Ignoring the Odds: Hazards of Not Adding the New Medical Model to Special Education Decisions:

The medical model of special education assumes that within-child or internal factors are etiologies of disordered school behavior. It traditionally has competed with the behavioral model, which assumes causation from environmental or external factors (Hewett & Forness, 1984). The behavioral model, however, has long been dominant within special education, especially for children with emotional or behavioral disorders (E/BD; Kauffman, 2001). Indeed, the medical model has been out of favor for so long that most professionals now active in special education do not remember its ever having been acceptable. Its origin in modern-era special education for children with learning or behavioral disorders was early in the second half of the 20th century, when underlying psychodynamic conflicts or, subsequently, minimal brain dysfunction were seen as etiologies of disordered school behavior or learning. It was assumed that these factors had to be diagnosed and treated before any meaningful school intervention could proceed. Such an interpretation of the medical model, at least at that moment in our understanding, probably deserved to be vilified. The point has been made, however, that the medical model can be interpreted as synonymous with scientifically based practice (Kauffman & Hallahan, 1974). In recent years, diagnosis prior to or concurrent with school treatment has gained considerably more significance, based on current evidence in genetics (Faraone, Tsuang, & Tsuang, 1999; Mash & Barkley, 1996; State, Lombroso, Pauls, & Leckman, 2000), brain imaging (Hendren, De Backer, & Pandina, 2000), and treatment validity (Mash & Barkley, 1996; MTA Cooperative Group, 1999a, 1999b) of child psychiatric disorders. Current mental health policy has thus begun to focus on destigmatization of such psychiatric disorders, given evidence that their treatability has in many cases begun to rival that of nonpsychiatric medical disorders (U.S. Surgeon General's Office, 2001). It is also safe to assume that those children identified in the category of emotional disturbance (ED) probably represent the most impaired of all children with emotional or behavioral disorders and are thus more likely to have a neurobiologic etiology (Forness et al., 1998; Gresham et al., 1998; Redden et al., 1999). Even postmodernists in special education might have a difficult time defending the proposition that these children are casualties simply of poor environments or of sociopolitical construction. A few children in the ED category may very well be products of an inconsistent or even psychopathogenic environment, but most children who represent the less than 1 % identified in this category are probably those whose behavioral or emotional responses are viewed, even by families and friends, as problematic within their immediate social context. Within-child or neurobiologic factors are probably more likely than environmental factors to be primary determinants of the poor emotional or behavioral development of these children. Functional behavioral analysis and subsequent behavioral intervention may well need to take specific psychiatric diagnoses into account, particularly in the case of those psychiatric disorders in which psychopharmacologic treatment appears to be critical to successful outcome. This is not to say that environmental events are inconsequential in either the expression or ultimately the treatment of children with E/BD. It is to say, however, that careful diagnosis has now become much more critical to effective treatment of these children and that a new version of the medical model may be fundamental to their special education outcome. This new version, rather than insisting that psychiatric diagnosis somehow determines choice of classroom management system or instruction in a behavioral intervention, posits that the most effective intervention likely involves a combination of behavioral and medical (i.e., psychopharmacologic) approaches. …