Association to consider the impact that the DSM has on children and adolescents in our public schools. If the criticisms outlined in the article excerpted above are legitimate, then fix the problems. If they are not, then make it clear why not. Otherwise, you are guaranteeing controversy and dissent. If nothing else, imagine how your constituents will feel when cross-examined at their first post-DSM-V special education Due Process Hearing.
“First, do no harm.”