Wednesday, March 17, 2010

ADHD - Medical Diagnosis or can school staff diagnose or challenge a diagnosis?

I have been having discussions with a lot of people regarding challenging versus surrendering to a medical diagnosis, especially ADHD.

Here is what I have found.

- The United States Dept. of Education is firmly against school personnel giving the "medical" diagnosis of ADHD. The rationale is focused solely on school staff not intruding on the medical doctor/family dynamic. School staff should not be giving opinions that could impact the administration of medication.
(Of course, one of the DOE's primary source was the American Association of Pediatrics (AAP), who, surprisingly, takes an extremely M.D.-centric view of the universe.) The AAP stance is that the DSM-IV criteria should be followed.

- The above fact does not interfere with the assessment of ADHD for educational purposes or legal requirements under IDEA or 504. They are treated as two separate issues. However, the DSM-IV is the prevailing criteria for eligibility.

So apparently, they are two completely separate diagnostic criteria that use the exact same diagnostic criteria!? (Although one requires specific educational impact.)

Therefore, school personnel don't HAVE to accept someone else's diagnosis for ADHD at face-value, but they do have to perform their own assessment and due diligence.

Likewise, we cannot require that someone gets a medical diagnosis before we would, say, consider a 504.
(I hope my mental health practitioner who asked this question is reading.)

We are responsible for pursuing the matter ourselves.

DISCLAIMER - The diagnostic conversation seems overly simplified and watered-down to me.


Under IDEA, each public agency—that is, each school district—shall ensure that a full and individual
evaluation is conducted for each child being considered for special education and related services. The
child’s individualized education program (IEP) team uses the results of the evaluation to determine the
educational needs of the child. The results of a medical doctor’s, psychologist’s, or other qualified professional’s
assessment indicating a diagnosis of ADHD may be an important evaluation result, but the
diagnosis does not automatically mean that a child is eligible for special education and related services.
A group of qualified professionals and the parent of the child determine whether the child is an eligible
child with a disability according to IDEA.
Children with ADHD also may be eligible for services under
the “Specific Learning Disability,” “Emotional Disturbance,” or other relevant disability categories of
IDEA if they have those disabilities in addition to ADHD.

Section 504 was established to ensure a free appropriate education for all children who have an impairment—
physical or mental—that substantially limits one or more major life activities. If it can be demonstrated
that a child’s ADHD adversely affects his or her learning—a major life activity in the life of
a child—the student may qualify for services under Section 504. To be considered eligible for Section
504, a student must be evaluated to ensure that the disability requires special education or related services
or supplementary aids and services.
Therefore, a child whose ADHD does not interfere with his or her
learning process may not be eligible for special education and related services under IDEA or supplementary
aids and services under Section 504.

Here is my take:

1 - School Psychologists have (or at least should be expected to have) the training and expertise necessary to formally diagnose any DSM-IV Disorder.
In fact, for many diagnoses, the battery used by school psychologists is better than many used in practice by many others in practice. This is supported by the fact that, in California, Licensed Educational Psychologists (LEP's) in practice are allowed to diagnose and bill for diagnosis in private practice with no additional training in this realm. Of course, individual results and competency will vary.

2 - Having the training and ability does not mean that they should be going down that road very often. Any time school psychologists working for an educational agency stray from education code and education-based decision-making things get precarious.

The decision if/when to focus on clinical diagnosis should be deferred to the chain-of-command at any given agency.

I expect all of my staff to be fully competent in diagnosing ADHD or any DSM-IV Disorder.

This is best done sparingly when we need to undo a previous diagnosis or to update a better differential diagnosis, and only when there are true treatment implications at stake. Too often, I see it done to quibble with other practitioners over "who is right" and not to forward a discussion on how to best serve a student.

For example, my last assessment was to refute consideration of an Asperger's Syndrome diagnosis from a quickie assessment performed by Dr. Buy-a-diagnosis and maintain the team's focus on the student's Emotional Disturbance/Mental Health and ADHD needs.

In this regard, I started with Ed Code but added DSM-4 for added emphasis.

Even then, I don't formally diagnose, I stick with the "walks like a duck, acts like a duck, quacks like a duck" type of language.

For example, I use language that perfectly matches DSM-4 criteria without announcing that I am doing that.

For ADHD, I may say, "There is no evidence of signs, symptoms, or impairment prior to the age of 7. Furthermore, the following cannot be effectively ruled out as alternative explanations. In fact, the evidence suggests that these are more likely causes of the presenting...."



  1. Eric -

    Good, and very interesting, post! A few comments:

    First, 504 does not require a child have difficulty with "learning" or require special education services. If a child has a problem with any major life activity (which might be "sitting or standing" for a child with ADHD who just can't sit still), they may be eligible for a 504 plan. (just a minor detail I wanted to clarify for your readers.)

    Second, although school psychologists may have adequate training to diagnose ADHD, I (as an advocate for parents and children) have a problem with this diagnosis coming from the school. While the school must give an "educational diagnosis" to qualify a child for services under IDEA, this is different from a "medical diagnosis." Schools have too many diverse interests and may not be thinking only of the child if they want a diagnosis. Furthermore, parents often see school officials as an "authority", and it is not the place of schools to encourage medication. I know (as a non-medicated ADHD adult!) that ADHD does not equal medication - but many parents don't.

    I completely agree with your "walks like a duck" way of doing things. It is much better (and more accurate) to describe facts and symptoms without giving a label to things. However, labels are necessary in many instances, which is an unfortunate consequence of current laws and regulations.

  2. Sorry, something appeared to have gotten lost in formatting.

    I have now corrected to missing block quotes in my formatting.

    It appears that the comments that you made in your first point are actually in response to the quote from the United States Department of Education. (But the bold formatting was me.)

    However, even then, we may be splitting hairs. Impact on learning does not necessarily mean that there is a problem with how information is being processed (as in a traditional Learning Disability).

    If symptoms of ADHD prevent the information from getting in the brain in the first place, learning is still impacted. Thus, it meets the parameters published by the DOE.

  3. As a pediatrician who does a lot of work with behavioral and learning disabilities, I want to mention that this goes both ways. There are times when we don't diagnose ADHD and the school insists it's there. In our area, they refuse to accept it could be the child has another problem, such as a learning disability or communication impairement that causes the inattention or hyperactivity. This seems to be especially true if these diagnoses require more intervention and accomodation on the part of the school.

    The flip side is that although I may make a diagnosis based on observation, scientific principles, and 9 years of training, the school or the school board who have no training in child development or psychology has the right to disregard it. This happened recently when a child I take care of who is HFA--so much so other kids have singled him out because he's "weird", and attacked him, resulting in stitches, and whose teacher admitted to mom the kid isn't doing well--decided to disregard my diagnosis. (The same teacher told the school board he was well.) I can't recall the words mom said they used, but in effect they said I was wrong adn the kid is normal. Now the family has to go another round to get this child the services he needs for a good education.

    When I do an eval and make a diagnosis, I involve the school, and consider all the info I can get from them. (I know not all physicians do the same.) It seems to me the school should do the same. We don't have full time psychologists in the schools here, so they have no personel qualified to "disregard" or even argue with my diagnosis. The "full" evalution done by the schools is often just an hour observation in the classroom, which is not adequate to diagnose ANY behavioral issue.

    Until we find a balance in the rules that requires physicians to consider school input--and requires schools to provide it!--and requires the school to accept a fully justfied-proof-and-reasoning-can-be-given diagnosis, we are never going to fully accomodate these children as they deserve.

  4. Your post is timely.
    I have been spending considerable time in IEPs for another school district, and I am amazed at the amount of time they spend discussing -outside of scope of practice - discussing their opinions about medication. I had to remind myself that I was a guest and juggle the "righteousness" versus "effectiveness" on sharing my opinions on that practice.

    Not that I am 100% any discussion on the topic, however, this goes back to people sharing the facts that lead to opinions, not the opinions themselves that I discussed in the my more recent post.

    Good collaboration is a two-way street.

    In the end, it is not about philosophy, but application and implementation.

  5. Thanks a lot for this great informative post I like it o much keep posting and updating the blog on regular basis.

    Smith ALan

  6. There are three different categories of ADHD symptoms: inattention, hyperactivity, impulsivity.