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Exploring the DISCO model of diagnosis

This article, compiled by the Lorna Wing Centre Team, aims to provide more understanding about the Diagnostic Interview for Social and Communication Disorders (DISCO) and its use in the diagnosis of autism spectrum disorders. The article also highlights DISCO's value in diagnosing women and girls with autism.

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Author: Lorna Wing Centre Team

Exploring the DISCO model of diagnosis

The Diagnostic Interview for Social and Communication Disorders (DISCO) is a dimensional approach to support experienced professionals to diagnose and develop further understanding of autism spectrum disorders.  This article has been drawn up to help to provide more understanding about the DISCO and its value in developing critical thinking skills in the diagnosis of autism spectrum disorders.

Diagnosis and understanding autism spectrum disorders

The term autism spectrum disorders (ASD) describes qualitative differences and impairments in social interaction, social communication and social imagination combined with restricted interests and rigid and repetitive behaviours. Autism spectrum disorders are diagnosed in children, young people and adults if these behaviours meet the criteria defined in the International Classification of Diseases of the World Health Organisation, tenth revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) and have a significant impact on function.

'Dimensional elements' are now used (DSM-5) in making any diagnosis of ASD which give an indication of how much someone’s condition affects them across many domains. This helps to identify how much support an individual needs. ASD is a behaviourally defined group of disorders which is heterogeneous in both cause and manifestation. In England, Wales and Northern Ireland recommendations about the process of recognition, referral and diagnosis of ASD are provided by the NICE guidelines. In Scotland this is provided by the SIGN guidelines.

The Diagnostic Interview for Social and Communication Disorders (DISCO)

The DISCO (Wing et al., 2002) has been designed and evaluated to assist in the diagnosis of individuals with a query of an autism spectrum disorder of all ages from infancy to old age and all levels of ability. The DISCO is a detailed semi-structured interview designed by Dr Lorna Wing and Dr Judith Gould to elicit a picture of the whole person from early years to present day functioning.

The primary purpose is to facilitate understanding of the pattern of social behaviour and communication over time and the skills and impairments that underlie an individual’s overt behaviour. In this way, it is possible to identify any manifestations of the autistic spectrum from the most obvious to the more subtle. The DISCO uses a dimensional approach to assessment rather than using arbitrary cut off points and placing individuals into distinct categories. This dimensional approach to clinical description is far more helpful for understanding needs and prescribing how best to help each individual.

Detailed information 

The special value of the DISCO is that it helps to collect information concerning all aspects of each individual’s skills and behaviour; not just the features of autism spectrum disorder.

Detailed information is collected to reflect the individual’s development over time as well as the current picture.   However, when there is no informant available to give an early history the items of the schedule can be completed for current skills and behaviour based on the current presentation.  This is an advantage over some other diagnostic schedules as it allows more flexible use of the DISCO diagnostic framework.  Also it gives information regarding other potential developmental, psychological or psychiatric disorders. It is noteworthy that the publication of DSM-5 (2013) now uses the model of autism being a spectrum and obviously builds upon the important work that was developed by Wing and Gould.

Women and girls

There is increasing awareness that we are missing girls and women on the autism spectrum and the assumption has been that there has been more autistic boys and men.  There is a need to consider the extent to which females on the autism spectrum present differently to males and to explore the possible gender differences in autism.  

In the DISCO examples are given of how the behavioural manifestations in the girls and women can differ from the males.  The ICD-10 does not give examples of the types of difficulties experienced by girls and women.  In order to recognise the different manifestations the questions in the DISCO take a much wider perspective regarding the social interaction, social communication and social imagination dimensions in addition to the special interests and rigidity of behaviour.  The Lorna Wing Centre has specific expertise in the diagnosis of girls and women.

A holistic approach

Another important feature of the DISCO interview is that it is closely integrated with all available sources of information. Final codes will reflect a rich holistic picture and draw on contributions from all involved. Additional psychological assessment is recommended alongside the DISCO, and all assessment information should be valued and collated to support the overall diagnostic process, including personal insight from the person themselves. The diagnostic formulation is not just based on a single interview and is NOT a checklist. Indeed, there is a strong emphasis and respect for clinical judgement. Although algorithms are provided for those wishing to use the formal classification systems these do not have to be used, as qualitative judgements are a valid alternative.

As previously stated, the DISCO framework is a highly flexible tool which can be adapted according to the unique nature of each case and the work context.  In complex cases, an in-depth analysis utilises the whole DISCO interview, but in more straightforward cases there is scope to work in a more qualitative way whilst still capturing the fundamentals of the dimensional style of diagnostic assessment.

To further support the diagnostic process, professionals with specialist knowledge and skills relating to these aspects of autism spectrum disorders are needed. The DISCO framework has been found to be very helpful in supporting a range of different professionals in developing their skills in diagnostic work and clinical practice. Parents tell us that they enjoy working together with professionals completing the DISCO as it helps them feel listened to. The overall process seems to help them tell their ‘story’ and to improve their understanding of their child. The narrative approach has a therapeutic effect.

DISCO training course

Training in the DISCO framework is over four days.  The training is over two stages:

  • pre-course work prior to stage one
  • interim coursework prior to stage two.

Coursework provides an opportunity for supervision and feedback from the specialist team for real cases. Participants comment on how useful they find this, especially if working with complex clientele. The training in the DISCO framework has proved to be valuable amongst many professionals and reaches out to a range of appropriately qualified professionals

Professionals will be accredited once they have completed the coursework and attended both stages of the training and have reached the required standards.

DISCO online

Accredited DISCO users can access and purchase DISCO online, a computer programme. It has primarily been designed to maintain the accuracy of the DISCO assessment whilst maximising time and resources. DISCO online can:

  • combine the manual, record form and algorithms
  • access notes for report writing
  • allow for easy analysis of cases for research
  • support immediate and accurate diagnoses.

Further information

For more information about DISCO or the Lorna Wing Centre for Autism please visit the website or email lornawingcentre@nas.org.uk

Date added: 20 January 2017

 

Comments

Thu, 26/01/2017 - 17:43

This type of diagnositic structure is well overdue.  What is also so good to read is that it helps professionals in their understanding of the individual's difficulties that they are seeking to help and takes into account, indeed, REQUIRES parental input and input from teh individual him/herslef.  This is what a diagnosis should be like; all inlcusive and a team effort.  Hoooraaay!   Let's hope that the days of the trying to fit an individual into a tight dignostic framework in order to get a diagnosis, using the very limited understanding and often inexperienced in autism professional, are long gone.  : ))  Joanna.