DIAGNOSING ELIGIBILITY DISPUTES: POTENTIAL IMPLICATIONS OF THE DSM-5 IAASE Fall Conference September 26, 2013 COURTNEY N. STILLMAN SRAGA HAUSER, LLC www.sragahauser.com 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 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 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 life- changing therapies and other services if not for an autism diagnosis.” -- www.autism-society.org (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 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 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 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 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 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 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 5/14-8.02(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 ILLINOIS LEGISLATION 105 ILCS 5/14-8.02(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 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