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The DSM-V: An Opportunity for Improved Practice

DSM - Learn the Law

Background

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and contains descriptions of symptoms and criteria for diagnosing a wide range of disorders. While it is primarily used by mental health practitioners as a guide to determining accuracy and consistency in diagnosis, there is considerable overlap in its use among professionals in educational and therapeutic settings who provide evaluation and treatment services to individuals of all ages who struggle with learning disabilities (LD). Significant changes in federal education law (i.e., No Child Left Behind, 2001; Individuals with Disabilities Education Act, 2004) during the past decade and efforts to update the current DSM-IV-TR (last revised in 2000) offer a unique opportunity for improving evaluation and classification practices that will benefit individuals with LD, their families and the professionals who constitute their communities of care.

It is NCLD's strong recommendation that the DSM-V reflect alignment of DSM codes and criteria with both language in federal law (specifically the Individuals with Disabilities Education Act) and with current research and practice in the field of learning disabilities.

 

The Relevance of DSM Codes in Educational Practice

During the pre-K and school age years, some students are recognized as having one or more educationally handicapping conditions and are provided services and supports that align with one of 13 federally prescribed specific categories of disability. The evaluation procedures that support classification decisions are based on state and local guidelines and these vary widely between settings. The nature of interventions that are tied to classification procedures are determined by teams of professionals and parents, and disability status is monitored over time using a variety of quantitative and qualitative measures including standardized assessment, progress monitoring and clinical judgment. In addition to relying on these educationally handicapping conditions for special education eligibility, evaluation personnel will often use DSM codes in “diagnosing” learning disabilities and related disorders of cognition, communication, and behavior.

For individuals who are beyond the K-12 school years, educational classification categories are replaced by DSM number codes which correspond to a broad range of disorders and provide a common framework and vocabulary for practitioners regardless of clinical orientation or geographic setting.

It is important to note that there is already considerable overlap in the terminology used by each of these classification systems. It is also important to note that teams of professionals often make their determinations and decisions based on different sets of data, increasing the risk of improper diagnosis, missed diagnosis and classification that does not lead to effective services and improved outcomes.

Specific Revisions to DSM-V Categories

The DSM, by definition and design, focuses attention on mental disorders in such areas as eating, sleeping, substance abuse, mood, anxiety, personality, and attention. It also makes specific reference to conditions that impact a person’s understanding or use of spoken or written language, as well as those that affect a person's ability to listen, think, speak, read, write, spell, or do mathematical calculations, under a section in the manual titled Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.

To better align the DSM-V with current research and practice in learning disabilities, NCLD recommends the following revisions in classification:

  • “Learning Disabilities” be used as an overarching category with subtypes including disorders of:
    • Word reading (“dyslexia”)
    • Reading fluency
    • Reading comprehension
    • Written expression
    • Mathematics calculation (“dyscalculia”)
    • Mathematics problem solving
  • “Learning Disabilities Not Otherwise Specified” be retained to capture difficulties that do not meet criterion for other areas but that constitute significant obstacles to learning, daily living and social-emotional well-being

 

An Opportunity for Improved Practice

Protocols for evaluation in the determination of medical and mental health disorders often rely upon clinical interview, laboratory testing and the effectiveness of pharmacological and other types of therapeutic intervention. Protocols for the determination of educational and communication disorders similarly include interview data from teachers, parents and others and also rely upon measures of achievement, and standardized and informal samples of performance and progress monitoring data gathered over time and in non-clinical settings.

To enhance the effectiveness of the DSM-V in determining the status of individuals who present with disorders of learning and behavior, NCLD recommends the following revisions in language:

  • Difficulties in academic learning cannot be attributed to intellectual disability, sensory impairment, emotional disorder or lack of educational opportunity
  • Multiple sources of data need to be used to assess academic skills, including but not limited to norm-referenced measures of academic achievement
  • Evaluation measures need to be culturally appropriate
  • “Contextualized assessment” (e.g., measures of progress over time, integrity and duration of instruction/intervention) should be considered as part of the determination of a disability or disorder


The revision of the DSM provides an unprecedented opportunity to align thinking and practice between these two influential sets of practices, each of which has significant influence in providing access to timely and effective services for individuals with LD across the lifespan.

Call to Action

NCLD believes that the recommendations above will enhance communication among practitioners throughout the helping professions, lead to greater precision in diagnostic and evaluation practices, and result in more collaborative and efficient instructional and behavioral interventions for those who struggle with learning disabilities in school, in the community and in the workplace.

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