I have had many parents become confused as to why their child might qualify for autism in a doctor’s setting, but the school says the child does not qualify for an IEP. Conversely, some students qualify for an IEP under the autism category, but despite repeated clinical assessments, they do not qualify for a clinical diagnosis.
What is the difference between the educational and clinical ‘diagnosis’ of autism?
The main difference between educational vs. clinical diagnosis is the fact that the school is not doing a full-blown autism assessment. They are looking for particular autistic behaviors known to cause problems in the school. Each state establishes the criteria they are looking for. As a result, a student is not receiving a diagnosis, but simply fits a set of criteria for one of the qualification categories on the IEP.
Understand how the school qualifies.
The goal of the school assessment process is to determine if a student qualifies for special education services. The goal is not to determine if the student has a clinical diagnosis of a condition. The student must pass BOTH qualification criteria to get an IEP:
- The student qualifies for a disability under one of the 13 categories listed on the IEP (autism being one of them).
- The student’s disability interferes with their ability to make progress in the educational setting.
When a school qualifies for criteria 1, they usually administer a simple autism assessment such as ADOS. This assessment involves several adults filling out questionnaires and then adding the numbers to see if the student fits the threshold for autism. ADOS is sometimes used in clinical settings, but it is only ONE of several methods used by doctors to diagnosis autism. The school on the other hand uses it to determine if the student presents with one or more of the most common symptoms of autism. If they do, they would satisfy criteria 1.
California Educational Autism ‘Diagnosis’ Criteria
The IDEA 34 CFR 300.7(c)(1) describes autism as: Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, that adversely affects a child’s educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. The term does not apply if a child’s educational performance is adversely affected primarily because the child has an emotional disturbance as defined in 34 CFR 300.7(b).
In the California Administrative Code, Title 5, Section 3030(g) it further elaborates and establishes 7 symptoms of autism they are looking for in the educational setting. The student must exhibit 2 or more of the following autistic-like behaviors:
- An inability to use oral language for appropriate communication.
- A history of extreme withdrawal or relating to people inappropriately and continued impairment in social interaction from infancy through early childhood.
- An obsession to maintain sameness.
- Extreme preoccupation with objects or inappropriate use of objects or both.
- Extreme resistance to controls.
- Displays peculiar motoric mannerisms and motility patterns.
- Self-stimulating, ritualistic behavior.
If a student in California has 2 or more of these behaviors, they would meet the standard for criteria 1 of the qualification process. This is not a diagnosis of autism. Indeed, students with ADHD, sensory processing disorder or severe anxiety may qualify using these criteria. It does not mean they are autistic, just that they fit into the educational mold of autism.
Look up the special education law in your state to find out how your state qualifies educational autism.
Clinical Autism ‘Diagnosis’ Criteria
The goal of a clinical diagnosis of autism is to determine if any treatments or therapies are needed outside of school, and to make sure those treatments will be covered by insurance.
The criteria for autism diagnosis in DSM-5 is similar to the educational criteria, but it has more specific criteria and more pervasive presentation. To be diagnosed with autism, the student must have all 3 of the following criteria:
- Difficulties in social emotional reciprocity, including trouble with social approach, back and forth conversation, sharing interests with others, and expressing/understanding emotions.
- Difficulties in nonverbal communication used for social interaction including abnormal eye-contact and body language and difficulty with understanding the use of nonverbal communication like facial expressions or gestures for communication.
- Deficits in developing and maintaining relationships with other people (other than with caregivers), including lack of interest in others, difficulties responding to different social contexts, and difficulties in sharing imaginative play with others.
The criteria in the DSM-5 also specifies that 2 of the following 4 repetitive and/or restricted behavior, interests, or activities are present:
- Stereotyped speech, repetitive motor movements, echolalia (repeating words or phrases, sometimes from television shows or from other people), and repetitive use of objects or abnormal phrases.
- Rigid adherence to routines, ritualized patterns of verbal or nonverbal behaviors, and extreme resistance to change (such as insistence on taking the same route to school, eating the same food because of color or texture, repeating the same questions); the individual may become greatly distressed at small changes in these routines.
- Highly restricted interests with abnormal intensity or focus, such as a strong attachment to unusual objects or obsessions with certain interests, such as train schedules.
- Increased or decreased reactivity to sensory input or unusual interest in sensory aspects of the environment, such as not reacting to pain, strong dislike to specific sounds, excessive touching or smelling objects, or fascination with spinning objects.
The DSM-5 has also added a severity rating to the autism diagnosis. There are 3 levels of severity:
- Level 1. “REQUIRING SUPPORT”: Individuals with this level of severity have difficulty initiating social interactions, may exhibit unusual or unsuccessful responses to social advances made by others, and may seem to have decreased interest in social interactions. Additionally, repetitive behaviors may interfere with daily functioning. These individuals may have some difficulty redirecting from their fixed interests.
- Level 2. “REQUIRING SUBSTANTIAL SUPPORT”: Individuals with this level of severity exhibit marked delays in verbal and non-verbal communication. Individuals have limited interest or ability to initiate social interactions and have difficulty forming social relationships with others, even with support in place. These individuals’ restricted interests and repetitive behaviors are obvious to the casual observer and can interfere with functioning in a variety of contexts. High levels of distress or frustration may occur when interests and/or behaviors are interrupted.
- Level 3. “REQUIRING VERY SUBSTANTIAL SUPPORT”: This level of severity causes individuals with ASD severe impairment in daily functioning. These individuals have very limited initiation of social interaction and minimal response to social overtures by others and may be extremely limited in verbal communication abilities. Preoccupations, fixed rituals, and/or repetitive behaviors greatly interfere with daily functioning and make it difficult to cope with change. It is very difficult to redirect this person from fixated interests.
Individuals who only exhibit the social/emotional challenges of autism would be given the diagnosis of Social Pragmatic Language Disorder (SPLD) in a clinical setting, but in an educational setting they could qualify for an IEP under autism.
Lack of Educational Progress is the Key to Qualification
What often happens in the educational setting is parents show up with a clinical diagnosis of autism, which the school has difficulty refuting. Then the school assesses for how behaviors may impede the educational progress of the student, and that is often where the student does not qualify.
While the autism may be obvious, the student may be making fine progress in school. This would mean the student does not satisfy criteria 2 for qualification for an IEP.
When this is the case, the parent must write detailed parent concerns and help make the case for their child needing extra support in school. It is common for schools to deny IEPs because students have good grades, ignoring the extra effort and stress they require to get those good grades.