TYPES OF DIAGNOSIS TYPES OF DIAGNOSIS Clinical diagnosis

TYPES OF DIAGNOSIS

TYPES OF DIAGNOSIS • Clinical diagnosis • Differential diagnosis • Direct diagnosis • Diagnosis by treatment • Diagnosis by exclusion • Group or team diagnosis • Instrumental diagnosis • Provocative diagnosis • Tentative diagnosis

CLINICAL DIAGNOSIS • Clinical diagnosis is the study of the signs and symptoms of a disorder. The signs being the objective observable features of the disorder, [e. g. motor weakness in CP- observable feature] and experiences of the client.

• ADVANTAGES q. Clinical diagnosis is reliable to an extent as it based on the signs observed which would bring into consideration theoretical knowledge q. This type of diagnosis is time efficient q. It becomes easy to counsel the client about the signs and symptoms which led to the diagnosis

• DISADVANTAGES q. The cause may be assumed which might be misleading as the assumed cause may not be the actual cause. q. E. g. Language symptoms after stroke; in some may be associated with problems in auditory system or adjustment of problems. q. It is important that theoretical knowledge put to use be accurate. q. The reliability of the client’s description of his experience is difficult estimate.

DIFFERENTIAL DIAGNOSIS • Differential diagnosis is, determining which of the two or more disorders with similar signs a client is manifesting by systematically comparing and contrasting across signs, history, observation and testing data of the disorder. E. g. Articulatory profile in mental retardation and hearing impaired. • The main objective is to compare and differentiate between the signs of the two disorders, leaving behind the similarities that exist between the two. • Hearing impaired produce consistent articulatory errors. Their front sounds are better produce. Where as, inconsistent pattern exists in a case with mental retardation. • Hence, by comparing and contrasting the corresponding signs observed, history and testing data, differential diagnosis can be made

• ADVANTAGES q. As the diagnosis is a systematic process of comparing and differentiating, which is completely based on theoretical knowledge having a firm basis, it is more reliable. Nothing is assumed or hypothetical. q. It is a time efficient procedure

• DISAVANTAGES q. Condition like genetically based language slowness or bio chemical condition may not have been considered. q. Paucity of existing information i. e. information might not be enough to compare. q. The conditions may still not have a complete answer. q. The accuracy of information on each disorder may be absent. q. E. g. it is very difficult to differentiate between mental retardation and autism as it requires high degree of accuracy of every minute information, which is hard to obtain. q. Contradictory results in the same case can lead to confusion. q. The observation skills of the clinician might be inadequate.

DIRECT DIAGNOSIS • Direct diagnosis is observing the structural anomaly presumed to be causing the speech disorder or one made on the basis of presenting signs that are distinctively or characteristically associated with a particular speech disorder

• ADVANTAGE q. It is a very easy process as the diagnosis is directly based on the presenting signs or structural anomalies. q. Chances are rare that these presenting signs or structural anomalies are misleading. q. Time consumed in the process is less. q. It is easy to counsel based on the observations made. q. There is no necessity to take a detailed case history involving personal questions like consanguinity, etc. , making the process simples.

• DISADVANTAGES q The clinician must be careful not to assume too quickly. q. Normal instances may also be present. qe. g. Numerous cases exist of individuals with short palate or short lingual frenulerness, or malocclusions that manifest adequate speech production. q‘Cleft palate speech’ may turn out to be on a speech model or initiative basis. q. The structural anomalities might not be the only cause or the actual cause.

DIAGNOSIS BY TREATMENT • Diagnosis by treatment is the one made on the basis of the results of a specific treatment plan. • It is important approach often used in hard to diagnose cases, or in case when insufficient data exists. • e. g. In cases of speech retardation where a suspicion of a minimal, lesional brain dysfunction exists but where socio emotional and intellectual immaturities are also present. Problems in deciding which the primary, secondary, and tertiary signs may arise and may not be easily answerable for various reasons.

• Hence, a treatment plan may be formed on the basis of the best estimate of the problem i. e. , the condition of the child and the progress made in therapy program. Previously, if any then, on the basis of the progress made by the child in the treatment program, a diagnosis may be made. • Greater progress indicates that the condition is due to environmental cause. • Lesser progress indicates that the condition may be due to child’s ability

LIMITATIONS • There is difficulty in understanding what exactly has to be done in therapy i. e. , which aspect has to be given more focus. • Secondary symptoms may be most handicapping by the time symptoms begin and hence progress in therapy aimed at those symptoms may result in the clinician identifying a secondary socio emotional cause as the original or primary cause of the problem • It is a time counseling process

• ADVANTAGES q. Diagnosis can be made in spite of insufficient data. q. The provisional therapy plans made tells about the loop holes and hence improve the plan and work only areas required to be worked upon

• DIAGNOSIS BY EXCLUSION q. Diagnosis by exclusion is made by eliminating all those speech disorders to which some of the presenting signs belong and leaving only one to which apparently all of them belong. It involves the identification of signs that are important to a particular disorder and excluding the rest.

• e. g. A case who is 8 years old has no mental retardation, no hearing impairment, no brain injury or no serious malocclusion, indicating the absence of any organic cause. Hence, by exclusion method, it is diagnosed as functional articulation disorder. • Similarly, adult dysphonia reveals that the client is free of any laryngeal pathology, has no apparent respiratory anomalies, and has no auditory perceptual problems; hence, it must be a case of psychogenic dysphonia

• LIMITATIONS q. Not being aware of all the possible back grounds for the presenting signs in any case is the major weakness of the diagnosis by exclusion approach.

GROUP OR TEAM DIAGNOSIS • A group diagnosis is made by the combined efforts of an organized group of specialists acting as a unit. • The speech pathologist and audiologist are frequently involved with group diagnosis in cases like infantile auacusis, cleft palate, cerebral palsy, mental retardation, psychogenic language disorder, etc. , • The team involving professionals from all related fields like ENT specialist, special educator, counselor, psychologist, plastic surgeon, prosthodontist, etc. , as the type of disorders demands

• ADVANTAGES q. All the consultant specialists being available under one roof as the best a client could ask for. q. The involvement of different professions makes sure that the disorder or clients’ conditional is analyzed from every point of view ensuring accuracy and rehabilitee

• DISADVANTAGES q. The availability of all team members can not be predicted. q. There might be communication gap across team members due to interference in communication among team members due to various reasons like differences in professional vernacular, professional interest, perceived status, etc. , q. The team members might have difficulty understanding each other q. Time factor forms another limitation. q. The expense of each an approach is yet another limiting factor. q. It is more expensive for clients to search for team of professionals.

INSTRUMENTAL DIAGNOSIS • This type of diagnosis is made with the assistance of clinical instruments. • It can also be included under behavioral approach, within which, the interest is in characterizing the clients’ performance in tasks that are relevant, rather than on identifying certain behaviors that are suggestive of a particular disease • The clinical instruments range from diagnostic tests and tools (like REELS, SECS, M-CHAT, SSI, SPI, etc. ) to instruments like, EGG, Nasometer, VAGHMI, Dr. Speech, Audiometer, etc. in this approach, having a normative value is extremely important. The case is diagnosis based on the amount of device from the normative value.

• e. g. : Nasometer measures the percentage of nasalance for oral sounds, for the phoneme |a|- 25% of nasalance is abnormal as it is deviant from the normative.

• DISADVANTAGES q. There might be problems with the working condition of the instrument. Calibration, which is a must, might not have been done q. It is necessary that the clinician possess a sound knowledge about using the instrument and be careful while doing so. q. E. g. : while using EGG, if the placement of electrodes is incorrect, the waveform morphology obtained will be incorrect q. Knowing the normative value for every instrument and parameter is very important. q. The clinician should be able to adapt theoretical knowledge practically while using the instrument.

• Problem with the instrument or operator error will lead to false results. • The tendency to accept without too much questioning the quantitative data acquired from an instrument is also a drawback. • It is important to know the trouble shooting methods for all instruments.

TENTATIVE DIAGNOSIS • Tentative diagnosis is the one made based upon information available at that time and is subject to change when additional information becomes available. • It is made frequently in complen cases of language delay which take time to diagnose • E. g. : In cases with hearing impairment along with attention deficit, i. e. multiple handicap condition, due to inconsistent responses, it becomes necessary to make a tentative diagnosis based on the information available them. • In rare condition like Apraxia, it is difficult to diagnose if the sequencing errors are inconsistent.

• DISADVANTAGES q. The limitation is time related. Time taken to gather information could be slow. q. It is necessary that the same examiner should deal with the client but it is not possible in students training instructions. q. When additional information is slow in appearing, the tentative diagnosis may evolve into a more permanent diagnosis by default

• ADVANTAGES q. This approach gives us a diagnosis for the time being. q. It gives an idea about the client’s condition enough to draft a treatment procedure and hence not delay the client’s treatment.

PROVOCATIVE DIAGNOSIS: • Provocative diagnosis is done when the clients look normal and hence, diagnosis is made after including symptoms of a suspected disorder. • E. g. : In doubtful cases of stuttering. That is, the client may out not manifest any signs of stuttering while being examined and the clinician may decide to attempt to provoke them by applying various forms of communicative stress. He may become a disinterested or a critical listener, or he may ask the individual to speak clearly. The client might imagine speaking to higher authority and try to speak faster.

• In a case of doubtful hearing impairment, the clinician can speak softly, rapidly; look away from the client and then check his/her responses

• LIMITATIONS q. Sometimes method of provoking signs could be artificial q. Individual may rarely find himself in such similar situations. q. Actual speaking experiences and hence the ‘findings’ may lose some of their importance. q. It might be a time consuming process.

• Therefore, the above mentioned nine approaches help us know and understand the client’s condition in an effective manner. It is the combination of the approaches that is used by a speech language pathologist and audiologist in order to help the client to the maximum extent.