Concerns and questions about eligibility and social (pragmatic) communication disorder

Transcription

1 Concerns and questions about eligibility and social (pragmatic) communication disorder Nickola Wolf Nelson, Ph.D., CCC-SLP Western Michigan University Presentation at ASHA Convention Orlando Florida Nov 2014

2 Disclosures: Nicki Nelson Served as a member of the DSM-5 committee on communication disorders, a subcommittee of the neurodevelopmental workgroup of the American Psychiatric Association Earns royalties from a textbook that discusses forms of language disorders and related neurodevelopmental disorders (Nelson, N. W. (2010). Childhood Language and Literacy Disorders: Infancy through Adolescence. Boston, MA: Pearson/Allyn & Bacon) Author and recipient of a research grant (IES Grant No. 324A to standardize a new diagnostic test, which may lead to a bias toward psychometric testing (Nelson, N. W., Helm-Estabrooks, N., Hotz, G. & Plante, E., 2011, Test of Integrated Language and Literacy Skills (TILLS, standardization version 2). Baltimore: Paul H. Brookes Publishing Co., Inc.)

3 Social (Pragmatic) Communication Disorder Diagnostic Criteria A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following: 1. Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for the social context. 2. Impairment of the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on a playground, talking differently to a child than an adult, and avoiding use of overly formal language.

4 Diagnostic Criteria (cont d.) 3. Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction. 3. Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous uses of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation).

5 Diagnostic Criteria (cont d.) B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination. C. The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities). D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar and are not better explained by autism spectrum disorder, intellectual disability, global developmental delay, or another mental disorder.

6 Differential Diagnosis Asperger s in DSMIV ASD in DSM5 Social (Pragmatic) Communication Disorder If meet criteria of: Social communication difficulties Restricted patterns of behavior If meet criteria of: Social communication difficulties But not, restricted patterns of behavior

7 Rationale for Social (Pragmatic) Communication Disorder Research support for Pragmatic Language Impairment (PLI) Children with semantic-pragmatic problems and socially inappropriate conversations interactions who do not meet criteria for autism (Bishop, 2000; Bishop & Norbury, 2002) 604 children in the Epi-SLI study did not meet SLI criteria, but met Bishop s criteria for PLI due to weak pragmatic skills with intact phonology, syntax, and semantics (Tomblin et al. 2004)

8

9 Rationale for Social (Pragmatic) Communication Disorder Not all children with social pragmatic issues meet criteria for autism spectrum disorders Both children with ASD and SCD may show Persistent difficulties in verbal and nonverbal communication Using communication for social purposes Ability to change communication to match context or needs of the listener Difficulty following rules for conversation and story telling Difficulty understanding what is not explicitly stated

10 No evidence-based standardized instruments Have no instruments with clear evidence of sensitivity and specificity Bishop s (2006) Children s Communication Checklist-2 U.S. Edition (CCC 2) A number of instruments have pragmatics in their titles It is not necessary to differentiate ASD and SCD on the basis of language, only restricted, repetitive behaviors

11 Small body of research Borderlands of autism (Botting & Conti-Ramsden, 1999) 10 children with pragmatic language impairment In wider project on language impairment compare with TL & SLI Identified with pragmatic impairments by teachers, SLPs, researchers Supported by scores from the Children s Communication Checklist (CCC) Results 4 of the 10 had difficulties that might be better described as having autism or Asperger s disorder All developed first words earlier than the SLI group More impaired in stereotyped language, rapport and context Social communication skills as measured by the CCC did not seem more impaired than in other children with SLI Peer interactions were rated as significantly poorer on Harter scale

12 Young, E.C., Diehl, J. J., Morris, D., Hyman, S.L. & Bennetto, L. (2005). Pragmatic language assessment: A pragmatics as social practice model. Language, Speech, and Hearing Services in Schools, 36, matched participants Test of Pragmatic Language (TOPL; D. Phelps-Terasaki & T. Phelps-Gunn, 1992) Strong Narrative Assessment Procedure (SNAP; C. J. Strong, 1998). On TOPL: ASD < controls On SNAP: ASD = controls on syntax, cohesion, story grammar, and completeness of episodes ASD < controls ability to answer inferential questions Research needed to develop formal assessment tools that target the unique language disabilities of high-functioning individuals with ASDs.

13 Other new possibilities Hyter, Y. (2007). Pragmatic language assessment: A pragmatics as social practice model. Topics in Language Disorders, 27, Nelson, N.W., Plante, E., Helm-Estabrooks, N., & Hotz, G. (2015). Test of Integrated Language and Literacy Skills (TILLS): Social Communication, Story Retell, Vocabulary Awareness

14 Nelson, N. W., Plante, E., Helm-Estabrooks, N., & Hotz, G. (2015). Test of Integrated Language and Literacy Skills TM (TILLS ). Brookes Publishing Co., Inc.

15 13. Social Communication David always uses hints to get his grandmother to buy him things. David is out shopping with his grandmother and sees some boots he wants. What do you think David would say? I think shopping with you is the best thing I like to do. Shawn always fishes for compliments. He was wearing his new closes when he met his friend on the way to the school party. What do you think Shawn would say? I think my new clothes are perfect to go fishing. I love to go fishing. I like to fish for

16 Comparison of Students with LLD and ASD with NL * ** * * ** Mean z-score NL (n=1030) LLD (n=215) ASD (n=40)

17 ASHA practice portals

18 Take Home Points People with ASD have language problems People with SCD have language problems Many of their language problems are similar to problems experienced by people with primary language disorder Some of their language problems differentiate them from people with primary or specific LLD Higher word structure knowledge and grammar Lower social skills, narrative skills, and inferencing Helping these students with their issues Anxiety Comprehension challenges (vocabulary, inferencing) Fitting in..requires more than a Friday lunch bunch!

19 References Bishop, D. V. M. (2000). Pragmatic language impairment: A correlate of SLI, a distinct subgroup, or part of the autistic continuum. In D. V. M. Bishop & L. B. Leonard (Eds.), Speech and language impairments in children: Causes, characteristics, intervention, and outcome (pp ). East Sussex: Psychology Press. Bishop, D. V. M. (2014). Ten questions about terminology for children with unexplained language problems. International Journal of Language and Communication Disorders, 49, Bishop, D. V. M., & Norbury, C. F. (2002). Exploring the borderlands of autistic disorder and specific language impairment: A study using standardized diagnostic instruments. Journal of Child Psychology and Psychiatry and Allied Disciplines, 43, Bishop, D.V.M., & Leonard, L. (). Speech and language impairments in children: Causes, characteristics, intervention, and outcomes. NY: Psychology Press. Botting, N. (2002). Narrative as a tool for the assessment of linguistic and pragmatic impairments. Child Language Teaching and Therapy, 18, Botting, N., & Conti-Ramsden, G. (1999). Pragmatic Language Impairment without Autism: The Children in Question. Autism, 3, Tomblin, J. B., & Zhang, X. (2006). The dimensionality of language ability in school-age children. Journal of Speech-Language-Hearing Research, 49, Tomblin, J. B., Zhang, X., Weiss, A., Catts, H., & Ellis Weismer, S. (2004). Dimensions of individual differences in communication skills among primary grade children. In M. L. Rice & S. F. Warren (Eds.). Developmental language disorders: From phenotypes to etiologies (pp ). Mahwah, NJ: Lawrence Erlbaum.

20 Navigating the diagnostic complexities of DSM-5 language and communication disorders: Keep your eye on SLI Mabel L. Rice University of Kansas Presentation at ASHA Convention Orlando Florida Nov 2014

21 Disclosure and acknowledgements Author, Pearson Corporation, Test of Grammatical Impairment, copyright now owned by author. No royalties. Available free at www2.ku.edu/~cldp/mabelrice/ Research funding from NIH Ro1DC001803, R01DC005226, P30DC005803

22 DSM-5 development of categories of communication and language disorders Language Disorder: Persistent difficulties in the acquisition and use of language across modalities (i.e. spoken, written, sign language or other) due to deficits in comprehension or production and language abilities that are substantially and quantifiably below age expectations Social (Pragmatic) Communication Disorder: Persistent difficulties in the social use of verbal and nonverbal communication including using communication for social purposes, impairment in the ability to change communication to match context or the needs of the listener, difficulties following rules for conversation and storytelling, and difficulties understanding what is not explicitly stated and nonliteral or ambiguous meaning of language Not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar. Rarely for children younger than age 4 years. Not ASD.

23 New questions about differential diagnoses Possible confusion about children with Specific Language Impairment, who have language impairments without other clinically significant disorders Relatively high prevalence 7-10% of children at school entry Likely to be overlooked and underserved: estimated that only about 25% are identified and enrolled in intervention Require a comprehensive language assessment plus an evaluation of nonverbal IQ Likely to encounter problems in learning to read Longitudinal studies document the language impairment persists into adulthood

24

25 SLI, cognitive abilities, and social consequences Children with SLI, by definition, do not have clinically significant nonverbal intellectual impairments Children with SLI have Language Disorders but not all forms of Language Disorders are SLI, such as language disorders + intellectual disorders, language disorders + hearing loss, language disorders + cerebral palsy, language disorders + epilepsy, and so on Children with SLI are unlikely to have speech disorders, based on studies in which all children are assessed (Shriberg, Tomblin, & McSweeny, 1999) Children with SLI enrolled in services are likely to have speech disorders, perhaps because speech intelligibility is more obvious (Zhang & Tomblin, 2000)

26 SLI, cognitive abilities, and social consequences Exclusion of the diagnosis of SLI as a specifier diagnosis under the general heading of Language Disorders from the final version of DSM-5 does not invalidate the diagnosis nor the rich research literature on the condition Instead, the current version of the DSM-5 makes it very important to consider the diagnosis of SLI as a condition possibly to be confused with the new diagnosis of Social (Pragmatic) Communication Disorder

27 Social consequences of SLI What is a child to do when they lack the language skills to fit in well with peers? They can appear to be introverted or socially awkward, although not in family settings They are less likely to speak up in groups/classroom settings They are less likely to be popular among peers They are less likely to be popular with their teachers They are less likely to generate stories, relate anecdotes or understand verbal humor such as knock-knock jokes or puns They are likely to have reading impairments and lower educational achievement They are likely to know these things about themselves, certainly by mid childhood, thereby adding to issues of self esteem

28 Will SLI children be misdiagnosed as Social (Pragmatic) Communication Disorder? Will require careful attention to the exclusionary condition for SCD: symptoms not attributable to low abilities in the domains of word structure and grammar In effect, the new DSM-5 Communication Disorder diagnostic categories will require a high level of professional diagnostic proficiency to avoid clinically significant diagnostic errors

29 Tracking the distinctions between language dimensions/disorders and social dimensions/disorders in DSM-5 Language Disorder: reduced vocabulary, limited sentence ability, impairments in discourse Social (pragmatic) Communication Disorder: deficits in using communication for social purposes; impairment in changing communication to match context or needs of the listener; difficulties following rules for conversation and storytelling; difficulties understanding what is not explicitly stated (idioms, humor, metaphors, multiple meanings) ASD: Deficits in social-emotional reciprocity; deficits in nonverbal communicative behaviors for social interaction; deficits in developing, maintaining, and understanding relationships

30 Overview of Diagnostic Characteristics Language Disorders Grammar Vocabulary Disorders Social Consequences Social Communication Disorders Social Disorders Restrictive Repetitive Patterns SLI SCD ASD

31 Why should we be concerned about possible misinterpretation of SLI? Misclassification of a child with SLI as CSD will obscure the clinical needs of a child with SLI Age-equivalent grammar and vocabulary are needed in order to build social competencies with peers A focus on communicative skills without recognition of the underlying difficulties with grammar and vocabulary will attempt to treat a social awareness problem that may not exist while overlooking the real driver of social awkwardness, that of limited language abilities relative to peers The notion of CSD can be confounded with social/cultural differences in children s backgrounds, along with multilingual status

32 Practical issues in language/communication assessment Fundamental to have a valid assessment of grammar and vocabulary abilities referenced to age peers ASD must be ruled out before a diagnosis of SCD can be considered. Are reliable and valid assessment tools available to make this differentiation? (See Statement of the Interagency Autism Coordinating Committee Regarding Scientific, Practice and Policy Implications of Changes in the Diagnostic Criteria for Autism Spectrum Disorder (DSM-5) issued in March 2014 for concerns about the need for validated assessment tools) Should clinicians rely on nonverbal indicators of social communication attempts? How are the developmental trajectories of ASD, SCD, SLI and other forms of Language Disorders to be considered in the diagnostic process? Is a language disorder more consistent over time than an SCD or the social communication indicators of ASD?

33 Implementing the DSM-5 diagnoses of communication disorders new needs arise An enhanced need for the diagnostic expertise of speech/language pathologists the identification of language disorders with or without other conditions A need to advocate for children with various forms of language disorders, including SLI, in order to avoid overlooking vocabulary and grammar deficits as an underlying cause of what appear to be social communication disorders An enhanced need for a diagnosis of language disorders for children with ASD in order to ensure appropriate services, when LD and ASD co-occur

34 Implications, Concerns & Questions About DSM-5 for Speech-Language Pathologists Janet McCarty ASHA Director of Private Health Plan Reimbursement Presentation at ASHA Convention Orlando Florida Nov 2014

35 Janet McCarty, M.Ed., CCC-SLP ASHA s Private Health Plans Advisor Disclosure Financial: Paid employee of ASHA Non-Financial: Contributor of for-sale ASHA products on the topic of health plan payments, coding, and payer advocacy. Receives no compensation for product sales.

36 Agenda DSM-5 and Potential Payment Problems Diverging Codes APA s Code Proposal DSM-5 and Other Communication Disorders Asperger s? State Actions

37 DSM-5: Potential Payment Problems? New DSM-5 codes for autism spectrum disorder and communication disorders do not correlate as well with ICD-9- CM/ICD-10-CM as they have in the past This may create health plan payment problems

38 DSM-5 or ICD-9/10-CM? Health Insurance Portability and Accountability Act (HIPAA) mandates ICD-9-CM/10 for billing and reporting for all electronic transactions DSM-5 codes are not HIPAA compliant from a billing standpoint

39 DSM-5 or ICD-9/10-CM? The DSM focuses only on mental disorders (315s); not the 784s, for example DSM-5 may be used by mental health professionals in the U.S. for diagnosing mental health conditions ICD-9/10-CM is used by the billing professional to process claims The two codes match, most of the time DSM-5 moves away from the past s good correlation with ICD-9/10-CM U.S. government's substantial engagement with WHO and ICD in the area of classification systems likely ensures ICD s status for billing purposes

40 Diverging Codes An example of diverging codes is DSM-5 s newly added condition social communication disorder (SCD) that does not (currently) appear in ICD-9/10-C But,..

41 APA Proposed Code Changes In September 2013, the American Psychiatric Association (APA) proposed a new ICD-10-CM code for social (pragmatic) communication disorder ASHA supports APA s social pragmatic communication disorder code ASHA is seeking more input with APA on future code proposals involving communication disorders

42 Other Communication Disorders Codes DSM-5 specifies Language Disorder, where it once specified Expressive Language Disorder and Mixed Receptive-Expressive Language Disorder DSM-5 currently lists Language Disorder as unspecified developmental disorder of speech and language. Why?

43 DSM-5 Language Disorder Code Updated In an online update of DSM-5 in late October 2013, Language Disorder (F80.9) is changed to F80.2. F80.2 describes mixed receptive-expressive language disorder, and is a more specific code.

44 What Happened to Asperger s Disorder? One of the more controversial changes in the DSM-5 involves grouping all of the subcategories of autism into a single category called autism spectrum disorder (ASD), which includes the elimination of Asperger s disorder. It remains to be seen if ICD-10-CM will adopt DSM-5 s description of autism spectrum disorder

45 Asperger s Syndrome Status According to information on the Autism Speaks website, "all individuals who currently have a diagnosis on the autism spectrum, including those with Asperger s syndrome or PDD-NOS, will not lose their ASD diagnosis. However, DSM-5 states, "Individuals with a wellestablished DSM-IV diagnosis of autistic disorder, Asperger's, or PDD... should be given the diagnosis of ASD. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for ASD, should be evaluated for social communication disorder."

46 State Actions Some states are already addressing potential changes in diagnoses. Connecticut introduced legislation that would allow a person diagnosed with autism spectrum disorder to retain the diagnosis despite any change in the new edition of the American Psychiatric Association s DSM-5, which was signed by the Governor on June 5, 2013.

47 DSM-5 Changes Parents (and SLPs, administrators, and others) should determine if DSM-5 changes will impact insurance reimbursement for services or eligibility for special education services at school.

48 Going Forward ASHA will continue to monitor the impact of DSM- 5 on coding diagnoses, health plan payments, and school services. Questions?

49 Role of SLPs with DSM-5 Diagnostic Criteria Diane Paul, PhD, CCC-SLP ASHA Director, Clinical Issues in Speech-Language Pathology Presentation at ASHA Convention Orlando Florida Nov 2014

50 Disclosures Paid employee of ASHA and may have bias toward ASHA products and services Served as a member of the DSM-5 committee on communication disorders, a subcommittee of the neurodevelopmental workgroup of the American Psychiatric Association Coordinate ASHA s comment teams and follow up related to DSM-5

51 Speech-Language Pathologist Role SLPs are directly involved in assessment and treatment of communication and related disorders included in DSM-5: Autism spectrum disorder Communication disorders Specific learning disorder Intellectual disabilities

52 Autism and Social Communication Disorder SLPs can and should diagnose and treat autism spectrum disorder and social (pragmatic) communication disorder

53 Speech-Language Pathologist Role Make sure that children with ASD are dually diagnosed with ASD and Language Disorder Be involved in differentiating ASD and social (pragmatic) communication disorder

54 Questions from Members Diagnosis is not limited to psychiatrists if a disorder is included in DSM-5. SLPs can continue to use assessment instruments specific to the former communication disorders criteria. IDEA criteria is applicable in school settings. DSM-5 criteria are typically not applied.

55 ASHA Resources The ASHA Leader articles Presentations at ASHA convention Social Communication booklet Autism brochure DSM page on ASHA s website

56