An article in yesterday’s New York Times looks at the history of the diagnosis of Asperger, the contrast to genuine Autism, and the prevalence of the diagnosis “a little bit of Aspergers” that we hear often today, in schools especially. The author, psychiatrist Paul Steinberg, feels the diagnosis, wrongly applied, is a serious disservice. Are we looking at “social disability”, which is very different, or is is autism?
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I face this issue often in my clinical work and via consultation with community agencies that provide support and services to children on the spectrum. There does seem to be a strong push from the school front to identify children with exceptional learning needs, although Asperger’s is not the only diagnosis that is brought forward. The difficulty that I and many of my colleagues contend with is the lack of consistent (and often appropriate) methods of assessment and diagnosis for Asperger’s syndrome. It is not uncommon for me to see school psychologists, with no formal training is diagnostic practices for the spectrum, provide a diagnosis or special education coding/placement for a student as being on the spectrum. The most egregious of these incidents occurs from people who are of the opinion that “My clinical experience is sufficient for me to provide a diagnosis. I don’t need fancy tests or scores”. This approach is the poorest type of professional practice that I believe contributes to inappropriate and over-diagnosis. Some children just have quirks about them, but their presenting difficulties do not measure up with a clinical diagnosis when appropriate clinical procedures are utilized.
The initial inclusion of Asperger’s in the DSM-IV was done with a mind to spur research efforts into the autism spectrum nosology. The culmination of the research efforts since that time has indicated 2 things: One, clinicians tend to be good (when following appropriate practices) at identifying a child as either on the spectrum or not. Two, we are very poor at specifying where exactly on the spectrum they are. Thus, the current proposed modifications in the DSM-5 are directed towards an amalgamation of the individual spectrum disorders.
It is my hope that clinicians will begin to appreciate appropriate clinical practices when assessing children. Resorting to pure subjective clinical judgement only leads to the lessening of the profession and the issue presented in the NY Times article. Most definitely, an inappropriate diagnosis is a disservice. The child, their family, and their school use the diagnostic label as a framework by which they understand the needs of the child and how to support them. Incorrect diagnosis of children results in ineffective services at best and a complete lack of appropriate services at worst. If we as a profession and a society truly want children with exceptional learning needs (whatever they may be) to be properly supported in the school environment, it has to begin with proper identification of those needs. Let’s strive towards that goal as a community and a profession!
Adam… I could not agree more. While school psychologists can continue their efforts to educate the public and work more collaboratively with other professionals (medics, SLP, soc. workers, school counselors etc) who also have ‘a foot in the door’ on diagnosing Asperger’s or any other exceptionality, we need to hold ourselves to the highest standard that is reflected in ethical practice and that is grounded in ‘best’ and evidence-based practices.
I wonder what the current situation is in countries not bound to the DSM IV soon to be superseded by something in the DSM V.
Perhaps some presentations at this year’s ISPA [to be held in Montréal] will let us know the current and near future practices à la ICD.