Swedish climate activist Greta Thunberg describes herself as having Asperger’s while others on the autism spectrum, such as Australian comedian Hannah Gatsby, describe themselves as “autistic”. But what’s the difference?

Today, the previous diagnoses of “Asperger’s disorder” and “autistic disorder” both fall within the diagnosis of autism spectrum disorder, or ASD.

Autism describes a “neurotype” – a person’s thinking and information-processing style. Autism is one of the forms of diversity in human thinking, which comes with strengths and challenges.

When these challenges become overwhelming and impact how a person learns, plays, works or socialises, a diagnosis of autism spectrum disorder is made.

Where do the definitions come from?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) outlines the criteria clinicians use to diagnose mental illnesses and behavioural disorders.

Between 1994 and 2013, autistic disorder and Asperger’s disorder were the two primary diagnoses related to autism in the fourth edition of the manual, the DSM-4.

In 2013, the DSM-5 collapsed both diagnoses into one autism spectrum disorder.

How did we used to think about autism?

The two thinkers behind the DSM-4 diagnostic categories were Baltimore psychiatrist Leo Kanner and Viennese paediatrician Hans Asperger. They described the challenges faced by people who were later diagnosed with autistic disorder and Asperger’s disorder.

Kanner and Asperger observed patterns of behaviour that differed to typical thinkers in the domains of communication, social interaction and flexibility of behaviour and thinking. The variance was associated with challenges in adaptation and distress.

Between the 1940s and 1994, the majority of those diagnosed with autism also had an intellectual disability. Clinicians became focused on the accompanying intellectual disability as a necessary part of autism.

The introduction of Asperger’s disorder shifted this focus and acknowledged the diversity in autism. In the DSM-4 it superficially looked like autistic disorder and Asperger’s disorder were different things, with the Asperger’s criteria stating there could be no intellectual disability or delay in the development of speech.

Today, as a legacy of the recognition of the autism itself, the majority of people diagnosed with autism spectrum disorder – the new term from the DSM-5 – don’t a have an accompanying intellectual disability.

What changed with ‘autism spectrum disorder’?

The move to autism spectrum disorder brought the previously diagnosed autistic disorder and Asperger’s disorder under the one new diagnostic umbrella term.

It made clear that other diagnostic groups – such as intellectual disability – can co-exist with autism, but are separate things.

The other major change was acknowledging communication and social skills are intimately linked and not separable. Rather than separating “impaired communication” and “impaired social skills”, the diagnostic criteria changed to “impaired social communication”.

The introduction of the spectrum in the diagnostic term further clarified that people have varied capabilities in the flexibility of their thinking, behaviour and social communication – and this can change in response to the context the person is in.

Why do some people prefer the old terminology?

Some people feel the clinical label of Asperger’s allowed a much more refined understanding of autism. This included recognising the achievements and great societal contributions of people with known or presumed autism.

The contraction “Aspie” played an enormous part in the shift to positive identity formation. In the time up to the release of the DSM-5, Tony Attwood and Carol Gray, two well known thinkers in the area of autism, highlighted the strengths associated with “being Aspie” as something to be proud of. But they also raised awareness of the challenges.

What about identity-based language?

A more recent shift in language has been the reclamation of what was once viewed as a slur – “autistic”. This was a shift from person-first language to identity-based language, from “person with autism spectrum disorder” to “autistic”.

The neurodiversity rights movement describes its aim to push back against a breach of human rights resulting from the wish to cure, or fundamentally change, people with autism.

The movement uses a “social model of disability”. This views disability as arising from societies’ response to individuals and the failure to adjust to enable full participation. The inherent challenges in autism are seen as only a problem if not accommodated through reasonable adjustments.

However the social model contrasts itself against a very outdated medical or clinical model.

Current clinical thinking and practice focuses on targeted supports to reduce distress, promote thriving and enable optimum individual participation in school, work, community and social activities. It doesn’t aim to cure or fundamentally change people with autism.

A diagnosis of autism spectrum disorder signals there are challenges beyond what will be solved by adjustments alone; individual supports are also needed. So it’s important to combine the best of the social model and contemporary clinical model.

Andrew Cashin, Professor of Nursing, School of Health and Human Sciences, Southern Cross University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Roles of health professionals are still unfortunately often stuck in the past. That is, before the shift of education of nurses and other health professionals into universities in the 1980s. So many are still not working to their full scope of practice.

There has been some expansion of roles in recent years – including pharmacists prescribing (under limited circumstances) and administering a wider range of vaccinations.

But the recently released paper from an independent Commonwealth review on health workers’ “scope of practice” identifies the myriad of barriers preventing Australians from fully benefiting from health professionals’ skills.

These include workforce design (who does what, where and how roles interact), legislation and regulation (which often differs according to jurisdiction), and how health workers are funded and paid.

There is no simple quick fix for this type of reform. But we now have a sensible pathway to improve access to care, using all health professionals appropriately.

A new vision for general practice

I recently had a COVID booster. To do this, I logged onto my general practice’s website, answered the question about what I wanted, booked an appointment with the practice nurse that afternoon, got jabbed, was bulk-billed, sat down for a while, and then went home. Nothing remarkable at all about that.

But that interaction required a host of facilitating factors. The Victorian government regulates whether nurses can provide vaccinations, and what additional training the nurse requires. The Commonwealth government has allowed the practice to be paid by Medicare for the nurse’s work. The venture capitalist practice owner has done the sums and decided allocating a room to a practice nurse is economically rational.

The future of primary care is one involving more use of the range of health professionals, in addition to GPs.

It would be good if my general practice also had a physiotherapist, who I could see if I had back pain without seeing the GP, but there is no Medicare rebate for this. This arrangement would need both health professionals to have access to my health record. There also needs to be trust and good communication between the two when the physio might think the GP needs to be alerted to any issues.

This vision is one of integrated primary care, with health professionals working in a team. The nurse should be able to do more than vaccination and checking vital signs. Do I really need to see the GP every time I need a prescription renewed for my regular medication? This is the nub of the “scope of practice” issue.

How about pharmacists?

An integrated future is not the only future on the table. Pharmacy owners especially have argued that pharmacists should be able to practise independently of GPs, prescribing a limited range of medications and dispensing them.

This will inevitably reduce continuity of care and potentially create risks if the GP is not aware of what other medications a patient is using.

But a greater role for pharmacists has benefits for patients. It is often easier and cheaper for the patient to see a pharmacist, especially as bulk billing rates fall, and this is one of the reasons why independent pharmacist prescribing is gaining traction.

Every five years or so the government negotiates an agreement with the Pharmacy Guild, the organisation of pharmacy owners, about how much pharmacies will be paid for dispensing medications and other services. These agreements are called “Community Pharmacy Agreements”. Paying pharmacists independent prescribing may be part of the next agreement, the details of which are currently being negotiated.

GPs don’t like competition from this new source, even though there will be plenty of work around for GPs into the foreseeable future. So their organisations highlight the risks of these changes, reopening centuries old turf wars dressed up as concerns about safety and risk.

Who pays for all this?

Funding is at the heart of disputes about scope of practice. As with many policy debates, there is merit on both sides.

Clearly the government must increase its support for comprehensive general practice. Existing funding of fee-for-service medical benefits payments must be redesigned and supplemented by payments that allow practices to engage a range of other health professionals to create health-care teams.

This should be the principal direction of primary care reform, and the final report of the scope of practice review should make that clear. It must focus on the overall goal of better primary care, rather than simply the aspirations of individual health professionals, and working to a professional’s full scope of practice in a team, not a professional silo.

In parallel, governments – state and federal – must ensure all health professionals are used to their best of their abilities. It is a waste to have highly educated professionals not using their skills fully. New funding arrangements should facilitate better access to care from all appropriately qualified health professionals.

In the case of prescribing, it is possible to reconcile the aspirations of pharmacists and the concerns of GPs. New arrangements could be that pharmacists can only renew medications if they have agreements with the GP and there is good communication between them. This may be easier in rural and suburban areas, where the pharmacists are better known to the GPs.

The second issues paper points to the complexity of achieving scope of practice reforms. However, it also sets out a sensible path to improve access to care using all health professionals appropriately.

Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health, and Department of General Practice and Primary Care, The University of Melbourne

This article is republished from The Conversation under a Creative Commons license. Read the original article.