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a single venerated blueprint of a particular view. It is in this context, we need to accommodate divergent views and perspectives in a debate if our aim is to reach towards at least a general agreement. Undoubtedly, this is true in case of autism since diversity in symptoms itself lead us to formulate different theories however; the theory construction should be strongly motivated by the commitment to understand the symptoms in a better way which enables us to explain the impairment from different theoretical standpoints. Though what I have written above is not explicitly related to what I am going to describe later nevertheless, I want to make the statement very clear that divergent views exist especially in case of autism moreover, in a philosophical sense, such diversity should not be treated as some random variations, as advocated by researchers who tend to support models of population thinking (earlier philosophers and researchers in cognitive neuropsychology) and diversity itself should motivate theory construction (as I understand it). Therefore with this philosophical support I accept and respect both Towinos (T) and Marias (M) divergent views. Leaving those different views apart, I will now try to give a brief summary about the debate. Though my original post was related to a change in DSM IV criteria it is in the same context T argued that a speech pathologist may not have any right to diagnose Autism. Though this argument was beyond the scope of the original post nevertheless, due to the contentious nature of the issue, it needed some serious discussion. In response to T s argument, M had some suggestions to give but I will first discuss T and come back to M later. First argument-T Autism is a medical diagnosis. SLPs do not have any right to diagnose Autism. They can only diagnose speech-language, cognitive-linguistics and swallowing aspects of autism. My response- By any standard of evidence, this claim has two aspects. First, by medical diagnosis T essentially means (and rightly so) the diagnosis based on DSM 1V by a physician. I understand from where his views are coming from. As T rightly pointed out, one need not go by American standards. Even by American standards lets examine what essentially this medical diagnosis by a physician means. I will talk about DSM 1V here since DSM V is still not used in practise. As we all know, DSM IV identifies three major areas for diagnosing autism. Impaired socialisation Impaired communication Repetitive or restricted patterns of behaviour, interests or activities
To diagnose autism as a medical condition, T argues that, it is the right of a physician and a physician may be more competent enough to diagnose. I would like to ask T that even if you think SLPs are not competent in assessing impaired socialisation and behavioural issues we are fully competent in assessing impaired communication. Therefore even in case of a medical diagnosis SLPs must and should have a role and I REJECT the idea that a medical diagnosis is entirely the responsibility of a physician. A physician, even though trained, cannot make a diagnosis without consulting SLPs. The question of ultimately who should be diagnosing Autism is rather debatable but by any standard, an SLP diagnosis by consultation with other team members should be acceptable. A physician may not be the best person to even assess impaired socialisation and behavioural problems. A clinical psychologist should assess this. Even if the physician is trained, the diagnosis of a clinical psychologist would make the assessment in these two areas more reliable. Second, I can understand T s knowledge in American standards in assessment and his views on it but, I am just pointing towards the flaws of such diagnosis and concerns expressed by many researchers in such faulty assessment by these physicians. It is also worth noting at this point that, the prevalence of autism increased because of such faulty diagnosis by these physicians and one of the reasons for changing DSM V is to reduce the number of diagnosis and identify the correct population. I must also say that DSM IV is widely used in many countries and we do not often rely on the diagnosis made by physicians (In India physicians do not even know about Autism, forget about diagnosis!!!!!!) In many other cultures, trained SLPs successfully work as a team in consultation with other members and diagnose Autism based on DSM criteria and also, using other checklists available. In Indian context, an SLP diagnosis together with behavioural and occupational therapy report is acceptable to get concessions from government. You cannot say such practises as substandard (T did not do so, but just to make the point clear). I can give the example of AIISH, Mysore and many children receive benefits from government after our diagnosis which physician is not even a part of. A physician often has no role to play and most likely it is paediatrist who play a major role initially (in many other cultures). DSM IV is widely used for research purposes also by trained people. Therefore the argument that medical diagnosis is the monopoly of physicians is something difficult to digest. Even if certain standard warrants it, many clinicians and researchers reject this idea. There should not be any hesitation in accepting flaws and we must be happy that some initiatives are now taken and DSM V will address some of these issues and hope the new criteria will help these physicians in a better way. Moreover, neurobiologists disagree with the term medical diagnosis because the current diagnosis of autism does not even in corporate any knowledge from this field. Also, as Dhanesh pointed out geneticists also should play a role. I argue that there is problem with the term medical diagnosis itself. In fact, it has nothing medical. Once some Neurobiologists fiercely argued that, just because reliable neuro biological test have not been developed, does give any anyone any reason to stop referring kids to them. Many times they also have important suggestions to make towards this medical diagnosis. After all these symptoms are
primarily neuro biological. My feeling is, as research progress and if the geneticists and neurobiologists could develop some sort of a diagnostic test then the burden of medical diagnosis should go away from these physicians. They have done enough harm and incredible injustice to the autism community and family members. Anyway the diagnostic test is a distant hope but researchers are hopeful. I cannot comment about the swallowing part as I am not an expert in that however, I would like to make a quick observation regarding T stand on assessing cognitive abilities in children with autism. Though I do not want to go into the details of cognitive impairments (deficit executive functioning) I just want to say that it would be better if this assessment is done by a neuro psychologist rather than SLP (but not physicians in any case). They are better equipped with tests concerning that. This is not a disagreement but just an observation. Second argument In support of Ts previous argument T explains DSM and suggests that DSM classification agrees Autism as a psychiatric disorder but not as a speech-language disorder. T further clarifies what exactly it means by psychiatric and is willing to give further information as he thinks the word can be misleading. My response-I agree with T. But unfortunately such was the confusion in DSM IV. Now as a better fit they changed it as impairment in social communication. Social communication will be a right terminology if you are considering autism primarily as a mental disorder. But there are some apprehensions about this. People think that they have taken out language impairment completely. But again language is just a part of social communication. In any case SLP is needed for this part of diagnosis. Changing terminologies for a better fit for a term such as mental disorder is okay in my view , provided, the role of each professionals are maintained. So these terminologies do not make any big difference. Of course, for an academic debate but not much impact clinically. 3rd argument T further argues that DSM is American based so the International community do not have to accept it. He further states that physicians needs to consult all other members for a diagnosis and further reiterate that SLPs job is to diagnose communication disorder and not the medical condition. My response-As far this argument is concerned, my above stand explains it. A medical diagnosis is impossible without SLP. DSM 1V is accepted and used across globe. SLPs, OTs, clinical psychologist and neurologists diagnose Autism. Physicians do not have to be a part of the team even to get medical benefits in many cultures. But I have no problem if a trained physician with proper consultation with other team members diagnose the child. This is not to say that SLPs cannot diagnose a medical condition. The present understanding of medical condition itself is questionable.
Final argument In his concluding remarks, T states that ICD had enlisted Autism under the category of disorders of psychological development and this understanding could be well beyond the expertise of SLPs. My response-I do not know clinically how this will affect but I agree with T from a psychological perspective. Again, this is one perspective and I do not see any reasons why we should not be questioning it. Also, it depends on the expertise and kind of training you receive. I can give Indian examples where clinical psychologists and speech pathologist work closely to understand ICD but I must admit that this is primarily done for research than clinically.
I will now discuss what M has to say about the entire issue. First argument In her initial response to T, M argues that she does not agree with the idea of doctors seeing a kid for just 5 minutes and making a diagnosis instantly. She is especially worried about the fact that the entire diagnosis can go beyond the original commitment to make an appropriate diagnosis to the extent of a hidden motivation, in this case she suspects the profit obtained from the nexus between doctors and pharmaceutical companies. My response-I have no objection except the fact that I completely agree with her. Second argument In her second argument M however, sympathise with T s views. M argues that misuse of diagnostic labels for economic or related benefits is prevalent in many cultures. This could be true in countries that receive huge governmental funding and parents may seek a diagnosis in order to get these concessions. Lastly, M suggests that every profession has valuable contribution towards making a diagnosis and it should be done in consultation with all the team members. My response-This looks like a very relevant but a different debate al together. I dont see how this argument is well connected with the primary argument that only physicians should diagnose this. So I cannot comment on this more. Primarily, this looks like an informal fallacy, however, generated with best intention to support an argument. Nonetheless, I can be easily wrong here.
Final argument The final remark of M is more interesting. In the first sentence M states that she would not take the liberty of calling somebody as autistic. M thinks that by now, there is a general agreement in the debate (at least to the idea of considering various domains related to autism before calling it as a disorder). She also thinks that she would not go beyond the extend of just saying that the symptoms are just suggestive of ASD and other neuro biological and neuro behavioural aspects need to be considered for a definitive and differential diagnosis. She draws examples particularly from Brocas aphasia to support her view and reiterates that even though one may be good at reading brain scans a diagnosis should be made after taking into the account of experts opinions. M stresses the importance of team work and repeats the need to make the diagnosis more client centred. M also suggest that the doctors should not be given the ultimate power to choose the fate of someones life and by stating this she thinks that stand by her initial argument. My response-I agree with the term autistic as it raises ethical questions. We should avoid thinking these disorders as exceptions if we want to build an inclusive society. I understand M s stand concerning the traditional SLP way of looking at a diagnosis is to just suggest and then give recommendations. However, I would like to diverge from Ms view and delineate the suggestions made by senior Indian researchers (which I am not going to name) here and I thought they were great suggestions. The feeling that SLPs cannot diagnose a disorder based on language characteristics is rather traditional. While we celebrate the interdisciplinary nature of our field, we need to set our record straight. In consultation with other professionals and available evidence and most importantly by assessing the communication impairment the SLPs should realize their strength in diagnosing cases language impairment (even in case of autism, SLI, aphasia etc). I would still agree with Ms argument (if we consider dementia) but not in case of aphasia , autism or SLI. This is not to say that SLP should make their own diagnosis without any consultation but in discussion with other members we must make a diagnosis. The terms suggestive, consistent (consistent is still fine) etc are misleading and as a profession if we would like to grow then we must come of this fear factor which was imposed on us traditionally by these doctors. We are SLPs, who gives quality service to patients and we must have all right to diagnose communication impairments independently. Regarding the last point raised by M I dont think I can have any disagreement on that.
Conclusion- I want to make a broad conclusion here. Though it may sound a bit different, I will refer my introduction to arrive at a conclusion. I will not summarize the debate again but would like to make a suggestion based on the introduction. As I said in my introduction, divergent views must exist and should exist in a discussion. In a clinical perspective, these divergent views based on different symptoms of disorder should motivate the theory construction. Ultimately this should lead us to experiments. DSM1V and our debate fall in this category. Multiple case studies are based on the assumption of divergent views
(philosophically) and autism research based on multiple case studies in this direction will give us understanding about pathology and also inform us about individual differences in a case by case way. This will eventually help us in diagnosis as well. So the point is, divergent views have got broader implications than we think and with that note, I want to bring a closure to my part of this debate. Thank you both.