Home Speech-Language Pathology Yes, DSM-5 Changes SLP-Relevant Disorder Categories: What You Need to Know

Yes, DSM-5 Changes SLP-Relevant Disorder Categories: What You Need to Know

by Diane Paul
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The speech-language pathology community has been abuzz for months about the pending release of the new Diagnostic and Statistical Manual of Mental Disorders because of expected changes to autism spectrum disorder and other communication disorders involving SLPs.

And indeed, the fifth edition, issued by the American Psychiatric Association last month, significantly changes ASD and several other SLP-relevant categories—and also unveils the new social (pragmatic) communication disorder.

As most SLPs well know, DSM is the standard classification of mental disorders used in clinical and community settings in the United States and other countries. The new edition is available first in print, with an electronic version to be offered later this year. See highlights of the changes to DSM-5 on the American Psychiatric Association’s website.

Here are some of the major changes in the category of Neurodevelopmental Disorders that are relevant to the work of speech-language pathologists:

 Intellectual disability (Intellectual developmental disorder)

  • Replaces the term “mental retardation” with “Intellectual disability (Intellectual developmental disorder).”
  • Relies more on adaptive functioning rather than on specific IQ scores.

Communication Disorders

Changed from expressive and mixed receptive-expressive language disorders to include:

  • language disorder
  • speech sound disorder
  • childhood-onset fluency disorder
  • social(pragmatic) communication disorder

Autism spectrum disorder (ASD)

  • Eliminates pervasive developmental disorder and its subcategories (autistic disorder, Rett’s disorder, childhood disintegrative disorder, Asperger’s disorder, pervasive developmental disorder-not otherwise specified). Instead, children meeting the criteria will be given a diagnosis of “autism spectrum disorder” with varying degrees of severity.
  • Omits criterion related to the development of spoken language.

 Specific Learning Disorder

  • Combines diagnoses of reading disorder, disorder of written expression, mathematics disorders, and learning disorder not otherwise specified.
  • Recognizes the need to use a variety of culturally and linguistically appropriate assessment tools and strategies and does not require use of a standardized measure.
  • Does not include oral language.
  • No reference to modalities of language.

Changes in the section on Neurocognitive Disorders pertinent to the speech-language pathology field include the following:

  • Dementia is considered a major neurocognitive disorder.
  • A less severe cognitive impairment is considered a mild neurocognitive disorder.

We were fortunate to have SLPs involved in developing some of the diagnostic criteria in DSM-5. Amy Wetherby was a member of the DSM-5 neurodevelopmental workgroup and chaired a subgroup on communication disorders. Mabel Rice, Nickola Nelson and I worked on this group. ASHA responded during the three public comment periods.

Now that the new edition is out, ASHA has assembled a DSM-5 response team coordinated by me and composed of Janet McCarty, Andrea (Dee Dee) Moxley, Froma Roth and Monica Sampson. We are developing resources to guide members and consumers on the changes, including at least three articles in upcoming issues of The ASHA Leader. The articles will include:

  • A comparative analysis of what ASHA recommended and what DSM-5 includes, with clinical implications for SLPs.
  • Coding implications for reimbursement.
  • Case studies to demonstrate how the changes will affect people with speech, language, communication and cognitive disorders.

ASHA also will communicate with consumers about what the DSM-5 might mean to them through podcasts, media interviews and other dissemination vehicles. A critical message we want to convey is that SLPs will continue to provide needed services, which are based on assessment of communication strengths and needs, and not on specific DSM-5 diagnostic labels.

ASHA would like to know how you think the changes in DSM-5 will affect your clinical practice. We also are seeking case studies that demonstrate impacts of the changes for a future Leader article. Please contact Diane Paul at dpaul@asha.org.

Diane Paul, PhD, CCC-SLP, is ASHA’s director of clinical issues in speech-language pathology.

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Mary Dreyer June 19, 2013 - 8:25 am

Since oral language disorders are a basis of reading disorders,but it seems they are not considered in the diagnosis of LD in the new DSM, it’s not clear to me how an understanding of oral language impairments would relate to diagnosis and treatment, or its place in eligibility proceedings in a public school setting. I often treat phonological issues, word retrieval, semantic organization, and syntax issues to support reading decoding and comprehension. Will this continue to be relevant in the DSMs new conceptualization of LD?

Diane Paul June 19, 2013 - 10:42 am

Dear Ms. Dreyer,
ASHA shares your concerns about the omission of oral language disorder as a criterion for specific learning disorder. In its comments before DSM-5 was published, ASHA emphasized the critical link between spoken and written language and language and learning. ASHA asked that language (listening and speaking) be included as an aspect of specific learning disorder. A potential implication may be that children with a specific learning disorder will also need to be diagnosed with a language disorder. Speech-language pathologists should be integrally involved in these diagnostic decisions.

Mary Dreyer June 19, 2013 - 11:21 am

So the practical outcome may be that kids are LD with SLI as a secondary disability rather than related. But maybe this SPED arcana is interpreted differently in different school systems.

Mary Dreyer June 19, 2013 - 8:27 am

Will social language pragmatic disorder take the place as Aspberger’s or high level autism for practical purposes?

Diane Paul June 19, 2013 - 10:21 am

Dear Ms. Dreyer,
I appreciate your questions. I understand that the changes in ASD and communication disorders MAY mean that some children with Asperger’s disorder (in accord with DSM-IV) or high functioning autism may now be diagnosed with a social (pragmatic) communication disorder. However, this would occur only when a child has deficits in social communication and social interaction, but does not have restrictive, repetitive behaviors, interests, and activities, which is the second DSM-5 criterion for ASD.

Mary Dreyer June 19, 2013 - 11:25 am

So those guys we were concerned would get lost still have a place. Though SPED categories are different than DSM… This sort of thing is how statistics get snarled. If these guys are not made eligible at all or for awhile until state and school districts figure it out, they will be in RTI indefinitely, so they will not (or will they?) show up in the incidence reports. Oh well; in the trenches we know it when we see it!

John C. Thorne, Ph.D., CCC-SLP June 19, 2013 - 5:28 pm

It will be interesting to see how “social(pragmatic) communication disorder” maps onto IDEA disability categories. If you look at IDEA, the category of “Autism” reflects disabilities significantly affecting verbal and non-verbal communication and social interaction that adversely affects educational performance (see Section 300.8(c) (1) (i)). Those second category behaviors that distinguish ASD from social(pragmatic) communication disorder in the DSM5 are discussed, but not mandatory, based on the wording in IDEA.

The language from IDEA:

“Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences.”

Our field will need to take the lead on how this subtle distinctions are interpreted in policy and in practice.

John C. Thorne, Ph.D., CCC-SLP June 19, 2013 - 5:30 pm

“this subtle” = “these subtle”

Diane Paul June 20, 2013 - 12:55 pm

Dear Dr. Thorne,
Thank you for raising the important points related to the need to compare IDEA and DSM-5 terminology and criteria. And I certainly agree about the critical leadership role for speech-language pathologists.

Emily Marshall July 22, 2013 - 1:18 pm

Dear Diane.
I am 25 & was diagnosed with aspergers when I was 22. I am totally thrown off by this DSM-5 terminology & criteria! When I found out I did not fall under the guidelines for ASD I was very upset because I was pretty sure I met them. For the last 3 years I actually felt like I belonged & I was going to get some help with my communication! I don’t have the hand flapping but I do move my feet constantly. It seems like I am fixated on people’s feet. I have penutbutter & jelly every day for lunch even if everybody is having something else, & I have to watch NCIS on Monday, Wednesday, Thursday, & Law & Order SVU on Tuesday & Friday or I am thrown off. I also talk about them all the time & when I am watching it feels like I’m in the show sometimes! I get so upset when my husband changes the channel when I’m watching NCIS or SVU evem if I have seen the episode 50 times. Sometimes I have a meltdown! However my psychologist still says that I have social pragmatic communication disorder which I’m totally confused about & now I’m just another number in this world!

Diane Paul July 23, 2013 - 11:50 am

Dear Ms. Marshall,
I am sorry that the new criteria have led to concern and confusion about your own diagnosis. According to DSM-5, “Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder…should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.” A speech-language pathologist can help determine if the behaviors you describe
are consistent with the criteria for “restricted, repetitive patterns of behavior, interests, or activities,” which include a wide range of behaviors. Regardless of which diagnosis you receive though, you should still receive the communication or other services you need.

Robert Rimac June 19, 2013 - 1:32 pm

Thanks for this very important interactive blog! You and the others have done outstanding work. Will there be any sessions at the ASHA Convention in Chicago to discuss these changes, or any other upcoming events we should know about?

Diane Paul June 20, 2013 - 1:02 pm

Dear Mr. Rimac,
We hope to have a lunchtime session related to changes in DSM-5 and possible implications for speech-language pathologists. When the convention program is determined, we will identify those sessions that have been accepted pertaining to DSM-5 and get the word out to members.

Andreanne laberge June 19, 2013 - 9:42 pm

I was reading today on the DSM 5 website that the Rett’s syndrome will not be included in the ASD diagnostic as it is a neurological disorder that may be associated with ASD. I’m confused the 2 information then…thank you!

Diane Paul June 25, 2013 - 7:36 pm

Autism spectrum disorder may be associated with Rett syndrome. DSM-5 indicates that differential diagnosis is needed between ASD and Rett syndrome. As indicated in DSM-5 , girls with Rett syndrome may have a “disruption of social interactions,” typically between 1-4 years. However, social communication skills typically improve after this period and “autistic features are no longer a major area of concern.” DSM-5 indicates that ASD may be diagnosed with Rett syndrome when all of the ASD criteria are met.

Robyn Stephen July 4, 2013 - 9:35 am

Thank you for the interesting exchange so far. I am a Speech Pathologist in Australia who works with children with ASD and their families. I am also a board member of Speech Pathology Australia. We are being asked at forums around the country run by government early intervention funding bodies what will be the role of SP in the diagnosis of ASD. Have you thought about the tests that you might use? I think your statement that provision of service will continue to be based on assessment of communication strengths and needs and not on specific DSM-5 diagnostic labels is very useful and clear.

Mary Dreyer July 5, 2013 - 10:38 am

I like to think about using theory of minds tasks, partly because they are diagnostically relevant but also because in my opinion, this piece of autism has a significant effect on academic success, or at least true understanding, rather than rote memorization, of academic material. It is difficult for someone who can’t get into another point of view to get meta– to explain situations outside himself– and then apply that knowledge. It relates to the concreteness of so many of our students who are otherwise very bright, and keeps them in those ‘nerdy’ concrete pursuits, academically, professionally, and socially.

Mary Dreyer July 5, 2013 - 10:39 am

I mean, TOM as PART of a comprehensive eval.

Robyn StePhen July 7, 2013 - 11:08 pm

Thanks Mary . I’m glad you used TOM to understand my question ie. What additional tests would be useful in addition to the usual comprehensive evaluation ? Do you use the TOPL for this sort of information and what else would you recommend ? In Australia we are under the pump this week to advocate for continued funding for those children/ students who would have previously been ASD but may now well move to SCD.

Mary Dreyer July 8, 2013 - 7:41 am

I’m partial to the Test of Problem Solving, which looks at language but also general awareness about how the world works; and various pragmatic checklists. For autism, it seems to me that standardized testing is particularly unlikely to capture the issues involved. There are some specialized tests for autism, of course . . . here, the psychologist administers them. I assume you are talking about kids who are verbal and not very low-functioning?

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