Educational Versus Medical: Why You Need to Understand the Difference!

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Medical Versus Educational Diagnosis

The word diagnosis is thrown around a lot when it comes to educational issues. This is VERY important: the school CANNOT make a MEDICAL diagnosis for your child! When the school says your child has autism and they will provide special education services to your child they are NOT medically diagnosing them with autism! What the school is saying is that your child fits the educational definition of autism as defined by your state.  

Under federal law (IDEA) there are only 13 categories that are recognized. These are autism, emotional disturbance, hearing impairment (including deafness), intellectual impairment, other health impairments, orthopedic impairment, specific learning disabilities, speech or language impairment, traumatic brain injury, and visual impairment (including blindness).  A school will only provide special education services IF your child falls into one of these categories.  Also, each state may have further refined how each category is defined making things more complicated.

A medical diagnosis is made when someone fits a medical definition for a condition.  This definition is found in the Diagnostic and Statistical Manual (DSM V).  We are currently on the fifth edition.  The medical diagnostic criteria for autism is:

Diagnostic Criteria for 299.00 Autism Spectrum Disorder

• Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text):

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understand relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

There is more to the definition but you get the idea.

You will often see a doctor use a ICD 10 billing code. Autism is F84.0. For medical billing you WANT SPECIFICALLY F84.0 versus F84.5 which is Asperger's syndrome. Why? Because your insurance company will probably reimburse you for F84.0 but not for F84.5! It is very important to pay attention to medical billing codes! Medical billing codes dictates what an insurance company will cover in the way of therapy and equipment. If you ever want to look at 

Related Services

These are the services you get from a school district like occupational, speech, and physical therapy.  These are the most common related services but there are many more that you can get in the educational setting.  I want to explain the difference between medical therapy and educational therapy.  This is VERY important for parents to understand since it is the source of many disagreements parents have with their local school district.

Medical versus Educational Model of Therapy

Educational Model
The Educational Model focuses on the skills impacting educational performance in all subject areas. Deficits are addressed through an Individual Education Plan (IEP) or 504 Plan that is agreed upon by the school-age child’s educational team. This model will focus solely on the outcome that enables a child to benefit from his/her educational program. Therefore, the school therapist(s) [Physical Therapist (PT), Occupational Therapist (OT), Speech Therapist (ST), or a combination thereof] will direct therapy so the child will gain skills to maximize his/her opportunities within the school environment. Therapy services are provided in school and most often within a group or classroom setting.

Eligibility: Eligibility for related services must be based on assessment, an educational need for service, and there must be approval of the IEP team.

Medical Model
The Medical Model generally focuses on the impairment regardless, of severity level to ensure that the child can successfully perform the basic activities of daily living (i.e., putting on their clothes, feeding themselves, speaking clearly their wants and needs, walking). Services are performed on a one-on-one basis in an outpatient clinic.

Eligibility: The physician or other certified practitioner along with a child’s parents/ guardian and licensed therapist determine the severity and impact on developmental areas or self-care skills and develop a Plan of Care (POC) for the therapist to follow.

Why is this Important?

Personally, I prefer medical therapy. Why?  The child gets direct one-on-one service with a therapist, there is no need to call a meeting to determine service, and the parent gets to help determine the goals of the therapy while educational therapy has the goals determined by others. I have rarely had my children in public school to take advantage of educational therapy.  We tends to stick with medical therapy. When they were small (4 years old) we got both educational therapy through the school and medical therapy from our insurance.  Yes, you can do both!  I HIGHLY urge you to do both if you have the opportunity! Why? Because it is practically impossible to get too much therapy!  Therapy is VITAL to resolve educational and sensory issues that impair learning! Even now, while we homeschool, therapy is the main goal for my children; not academics! They can learn better when their issues are addressed so it's worth spending the time on therapy.

I know this is a brief explanation but I hope this helps you understand the subtle but important differences in the medical versus educational model of therapy.  Please feel free to contact me if you have any questions.  You can also join my Facebook group at IEP Assistance and Special Needs Parenting Advice.