Ellen M. Frye, Ed.D.
TEDA Conference
April 8, 2011

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?

Types of mental health professionals
(Kline & Silver, 2004) and school equivalents
• Psychiatrist
• Psychologist
• Social worker
• Psychiatric nurse
• Mental health counselor
• Instrumentation- Clinical interview to examine all systems to include family history to examine genetic links, familial patterns… Implications for educational model???
•School:
•Psychologist
•Social worker
•Nurses
•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?

• Definitions mandated by IDEA
• Definition based upon psychiatric model – DSM-IV
• Service delivery mandated by
IDEA
• Service delivery transferred to schools
• Data supplied by teacher, parents, psychometric instruments
• Category of disability contributes to determination of appropriate services and placement into special education class.
• 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 3 rd -party financial reimbursement from insurance companies & other sources

• 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 8 th revision of ICD
– Included ‘Behavior Disorders of Childhood &
Adolescence’

• 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

• 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

• DSM-IV-TR (2000)
– 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

• 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
• Honorable mention-Developmental Coordination d/o

• 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.

• 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

• 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.

• 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

• 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?)

• 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.

• 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.

• (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

• (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

• 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’ deviations…unless usually defined as 2 standard

• “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
– 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)”

• 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.

• 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

• 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.

• 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

• 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

• 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

• (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

• (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

• 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

• S evere & 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

• 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 DSM-
V criteria proposed
• Autistic Disorder—no change from DSM-IV
• Childhood Disintegrative Disorder,
Asperger’s Disorder, PDD/NOS—to be
“subsumed under other diagnoses (no DSM-
V criteria proposed)”

• IDEA definition

• 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

• 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.

• 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

• 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

• Attention Deficit/Hyperactivity Disorder
• Attention Deficit/Hyperactivity Disorder-
NOS
• 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

• 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 3 rd 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!)

• 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

• 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)

• 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

• 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: efrye@lubbockisd.org
ellen.frye@wayland.wbu
.edu