Navigating a Course Between Terms: PLI or PDDNOS

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Navigating a Course Between Terms PLI or PDD-NOS?
Presented at ASHA Miami, FL Nov., 2006 by Rhea
Paul, Ph.D., CCC-SLP Southern Conn. State
U. Yale Child Study Center PaulR1_at_southernct.edu

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Provocative Statement 1

• There is no such thing as the
• Autism Spectrum
• What would it mean if this were true?

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How we think about PLI depends on how we define
ASD

• Is autism a range of severities within one
  condition?
• Could it be several conditions?
• Those involving social disorders
• Those involving communication disorders
• Those involving stereotyped and repetitive
  behaviors?
• Some of these might converge or diverge w/in
  individuals

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Happe, Ronald, Plomin, 2006

• There are low correlations among the three major
  symptoms of ASD
• In the general population
• In twins
• In children with extreme scores on these traits
• Children can be found who show isolated deficits
  in one or another of these 3 areas.
• Genetic studies fail to find a gene for autism
• It is not autism that is heritable
• Genetic effects are specific to one of the three
  components,
• It is not autism that runs in families, it is the
  broader phenotype
• Sub-clinical manifestation of one of the triad of
  symptoms

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Happe, Ronald, Plomin, 2006

• Argue for measuring each of the three types of
  symptoms separately
• Argue for thinking of heterogeneity in the
  syndrome not as noise but as the result of the
  variation of three separate traits that interact
• There may be many individuals with isolated
  impairments in one aspect of the triadwho show
  difficulties comparable in severity to those of
  autism (p. 1220).
• Could PLI be an example?

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PLI vs. PDD-NOS

• To understand the role of PLI, we need to
  understand PDD-NOS.
• PDD-NOS is the Dx given when a child fails to
  show sufficient deficit in all 3 components of
  autism, but has a significant social disorder.
• NOS is used consistently throughout DSM for
  conditions that fail to meet the full criteria
  described in the manual (e.g., Psychotic
  Disorder-NOS)
• Is this a real disorder?

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How does PDD-NOS Differ from Autism Paul et
al., (2004)

• Studied patterns of adaptive behavior on Vineland
  Adaptive Behavior Scale in
• 20 Ss w/ Autism 20 w/ PDD-NOS
• 4-12 years of age
• Matched for nonverbal IQ (60-90 average 75)
• Major differences between groups were in
  Expressive Communication on the Vineland
• Discriminant Function Analysis correctly placed
  subjects in dx groups with 8o accuracy using
  only
• Use of sentences,
• questions,
• prepositions
• No other significant differences were found on
  Vineland

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How does PDD-NOS Differ from Autism?

• PDD-NOS is a diagnosis given when children have
  better basic language skills than peers with
  similar cognitive levels, and are using language
  in a communicative way,
• PDD-NOS diagnosis may not reflect a lower degree
  of severity along a spectrum rather it reflects
  a higher level of expressive skills.
• In these children with higher communication
  skills, pragmatic deficits are likely to be more
  noticeable.

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Lumpers vs. Splitters

• All these autisms are currently lumped within
  one category
• Because they seem to share a central feature
  social deficit
• Sometimes this is manifested in interpersonal
  behaviors sometimes in communicative behaviors.
• Stereotyped an repetitive behaviors are less
  central to the syndrome
• Can be seen in other disorders
• Are not always seen in ASD
• Lack of imaginative play sometimes substitutes
  for this category
• It could be possible to split the syndrome into
  subcategories
• Currently subcategories are defined by
  communication history
• AS no history of language delay
• CDD language that developed, then regressed
• RS really not an ASD at all

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Lumpers vs. Splitters-cont.

• With a splitters view, there could be several
  varieties within what we now call ASD
• Autism Contains all current features of syndrome
• Social Communicative Disorder Withdrawn or
  passive w/ significantly delayed language, w/out
  significant stereotypies
• Pragmatic Language Impairment Active but odd
  presentation related, as dyslexia is related to
  reading comprehension disorder, but separable
• Could have differing genetic roots natural
  histories

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What Difference Does it Make?

• Advantages of current lumper view
• Makes the common thread among these disorders
  stand out
• Makes diagnosis simpler, easier to understand
• Makes service procurement easier system is in
  place
• Disadvantages
• Current major categories (Autism PDD-NOS) dont
  do a good job of describing individuals
• PDD-NOS category is most problematic
• Can be diagnosed whenever any of the three
  cardinal symptoms is present
• Is misleading in that SOME cases who receive this
  Dx do NOT have PERVASIVC disorders
• instead they have circumscribed problems with
  social uses of language

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PDD-NOS vs. PLI

• PDD-NOS comes from the psychiatric tradition
• NOS is used to characterize a disorder that does
  not meet full criteria
• Implies a lower level of severity, with same
  range of symptoms
• PLI is not an official diagnosis in the U.S.
• Not guaranteed to make child eligible for
  services
• Not covered by insurance

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PLI and the SLP

• PDD-NOS emphasizes the psychiatric nature of the
  disorder
• Implies a relatively secondary role for the SLP
• Yet for many of these children communication
  deficits are not only primary they may be the
  only significant area
• Wouldnt it make sense for these children to be
  called PLI, rather than PDD-NOS?

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Reality Bites

• ASD may be more appropriately thought of as a
  series of subcategories of disorder rather than a
  spectrum.
• There may be a variant in which basic language
  skills are intact, children are eager to engage
  socially, but have poor abilities to use language
  to accomplish this.
• PLI may be a good description of this variant.
• PDD-NOS an unfortunate nomenclature.
• BUT politically, introducing PLI as a dx would be
  a major undertaking.

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References

• Happe, F., Ronald, A., Plomin, R. (2006). Time
  to give up on a single explanation for autism.
  Nature Neuroscience, 9, 1218-1220.
• Paul, R., Miles, S., Sparrow, S., Cichetti, D.,
  Klin, A., Volkmar, F., Coflin, M. Booker, S.
  (2004). Micro-analysis of adaptive behaviors in
  children with autism and Pervasive Developmental
  Disorders-Not Otherwise Specified. Journal of
  Autism and Developmental Disorders, 34, 223-228