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The DSM as a Second Language for the School Psychologist: A Guide to Translation
p91982$$40
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p. 637
Book Review The DSM as a Second Language for the School Psychologist: A Guide to Translation House, Alvin E. DSM-IV Diagnosis in the Schools New York: The Guilford Press; 1999 230 pp., $28.95, ISBN 1-57230-346-8 Reviewed by: Margaret Inman Linn,* Center for Education, Widener University
The traditional role of the school psychologist is a familiar one. We are expected to be the first to interpret a student’s behavior or learning pattern and to translate that behavior into an educational diagnosis. We must then work with teachers to move from diagnosis to an effective intervention plan. Finally, we must explain the diagnosis and proposed intervention, originally developed in the language of special education, to the parents and the child. These multiple tasks require extensive knowledge of psychology, child development, and education. We now face a new professional demand. Hoping for additional resources to cover the rising costs of special education, school administrators are now looking to insurance providers for reimbursement of services provided to children with special needs. To satisfy the requirements of insurers for reimbursements, school psychologists will be expected to turn a child’s educational diagnosis into a psychiatric diagnosis using the language of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. In DSM-IV Diagnosis in the Schools, Dr. Alvin House provides the school psychologist with a dictionary to make the required translations. Today school psychologists, the gatekeepers of special education services, make placement decisions based on our classification system—Individuals with Disabilities Education Act (IDEA). Most of us have acquired our expertise in schools of education and have limited experience with the primary language of the psychiatric classification system, the DSM-IV. In this instructive book, House reassures us that school psychologists have the knowledge base and clinical skills necessary to master the imposing DSM-IV. He attempts to bridge the diagnostic gap between school psychologists and mental health professionals by promising a text that will familiarize us with the “main features of this (the DSM) approach to understanding and *Direct all correspondence to: Margaret Inman Linn, Center for Education, Widener University, One University Place, Chester, PA 19013. E-mail: ⬍[email protected]⬎. Journal of Applied Developmental Psychology 20(4): 637–641 Copyright 2000 Elsevier Science Inc. ISSN: 0193-3973 All rights of reproduction in any form reserved. 637
p91982$$40
638
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p. 638
LINN
classifying emotional, behavioral, and cognitive disturbances in adjustment” (p. 11). His goal is to teach the practicing school psychologist how to use the DSM-IV in a thoughtful, ethical, and efficient manner, and he provides us with one tool to master this task. DSM-IV Diagnosis in the Schools is a resource, a reference book, a guide. With House’s guidance, it is possible to bridge the clinical and educational worlds. This text has many other uses beyond teaching the school psychologist to use the DSM-IV for diagnostic classification of students after evaluation. School psychologists are often required to interpret the reports of professionals working in clinics, agencies, and hospitals outside the field of education, and often these reports are written in mental health language and culminate in a DSM-IV diagnosis. With the growing awareness of the need to identify all degrees of disability as early in the child’s life as possible and the subsequent increase of clinics serving the early intervention population, it is more likely than ever that children with special needs will enter school with a DSM-IV diagnosis in hand. Additionally, the full inclusion movement has significantly increased the number of children with moderate to severe disabilities in our public schools. Generally, students who exhibit disabilities such as autism are diagnosed within the first few years of life and are reevaluated often—many have several diagnoses. With both populations, it is important that previous evaluation results be interpreted accurately and translated into educational terminology to provide an appropriate educational program. In addition, it is essential that someone in the educational system, most likely the school psychologist, be able to communicate with the mental health system that provides these services. The issue remains, however, that the medical and educational professions have fundamentally different conceptualizations of difference. At their most basic levels, the DSM-IV, written by physicians for physicians, classifies mental disorders; IDEA, written by legislators for educators, classifies educational disabilities. It should be no surprise that school psychologists may have difficulty fitting the criteria of the psychiatric classification system into the framework of special education. House’s book recognizes the incongruities of the two systems and provides an important first step to help us reconcile them. DSM-IV Diagnosis in the Schools is organized into three parts: an overview of the system and use rules, a presentation of the different symptom patterns (e.g., personality disorder) that a school psychologist may encounter, and an important discussion of the issues that may arise as we confront the DSM-IV (e.g., ethics, the case record, DSM-IV vs. IDEA). Part I, “Diagnostic Issues and the Use of DSM-IV,” is a primer on the DSMIV. This section presents an introduction to psychiatric classification and its relation to developmental issues and an overview of the DSM-IV diagnostic system. Professionals with either cursory or out-dated experience with DSM systems will find this section clearly written and very useful. House addresses basic questions such as: What is the difference between a disorder and a syndrome, a subtype and a specifier, recovered and full remission? What is an acceptable GAF? When is it appropriate to use a V Code, or the NOS option? This section presents the fundamentals of the classification system, first establishing terminology—defining and discriminating between disorder, illness, signs, symptoms, and syndromes—then providing a complete explanation of the Multiaxial Classification, axis by axis. Part I ends with a
p91982$$40
12-28-99 10:33:55
BOOK REVIEW
p. 639
639
useful discussion of diagnostic conventions and multiple diagnoses, providing the novice reader with a clear understanding of the structure of this often imposing system and the more experienced psychologist with an excellent review of the most important features of the DSM-IV Manual. When finished with Part I, the reader is likely to feel that mastery of DSM-IV is within reach. In Part II, “Guidelines for Evaluation of Presenting Problems,” House reviews categories of common presenting concerns for children and adolescents. The individual presentation of each disorder is well done—symptomatology, age-of-onset criterion, comorbid diagnoses, base rates, and potential uses of the category are discussed in reader-friendly terms for selected disorders. DSM-IV criteria are not reiterated, but House raises important differential diagnosis issues for each category. By the author’s admission, discussion of specific diagnoses is brief, often omitting information about the “pattern, course and variant expression” of a disorder and referencing is “sparse.” This is a wise choice, because this text is meant to be used in conjunction with the DSMIV—the author avoids redundant presentation of material. The length of discussion for each diagnostic category varies; some, such as ADHD (which underwent extensive empirical field testing for the DSM-IV) are lengthy, whereas others such as Selective Mutism are touched on lightly. Less helpful is the design of Part II, intended to help the reader develop “a rapid familiarity with the DSM-IV framework” (p. 40). The chapters are organized thematically rather than following the DSM-IV structure, and this may prove confusing for the novice diagnostician. It is the organization of the DSM-IV that first introduces a new user to the conceptual framework of the system, but this organizational structure is lost with House’s reinterpretation. Although some diagnoses are where one would expect—for example, in well-established categories such as externalizing problems, internalizing problems, personality disorders—others are in the author’s own, less familiar categories. For example, Sexual and Gender Identity Disorders, an entire chapter in DSM-IV, are discussed here under the category Highly Focused Symptom Patterns, a term not commonly used in diagnostics. Part III, “The Application of DSM-IV in School Settings: Issues and Topics,” is divided into several short chapters, more like essays, dealing with ethics, the case record, seeking reimbursement, IDEA, and concerns about psychiatric classification. In this section the author, speaking as a clinical psychologist with extensive experience training students in the assessment process, presents his views on differences between clinical and school psychologists, ethical and professional responsibilities, the limitations of clinical judgment and the biases of DSM-IV system. Readers will find the ethical and professional practice discussions enlightening and the more practical section on the process of seeking reimbursement to be valuable. Throughout the text, the author’s tone is supportive. His view that use of the DSM-IV is an appropriate and attainable professional activity for school psychologists will comfort the neophyte psychologist. He seems to anticipate our concerns. For example, in cases of diagnostic disagreement, House asserts that the “correct diagnosis is based on the best formulation of the data that is available at the time” (p. 192). He reassures us that our formulation need not agree with previous or future assessments performed by other professionals to be correct. He encourages us, but at the same time reminds us of our limitations and ethical responsibilities.
p91982$$40
640
12-28-99 10:33:55
p. 640
LINN
Mastering the DSM-IV is a major career task, and we are encouraged to go about this task responsibly, by seeking further training and supervision. Indeed, I envision school districts organizing in-service training using House’s text as a guide. Historically, the DSM-IV has not been regarded as particularly useful for the school psychologist. The four previous editions of the DSM did not correspond well to the P.L. 94-142 system and did not address strategies for assessment or intervention in education. However, with this most recent edition of the DSM, Power and DuPaul (1996), for example, encourage school psychologists to consider the Manual as a relevant tool for learning about the course of complex communication disorders and behavioral and social disorders (Power & DuPaul, 1996). Still, their enthusiasm is moderated by cautions about the limitations of the DSM system for educational applications, most notably the complex process of differential diagnosis. In DSM-IV Diagnosis in the Schools House handles this mismatch in a straightforward manner. He attempts to map the criteria for IDEA onto each DSM-IV diagnosis, while acknowledging the awkwardness of fit. Through his format of “IDEA Notes,” House discusses potential relationships between DSM-IV diagnoses (and, when appropriate, ICD diagnoses) and qualifying conditions for special education services under specific IDEA categories. IDEA Notes are used selectively, generally with regard to broad categories (e.g., Disruptive Behavior Disorders, Anxiety-Related Mental Disorders), and each note identifies the IDEA category that corresponds to the disorder. In some cases, additional information such as important forms of documentation and additional Axes information necessary for establishing eligibility for special education is included. Even with the valuable contribution of this text, the issue remains that the DSM-IV and IDEA are not congruent. Diagnosis of disability in special education is narrow, based on psychometric assessment of the student’s ability to function within the academic environment. Diagnosis of mental disorder is based on clinical judgment about the individual’s personal distress, their failure to adapt to that distress in all aspects of their lives, or both. House’s concerns about the difficulties in trying to map one system onto the other reiterate concerns made by the field of school psychology—despite many commonalities, each system articulates disability differently. As intended, House’s book will be most useful during the diagnostic phase of the school psychologist’s job—helping us with the interpretation and translation of student behavior or learning patterns. Just as important, however, is our ability to collaborate with teachers to move from diagnosis to intervention. How do the disorders under consideration play out in the educational setting and what are the effective interventions? How does the student with Oppositional Defiant Disorder respond to frustration in the classroom and what are the suggested treatment options for ODD? How flexible is the student with Obsessive Compulsive Disorder in responding to the differing demands of the adults in his school and what interventions can be implemented in the educational setting? Now that we can be more confident about using the DSM-IV for diagnosis, it would be extremely useful to have guidelines for the collaboration and intervention phase of our role as well—translating classroom-based behavior into DSM-IV criteria and subsequently
p91982$$40
12-28-99 10:33:55
BOOK REVIEW
p. 641
641
to translate a diagnosis into intervention strategies. Hopefully, to this end, House will next provide us with a guide for these tasks that is as thoughtful as the one he has given us for our diagnostic responsibilities.
REFERENCE Power, T. J., & DuPaul, G. J. (1996). Implications of DSM-IV for the practice of school psychology: Introduction to the mini-series. School Psychology Review, 3, 255–258.
12-28-99 10:33:55
p. 637
Book Review The DSM as a Second Language for the School Psychologist: A Guide to Translation House, Alvin E. DSM-IV Diagnosis in the Schools New York: The Guilford Press; 1999 230 pp., $28.95, ISBN 1-57230-346-8 Reviewed by: Margaret Inman Linn,* Center for Education, Widener University
The traditional role of the school psychologist is a familiar one. We are expected to be the first to interpret a student’s behavior or learning pattern and to translate that behavior into an educational diagnosis. We must then work with teachers to move from diagnosis to an effective intervention plan. Finally, we must explain the diagnosis and proposed intervention, originally developed in the language of special education, to the parents and the child. These multiple tasks require extensive knowledge of psychology, child development, and education. We now face a new professional demand. Hoping for additional resources to cover the rising costs of special education, school administrators are now looking to insurance providers for reimbursement of services provided to children with special needs. To satisfy the requirements of insurers for reimbursements, school psychologists will be expected to turn a child’s educational diagnosis into a psychiatric diagnosis using the language of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. In DSM-IV Diagnosis in the Schools, Dr. Alvin House provides the school psychologist with a dictionary to make the required translations. Today school psychologists, the gatekeepers of special education services, make placement decisions based on our classification system—Individuals with Disabilities Education Act (IDEA). Most of us have acquired our expertise in schools of education and have limited experience with the primary language of the psychiatric classification system, the DSM-IV. In this instructive book, House reassures us that school psychologists have the knowledge base and clinical skills necessary to master the imposing DSM-IV. He attempts to bridge the diagnostic gap between school psychologists and mental health professionals by promising a text that will familiarize us with the “main features of this (the DSM) approach to understanding and *Direct all correspondence to: Margaret Inman Linn, Center for Education, Widener University, One University Place, Chester, PA 19013. E-mail: ⬍[email protected]⬎. Journal of Applied Developmental Psychology 20(4): 637–641 Copyright 2000 Elsevier Science Inc. ISSN: 0193-3973 All rights of reproduction in any form reserved. 637
p91982$$40
638
12-28-99 10:33:55
p. 638
LINN
classifying emotional, behavioral, and cognitive disturbances in adjustment” (p. 11). His goal is to teach the practicing school psychologist how to use the DSM-IV in a thoughtful, ethical, and efficient manner, and he provides us with one tool to master this task. DSM-IV Diagnosis in the Schools is a resource, a reference book, a guide. With House’s guidance, it is possible to bridge the clinical and educational worlds. This text has many other uses beyond teaching the school psychologist to use the DSM-IV for diagnostic classification of students after evaluation. School psychologists are often required to interpret the reports of professionals working in clinics, agencies, and hospitals outside the field of education, and often these reports are written in mental health language and culminate in a DSM-IV diagnosis. With the growing awareness of the need to identify all degrees of disability as early in the child’s life as possible and the subsequent increase of clinics serving the early intervention population, it is more likely than ever that children with special needs will enter school with a DSM-IV diagnosis in hand. Additionally, the full inclusion movement has significantly increased the number of children with moderate to severe disabilities in our public schools. Generally, students who exhibit disabilities such as autism are diagnosed within the first few years of life and are reevaluated often—many have several diagnoses. With both populations, it is important that previous evaluation results be interpreted accurately and translated into educational terminology to provide an appropriate educational program. In addition, it is essential that someone in the educational system, most likely the school psychologist, be able to communicate with the mental health system that provides these services. The issue remains, however, that the medical and educational professions have fundamentally different conceptualizations of difference. At their most basic levels, the DSM-IV, written by physicians for physicians, classifies mental disorders; IDEA, written by legislators for educators, classifies educational disabilities. It should be no surprise that school psychologists may have difficulty fitting the criteria of the psychiatric classification system into the framework of special education. House’s book recognizes the incongruities of the two systems and provides an important first step to help us reconcile them. DSM-IV Diagnosis in the Schools is organized into three parts: an overview of the system and use rules, a presentation of the different symptom patterns (e.g., personality disorder) that a school psychologist may encounter, and an important discussion of the issues that may arise as we confront the DSM-IV (e.g., ethics, the case record, DSM-IV vs. IDEA). Part I, “Diagnostic Issues and the Use of DSM-IV,” is a primer on the DSMIV. This section presents an introduction to psychiatric classification and its relation to developmental issues and an overview of the DSM-IV diagnostic system. Professionals with either cursory or out-dated experience with DSM systems will find this section clearly written and very useful. House addresses basic questions such as: What is the difference between a disorder and a syndrome, a subtype and a specifier, recovered and full remission? What is an acceptable GAF? When is it appropriate to use a V Code, or the NOS option? This section presents the fundamentals of the classification system, first establishing terminology—defining and discriminating between disorder, illness, signs, symptoms, and syndromes—then providing a complete explanation of the Multiaxial Classification, axis by axis. Part I ends with a
p91982$$40
12-28-99 10:33:55
BOOK REVIEW
p. 639
639
useful discussion of diagnostic conventions and multiple diagnoses, providing the novice reader with a clear understanding of the structure of this often imposing system and the more experienced psychologist with an excellent review of the most important features of the DSM-IV Manual. When finished with Part I, the reader is likely to feel that mastery of DSM-IV is within reach. In Part II, “Guidelines for Evaluation of Presenting Problems,” House reviews categories of common presenting concerns for children and adolescents. The individual presentation of each disorder is well done—symptomatology, age-of-onset criterion, comorbid diagnoses, base rates, and potential uses of the category are discussed in reader-friendly terms for selected disorders. DSM-IV criteria are not reiterated, but House raises important differential diagnosis issues for each category. By the author’s admission, discussion of specific diagnoses is brief, often omitting information about the “pattern, course and variant expression” of a disorder and referencing is “sparse.” This is a wise choice, because this text is meant to be used in conjunction with the DSMIV—the author avoids redundant presentation of material. The length of discussion for each diagnostic category varies; some, such as ADHD (which underwent extensive empirical field testing for the DSM-IV) are lengthy, whereas others such as Selective Mutism are touched on lightly. Less helpful is the design of Part II, intended to help the reader develop “a rapid familiarity with the DSM-IV framework” (p. 40). The chapters are organized thematically rather than following the DSM-IV structure, and this may prove confusing for the novice diagnostician. It is the organization of the DSM-IV that first introduces a new user to the conceptual framework of the system, but this organizational structure is lost with House’s reinterpretation. Although some diagnoses are where one would expect—for example, in well-established categories such as externalizing problems, internalizing problems, personality disorders—others are in the author’s own, less familiar categories. For example, Sexual and Gender Identity Disorders, an entire chapter in DSM-IV, are discussed here under the category Highly Focused Symptom Patterns, a term not commonly used in diagnostics. Part III, “The Application of DSM-IV in School Settings: Issues and Topics,” is divided into several short chapters, more like essays, dealing with ethics, the case record, seeking reimbursement, IDEA, and concerns about psychiatric classification. In this section the author, speaking as a clinical psychologist with extensive experience training students in the assessment process, presents his views on differences between clinical and school psychologists, ethical and professional responsibilities, the limitations of clinical judgment and the biases of DSM-IV system. Readers will find the ethical and professional practice discussions enlightening and the more practical section on the process of seeking reimbursement to be valuable. Throughout the text, the author’s tone is supportive. His view that use of the DSM-IV is an appropriate and attainable professional activity for school psychologists will comfort the neophyte psychologist. He seems to anticipate our concerns. For example, in cases of diagnostic disagreement, House asserts that the “correct diagnosis is based on the best formulation of the data that is available at the time” (p. 192). He reassures us that our formulation need not agree with previous or future assessments performed by other professionals to be correct. He encourages us, but at the same time reminds us of our limitations and ethical responsibilities.
p91982$$40
640
12-28-99 10:33:55
p. 640
LINN
Mastering the DSM-IV is a major career task, and we are encouraged to go about this task responsibly, by seeking further training and supervision. Indeed, I envision school districts organizing in-service training using House’s text as a guide. Historically, the DSM-IV has not been regarded as particularly useful for the school psychologist. The four previous editions of the DSM did not correspond well to the P.L. 94-142 system and did not address strategies for assessment or intervention in education. However, with this most recent edition of the DSM, Power and DuPaul (1996), for example, encourage school psychologists to consider the Manual as a relevant tool for learning about the course of complex communication disorders and behavioral and social disorders (Power & DuPaul, 1996). Still, their enthusiasm is moderated by cautions about the limitations of the DSM system for educational applications, most notably the complex process of differential diagnosis. In DSM-IV Diagnosis in the Schools House handles this mismatch in a straightforward manner. He attempts to map the criteria for IDEA onto each DSM-IV diagnosis, while acknowledging the awkwardness of fit. Through his format of “IDEA Notes,” House discusses potential relationships between DSM-IV diagnoses (and, when appropriate, ICD diagnoses) and qualifying conditions for special education services under specific IDEA categories. IDEA Notes are used selectively, generally with regard to broad categories (e.g., Disruptive Behavior Disorders, Anxiety-Related Mental Disorders), and each note identifies the IDEA category that corresponds to the disorder. In some cases, additional information such as important forms of documentation and additional Axes information necessary for establishing eligibility for special education is included. Even with the valuable contribution of this text, the issue remains that the DSM-IV and IDEA are not congruent. Diagnosis of disability in special education is narrow, based on psychometric assessment of the student’s ability to function within the academic environment. Diagnosis of mental disorder is based on clinical judgment about the individual’s personal distress, their failure to adapt to that distress in all aspects of their lives, or both. House’s concerns about the difficulties in trying to map one system onto the other reiterate concerns made by the field of school psychology—despite many commonalities, each system articulates disability differently. As intended, House’s book will be most useful during the diagnostic phase of the school psychologist’s job—helping us with the interpretation and translation of student behavior or learning patterns. Just as important, however, is our ability to collaborate with teachers to move from diagnosis to intervention. How do the disorders under consideration play out in the educational setting and what are the effective interventions? How does the student with Oppositional Defiant Disorder respond to frustration in the classroom and what are the suggested treatment options for ODD? How flexible is the student with Obsessive Compulsive Disorder in responding to the differing demands of the adults in his school and what interventions can be implemented in the educational setting? Now that we can be more confident about using the DSM-IV for diagnosis, it would be extremely useful to have guidelines for the collaboration and intervention phase of our role as well—translating classroom-based behavior into DSM-IV criteria and subsequently
p91982$$40
12-28-99 10:33:55
BOOK REVIEW
p. 641
641
to translate a diagnosis into intervention strategies. Hopefully, to this end, House will next provide us with a guide for these tasks that is as thoughtful as the one he has given us for our diagnostic responsibilities.
REFERENCE Power, T. J., & DuPaul, G. J. (1996). Implications of DSM-IV for the practice of school psychology: Introduction to the mini-series. School Psychology Review, 3, 255–258.