Published Online: June 3, 2013
Published in Print: June 5, 2013, as Disability Definitions Undergo Revisions in Psychiatric Guide

Disability Definitions Revised in Psychiatric Manual

The psychiatry profession's newly revised reference manual on mental disorders changes the definition and classification for many disabilities commonly seen in schools, but those changes—at times extensive—are unlikely to have an immediate impact on services for students with disabilities, special education experts say.

The reason: Schools are guided primarily by the federal Individuals with Disabilities Education Act, which offers its own definitions for disabilities, such as specific learning disorder and autism spectrum disorder, that can trigger the provision of special education services.

At the same time, special educators agree that the changes, 14 years in the making, require parent and school-level educator awareness and eventually may result in students' receiving different labels that encapsulate the areas where they need extra help.

The fifth revision of the Diagnostic and Statistical Manual of Mental Disorders, otherwise known as the DSM-5, was released by the American Psychiatric Association last month after extensive study and public comment. The organization describes the manual as a handbook that provides a "common language for clinicians," and that also offers a method of ensuring that diagnoses of mental disorders are consistent and reliable among practitioners.

By The Book

The fifth revision of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association, is the standard classification of mental disorders used by mental-health professionals in the United States and contains a listing of diagnostic criteria for every psychiatric disorder recognized by the U.S. health-care system. The most recent edition includes several definitional changes to disorders that are often seen in school contexts.

Attention Deficit Hyperactivity Disorder
Definition: A pattern of behavior in multiple settings characterized by symptoms such as failure to pay close attention to details, difficulty organizing tasks and activities, fidgeting, excessive talking, and inability to stay seated.

What's Changed? “Several” symptoms must be present in more than one setting; symptoms must be present before age 12 instead of before age 7; examples have been included to illustrate the types of behaviors children, adolescents, and adults might experience.

Autism Spectrum Disorder
Definition: characterized by communication deficits, such as responding inappropriately in conversation; dependence on routines; high sensitivity to changes in environment; and intense focus on inappropriate items.

What's Changed? Four separate disorders, including Asperger’s syndrome and “pervasive developmental disorder-not otherwise specified,” have been folded into a single umbrella disorder.

Disruptive Mood Dysregulation Disorder
Definition: Children up to age 18 who exhibit persistent irritability and frequent episodes of extreme temper tantrums.

What's Changed? This disorder is new with the DSM-5 and is meant to address concerns about overdiagnosis and overtreatment of bipolar disorder in children.

Intellectual Disability
Definition: Impairment of general mental ability that affects adaptive functioning in three domains: conceptual (reading, writing, math, reasoning); social (empathy, judgment, interpersonal communications); and practical (money management, job responsibilities, personal care).

What's Changed? The term “mental retardation” has been removed; severity of impairment should be based on adaptive functioning and not IQ score alone.

Oppositional Defiant Disorder
Definition: An ongoing pattern of anger-guided disobedience, hostility, and defiant behavior toward authority.

What's Changed? The criteria explain how frequently the behaviors must occur to differentiate them from normal development in children; symptoms have been grouped into angry/irritable mood, argumentative/defiant behavior, and vindictiveness.

Social Communication Disorder
Definition: A persistent difficulty in social uses of verbal and nonverbal communication, such as greeting or exchanging information; following rules for conversation or storytelling, such as taking turns in conversation; and understanding what is not explicitly stated and nonliteral or ambiguous meanings of language.

What's Changed? The disorder is new to the DSM-5. It is meant to identify people who have some of the communication deficits associated with autism, but who do not have repetitive or restricted behavior patterns.

Specific Learning Disorder
Definition: Deficits that affect academic achievement in areas such as reading, writing or mathematical reasoning.

What's Changed? Specific diagnoses such as dyslexia or dyscalculia have been folded into this disorder. As part of the diagnosis, clinicians can provide greater detail as to the type of deficits present.

The new manual was meant to encompass new research findings in the field of mental health. It describes more than 300 officially recognized disorders.

Criteria Broadened

Though the DSM-5 does not control provision of school services, many students have disabilities that are covered by the manual. For example, in fall 2011, of the approximately 5.8 million students ages 6 to 21 in special education, 2.4 million were categorized as having a specific learning disability. About 407,000 had autism. Both disorders are in the manual.

Among the changes in the DSM-5 is the elimination of Asperger's syndrome and other disorders that were considered subtypes of autism. Instead, only one disability, "autism spectrum disorder," will exist, with varying levels of severity.

The manual also creates a new category, "social communication disorder," for people who may have difficulty with conversational skills but do not have restricted or repetitive behaviors associated with autism.

The diagnostic criteria for ADHD were modified in ways that will make it easier for adults to be diagnosed. For example, the DSM-5 now states that impairing symptoms must have been present before age 12 instead of before age 7; research suggests no difference in outcome or severity of the disorder for people whose symptoms were noted earlier, according to a fact sheet from the psychiatric organization.

Similar to the changes reflected in the label of autism spectrum disorder, the manual now brings together several learning disorders—reading disorder, mathematics disorder, and disorder of written expression, among them—into one category, "specific learning disorder." Dyslexia and dyscalculia are not official diagnoses in the new manual as they were in the past.

That change reflects current practice, said Elizabeth Parrett, who coordinates special education services for students at Kennett High School in Kennett Square, Pa. "A lot of people in school systems tried not to use the term 'dyslexia,' " she said. "We try to talk about disabilities in reading comprehension, or reading fluency."

Comparing With IDEA

Some of those changes bring the manual closer to the 13 disability categories identified in the IDEA, said Stephen E. Brock, a professor of school psychology at California State University, Sacramento, and the president-elect of the National Association of School Psychologists. For example, the IDEA only names "autism" or "specific learning disability" as categories, as opposed to Asperger's syndrome or dyslexia.

The chief difference between the DSM-5 and the main law that governs special education is that simply the presence of symptoms is not enough to trigger special education services, Mr. Brock said. The disability symptoms must have some negative effect on a student's academic performance before special education is merited.

The psychiatrists' manual "does not direct our authority, but it absolutely should direct our attention," Mr. Brock said. School psychologists should have basic familiarity with the manual, he said, so that they can understand if a child comes to school with a particular diagnosis from a clinician.

Ruth Hughes, a clinical psychologist and the chief executive officer of the Landover, Md.-based organization Children and Adults with Attention-Deficit/Hyperactivity Disorder, or CHADD, also does not expect that the revised manual will affect students in a major way.

The manual notes that most of the changes in that classification were meant to expand the definition of ADHD from a childhood disorder to one that also affects a significant number of adults. "While the symptoms may change over time, they don't go away," Ms. Hughes said.

The changes to the diagnostic criteria related to autism may have more effect on students than do other revisions to the manual, say experts in that disability.

Autism Changes

The establishment of social communication disorder as a category offers a more precise definition of disabilities for students who struggle to follow conversational rules, such as taking turns speaking, or who have trouble understanding ambiguous uses of language.

Previously, such children might have been diagnosed as having "pervasive developmental disorder—not otherwise specified," or PDD-NOS, a catchall diagnosis for people who exhibited some traits associated with autism, but not all of them. Diane R. Paul, the director of clinical issues in speech-language pathology for the American Speech-Language-Hearing Association, in Rockville, Md., said speech-language pathologists already have been serving students with those social communication deficits.

Speech-language pathologists are not just "speech correctionists," said Ms. Paul, who served on the communication-disorders advisory committee for the new manual; they are trained to help with a variety of communication issues, not just those relating to spoken language.

Related Blog

Peggy Shaefer Whitby, an assistant professor of special education at the University of Arkansas at Fayetteville, said the new classification may pose a puzzle to school teams that have not seen the diagnosis of social communication disorder before.

"How is the [individualized education program] team going to look at this and determine how to serve these kids?" said Ms. Whitby, who specializes in autism.

Such students may be served by speech-language pathologists on a "pullout" basis, removing them from the classroom on a limited basis for services. But that model may not be enough for those students' needs, Ms. Whitby said, so IEP teams must be aware if their needs are more intensive.

"I don't think it'll have a huge impact in the schools, as long as we do what's right, and that's serve the kid, and not the diagnosis," Ms. Whitby said.

Vol. 32, Issue 33, Page 7

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