'Not at the diagnosis point': Dealing with contradiction in autism assessment teams

The role of administrative categories in the globalisation of a psychiatric concept: Case studies of autism in Japan

This paper explores how what I call 'administrative categories' have been adopted by the Japanese government and experts in autism support and what roles these categories have played in local settings. Since support practices for children and adults with autism began in the 1950s in Japan, the Japanese government and people engaging in autism support have used Japanese-specific administrative categories, instead of relying on a medical concept of autism, such as 'severe moving disabilities' (SMD), 'emotional disturbance', and 'extremely disruptive behavioural disorders' (EDBD). To understand the emergence of these three autism-related administrative categories in Japan, historical materials published from the 1950s to the 1990s by Japanese authors (doctors, psychologists, teachers, educationalists, welfare workers, government officials, and parents) and interview data with 19 leading experts of autism in Japan were collected and analysed thematically. The analysis revealed that the governmental ministries aimed to focus on establishing administrative support by avoiding engaging in aetiological debates among doctors, and to describe the political agenda more vividly. Administrative categories filled the gap between local interests and international medical concepts, enabling the concept of autism to be rooted in Japan's administrative systems. Three roles of administrative categories were identified: i) separation from medicine, ii) describing local problems, and iii) claimsmaking to wider actors and the public. I concluded that looking purely at medical and specifically diagnostic concepts limits our understanding of the formation of practices regarding disabilities, and thus more focus should be placed on categorisation practices outside of medicine. In addition, to the literature on the globalisation of Euro-American psychiatric concepts, this study contributes to our knowledge of a form of locality that has not been central in the exploration of the influence of globalisation on local settings and the relationships between the local and the global.

Autistic adults' perspectives and experiences of diagnostic assessments that include play across the lifespan

LAY ABSTRACT

Play is often included in autism diagnostic assessments. These assessments tend to focus on negatives and how people who are not autistic interpret observable behaviours. It is important to take a neurodiversity-affirmative assessment approach. This involves focusing on what autistic people say and looking at strengths and needs. We wanted to find out how autistic adults experience diagnostic assessments that include play. We asked autistic and non-autistic people to help us design our study and interview questions. We then interviewed 22 autistic adults to find out what they think about the use of play in assessments. We used a qualitative method called interpretative phenomenological analysis to analyse the data. Autistic adults told us about the different ways play was included in their diagnostic assessments. For example, some completed a diagnostic tool called the Autism Diagnostic Observation Schedule. Autistic adults also talked about the importance of considering how autistic people are different to each other. For example, we found that play may not be useful for assessing women or girls who mask. This suggests that professionals should adopt a personalised approach to diagnostic assessments that use play catering to each person's needs. Our findings also suggested that professionals should assess strengths and differences as well as needs.

Autism Detection in Children: Integrating Machine Learning and Natural Language Processing in Narrative Analysis

Despite the consensus that early identification leads to better outcomes for individuals with autism spectrum disorder (ASD), recent research reveals that the average age of diagnosis in the Greek population is approximately six years. However, this age of diagnosis is delayed by an additional two years for families from lower-income or minority backgrounds. These disparities result in adverse impacts on intervention outcomes, which are further burdened by the often time-consuming and labor-intensive language assessments for children with ASD. There is a crucial need for tools that increase access to early assessment and diagnosis that will be rigorous and objective. The current study leverages the capabilities of artificial intelligence to develop a reliable and practical model for distinguishing children with ASD from typically-developing peers based on their narrative and vocabulary skills. We applied natural language processing-based extraction techniques to automatically acquire language features (narrative and vocabulary skills) from storytelling in 68 children with ASD and 52 typically-developing children, and then trained machine learning models on the children's combined narrative and expressive vocabulary data to generate behavioral targets that effectively differentiate ASD from typically-developing children. According to the findings, the model could distinguish ASD from typically-developing children, achieving an accuracy of 96%. Specifically, out of the models used, hist gradient boosting and XGBoost showed slightly superior performance compared to the decision trees and gradient boosting models, particularly regarding accuracy and F1 score. These results bode well for the deployment of machine learning technology for children with ASD, especially those with limited access to early identification services.

Regulating diagnosis-Molecular and regulatory sub-stratifications of lung cancer treatment

The sociology of diagnosis has shown that diagnosis not only serves to label the underlying cause of disease but also to provide access to services and resources. Elaborating on this double-affordance of diagnosis, this article examines how precision medicine reconfigures diagnosis as a label and as a process in regulatory and clinical settings. Reporting from an ethnographic case study of the introduction of immunotherapy for lung cancer, the paper unfolds the uncertainties involved in dissecting diagnosis into layers and examines the efforts and negotiations it takes to enable these layers to work both as clinical entities and regulative entities with the purpose of delineating access to treatment. I suggest that the work of subdividing diseases into molecularly defined categories for the purpose of delineating treatment-eligible populations can be labelled 'diagnostic sub-stratification' and argue that it is pertinent to understand the political capacity of this strategy. Diagnostic sub-stratification involves a push of diagnosis from the clinic 'up' into the regulatory system and 'out' into the laboratories, obscuring who is accountable for the diagnostic categories employed to define patients' treatment access.

Stratified medicalization of schooling difficulties

Medicalization is a central topic of concern in the sociology of disability and of health and illness. In this paper, I examine how medicalization is inequitably applied and circulates in the context of schools, specifically in serving students with educational disabilities. My aim is to advance understandings of medicalization through this case. Using a mixed-methods design, I first show, descriptively, how race and gender intersectionally predict educational disability status in a dataset of all Wisconsin public school students. Next, I examine how racial and gender disparities in disability status are produced at the micro level, using interviews with 27 Wisconsin teachers, including in-depth discussions of 73 individual students that were struggling academically or behaviorally. My quantitative findings show variation by race, gender, and disability category: White children have higher probability of special education receipt than comparable children of color for academic difficulties, but lower probability for behavioral difficulties, and girls have lower probability than comparable boys overall. My interview data suggest that these disparate outcomes reflect stratified medicalization processes, in which institutional constraints, status beliefs, and cultural discourses of race and gender shape both stratified noticing of schooling difficulties and stratified interpretation of those difficulties as medicalized conditions.

Autism diagnosis as a social process

LAY ABSTRACT

When a child or adult is referred for an autism diagnosis, clinicians from different backgrounds work together to make a diagnostic decision. A few studies have asked clinicians in interview how they feel about diagnosis and what the challenges are. We interviewed clinicians in child and adult assessment services in England, and from different professional backgrounds, about the challenges of autism diagnosis and the factors that might influence the assessment process. We found that there were a number of challenges in autism diagnosis, especially when someone coming for diagnosis was considered to be near the diagnostic threshold. Clinicians told us that making a diagnosis was like creating a 'narrative': looking at many different factors that told a story about a person, rather than just looking at the results of diagnostic tests. Clinicians do not always agree with the results of those tests and have to use their specialist clinical judgement to make decisions. Clinicians were concerned about the amount of time people have to wait for an autism assessment, and the resulting pressure on the assessment process. The findings of this work can help us to understand how diagnosis happens and consider ways in which it can be improved for adults, children and families coming for assessment, as well as clinicians.

Uncertainty and the inconvenient facts of diagnosis

One common contemporary usage of the term "diagnostic uncertainty" is to refer to cases for which a diagnosis is not, or cannot, be applied to the presenting case. This is a paradoxical usage, as the absence of diagnosis is often as close to a certainty as can be a human judgement. What makes this sociologically interesting is that it represents an "epistemic defence," or a means of accounting for a failure of medicine's explanatory system. This system is based on diagnosis, or the classification of individual complaints into recognizable diagnostic categories. Diagnosis is pivotal to medicine's epistemic setting, for it purports to explain illness via diagnosis, and yet is not always able to do so. This essay reviews this paradoxical use, and juxtaposes it to historical explanations for non-diagnosable illnesses. It demonstrates how representing non-diagnosis as uncertainty protects the epistemic setting by positioning the failure to locate a diagnosis in the individual, rather than in the medical paradigm.