What's New, What's Hot, What's In, What's Out? The DSM-5 and Special Education Law

Transcription

1 What's New, What's Hot, What's In, What's Out? The DSM-5 and Special Education Law Attorney Paige L. Tobin, Murphy, Lamere & Murphy Naami S. Turk, Psy.D.

2 2 DSM-5: Why the changes? Goal: use most evidence-based criteria to help clinicians accurately and consistently diagnose DSM -5 was 13 years in the making Revisions through the years reflect trends in research, clinical practice and sensitivity to emerging historical and cultural trends

3 3 Eligibility Overview DSM-5 Diagnosis IDEA Eligibility Disability Categories = Impairments 34 CFR 300.8(c) and 603 CMR 28.02(7) Getting the right disability determination (not diagnosis) and FAPE

4 4 Impact of Disability Determination on FAPE Intent of IDEA is that IEPs contain correct disability determination and categories What is the impact of a failure to include an accurate disability diagnosis? Fort Osage R-1 School District v. Sims, 641 F.3d 996 (8 th Cir. 2011)

5 5 Technical Assistance Advisory Sped DSM-5 is one diagnostic tool changes in the DSM-5 diagnostic categories do not alter a student's current eligibility status or IEP, nor does it change any of the federal and state laws or regulations related to the determination of special education eligibility or services

6 6 Evaluation Under the IDEA, the evaluation must be sufficiently comprehensive to identify all of the child s special education and related service needs, whether or not commonly linked to the disability category which the child has been classified. 34 C.F.R (6)

7 7 What to do? Return to the IDEA: The Team shall: use a variety of assessment, tools and strategies to gather functional, developmental and academic information. Sec. 614 (b)(1) not use any single measure or assessment as the sole criteria for determining whether a child has a disability or determining appropriate educational programs for the child. Sec. 614 (b)(2)(b) DSM-5 agrees!

8 8 DSM-5 Assessment Requires holistic approach to assessment and diagnosis Sound familiar?

9 9 Autism Spectrum Diagnosis The new criteria presents a new opportunity for Teams Use the differing levels of severity to plan services and supports that are targeted to individual skill deficits Address parents fears about losing the diagnosis DSM-5 grandfather clause - all students with current diagnoses of ASD, PDD-NOS, Asperger s under DSM-IV Insurance Issues

10 10 Social Communication Disorder Technical Assistance Advisory : For students with social pragmatic communication issues diagnosed with SCD, Team may need to crosswalk to the MSER definition of autism MGL Chapter 71B 3: 1. Verbal and nonverbal 2. Social interaction skills 3. Unusual responses to sensory experiences 4. Resistance to environmental or routine changes 5. Repetitive activities/stereotyped movements 6. Behavioral interventions 7. Other needs, including social/emotional, copyright generalization Paige L. Tobin, Esq. and Naami Turk, Psy.D.

11 11 Intellectual Developmental Disorder Requires assessment across 3 domains: Conceptual Social Practical Teams: Focus on function the impact of the deficit on functioning needed for school, home, community and life

12 12 Specific Learning Disorder Broadened category to increase diagnostic accuracy and target interventions Diagnosed through clinical review of: History Testing Teacher observations RTI

13 13 Removal of Bereavement Exclusion from PTSD Impact on child find? 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. 34 CFR (c)(4)(i)

14 14 What does this mean for a Team? Many of the diagnostic criteria require analysis of the student s functioning at school For IEES: Trust, but verify IEE should trigger release for communication Respectful but probing questions

15 15 What about our evaluations? Focus on function Gather information from a variety of sources Target individual and specific patterns of need Impact of any RTI process

16 16 DSM An attempt to define mental disorders Via the 4 c s Categorize Classify Clarify Communicate

17 17 The 5 th C Challenges Human behavior isn t categorical Behavior changes over time There are evolving cultural and historical influences Human development isn t static Ever growing and changing bodies of research AKA PEOPLE ARE A WORK IN PROGRESS

18 18 DSM 5 Major Changes Philosophical Structural Diagnostics

19 19 Philosophical Changes Increased cultural awareness Increased sensitivity to gender issues More child aware: Kids will be kids Increased awareness of functional ability

20 20 Structural Changes Order of appearance of classifications now follows developmental trajectory No more NOS now it s Unspecified Increased number of specifiers for many disorders GAF replaced by WHODAS (pp in DSM 5) Multi axial diagnostic framework is gone

21 21 Classification Categories Increased from 17 to 20 And within the classification categories Some diagnoses have been Removed Renamed Collapsed Added

22 22 What I ll be addressing Changes that are most likely to impact specifics associated with educational planning process Changes within the neurodevelopmental category Changes within diagnostic categories associated with social/emotional educational impairment Changes associated with disorders that can be tricky in terms of determining eligibility

23 23 BIPOLAR DISORDER- what s new? You ll be seeing less of this as a diagnosis New diagnostic criteria for childhood onset of Bipolar 1 Changed because over and/or misdiagnosed has ramifications for treatment New criteria tighten things up 4 DISTINCT EPISODES in a 12 month period Bipolarity negates chronicity EPISODES means 4 events of mania and depression in a 12 month span (not chronic depression or chronic mania/irritability)

24 24 BIPOLAR DISORDER cont d Mania = hyperactivity, irritability, psychosis driven grandiosity, elated/expansive mood, racing thoughts, refusing to sleep Depression = change in personality, morbid outlook toward life, pessimistic about the future, drop in grades, some suicide ideation, ongoing somatic complaints (ongoing during the depressive phase)

25 25 DEPRESSIVE DISORDERSwhat s new? Disruptive Mood Dysregulation Disorder DMDD New disorder in DSM5 Severe, recurrent temper outbursts manifested verbally and/or behaviorally that are disproportionate in intensity or duration to the situation or provocation. Outbursts occur on average 3 + times per week. Mood between temper outbursts in persistently irritable or angry most of the day.

26 26 DMDD cont d Symptoms can t be attributed to another physiological or neurological condition Age of onset is before 10 years. Has to be present for at least 12 months, observable by others in 2 of 3 settings (at home, at school, with peers) Diagnosis cannot be made for the first time before age 6 or after age 18.

27 27 DMDD cont d Cannot co-exist with ODD, Intermittent Explosive Disorder or Bipolar Disorder Can co-exist with Major Depressive Disorder, ADHD and Conduct Disorder*. *Since DMDD and Conduct Disorder can co-exist, now some Conduct Disorders may fall into the social emotional disability category if there is a comorbid DMDD diagnosis. DMDD trumps ODD not going to see them together because if child meets criteria for ODD and DMDD they are given the DMDD diagnosis Severe ODD now is DMDD and falls into the emotional impairment category- has new ramifications for eligibility

28 28 DEPRESSIVE DISORDERS what s new? PERSISTENT DEPRESSIVE DISORDER Replaces dysthymia Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others. While depressed, presence of at least 2 of the following are needed for a diagnosis: Poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, feelings of hopelessness. For kids and teens it s 1 year ongoing with primarily an irritable mood and no sign of mania

29 29 A word about conduct disorder Age of onset is a prognostic indicator Specifiers are prognostic indicators

30 30 NEURODEVELOPMENTAL CATEGORY Intellectual Developmental disorder/intellectual disability Specific Learning disorder ADHD ASD Social (Pragmatic) Communication Disorder

31 31 Intellectual Development Disorder (aka Intellectual Disability) Onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social and practical domains. Specifiers mild, moderate, severe, profound IQ ( /- 5) is only one piece of the diagnostic determination process The other piece is adaptive functioning.

32 32 Intellectual Disability- cont d Deficits in adaptive functioning what does this mean?? Without ongoing supports, the adaptive deficits limit function in one or more activities of daily life such as communication, social participation, independent living across multiple environments (home, school work, community.)

33 33 Intellectual Disability cont d Differential Diagnoses include ASD, SLD, Communication Disorders (e.g. expressive and/or receptive language)

34 34 Specific Learning Disorder There are 4 diagnostic criteria that must be met based on a clinical SYNTHESIS of the individual s history (i.e. developmental, medical, family, educational), school reports and psychoeducational assessments. Specifiers identify the area where there is a learning impairment and also identify the level of severity (mild, moderate, severe see pp in the DSM 5)

35 35 Specific Learning Disability-cont d DSM Diagnostic Criteria Difficulties learning and using academic skills as indicated by at least 1 of 6 symptoms persisting for at least 6 months, despite the provision of interventions that target those difficulties. understanding the meaning of what is read inaccurate, slow or effortful word reading difficulties with spelling difficulties with written expression difficulties mastering number sense, facts or calculation difficulties with mathematical reasoning

36 36 Specific Learning Disability- cont d DSM Diagnostic Criteria The affected academic skills are substantially and quantifiably below chronological age and cause significant interference with academic or occupational performance or with activities of daily living as confirmed by individually administered standardized achievement measures and comprehensive clinical assessment.

37 37 Specific Learning Disability- cont d DSM Diagnostic Criteria Difficulties begin during school age years but may not become fully manifest until the demands for those affected academic skills exceed the individual's limited capacities (e.g. timed tests, lengthy reading or writing assignments, increased academic load.)

38 38 Specific Learning Disability- cont d DSM Diagnostic Criteria Difficulties are not better accounted for by intellectual disabilities, uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial adversity, lack of proficiency in the language of academic instruction or inadequate educational instruction.

39 39 QUICK ADHD UPDATE ADHD and Autism Spectrum Disorder can now present as co-existing diagnoses Symptoms now need to be present before age 12 (used to be age 7) Still need to have meet criteria for at least 6 symptoms and they need to be observed by 2 people in different settings

40 40 Autism Spectrum Disorder Individuals with a well-established DSM 4 diagnosis of Autistic Disorder, Asperger s Disorder or PDD, NOS should be given the diagnosis of ASD. THIS MEANS IF SOMEONE WAS DIAGNOSED WITH ANY OF THESE DISORDERS PRIOR TO they are grandfathered in to the new ASD classification.

41 41 ASD cont d Diagnostic Criteria Persistent deficits in social communication and social interaction across multiple contexts For example: Deficits in social-emotional reciprocity Deficits in nonverbal communicative behaviors used for social interactions Deficits in developing, maintaining and understanding relationships

42 42 ASD cont d Diagnostic Criteria Restricted, repetitive patterns of behavior interests or activities by at least 2 of the following: Stereotyped o repetitive motor movements, use of objects or speech Insistence on sameness, inflexible adherence to routines, or ritualized patters of verbal or nonverbal behavior Highly restricted, fixated interests that are abnormal in intensity of focus Hyper or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment

43 43 ASD cont d Diagnostic Criteria Symptoms must be present in the early developmental period Symptoms cause clinically significant impairment in social occupation or other important areas of current functioning Symptoms are not better explained by intellectual disability or global developmental delay.

44 44 ASD - specifiers 3 levels (see p 52 in DSM 5) Level 1 requiring support Level 2 requiring substantial support Level 3 requiring very substantial support

45 45 Social (Pragmatic) Communication Disorder New diagnosis in DSM 5 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 of the ability to change communication to match context or the needs of the listener Difficulties following rules for conversation and storytelling Difficulties understanding what is not explicitly stated

46 46 S(P)CD Diagnostic Criteria cont d Deficits results in functional limitation in effective communication, social participations and relationships, academic achievement or occupational performance individually or in combination Onset of symptom in the early developmental period (but may not fully manifest until social social communication demands exceed limited capacities.) Symptoms are not attributable to another medical or neurological condition or low abilities in language.

47 47 For More Information: Paige L. Tobin, Esq. Murphy, Lamere & Murphy, P.C. 10 Forbes Road, West Braintree, MA