The clinical and educational systems: differences and similarities.

Two systems are currently used in the United States to diagnose and classify school-age children with autism for special education services. These are the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision (DSM-IV-TR; American Psychiatric Association, 2000) and the 1997 amendments to the Individuals with Disabilities Education Act. This article reviews the DSM-IV-TR and compares and contrasts the diagnostic criteria with the educational requirements. Problems with using a dual classification system are highlighted.

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Parents' Dilemmas

The parents have just received the diagnosis from their doctor; their child has a pervasive developmental disorder hOt otherwise specified (PDDNOS). A social worker has spent hours talking with them about the implications of the diagnosis and the needs for their child, including those related to education. They are relieved to learn that their child does not have a more severe autistic disorder and are pleased to finally get a diagnosis. The parents take their paperwork to the school. They are surprised to find out that the school personnel have to conduct additional specific tests before they can determine if their child is eligible to receive special education and related services. When the school personnel finish their testing process, they tell the parents that their child has autism. This is very upsetting to the parents because they have spent hours learning that their child does not have an autistic disorder. What kind of services will their child get? They wonder if they should call an attorney.

If is not unusual for school officials to suspect that a student has an autistic disorder or PDDNOS. School personnel may or may not have recommended that the child receive an independent evaluation. After conducting eligibility tests, the school officials conclude that the child does indeed meet eligibility criteria for autism. However, school officials decide to place the student in the least restrictive educational environment. The parents are not informed that the school personnel suspect autism. Since the child is only 6 years old, they decide to offer the parents services under the category of developmentally delayed because this is a less stigmatizing educational label. On the child's 9th birthday, the parents are told their son meets the criteria for autism. He has been in school for 3 years and no one told them until now. Has he been receiving an appropriate program? Is the eligibility category correct? What do the parents do now? Are the school officials correct? Do they need an independent evaluation? Do they need an attorney or an advocate?

A psychologist identifies a child as having an autistic disorder and recommends special education placement. After a thorough educational evaluation, school personnel recommend an inclusive placement with educational supports because the child is high functioning. Although contrary to the law, the clinician feels the school has made a mistake and continually sends letters recommending placement in a classroom for individuals with autism. The school decides they have correctly placed the child in the least restrictive educational alternative. Who is right? The parents feel that their child is benefiting from his educational placement, but isn't the doctor supposed to know more? What should the parents do?

Typical Scenarios and Complications

The scenarios described reflect some of the related situations that can arise as a result of the confusion between the clinical and educational diagnosis of autism and related disorders as a result of two diagnostic systems. Licensed clinicians such as psychiatrists, psychologists, and counselors typically use the Diagnostic and Statistical Manual of Mental Disorders (DSM). The most recent edition of the DSM is the text-revised fourth edition (DSM-IV-TR; American Psychiatric Association [APA], 2000). Autistic disorder (see Figure 1) is included in the DSM-IV-TR under the category of Pervasive Developmental Disorders along with four other disorders: Asperger syndrome, Rett's syndrome, childhood disintegrative disorder, and PDDNOS. With the exception of PDDNOS, these other pervasive developmental disorders are outside the scope of this article (see Figure 2).

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School systems do hot diagnose school-age children using the DSM; rather, it is the responsibility of school personnel to determine if a student is eligible for services under 1 of 13 federal disability categories (Individuals with Disabilities Education Act: Part 300, Assistance to the States for the Education of Children with Disabilities [IDEA Part 300], 1999). One of these categories is autism (see Figure 3). Each state promulgates the criteria and specific eligibility definition for autism (for a sample of state criteria, see Table 1). This clouds the issues even further because states vary in both their definitions of autism and the diagnostic tests that are required. In order to understand the similarities and differences in the clinical and educational systems, it is helpful for the reader to have an awareness of the background and standards of both nomenclatures.

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The DSM Clinical System

As previously discussed, autistic disorder is one of rive disorders classified under the category of Pervasive Developmental Disorders in the DSM. Autistic disorders must be evident before age 3. The DSM-IV-TR indicates that there is an associated frequency of mental retardation in most cases, which can range from mild to profound (APA, 2000). Additional research has placed the estimate of mental retardation at 50% (Freeman, 2000). Autistic disorder is frequently associated with a diverse group of medical conditions, including seizure disorders, Fragile X, and tuberous sclerosis (APA, 2000).

In order to meet criterion for autistic disorder, an individual must demonstrate six or more qualitative impairments in the area of communication, socialization, and repetitive and restrictive behaviors. Specific behavioral examples are given under each of the three areas (see Figure 1). To diagnose autism, the clinician must determine that the individual has at least two behaviors demonstrating qualitative impairments in communication, one behavior demonstrating qualitative impairment in socialization, and one behavior demonstrating repetitive and restrictive behavior. Two additional behaviors from any of the three categories must be identified for a total of six or more qualitative impairments from the list. Another individual with autism may exhibit six completely different characteristics of the diagnosis. It is certainly easy to understand why individuals with autism are so different.

In addition to the evidence of these six or more behaviors, delays or abnormal functioning must be demonstrated in one of the following areas: social interaction, language as used in social communication, and symbolic or imaginative play. Other disorders that may mimic autistic disorder, such as Rett's syndrome or childhood disintegrative disorder, must be ruled out before finalizing the diagnosis.

The DSM clinical system uses a five-level multiaxial system to describe an individual's clinical level of functioning, with codes corresponding to various diagnoses. The purpose of this multiaxial system is to address all the needs of the individual instead of relying on a single diagnosis as a descriptor. Axis I is used to diagnose clinical disorders and other conditions that may be the focus of clinical attention, such as autistic disorder. Axis II is reserved for …