Limitations of the DSM-IV
Natalie Muth (leader), Angela Fry, Sarah Remakel-Henkles, Lisa Ludwig, Emily Olsen, Lauren Kittelson, Mark Groen, Amy Zirkelbach, Jaime Strickler, Jodi Albertson, Patresa Hartman

Limitations of the DSM-IV are listed as follows:

• Creates labels for individuals diagnosed using DSM-IV criteria. Such labels can stigmatize and discriminate.
  
• Diagnostic criteria are not valid for many DSM-IV disorders.
  • Lacks predictive validity
    • Diagnostic systems are not always linked to treatment outcomes.
• DSM-IV criteria are not always reliable.
  
  • Test-Retest reliability
    
    • Diagnoses have been known to change over time.
      
    • Symptoms associated with a disorder tend to change or disappear over time.
  • Interrater reliability
    
    • One diagnostician may diagnose a group of behaviors as a particular disorder, where another diagnostician may categorize the symptoms as something else.
      
• DSM-IV classifications oversimplify psychological phenomenon.
  
• DSM-IV diagnostic systems are not linked to treatment.
  
• Centers the problem within the individual rather than considering situational events or context.
  
• DSM-IV lists symptoms but fails to tell diagnosticians how to properly assess whether or not a client exhibits specific symptoms.
  
• The DSM-IV groups behaviors as constructs.
  
  • Constructs are hypothetical and subjective.
    
• Many diagnostic criteria overlap between disorders.
  
• Classifies individuals by disorders rather than an individual.

Applying the DSM-IV Criticisms to Other Diagnostic Classifications

• Functional Behavioral Analysis
  
  • Does not categorize using DSM-IV criteria.
    
  • Considers the environment and situational variable rather than putting the problem within the individual.
    
  • Behavior observed is linked to interventions.
    
  • Does not put a label on observed behaviors.
    
• IDEA
  
  • Labels are used for placement in educational settings.
    
  • Labels help professionals communicate.
    
  • Labels may create self-fulfilling prophecies.
    
  • Produces funding for individuals and/or institutions.

Advantages of the DSM-IV

• Helps professionals communicate understanding about specific individuals.
  
• Many times DSM-IV diagnoses are required for certain families and/or institutions to receive funding.
  
  • Schools cannot receive necessary funding without percentage of children who have a diagnosed disorder.
    
• Sometimes gives patients an answer to what they have been dealing with. They may feel relieved their problems are linked to a disorder and/or know that others suffer from similar symptoms.
  
• There are many DSM-IV disorders, which are biologically/genetically linked, and thus DSM-IV criteria for these disorders are valid and linked to treatment outcomes (e.g., schizophrenia, dementia, depression).

Reason why Classification Systems are Relevant for School Settings

• Diagnostic systems relevant to receive 504 plan (without 504 plan regular education children with special needs may not receive necessary services).
  
• Diagnostic systems help professionals communicate (e.g., symptoms to look for).
  
• Diagnostic systems sometimes relevant in order to receive special services (e.g., medical, psychological, counseling).

Reasons why Classification Systems are not Relevant for School Settings

• Separates children, which can cause stigmatization and limit learning opportunities.
  
• Can create self-fulfilling prophecies among teachers and school personnel.
  
• Puts labels on individuals.
  
• Classifies a person by a disorder or disability rather than as an individual.
  
• Centers problems within the child rather than considering situational factors or classroom/school environment.

Possible Alternative to Diagnostic Schema

• Approach every student on an individual bases, identifying both positive and negative characteristics (e.g., this individual is 2 grades below in reading, but performs in the above range on the WISC, is 1.5 grades above in math, and demonstrates difficulty concentrating in all school subjects).
  
• Classify in grandiose categories (e.g., have 2 diagnostic categories, those with special needs and those without).

Group discussion: Yi Ding (group leader), Mike, Wes, Julie, & Joe

I. Use of Diagnostic Systems
Diagnostic Systems remain the most well-developed procedure for determining the need for service. Formal diagnostic systems will probably continue to be used for placement decisions until decision-making systems with better validity, reliability, and practicality and designed. The diagnostic systems exist for several reasons, such as identifying services needs, enhancing communication among professionals, and basing practice on research findings. There are also financial, administrative, advocacy, and other reasons for diagnostic systems.

II. Diagnostic Systems
There are a number of diagnostic and pseudodiagnostic systems, including Section 504 of the Rehabilitation Act of 1974 and The American Association on Mental Retardation's publication Mental Retardation (1992) publication Mental Retardation: Definition, Classification, and Systems of Support, among others. The classification systems associated with the 1990 implementation of the Individuals with Disabilities Education Act (PL101-475) and the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) have had the daily diagnostic work of the psychologist who practices with school-aged children.

1. The Diagnostic and Statistical Manual of mental Disorders
The ancestor of the well-known modern version of the DSM-IV (American Psychiatric Association, 1994) was published in 1894. The manual was the foundation for the modern International Statistical Classification of Diseases, Injuries, and Causes of death (ICD). The DSM-IV fills the gaps in the ICD by providing a comprehensive classification of mental disorders and it provides scientific support for its diagnostic criteria. The DSM-IV used literature reviews, data reanalyzes and field trials to develop many of its classifications.
2. DSM-IV Diagnostic Criteria for ADHD
The ADHD criteria of the DSM-IV provide a useful example of the modern status of the DSM system because they are based on extensive research. Modern research has allowed the DSM system to make great strides in its psychometric sophistication.
3. The Individuals with Disabilities Education Act
The IDEA nosology, more concerned with establishing eligibility for services, does not seek the diagnostic specificity of the ICD-9 or DSM-IV that is required to link specific interventions to diagnosis.
4. Dimensional and Categorical Methods of Diagnosis
Categorical systems are essentially dichotomous in nature. A dimensional approach allows the clinician to classify the full range of behavior for all children evaluated both in and out of the school. Dimensional approaches can have greater predictive validity than categorical methods.

III. The Traditional Clinical Diagnosis Strategies & Behavioral Assessment & Functional Analysis

1. Traditional Clinical Diagnostic Strategies
(1) The Diagnostic and Statistical Manual of Mental Retardation
The DMS is based on a structural model of assessment. The diagnosis is based on form or topograghy of behavior with little emphasis on the etiology of the category. Traditionally, the DMS has been rejected for a variety of reasons including the medical model conceptualization of behavior, various psychometric concerns over the application of the diagnostic process, the relevance for this particular model for designing special education programs, and more recently, treatment utility.
Several reasons for considering DSM might be advanced.
The first reason maybe that there is little empirical evidence showing it enhances the contributions to the selection, development, or implementation of treatment programs. The second, the application of the DSM diagnostic process is not static. Broad description of the topography of a disorder may prompt practitioners about symptoms to investigate further using empirically based measures.
The third, it does not specify the range, scope, and content of assessment tactics that might be used to render a diagnosis or treatment program. In many easy DSM is a "setting event" for a diagnostic problem-solving process that can expand in many directions with different devices.

(2) Multiaxial Empirically Based Assessment
As an alternative to clinical diagnosis using DSM, some have proposed a model of assessment labeled multiaxial empirically based assessment. In this assessment, multiple sources of data are gathered by multiple imformants along an axis approach which is applied which is applied within a developmental framework ranging from preschool to high school age: parent reports, teacher reports, cognitive assessment, physical assessment, and direct assessment of the child. This assessment approach is labeled empirical because the instruments have been normed and standardized and provide clinical cutoff scores for decision making the diagnostic process. The multidimensional approach to diagnosis assessment does share limitations with the DMS.

2. Other Analysis Strategies
(1) Behavioral Assessment Strategies
Behavioral assessors typically begin the diagnostic problem-solving by selecting a target problem behavior. The basic for keystone targets behavior selection are response covariation (i.e., important in target behavior in addition to the behavior initially targeted, and possibly improved, as a function of treatment) and template matching (involving analyzing the effective behaviors of individuals in a natural setting and using these as a standard for the target behavior of the client).

(2) Functional Analysis
Functional assessment involves an analysis of the functions of behavior: functions are related to such constructs as positive and negative inforcement. O'Neill, Horner, Albin, Storey, and Sprague (1990) indicated that functional analysis is complete when three main outcomes are established: (a) description of the undesirable behavior in operational terms; (b) prediction of the times and situations when the undesirable behavior will or will not be performed across settings; and (c) a definition of the functions, such s maintaining reinforcers, that the behaviors are producing for the individual. One methodology for functional analysis involves descriptive assessment. Another type of functional analysis involves creating an analogue to a natural setting and actually manipulating the conditions such as antecedents and consequences hypothesized to control behavior in this simulated environment.
As another opinion, analogue experimental approaches and descriptive methodologies can be combined to facilitate a functional analysis.

IV. Assessment Versus Diagnosis And Classification
Diagnosis is only the objectives of assessment. The objectives of the evaluation must be delineated at the outset of the assessment protocol since this decision affects test selection, scheduling, and virtually all other aspects of the assessment process. The adept psychologist will be mindful of the multiple purposes of the assessment to ensure that the primary questions of interest can be answered by the battery of tests and procedures utilized. Moreover, diagnosis is only one assessment purpose, and it should not be reified as the ultimate one. On the other hand, diagnosis may in some cases actually be orthogonal to the assessment process that is necessary for treatment planning or other objectives. What's more, diagnosis may have implications for treatment, depending on the results of research related to particular diagnoses.