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JCPSLP
Volume 16, Number 2 2014
Journal of Clinical Practice in Speech-Language Pathology
with less reliance on broad diagnostic labels and a greater
focus on the each person’s individual strengths, needs,
and learning profile. Tightening the criteria to exclude
children with sub-threshold ASD symptoms (many of whom
would meet the criteria for social communication disorder)
may have some impact on research, as presumably, the
inclusion of children with sub-threshold symptoms in
treatment studies leads to greater treatment effects. It
remains to be seen whether researchers will move quickly
to adopt DSM-5 criteria in acknowledging this issue, and
whether journals will adopt standards regarding participant
diagnoses. At the time of writing, a PubMed search using
the term “social communication disorder” revealed no
clinical trials, suggesting that research examining the nature
and outcomes of this disorder is still in development.
In looking forward to the next 12 months and beyond,
it is difficult to predict what future impact the changes in
diagnosis will have on policy and practice. In Australia, the
National Disability Insurance Scheme is currently being
trialled in a number of sites, with the view to full rollout
in 2016–18. It is likely that the advent of this scheme will
see diagnosis-specific funding (e.g., the Helping Children
with Autism Package) replaced with the comprehensive
scheme. Yet the mechanisms by which funding under
the NDIS will be allocated are still being developed. If the
scheme is based on needs, rather than diagnosis, it may be
tempting policy-makers to look to the new severity ratings
described in DSM-5 for guidance as to the level of funding
required. Participants in the Department of Human Services
consultation process last year expressed clear opposition to
any such approach (Department of Social Services, 2013),
and the sentiment is echoed in the research literature
(Vivanti et al., 2013).
The Department has acknowledged work currently
underway at the Karolinska Institutet Center of
Neurodevelopmental Disorders (KIND) to develop a core
set of descriptors for ASD that will provide a universally
accepted framework for describing individual functioning
within the International Classification of Functioning,
Disability and Health (ICF Research Branch, 2014).
Similar core sets are available for individuals with other
developmental disabilities (e.g., cerebral palsy) and so have
the potential to provide a consistent and useful approach
for measuring individual needs.
It also remains to be seen what impact, if any, the
changes in diagnostic criteria may have on the “culture of
autism”, particularly for individuals who identify themselves
as having Asperger’s disorder. Presumably, it is the
explanatory power of the diagnosis of ASD in helping
people understand themselves and others that may confer
a sense of self-understanding and identity, rather than
the diagnostic label itself. To date no research has been
published examining the possible impact of changes in
the diagnostic criteria on sense of self-understanding and
identity among individuals with ASD. However, it would
seem likely that just as diagnosticians may continue
to choose which criteria they feel are most suitable to
describing individual strengths, needs, and learning profiles,
so will individuals with ASD who choose to share their
diagnosis with others.
It is perhaps worth noting that speech pathologists
have always highlighted the importance of focusing on
the strengths, needs, and learning profiles of each child,
adolescent, and adult with whom they work. Accordingly,
meet criteria for ASD under DSM-IV, but not the more
stringent DSM-5. The consultations were conducted in
each state and territory in the middle of 2013, with a final
report published at the end of the year (Department of
Social Services, 2013).
With regard to diagnosis and funding, in essence,
nothing has changed since the release of DSM-5. The
government’s policy response has been to declare that
children may receive funding through the Department
of Social Services if they have a “conclusive” and
“acceptable” diagnosis of either autism, autism spectrum
disorder, autistic disorder, Asperger’s disorder, childhood
disintegrative disorder, or PDD-NOS. Notably, the DSM-IV
diagnosis of Rett’s disorder is no longer seen as a mental
health disorder (like ASD) following the identification of its
genetic basis, and children with Rett’s disorder now receive
funding through the alternative “Better Start” package.
Essentially, for the purposes of funding, children can be
diagnosed with “autism” based on the criteria published
in the third edition of the DSM (American Psychiatric
Association, 1994) onwards, highlighting the relevance
of the core symptoms of ASD, which have remained
unchanged over time, in determining eligibility for funding.
Accordingly, this policy decision means that there has so far
been little impact on practice with regards to diagnoses and
funding of speech pathology services for children with ASD
and their families.
But what impact have changes in the diagnostic
criteria had on the availability of services to children
presenting with sub-threshold ASD symptoms, who did
not meet the specific criteria for autistic disorder under
DSM-IV, but rather one of the broader autism spectrum
sub-classifications (e.g., Asperger’s disorder, PDD-
NOS)? Research to date indicates that approximately
10% of children previously diagnosed with ASD using
DSM-IV, would not meet the DSM-5 criteria, particularly
those with PDD-NOS (Lohr & Tanguay, 2013). Instead,
these children with sub-threshold ASD symptoms are
most likely to be diagnosed with the new diagnostic
label of
social communication disorder
under DSM-5,
which does not attract specialist funding for services.
Given that diagnosticians in Australia are currently free
to choose whether they use DSM-IV or DSM-5 for the
purposes of determining eligibility for funding (Department
of Social Services, 2013), it is possible that the same
child presenting with the same needs at two different
diagnostic assessments, could leave one assessment with
a diagnoses that confers specialist funding and the other
without, simply based on the criteria used. Presumably, this
opens the gate for inconsistent application of diagnostic
criteria within and across diagnosticians, with clinical and
ethical implications. The Department of Social Services has
indicated that they will review their policy regarding support
for children diagnosed with social communication disorder
in late 2014, once data regarding the rate of diagnosis and
support needs become clearer.
Despite concerns regarding the impact on research, a
non-systematic review of the recent studies in the
Journal
of Autism and Developmental Disorders
and other key
journals in the ASD field reveals no reference to the DSM-5
changes posing a major barrier to conducting research or
interpreting findings. In fact, the changes have coincided
with increasing calls (e.g., Trembath & Vivanti, 2014) for
a greater focus on individual differences in ASD research,
