Caveat Emptor: Considerations before Buying In to the "New" Medical Model.

* Forness and Kavale (2001) have argued forcefully that the field of emotional or behavioral disorders (E/BD) should embrace what they call the "new" medical model, which they represent as being a more relevant and effective version of the traditional medical model. They also suggest that this "new" medical model should be merged with a behavioral model to provide more efficacious services for children with E/BD. Forness and Kavale maintain that the addition of psychiatric diagnoses to functional analysis and positive behavioral support programming results in more beneficial treatment outcomes for students with E/BD. That is, the application of psychiatric diagnoses in the assessment process has treatment validity, which will enhance treatment outcomes above and beyond functional analysis and positive behavioral support alone. There are a number of issues that professionals in the field of E/BD should consider before unquestioningly buying into this "new" medical model. Forness and Kavale have focused much of their review on the recent findings regarding pharmacological treatment of children with attention deficit/hyperactivity disorder (ADHD); a category not formally recognized as such in the Individuals with Disabilities Education Act (IDEA). The position taken in this commentary is that there is nothing "new" in the proposed "new" medical model because it, like the traditional medical model, continues to engender a within-child, underlying disease process conceptualization of behavior at the expense of considering ecological (i.e., contextual, environmental) causative factors in determining behavior problems. In addition, there is little solid empirical evidence substantiating the position that psychiatric diagnoses have any substantial treatment validity. In short, it has not been demonstrated that these diagnoses have incremental value in producing better treatment outcomes. This article argues for using a resistanceto-intervention approach to E/BD for functional behavioral assessment and intervention (Gresham, 1991; Gresham, Lane, & Lambros, 2000) rather than unequivocally adopting the medical model conception and treatment of E/BD advocated by Forness and Kavale. The resistance-to-intervention model would identify students as eligible for E/BD services if, and only if, they fail to show adequate response to interventions that have been implemented with integrity over a reasonable period of time. Is the Medical Model Adequate in Explaining Behavior? Perhaps the most disquieting aspect of the call for the new medical model is that it medicalizes the entire field of E/BD based primarily, if not exclusively, on an appeal to authority (i.e., medicine) rather than on sound empirical evidence. In fact, the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) of the American Psychiatric Association (APA, 1994) requires that for a diagnosis of most Axis I disorders (e.g., ADHD, conduct disorder [CD], oppositional defiant disorder [ODD]), it is necessary to establish that the disorder is not due to a general medical condition. As such, it would seem necessary to consult a physician before making any of these DSM-IV diagnoses. If practitioners in the field of E/BD are to use psychiatric diagnoses from the DSM-IV, then school districts must be prepared to (a) make financial considerations for physicians to assist in making these diagnoses and/or (b) relinquish primary control over their assessment and intervention processes to the medical-psychiatric community. However, I have a more fundamental disagreement with the medical model that is reflected in the following logic used by Forness and Kavale (2001): [A]pproximately two-thirds had a definitive psychiatric diagnosis other than ODD/CD based on structured interviews ... approximate odds from both types of estimates are that at least three in every five cases of ODD/CD appear to have an underlying psychiatric diagnosis that probably accounts for the noncompliant or aggressive classroom behavior in question. …