JURIST Guest Columnist Susan Schneider, Syracuse University College of Law, Class of 2015, explores criticisms of the DSM-5 after the US Supreme Court used it as the sole national standard to define intellectual disability in Hall v. Florida…In its 2002 decision Atkins v. Virginia, the US Supreme Court declared that executing a person with intellectual disability is cruel and unusual punishment in violation of the Eighth Amendment. In the opinion, the court did not thoroughly explain how states were to define intellectual disability, only stating that it requires “subaverage intellectual functioning,” “significant limitations in adaptive skills” and that both of which must “manifest before age 18.” As for specific methods for identifying such factors, none were given: “we leave to the States the task of developing appropriate ways to enforce the constitutional restriction upon its execution of sentences.”

Twelve years later, in Hall v. Florida, a discussion at the highest level has finally taken place regarding the definition of intellectual disability. Hall, on death row since 1981, appealed his sentence several times throughout the years, most recently on grounds of intellectual disability. In order to prove “subaverage intellectual functioning,” Florida required an IQ score of 70 or below. Hall’s lowest admissible IQ score was 71. That one-point difference barred Hall from offering any other evidence of intellectual disability, including the testimony of teachers, family members, doctors and experts that Hall had “significant limitations in adaptive skills.” Hall’s appeal reached the US Supreme Court this year.

The decision handed down by the court in Hall declared that Florida’s interpretation of their own state law was unconstitutional. They deemed the strict IQ score cutoff as inappropriate and that, within a certain range, defendants must be allowed to present additional evidence of intellectual disability. On the surface, this defining moment for intellectual disability is more expansive, less reliant on strict test scores and gives a better understanding of how the first two requirements from Atkins should be applied. However, the method the court used to come to such a conclusion is much debated.

The first and most substantial method the court utilized when constructing its more expansive definition was to consult the work of medical experts and professionals. This is extremely common for all levels of courts and legislatures when working with medical assessments and examinations. However, except for research on successfully administering IQ tests and attaining accurate scores, the court relies almost exclusively on the American Psychological Association (APA) and the American Psychiatric Association’s publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to guide their definition of intellectual disability.

The problem here lies not in the definition itself, but in the reliance on the DSM-5 as a national standard. The court split 5-4 on the Hall decision, and the dissent strongly criticized the court’s reliance on the DSM-5 as “sharply depart[ing] from the framework prescribed in prior Eighth Amendment cases and adopt[ing] a uniform national rule that is both conceptually unsound and likely to result in confusion.”

Although the APA is one of the most recognized organizations in the field of psychology, and the DSM has commonly been referred to as the “bible” within the field of psychiatry, the American Psychiatric Association does not hold exclusive rights on defining intellectual disabilities or disorders, nor is there a consensus within the field that the DSM is correct. In fact, over 50 organizations openly criticize the DSM-5 and called for severe revisions before its distribution, including well over a dozen divisions within the APA.

The dissent described several issues with relying on a single organization’s viewpoints. First, the court strayed from basing standards on those held by American society as a whole and instead based them on standards held by professional societies—most notably those reliant on the DSM-5. Essentially, this ruling allows a single organization to control the standards by which we define intellectual disability across the nation and endorses the APA and their DSM-5 as the sole national standard. As the dissent poignantly notes, this decision elevates the American Psychiatric Association’s current views to a constitutional level.

Second, the dissent remarks that this reliance and endorsement may lead to confusion as the American Psychiatric Association’s views will change in the future. As a fifth edition, this DSM provides the fifth version of the APA’s position on and definition of intellectual disability. It is certain that there will be future versions of the DSM, and that those editions will add to, edit, detract from or possibly rescind current definitions and standards.

Lastly, the dissent notes that the DSM-5 is meant as a diagnostic tool for social services, such as school aid, employment accommodations and health insurance. The DSM-5 is not tailored for analyzing the penological determinations necessary to determine if the death penalty is appropriate for an individual, such as the correlation between criminal activity and the severity of the punishment.

But the issues do not end there. Of the numerous experts and organizations that criticize the DSM-5, the most concerning complaint is the lack of scientific rigor and independent review. One of the main components of a proper and valid scientific theory or declaration is that it be subjected to peer review and publication, and gain validity in the relevant scientific community; in this case, psychiatry.

Allen Frances, MD, chaired the previous DSM’s task force, but now staunchly opposes the DSM-5. Accordingly, he attests that the American Psychiatric Association ignored professional, public and press accusations that the revisions produced within the DSM-5 lacked scientific support. Frances stated that “field trials produced reliability results that did not meet historical standards and deadlines were consistently missed.” Frances further stated that “the opposition to the DSM-5 comes from all over the world and includes tens of thousands of psychiatrists, clinical psychologists, counselors, social workers and other mental health practitioners.” The people who oppose DSM-5 belong to many different schools of thought, but unite in the worry that it is not safe or scientifically sound. In no way has the DSM-5 attained the necessary “widespread acceptance” to be considered the sole source for a national standard, at a constitutional level, by the highest court in our country.

This lack of independent review and acceptance may stem from an even more critical aspect, the growing influence of the pharmaceutical industry on the changes integrated into the DSM-5. The percentage of task force members who have financial ties to the pharmaceutical industry has grown from 57 percent for the DSM’s fourth edition, to 69 percent for the DSM-5. The many that criticize the DSM-5, including several divisions within the American Psychological Association, argue that the manual has taken a huge step towards overly “medicalizing” disabilities and disorders.

With so many in the disability community fighting society’s generally-held medical view of their abilities (an individual has a problem or illness that must be cured), and actively encouraging a social view instead (an individual may need accommodations, but is a person first instead of a medical diagnosis), a task force that favors viewpoints and opinions offered by the pharmaceutical industry is one to be closely scrutinized. If this task force does not take into account criticism of their guidelines on research, independent peer review and the soundness of their methods and conclusions, the American public should also be concerned.

American society and medical professionals should sit up and take notice when this task force, under the auspices of the American Psychiatric Association, becomes thoroughly endorsed and relied upon by the US Supreme Court as the sole source defining intellectual disability. Their opinions are elevated to a constitutional level as the single organization to create, maintain and revise a national standard.

The Supreme Court could have easily avoided such a sweeping endorsement of the American Psychiatric Association and their DSM-5 as the sole source for a national standard by incorporating other organizations into their opinion. There are many within the medical field and the disability community that adamantly agree with the new, more expansive and flexible criteria for defining intellectual disability laid out by the Supreme Court’s ruling, but the court’s obvious preference for and reliance on the DSM-5 deserves criticism.

Susan Schneider earned her Bachelor of Arts from Binghamton University. She is a joint J.D./M.S. candidate in Cultural Foundations of Education with a Certificate for Advanced Study in Disability Studies from Syracuse University School of Education. She works as a Law Research Assistant at the Burton Blatt Institute and is an editor for the Disability Law & Policy e-Newsletter.

Suggested citation: Susan Schneider, Hall v. Florida: Over Relying on a Single Source to Set a National Standard , JURIST – Dateline, July 31, 2014, http://jurist.org/dateline/2014/07/Susan-Schneider-intellectual-disability.php