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Medical Diagnosis of Autism vs. Educational Eligibility of Autism

After working in the field of ABA therapy services for over ten years, I still find that families express confusion regarding the difference between a medical diagnosis of autism and an educational eligibility evaluation for autism within the public school system.

A medical diagnosis of autism spectrum disorder (ASD) is typically provided by a psychologist, developmental pediatrician, or neurologist. This clinician will perform a comprehensive battery of assessments that may include measures such as the ADOS-2 (Autism Diagnostic Observation Schedule-2), CARS-2 (Childhood Autism Rating Scale-2), ASRS (Autism Spectrum Rating Scale) and other related assessment scales. After gathering extensive background information on the child and interpreting the results of the assessments administered, the diagnosing provider will determine if the child meets the diagnostic criteria for autism spectrum disorder according to the Diagnostic and Statistical Manual of Mental Disorders – 5 (DSM-5). Based on the DSM-5, the child must have (1) persistent deficits in social communication and social interaction across multiple contexts as well as (2) the presence of restricted, repetitive patterns of behavior, interests, or activities. These symptoms must have been present during early development, cause clinically significant impairments, and not be better explained by another disability or developmental delay. The DSM-5 also currently requires the diagnosing provider to classify the severity of autism from level 1 (requiring support) to level 3 (requiring very substantial support). Additionally, the provider should also specify whether the child has a language impairment or cognitive impairment. The official medical diagnostic code for autism spectrum disorder is F84.0. A medical diagnosis of autism spectrum disorder is required by most insurance companies to access therapy services like ABA, speech, occupational, or physical therapy. Additionally, most insurance companies are now requiring an updated medical diagnosis every three years.

An educational eligibility evaluation for autism within a child’s school district will look slightly different from a medical evaluation for autism. It is conducted for the purpose of determining whether the child will qualify for access to special education services. While similar assessment measures may be completed during a school eligibility evaluation, it will not provide your child with a diagnosis of autism spectrum disorder. The child will typically be evaluated by a multidisciplinary team comprised of a licensed specialist in school psychology (LSSP), speech pathologist, and other special education team members. A school eligibility evaluation under the classification of autism is based on federal law (IDEA – Individuals with Disabilities Education Act), and generally refers to a broad disability category. If your child is evaluated and determined to qualify for special education services under the category of autism (AU), he or she may be provided accommodations or modifications to the regular education environment. An individualized education plan (IEP) or 504 plan will be developed by the public school system and will outline the specific details of your child’s services and goals. If your child qualifies for special education services within the public school system, your family will still need to gain a medical diagnosis of autism in order to access therapy services outside of the school setting and vice versa (e.g., a medical evaluation of autism does not secure your child immediate access to special education services within the public school system). Both types of evaluations will be required to access school and private therapy services.

If you have additional questions regarding a medical diagnosis versus educational eligibility under the category of autism, or if you would like to schedule a consultation to discuss your child’s diagnosis and IEP, please reach out to Dr. Hoppe to schedule an appointment today. NTX Psychological Services, PLLC is located in McKinney, Texas.

1 Comment

May 05, 2023

I found this article to be so helpful in clarifying the distinction between the medical diagnosis of autism and the educational diagnosis of autism. It is clear that both evaluations are required to get medical and educational services for a child.

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