Controversy: the creation of diagnostic "haves" and "have-nots," an inadvertent cause of healthcare disparities among neurodevelopmental disabilities

Clinical Presentation and Questions of Identity, Camouflaging, and Self-diagnosed Autism in a Nonbinary Young Adult

CASE PRESENTATION

Vee is a nonbinary (sex assigned at birth: female) 16-year-old 11th grader presenting for their initial multidisciplinary team assessment (including developmental-behavioral pediatrics and psychological assessment). Vee's family first became concerned about their development when they were in pre-kindergarten. The school had concerns related to autism and provided Vee with an Individualized Education Plan (IEP) for autism-related services, although a formal medical diagnosis was never made. Vee "lost" the autism classification and associated services when they were in the first grade and no longer qualified for an IEP. However, concerns regarding social skills and identity persist 10 years later, and Vee is now questioning whether they are on the autism spectrum. Vee has carried historical diagnoses of obsessive-compulsive disorder (OCD), anxiety, depression, attention-deficit hyperactivity disorder, and specific learning disabilities-none of these diagnoses entirely explaining or satisfying Vee's long-standing sense of neither understanding nor being understood by others. Although symptoms of OCD, including intrusive thoughts, have significantly improved with therapeutic intervention, Vee still struggles with mood and anxiety. Their anxious tendencies include hair pulling and storing the hair in boxes. They "hate" school and often engage in school refusal; this has notably worsened since Vee entered middle school. Upon the start of high school, Vee disclosed that they identify as nonbinary to their parents, best friends, and school counselor.Vee struggles with social interactions, especially in novel social situations, and there is a history of bullying. They have 2 best friends, who both recently moved away. Most of their friends are in the online community. Vee has always preferred independent play, loves anime and rescuing animals, and is very imaginative and artistic. Vee has an early history of lining up items, toe-walking, and sensory sensitivities to loud noises, aesthetics of rooms and clothing, and textures of clothing. Vee can be aggressive toward their mother when they are frustrated and may even punch walls. They are not aggressive with any other individuals. Her mother wonders where "nonbinary begins and neurodiversity ends, never mind just being a teenager!"During the course of the assessment, which included Module 4 of the Autism Diagnostic Observation Schedule, Second Edition, Vee used little to no eye contact to manage their social interactions. They spoke in a flat monotone, and their use of gestures was greatly reduced for age; their gestures were also stiff and poorly coordinated. During the course of the assessment, Vee narrated their thought process in what they characterized as their "vocal stim": silly voices, catch-phrases and blurted swear-words. Vee explained how they use their vocal stim at different times to discharge nervous energy, entertain friends, and cope with challenging situations. Vee and their family are desperately seeking an answer to why they are so "different" from other young adults. Ultimately, the team conferred a diagnosis of autism spectrum disorder, much to the relief and expressed appreciation of Vee and their family. How can the team proceed from here and support Vee and their family?

Rethinking diagnosis-based service models for childhood neurodevelopmental disabilities in Canada: a question of equity

Neurodevelopmental disability in children covers a vast array of congenital and acquired long-term conditions associated with brain or neuromuscular impairments that impact function. While some presentations of neurodevelopmental disability align with diagnostic labels, many do not, leaving children whose conditions don't fit neatly under diagnostic labels struggling to access services or families and professionals feeling pressured to assign a diagnostic label in order to access services. In this paper, we (1) discuss the evidence showing that there is often a mismatch between a child's neurodevelopmental diagnosis, or lack of diagnosis, and function, (2) comment on the inequities exacerbated by diagnosis-based approaches for services, and (3) highlight the potential benefits of using a function and participation-based approach for providing services to children with neurodevelopmental disabilities. We close with three calls to action for function and participation-based approaches that could better support equitable services for children with neurodevelopmental disabilities.

Terminology and descriptions of navigation and related practices for children with neurodisability and their families: a scoping review

BACKGROUND

Children with neurodisability (ND) represent a significant population with a demonstrated need for coordinated support. Patient navigation has a primary focus on: facilitating access to and connection amongst fragmented systems; as well as the provision of educational and emotional support. Given the distinct needs of children with ND and their families, programs built upon such core concepts could be of great benefit. The diversity of terminology encompassing navigation-related concepts and activities (e.g., care coordination, case management, family support), however, presents challenges to both practice and research. This scoping review examined the terminology and descriptions provided within published articles on navigation-type models for children with ND and their families.

METHODS

The scoping review was conducted according to the Joanna Briggs Institute methodology. A preliminary search was completed on PubMed (NCBI), MEDLINE (Ovid) and CINAHL (EBSCO) to identify initial search terms, upon which a full search strategy was developed and executed in MEDLINE (Ovid) and CINAHL (EBSCO). After screening records according to our inclusion and exclusion criteria, a full-text review of relevant articles was conducted and data extracted using a researcher-developed tool. Under close supervision by the research team, study selection was primarily performed by one author.

RESULTS

Of the 2597 papers identified, 33 were included in the final review. From the included papers, a total of 49 terms were extracted, 20 of which were unique. Across the diversity of terminology observed, articles provided detailed and rich descriptions characterized by four central domains, namely: (i) what navigation-related resources, supports and services aim to facilitate and (ii) provide; (iii) descriptions of their intended outcomes; as well as (iv) guiding principles.

CONCLUSIONS

This scoping review addresses a gap in our knowledge related to the specification of patient navigation and related supports as applied to the specific context of children with ND and their families. Given the particular needs of this population, we propose an empirically-informed integrative model that synthesizes the findings from this scoping review. We suggest that this framework can be used as a guide to the mindful characterization of how supports aiming to connect children and families to needed service are termed and described within future research and in practice.