WHAT IS THE DSM? WHAT IS THE DSM? 2013 SRAGA HAUSER, LLC 1 DIAGNOSING ELIGIBILITY DISPUTES: POTENTIAL IMPLICATIONS OF THE DSM-5

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1 DIAGNOSING ELIGIBILITY DISPUTES: POTENTIAL IMPLICATIONS OF THE DSM-5 IAASE Fall Conference September 26, 2013 COURTNEY N. STILLMAN SRAGA HAUSER, LLC WHAT IS THE DSM? WHAT IS THE DSM? Diagnostic and Statistical Manual of Mental Disorders Published by the American Psychiatric Association (APA) First edition in 1952 with periodic revisions Used by health care professionals around the world Generates $ 5 million in revenues for APA annually 2013 SRAGA HAUSER, LLC 1

2 WHAT IS THE DSM? Guides diagnosis and research (but not treatment or medication) Provides common language and criteria for mental disorders Impacts insurance coverage and eligibility Informs public health law and policy, education and forensic science WHAT IS THE DSM-5? Organized over the lifespan starting with conditions manifested in childhood Multi axis changed such that former Axis I, II and III are combined into diagnostic label with separate notifications for psychosocial and contextual factors (Axis IV) and disability (Axis V) Alignment with World Health Organization s International Classification of Diseases (ICD-II) WHAT IS THE DSM-5? Intense Criticism of the DSM-5: Phony diagnostic categories... Developed to help psychiatrists to help them make money. -- William Glasser, in The National Psychologist (Susan Bowman, 2006) 2013 SRAGA HAUSER, LLC 2

3 WHAT IS THE DSM-5? Intense Criticism of the DSM-5: The relentless march to lexicalize normalcy out of existence Allen Frances, Duke University Professor and Former Chairman of the DSM-IV Task Force in Huff Post (March 28, 2012) WHAT IS THE DSM-5? Intense Criticism of the DSM-5: The Autism Society of America feels there needs to be an in-depth assessment of the impact the DSM-5 would have on individuals receiving services today and in the future. Of particular concern are those who could not afford lifechanging therapies and other services if not for an autism diagnosis (1/20/12) ILLINOIS RESPONSE 215 ILCS 5/356z.14 Autism Spectrum Disorders: If an individual has been diagnosed as having an autism spectrum disorder, meeting the diagnostic criteria in place at the time of diagnosis, and treatment is determined medically necessary, then that individual shall remain eligible for insurance coverage under this section even if subsequent changes to the diagnostic criteria are adopted by the American Psychiatric Association. (effective 1/1/13) 2013 SRAGA HAUSER, LLC 3

4 ILLINOIS RESPONSE Illinois House Resolution 1079: Created a Task Force on Mental Health Diagnosis within Illinois Law to thoroughly survey the Illinois Statutes and Administrative Code to determine where laws and government functions depend on mental health, illnesses or disorders and produce a report, not later than December 31, 2014, with recommended statutory changes to recognize best practices and highlight areas of major disagreement within the mental health profession. ILLINOIS RESPONSE Illinois House Resolution 1079: The Task Force was created due to the intense criticism of the proposed changes in DSM 5, including the potential overdiagnosis of new or rare disorders, possible misdiagnosis of autism, and the potential of over medication. Although the DSM cautions against using the manual for legal purposes, Illinois courts and agencies use psychiatric diagnoses for establishing competence, criminal responsibility, and disability. Vast state resources and tax monies are also expended based upon the DSM. WHY IS THE DSM RELEVANT TO SPECIAL EDUCATION? 2013 SRAGA HAUSER, LLC 4

5 RELEVANCE OF DSM-5 Reviewing private evaluations, provided by parents, based on DSM diagnoses To understand the difference between educational definitions of disability and DSM criteria Eligibility Determinations for IEPs and Section 504 Plans Provision of FAPE CHANGES TO SPECIFIC DIAGNOSES ATTENTION DEFICIT/ HYPERACTIVITY DISORDER 2013 SRAGA HAUSER, LLC 5

6 ADHD: CHANGES IN DSM-5 Symptoms must be present before age 12 (in DSM-IV, symptoms causing impairment must have been present before age 7) Confirmation of substantial symptoms across settings typically cannot be done accurately without consulting informants who have seen the individual in those settings ; several symptoms required in each environment ADHD: CHANGES IN DSM-5 Examples added to apply across the lifespan Comorbid diagnosis with autism is now allowed Placed in neurodevelopmental disorders section of DSM ADHD: POTENTIAL IMPLICATIONS Increase in ADHD diagnosis due to expanded age range Middle schools may have more requests for IEPs and Section 504 Plans related to ADHD Decrease in number of students privately diagnosed based solely on parent report and office visit Parents have increased expectations for special education due to school involvement in private evaluator s data collection 2013 SRAGA HAUSER, LLC 6

7 AUTISM AUTISM: CHANGES IN DSM-5 There are no longer separate diagnoses of autism, Asperger s Disorder and PDD-NOS Now Autism Spectrum Disorder DSM-IV criteria of impairments in social interaction and communication are combined into one criteria of persistent deficits in social communication and social interaction. DSM-5 also requires restricted repetitive behaviors, interests or activities AUTISM: CRITERIA IN DSM-5 Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history: Deficits in social-emotional reciprocity Deficits in nonverbal communicative behaviors used for social interaction Deficits in developing, maintaining and understanding relationships 2013 SRAGA HAUSER, LLC 7

8 AUTISM: CRITERIA IN DSM-5 2 of 4 characteristics of restricted, repetitive patterns of behavior, interests or activities: Stereotyped or repetitive motor movements, use of objects, or speech Insistence on sameness, inflexible adherence to routines or ritualized patterns of verbal or nonverbal behavior Highly restricted, fixated interests that are abnormal in intensity or focus Hyper or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment AUTISM: CRITERIA IN DSM-5 Delay in language development is no longer required AUTISM: CHANGES IN DSM-5 Three levels of severity for autism spectrum disorder Level 3 - Requiring very substantial support - severe deficits in verbal and nonverbal social communication, extreme difficulty coping with change, marked repetitive behaviors, great distress in changing focus or action 2013 SRAGA HAUSER, LLC 8

9 AUTISM: CHANGES IN DSM-5 Three levels of severity for autism spectrum disorder Level 2 - Requiring substantial support - marked deficits in verbal and nonverbal social communication, difficulty coping with change, frequent repetitive behaviors, distress in changing focus or action AUTISM: CHANGES IN DSM-5 Three levels of severity for autism spectrum disorder Level 1 - requiring support - noticeable deficits in social communication, difficulty switching between activities, organization and planning problems hamper independence ILLINOIS LEGISLATION 105 ILCS 5/ (b) Identification, Evaluation and Placement: In the development of an IEP for a student with a disability on the autism spectrum (which includes autistic disorder, Asperger s Disorder, PDD-NOS, childhood disintegrative disorder, and Rett Syndrome, as defined in the DSM-IV (2000), the IEP team shall consider all of the following factors: Verbal and nonverbal communication needs Need to develop social interaction skills 2013 SRAGA HAUSER, LLC 9

10 ILLINOIS LEGISLATION 105 ILCS 5/ (b) Identification, Evaluation and Placement (cont.): Needs from unusual sensory experiences Needs from resistance to change in environment or routine Needs from repetitive or stereotyped activities Need for positive behavioral interventions, strategies Other needs impacting progress in general curriculum IDEA DEFINITION OF AUTISM: A developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, 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. NEW: SOCIAL (PRAGMATIC) COMMUNICATION DISORDER Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following: Deficits in using communication for social purposes Impairment in the ability to change communication to match context or the needs of listener Difficulties following rules for conversation and storytelling Difficulties understanding what is not explicitly stated Symptoms must be present in early childhood Differential diagnosis from autism spectrum disorder, social anxiety disorder 2013 SRAGA HAUSER, LLC 10

11 AUTISM: POTENTIAL IMPLICATIONS New York Times 1/19/12 citing study by Mattila et al, 2011: Proposed changes in the definition of autism will sharply reduce the skyrocketing rate at which the disorder is diagnosed Only 45% of children and adults with higher functioning autism will qualify under DSM-5 Access to services may be threatened for people with autism who are high functioning AUTISM: POTENTIAL IMPLICATIONS Autism Speaks 10/2/12: A large study, led by Catherine Lord, Ph.D. of Weill Cornell Medical College, concludes that the new DSM-5 autism criteria will identify 90 percent of those identified under DSM-IV as having some form of autism. AUTISM: POTENTIAL IMPLICATIONS DSM-5 Note: Individuals with a well-established DSM-IV diagnosis of Autistic Disorder, Asperger s disorder or PDD-NOS should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder SRAGA HAUSER, LLC 11

12 AUTISM: POTENTIAL IMPLICATIONS What eligibility for social (pragmatic) language disorder speech language disorder? Autism? How to provide services to students with social (pragmatic) language disorder? Section 504 or IDEA? Parent confusion SPECIFIC LEARNING DISABILITY SLD: CHANGES IN DSM-5 There are no longer separate diagnoses of reading disorder, mathematics disorder, disorder of written expression or LD NOS. Terms dyslexia and dyscalculia not used, but acknowledged as alternative terms SRAGA HAUSER, LLC 12

13 SLD: CHANGES IN DSM-5 Diagnostic criteria of difficulties learning and using academic skills, as indicated by the presence of at least one symptom that persisted for at least 6 months, despite the provision of interventions that target those difficulties. SLD: CHANGES IN DSM-5 Symptoms of specific learning disorder Inaccurate or slow and effortful word reading Difficulty understanding what is read Difficulties with spelling Difficulties with written expression Difficulties mastering number sense, number facts or calculation Difficulties with mathematical reasoning SLD: CHANGES IN DSM-5 Affected academic skills are substantially and quantifiably below those expected for person s age and cause significant interference with academic or occupational performance or daily living skills as confirmed by standardized achievement measures and clinical assessment. Learning difficulties begin during school age years SRAGA HAUSER, LLC 13

14 SLD: CHANGES IN DSM-5 Exclusionary factors: Intellectual Disability or Global Developmental Delay Uncorrected visual/auditory acuity Other mental/neurological disorders Psychosocial adversity Lack of educational opportunity SLD: POTENTIAL IMPLICATIONS Movement away from IQ-achievement gap in private, as well as school evaluations Decrease in LD diagnosis SLD: POTENTIAL IMPLICATIONS DSM-5 SLD IDEA 2004 SLD Reading Reading word reading accuracy basic reading skills reading rate or fluency reading fluency reading comprehension reading comprehension 2013 SRAGA HAUSER, LLC 14

15 SLD: POTENTIAL IMPLICATIONS DSM-5 SLD Written Expression Spelling accuracy Grammar and punctuation accuracy Clarity or organization of written expression IDEA 2004 SLD Written Expression SLD: POTENTIAL IMPLICATIONS DSM-5 SLD IDEA 2004 SLD Mathematics Mathematics Number sense Mathematics calculation Memorization of Mathematics reasoning arithmetic facts Accurate or fluent calculation Accurate math reasoning Oral Expression Listening Comprehension INTELLECTUAL DISABILITY 2013 SRAGA HAUSER, LLC 15

16 INTELLECTUAL DISABILITY: CHANGES IN DSM-5 No criteria changes Replaces mental retardation with intellectual disability Diagnosis based less on IQ score and more on clinical assessment of functional abilities Severity based on adaptive functioning rather than IQ score SPEECH LANGUAGE IMPAIRMENT COMMUNICATION: DSM-5 Language disorder (combines expressive disorder and mixed receptive-expressive language disorder) Speech sound disorder (new name for phonological disorder) Child onset fluency disorder (new name for stuttering) Social (pragmatic) communication disorder 2013 SRAGA HAUSER, LLC 16

17 LANGUAGE: POTENTIAL IMPLICATIONS Some children diagnosed with PDD-NOS under DSM-IV may meet DSM-5 criteria for social (pragmative) communication disorder Change in IDEA eligibility from autism to speech-language impairment? DEPRESSION DEPRESSION: CHANGES IN DSM-5 Added depressive disorders, including Disruptive Mood Dysregulation Disorder and Premenstrual Disphoric Disorder Removal of Bereavement Exclusion 2013 SRAGA HAUSER, LLC 17

18 DEPRESSION: POTENTIAL IMPLICATIONS More students diagnosed with depression disorders? Criticism that grief may become a mental illness. DISRUPTIVE, IMPULSE- CONTROL AND CONDUCT DISORDERS INTERMITTENT EXPLOSIVE DISORDER In addition to physical aggression, now verbal aggression and nondestructive/non-injurious physical aggression meet outburst criteria Child must be at least 6 years old Outburst must cause marked distress in the child or impairment in occupational or interpersonal functioning or have financial or legal consequences 3 months of verbal aggression or non-injurious physical aggression or 3 physical assaults, property destruction in 12 months 2013 SRAGA HAUSER, LLC 18

19 BEHAVIOR: CHANGES IN DSM-5 Refinements in Oppositional Defiant Disorder No change in conduct disorder No social maladjustment mental health diagnosis ADHD is frequently comorbid with behavior disorders, but was moved to neurodevelopmental disorders NEW DIAGNOSES NEW: DISRUPTIVE MOOD DYSREGULATION DISORDER A. Severe, recurrent temper outbursts manifested verbally and/or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation B. The temper outbursts are inconsistent with developmental level C. Temper outbursts occur, on average, 3 or more times per week D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g. parents, teachers, peers) 2013 SRAGA HAUSER, LLC 19

20 NEW: DISRUPTIVE MOOD DYSREGULATION DISORDER Symptoms have been present for 12 or more months without a period of longer than 3 months without all symptoms Criteria A and D are present in at least 2 or 3 settings (home, school, with peers) and are severe in at least one of these settings Diagnosis cannot be made before age 6 or after age 18 and age of onset is before 10 There has not been a period longer than a day when the full symptom criteria (other than duration) for a manic or hypomanic episode have been met NEW: DISRUPTIVE MOOD DYSREGULATION DISORDER Differentiate from bipolar symptoms to address concerns about potential over-diagnosis and overtreatment of bipolar disorder in children Core feature is chronic, severe, persistent irritability that is demonstrated by tantrums and persistently angry mood Emotional Disability NEW: PREMENSTRUAL DYSPHORIC DISORDER In the majority of menstrual cycles, must have at least 5 symptoms overall in the week before onset, start to improve within a few days after menses onset and become minimal or absent in week post menses. Causes significant distress or interference with school work, activities, relationships 2013 SRAGA HAUSER, LLC 20

21 NEW: PREMENSTRUAL DYSPHORIC DISORDER One or more of the following: Marked affective lability Marked irritability, anger or increased personal conflict Marked depressed mood Marked anxiety or tension NEW: PREMENSTRUAL DYSPHORIC DISORDER One or more of the following: Decreased interest in usual activities Subjective difficulty concentrating Lethargy Marked change in appetite, overeating, specific food cravings Hypersomnia or insomnia Overwhelmed Physical symptoms NEW: SOMATIC SYMPTOM DISORDER One or more somatic symptoms are distressing and significantly disrupt daily life Excessive thoughts, feelings or behaviors related to the somatic symptoms as manifested by at least one of these: Persistent and disproportionate thoughts about seriousness of symptoms; Persistently high level of anxiety about symptoms or health Excessive time devoted to symptoms 2013 SRAGA HAUSER, LLC 21

22 NEW: SOMATIC SYMPTOM DISORDER Symptoms last more than 6 months In children, most common symptoms are recurrent abdominal pain, headache, fatigue, nausea Young children may have somatic complaints, but rarely worry about illness until adolescence SOMATIC SYMPTOM DISORDER IMPLICATIONS Medical illness, such as cancer, fibromyalgia, chronic fatigue syndrome, may lead to a mental health diagnosis NEW: EXCORIATION (SKIN PICKING) DISORDER Recurrent skin picking resulting in lesions Repeated attempts to decrease or stop skin picking Causes clinically significant distress or impairment in social, occupational or other important functioning Not attributable to another medical condition or mental disorder 2013 SRAGA HAUSER, LLC 22

23 NEW: EXCORIATION (SKIN PICKING) DISORDER Spend significant amounts of time on picking behavior, usually at least 1 hour per day picking, thinking about it or resisting urges Usually face, hands or arms and may be healthy skin, scabs, pimples Usually does not occur in the presence of others, except immediate family members NEW: EXCORIATION (SKIN PICKING) DISORDER Students may miss school, have difficulty managing school responsibilities and difficulty studying An obsessive-compulsive disorder Similar to hair pulling disorder Hoarding Disorder OTHER: Binge Eating Disorder Gender Dysphoria PTSD 2013 SRAGA HAUSER, LLC 23

24 IDEA DEFINITION OF EMOTIONAL DISTURBANCE One or more of these characteristics over a long period of time and to a marked degree that adversely affect a child s educational performance: Inability to learn that cannot be explained by intellectual, sensory or health factors Inability to build or maintain satisfactory interpersonal relationships with peers and teachers Inappropriate types of behavior or feelings under normal circumstances IDEA DEFINITION OF EMOTIONAL DISTURBANCE General pervasive mood of unhappiness or depression Tendency to develop physical symptoms or fears associated with personal or school problems IDEA DEFINITION OF EMOTIONAL DISTURBANCE Haubold v. Great Valley School Dist., 113 LRP (E.D. Pa. 2013): Student who engaged in multiple, violent tantrums at home, and exhibited, to a marked degree, inappropriate behaviors at home was not eligible for special education as ED. At school she exercised self-control and neither her grades nor her assessments showed negative impact at school. Her behavior did not adversely affect her education SRAGA HAUSER, LLC 24

25 THE DSM IN IDEA CASE LAW THE DSM IN IDEA CASE LAW: Marshall Joint School Dist. No. 2 v. C.D., 616 F.3d 632 (7 th Cir. 2010): A physician s diagnosis and input on a child s medical condition is important and bears on the team s informed decision on a student s needs but a physician cannot simply prescribe special education; rather IDEA dictates a full review by an IEP team of parents, regular education teachers, special education teachers and an LEA representative THE DSM IN IDEA CASE LAW: K.S. v. Fremont Unified School Dist., 679 F.Supp. 2d 1046 (N.D. Ca. 2009): In methodology dispute in which parent alleged student could have made more progress with ABA and that district could not diagnose a cognitive disability without an IQ score, the court stated that the question was not whether student could properly be diagnosed with a cognitive disability under the DSM, but whether the district s special education services appropriately addressed her needs, including any cognitive impairment she may have displayed SRAGA HAUSER, LLC 25

26 THE DSM IN IDEA CASE LAW: J.S. v. Shoreline School District, 220 F.Supp. 2d 1175 (W.D. Wa. 2002): The Court cited the DSM-IV description of ADHD, as possibly manifesting as oppositionality, along with evidence of the student s classroom behavior, and the testimony of the student s psychiatrist to reject the parent s child find claim that the district had failed to separately evaluate the student for ODD. THE DSM IN IDEA CASE LAW: W.G. v. New York City Dep t. of Ed., 801 F.Supp. 2d 142 (S.D.N.Y. 2011): Even if a student has a DSM diagnosis, to be eligible as ED, the diagnosis must adversely impact educational performance Even with a DSM diagnosis, if student s problem is social maladjustment, student is not eligible for special education THE DSM IN IDEA CASE LAW: T.L. v. New York City Dep t. of Ed., 2013 WL (E.D.N.Y. 2013): The court cited extensive information from the DSM-IV describing the seriousness of PICA and then remanded to the hearing officer to determine if the proposed classroom environment would meet the student s needs resulting from PICA SRAGA HAUSER, LLC 26

27 THE DSM IN IDEA CASE LAW: Lauren G. v. West Chester Area Sch. Dist., 906 F.Supp. 2d 375 (E.D. Pa. 2012): The court used the DSM description of Dysthymic Disorder, as a chronic state of depression for a duration of at least two years within which no more than two months are free of mood symptoms, as a factor in determining that the school violated child find. SPECIAL EDUCATION ISSUES SPECIAL EDUCATION ISSUES DSM diagnosis does not equal IDEA/504 eligibility 2013 SRAGA HAUSER, LLC 27

28 SPECIAL EDUCATION ISSUES Additional DSM-5 diagnoses and more requests for eligibility Districts can request their own evaluation Differentiate between DSM diagnosis and special education eligibility SPECIAL EDUCATION ISSUES IDEA Eligibility Student has one or more of 14 IDEA recognized disabilities Disability results in adverse affect on educational performance Student needs special education SPECIAL EDUCATION ISSUES Section 504 Eligibility Student has mental or physical impairment as defined under Section 504 Impairment results in substantial limitation on one or more major life activities (including, but not limited to learning) Need for special education or related aids and services 2013 SRAGA HAUSER, LLC 28

29 SPECIAL EDUCATION ISSUES Mitigating measures Quest for testing accommodations Broad scope of Section 504 impairment and major life activities Response to Intervention Label disputes Manifestation determinations 2013 SRAGA HAUSER, LLC 29