Medical Diagnosis vs. IEP Eligibility: What is the Difference?

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Parents are often surprised to learn that a medical diagnosis, such as autism, is not all that is needed to qualify for an IEP (Individual Education Plan). This medical vs. educational question also frequently comes up with ADHD and when schools resist using terms like “dyslexia.” So, what’s the deal? Good question. 

In this article I’ll go over the difference between a medical diagnosis and eligibility for an IEP, and I’ll include some tips for working with the school when you have a medical diagnosis for your child.

The Highlights:

  • A medical diagnosis is not sufficient to qualify for an IEP, but it can help get the process started
  • Just like you can have a medical diagnosis and not qualify for an IEP, a student may also qualify for an IEP but not fit the diagnostic criteria for a medical diagnosis 
  • You do not have to disclose your child’s medical diagnosis or outside evaluations to the school
  • If you decide to disclose your child’s diagnosis to the school, you do not have to provide more than the fact of the diagnosis (e.g. a letter from the diagnosing professional) 
  • Providing the full evaluation results and/or recommendations from the diagnosing professional may help the school with its evaluation, and ultimately may help your child as well
  • If you’re unsure what to disclose or when, or unsure what the school’s response means, an education lawyer can advise you

Fact: A medical diagnosis does not automatically qualify a student for special education and related services (an IEP).

A common tale: You’re a parent. You know your child is struggling in school. You ask the pediatrician about it. Pediatrician sends you to another professional. That person does a million tests, evaluations, and assessments. You do all the questionnaires. You get back a diagnosis. Great! (This is best case scenario. Often, getting a diagnosis is so. much. harder.) 

Now, off you go to the school, letting them know of the diagnosis. You expect an IEP. Finally, some help! 

But wait. The school says they need to do evaluations. Why?? More evaluations??! Well, yes. That is how it works. It might feel like you’re being misled. You’re not (for now). 

Medical Diagnosis vs. IEP Eligibility

What is a Medical Diagnosis?

  • Made by a medical doctor or other clinical professional (this one is pretty obvious)
  • Made in relation to a need for treatment based on diagnostic criteria (e.g. from Diagnostic and Statistical Manual of Mental Disorders (DSM). The most recent version of the DSM is DSM-V-TR, published by the American Psychological Association in March 2022).
  • Aim to maximize the patient’s quality of life    

What is an IEP Eligibility Determination?

  • Made by a group of educators, admin, school personnel, and the parent (the IEP team)
  • Made in relation to a need for services based on requirements set out in the Individuals with Disabilities Education Act (IDEA)
  •  Aim to allow the student to access their education

Why does the school want to do their own evaluations?

Short answer: the disability has to affect the student’s education for the child to qualify for an IEP but not for a medical diagnosis. 

Longer answer: While the school may use testing results done by a doctor, psychologist, or other clinician in determining IEP eligibility, the standard is different.  

To qualify for an IEP, a student must,

  1. Have a disability that falls under one of the 13 categories of disability under the IDEA (34 C.F.R. §300.8), and
  2. Because of the disability, need special education and related services to be involved in and progress in the general education curriculum.
 
A medical diagnosis may be enough to meet the first requirement, but a that alone doesn’t show an effect on the child’s education or a need for specially designed instruction (i.e. special education). 

The school will probably want to do their own testing. They should consider recommendations from any testing results or diagnosis you provide. Have the data to back up your requests for any accommodations, modifications, and services. 
 

Notes and Take Aways:

Schools and school personnel do not “diagnose.” They (together with the parent) identify eligibility. Maybe that seems like splitting hairs. And maybe it is overly technical. I get it. This is a strange world. But, that is how things work. This is the language schools use and the procedure they follow to determine eligibility. 

A child does not have to fit DSM criteria for autism, for example, to qualify for an IEP under the autism eligibility category under IDEA. The criteria and standards are not the same. So, a student may have a medical diagnosis indicating a disability but meet IEP eligibility criteria under a different category (e.g. ADHD diagnosis, Specific Learning Disability (SLD) eligibility based on school testing). 

For a medical diagnosis, the actual diagnosis determines what treatments, medications, or therapies may be available through insurance. With IEP eligibility, though, once the child has qualified for an IEP, the actual category of eligibility is not as important.* An SLD eligibility category may lead to an IEP that has accommodations for executive functioning deficits common to ADHD, for example. 

Now that you know the difference between medical diagnosis and IEP eligibility, you can move on to making sure the school tests in all areas of suspected disability using appropriate evaluations, and working with the team to determine eligibility and identify the supports your child needs to access their education. 

*Caveat about category of eligibility not being as important: One category of eligibility, Emotional Disturbance (ED), can carry a stigma. It shouldn’t, but it might. Adults have their biases. If there is another option of eligibility, people often prefer not to select ED. Also note that anxiety may qualify under the Other Health Impairment (OHI) category and need not be labeled ED (check your state on this. And, it may take some advocacy skills to get there). 

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