HELP FOR PARENTS OF CHILDREN WITH ASPERGER'S & HIGH-FUNCTIONING AUTISM

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The Rage Cycle in Aspergers: Group Discussion

I am reading about the rage cycle with Aspergers or High Functioning Autistic kids. One of my son's problems is his meltdowns and tantrums.

The cycle is supposed to have three parts:

1) Rumbling (like warnings of thunder)
2) Rage (the storm)
3) Recovery (the calm after the storm. Sometimes if handled poorly it can merely be the eye of the storm).

Various suggestions were made regarding interventions during the rumbling stage.

My son's camp therapist has not been successful at preventing blow ups. As a matter of fact, a good day seems to be followed by a seriously bad day.

Does anyone have any experience working with this?

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Oh, I know these tantrums very well. They're very hard to get under control.

I don't know what methods my mother used on me. Or better I don't know what method worked. I know what she tried. She tried to bring me in my room and let me stay there until I calmed down. But too much damage was done that way, because when in rage, I ripped down curtains, kicked furniture and walls, destroyed toys and handicrafts of mine. I was always horrified by what I had done when the fit was over, but at the time of rage I could only hardly help doing it.

She tried to hold me, but it made me only more furious and I tried everything to struggle free. If she had held on, we had both been hurt seriously.

She tried to talk to me and to distract me, but that was next to useless. I wasn't able to listen and the mere sound of the voice added to my rage.

Basically she always secured my little sister from me (because, sad as it is, if she'd come in my way I'd have hurt her) and then waited it out. That is what worked best.

Also she became a real master in watching out for possible triggers. That didn't help the fact that it came to such meltdowns, because the energy and frustration inside me was there and needed to come out sooner or later, but it (sometimes) helped to avoid the tantrums to happen in unpleasant moments.

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My son (he is moderately autistic and not aspergers) would have tremendous tantrums, they made me feel helpless because I never knew what caused them. He would do things like throw his dinner across the room, start screaming and tearing off his clothes while he was getting ready for school. I was told just to wait them out. Then I could get him to redress, or clean his dinner off the floor. Luckily he has fewer of these outbursts.

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Piper, my son will get upset when he feels an injustice has been done or as if he is being blocked from doing something he wants to do in an unreasonable way. Afterwards, he feels sorry that he reacted so strongly.

I have found that it if I try to explain the reasons for my requests before he goes into a rage, then if it is logical to him, he will comply without the rage. For example, I tried to explain the reason one washes one's hands after using the bathroom. He still needs to be reminded but does it.

My son has done some damage from his rages, including kicking a door off its hinges when he was 5! At this point, I simply try to keep the house clean. Our furnishing is very simple. I've delayed my desire to have a beautiful interior lest he (now the dogs!) ruined it.

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Getting upset over injustices sounds very familiar to me. Also being kept away from doing something of my interest was a big trigger for me.

I remember that the worst tantrum I ever had, was over a happy-meal toy my little sister had gotten while I had been at a school camp. I was already much stressed from two days away from home and that toy, and the injustice that my sister had gotten one and I had not (A MAJOR injustice to me), was the trigger to the worst tantrum I and my Mother can remember.
Also if others insisted that I did things different than I wanted to, upset me very much.

It's interesting, because logic reasoning helped preventing tantrums with me, too. It's still the same today. Once I understand something I'm fine with it and can handle it very good.

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Thanks for letting me know that!

I can really sympathize with you about that toy. After being at camp where you had to cope with all of those people, not getting the toy seemed like "the last straw" or the event that caused the tantrum after all of that tension had built up.

It is hard to realize that people are very illogical creatures sometimes and to realize that it doesn't even bother many of them to be so illogical! They accept things that seem to be wrong and don't even give it a second thought. And they think that the person that is trying to correct them is trying to make trouble.

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theses rage cycles sound like seizures. Are they? That kind of anger is not normal. It doesn’t sound like it happens on purpose. Parents should know that it could be a seizure. You might have that checked out. I know the rages you are talking about though medication can help too.

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That's a really good analogy. But I think actual seizures are due to an irregular type of brain wave activity. I'm not so sure that these rages can be tracked on an EEG. My son's EEG was normal, but they do say that children with Autism Spectrum Disorder (ASD) can develop seizures in adolescence.

I think that these can be prevented more so than seizures, but I can be wrong.

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My EEG did never show any irregularities, either.

Another thing that sets them apart from seizures is that the rages are not impossible to control. It's next to impossible to do that as a child (at least it was for me, because I tried very hard to sometimes and it just never worked), but getting older I got more control about them.
At the moment I can control them so much that I can stay pretty calm when I feel overwhelmed with something. I do still get upset, but I have learned to verbalize my anger and my feelings, I don't destroy things anymore, and apart from crying, which I usually can't help, I'm fine. Screaming helps a lot to. Really loud screaming. Instead of kicking things I learned to scream. It has the same effect, only it doesn't cause damage.

Also I've learned that some things aren't worth being upset about. Some really stupid things happen, people do things "wrong" very often, don't understand my point of view and many things are very frustrating still, but my tolerance for them has increased throughout the years. My feelings over those things don't overwhelm me nearly as much as they used to do anymore.

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Rowena's hurt all of us pretty badly at one point or another. Even Keven hasn't come through unscathed. Rowena is exceptionally strong and someone Kevin ended up with a broken wrist in the process.

I had a lot of problems with such things when I was younger. Now, I have it a lot more under control, though sometimes that control is a very fragile thing. Kevin's getting good at recognizing such times and avoiding me. (For me, that's the best way to deal with it, because that's basically what my parents did... tossed me into the bedroom and ignored it) Not the best solution, but now, because of that, it's what I'm used to.

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My natural mother would ridicule me knowing full well that she was making a bad situation worse. I was glad when she outgrew her slapping sprees.

I have no idea why or how anybody could possibly think slapping does any good at all. I think it is cruel, painful and very humiliating.

No child WANTS to vent like this, but slapped, ridiculed and pushed past a certain point with few outlets...you finally outgrow it.

Another thing I found upsetting was when she'd sing the praises of Other People's Children.

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My oldest uncle had an explosive temper his entire life (luckily, I was spared that side of him). When he was a boy, his paternal grandfather used to whip him for it. I seriously doubt that did him a damn bit of good. (This uncle died the summer of 2002).

I don't believe in whipping.

He was always "highly charged" and when I visited him in fairly recent years, he said that when he was upset he "had something wrong with his nervous system." The man was more highly charged than I EVER was! (I don't know if he had synesthesia). He had a myriad of interests, raised a family and successfully ran his own business until age 86 in the summer of 2000. My oldest uncle was deeply involved in whatever he was doing. He, like my youngest and favorite uncle was gifted.

I don't know if he would be considered on the spectrum or not and I never thought about it until now. It's just that now that I know more about it, I wonder in retrospect if he might have had Aspergers tendencies as well.

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I've learned that trying to talk to someone in a rage is pointless. Only infuriates them further. Any type of physical restraint also seems to make it worse. Loud noises or bright lights also seem to exacerbate the situation.

One young autistic boy I knew would run into the class coatroom when he was very upset. He'd throw himself on the floor and sob and kick his feet. There was no window and the closet was dark. After a few minutes, he'd be calmer. At that point, he'd usually ask that I rub the back of his neck. He found that calming.

I later realized that whenever he was anxious or stressed, he'd want me to apply pressure to the back of his neck, below the hairline. I once read something that said the neural bundling at that point of the body was very influenced by physical manipulation. Perhaps this little boy realized something scientists are only starting to study. Pressure on this spot helped him not lose control. However, once he had lost control, touching him did not help - it made things worse.

My Aspergers Child: How to Prevent Meltdowns and Tantrums

Asperger's Teens & Aggression

“My teenage son is very aggressive and lacks any type of impulse control. He cannot be left alone with his siblings. Does you have any recommendations? I know he does not want to do these things, because when we talk about it, he says he loves his sister, etc., but he hurts her all the time. My poor daughter has to put up with his aggressions on a daily basis. I can't watch him every second he's awake. I also can't put either child in a protective bubble or send my son to his room and leave him there all day. I really don't know what to do with him and I'm not a big advocate of drug therapy.

He's starting to internalize his behavior, and now said to me this morning that he's a bad boy even though no one tells him that, not us, or his teacher. I worry about his self-esteem as he grows older. We praise him when he's good, but he gets a ton of negative feedback: “Don't do this… don't do that, etc… you need to go to your room for hitting your sister"… I constantly feel like I have to micromanage him. But he knows he's in time-out or in his room a lot, and I do that so he can calm down or to protect his siblings. Any advice would be helpful.”


Unfortunately, for some teens on the autism spectrum, aggression may become quite common when reaching adolescence, and this may be clearly influenced by the parenting styles of the teen's mother and father. In fact, one of the key factors in determining an AS or HFA youngster's tendency to develop aggression later in life may involve the presence of a maternally sensitive woman who can also balance the discipline and aggression in life.

In many of today's American families, it is not uncommon to find that both the mother and father are relatively absent from the youngster's life (e.g., due to work-related issues). Because a youngster's mental health is often greatly influenced by (a) the presence of maternal nurturing and (b) the balance of a father's discipline, when either of these are absent in the life of an AS or HFA youngster, confusion abounds and aggression usually develops. If you are the parent of a teenager on the autism spectrum, it is important to provide this balance to your child-rearing efforts.

If you are a single mother, and your child's father is not present, you can expect your youngster's aggression will undoubtedly be present as you provide the maternal sensitivity your youngster needs while also attempting to be the disciplinarian. Because Asperger's kids have trouble differentiating social cues, and are confused by discipline when expressed by their mother, the authoritarian type of parenting is often met with aggression. For this reason, having a male role model (e.g., uncle, grandfather) who can provide that discipline while you provide the maternal sensitivity will go a long way in your youngster's long-term development.

Conversely, if you are a father who is raising an AS or HFA child alone, you will want to be sure that you find ways to be sensitive and nurturing to your youngster's needs. Because fathers are more likely to be the authoritarian, a woman's sensitivity will be important in your youngster's mental health. Often, this role can be filled by a woman who is an aunt or grandmother, and does not necessarily mean that a step-mother has to be in the picture.

Asperger’s is a developmental disorder that affects many kids by resulting in abnormal social development. For parents, offsetting the risk for development of aggression is most likely achieved by first identifying your parenting style - as either disciplinarian or nurturing - and then finding someone who can fulfill the role as the opposite parenting style. Trying to manage both the motherly role and the fatherly role often leads to confusion in the Asperger’s youngster, which may exacerbate Asperger’s-related complications in adolescence. Of course, it is not always possible to find a co-parent, but the ideal scenario would involve such an individual.

Discipline for Defiant Aspergers Teens

Aspergers and OCD

Question

My son has Aspergers and OCD and he will have hand tremors that he is not aware of. I am trying a more holistic approach but this is not covered by insurance. I wish I knew which ones were beneficial and which ones are not beneficial.

Answer

Traditional treatment for obsessive-compulsive disorder involves a combination of medication and behavioral therapy techniques. The traditional medicines used in this process are SSRI’s, or serotonin selective reuptake inhibitors.

Many parents do not want to treat their children suffering from OCD with these traditional methods, but turn to holistic methods of treatment. Because holistic therapies are designed to treat the whole person, not just the symptoms of a disease or disorder, holistic approaches appeal to many people. Holistic therapies can be added to traditional medical approaches, or can be tried by themselves.

Holistic practices often take into consideration lifestyle factors and address physical aspects of treatment, nutritional aspects, environmental, and social and spiritual elements. In seeking alternative treatments, take into consideration your beliefs and practices.

Holistic therapies for OCD are designed to relieve mental anguish. Many people find yoga and meditation to be effective in calming the mind and the body and strengthening the connection between the two. Aromatherapy can help a person reach a more peaceful and harmonious place. Hypnotherapy and acupuncture have also been found to be successful in treating various disorders. Behavioral therapies are often effective in conjunction with some of these alternative treatments.

In her book, “Freeing Your Child from Obsessive-Compulsive Disorder,” Tamar E. Chansky has created a step-by-step program designed to help parents work with children to free them from the cycle of OCD. This program was created with the goal of helping the child take back control of his life using these techniques. The techniques are designed to work with children who are either on or off medication. This method can be very effective in helping a child break free of this debilitating disorder.

It is difficult to say which holistic methods will work best with your child. Speak with your child’s physician and gain his help in creating a treatment plan for you child. Also solicit advice from trusted holistic practitioners who can suggest a holistic course of treatment.

Aspergers Kids Are In A World Of Their Own

"My 10 year old daughter has been diagnosed with Aspergers. It is a constant struggle to get her to pay attention or to even look at me. She seems in a world of her own sometimes. Any suggestions?"

Adults who are diagnosed with Aspergers have suggested that it is easier for them to make eye contact if they don’t have to listen. Some describe situations where having to make eye contact causes breaks in their concentration. So clearly there are some problems for individuals with Aspergers if they have to do more than one task like this at the same time (i.e., eye contact and listening).

It is also difficult for a youngster with Aspergers to understand what a person is communicating through eye contact. Others actually describe the experience of having to make eye contact as frightening.

It is important to recognize that Aspergers is a neurological disorder (caused by a medical problem with the brain) and the youngster is not choosing to behave this way. In fact it may well be a way of the youngster coping with their environment.

You can create a conducive environment by:

1. Frequent breaks - Allow her to take frequent breaks, or break work into small blocks; she will be able to perform better.

2. Minimizing distractions - Minimize the distractions for your daughter, provide direction in simple one-two step directions and provide ample times and cues (verbal and/or visual) for completing the task.

3. Providing structure - Providing structure to her day and routines, where the same activities occur at the same time every day, will let her know what to expect.

Non-Drug Treatments for Aspergers?

"Are there any non-drug treatments for AS?"

Some moms and dads introduce specific diets for their kids with Aspergers in an attempt to improve the condition or relieve uncomfortable physical symptoms. The most widely known diet for kids on the autistic spectrum is the Gluten/Casein free diet (GF/CF diet). In this diet all wheat and dairy products are removed.

Reported effects include the reduction of any existing gut/digestive problems, improved attention, eye-contact and general behavior. The diet has many devoted followers, but all evidence at this time is anecdotal and nothing has been proven.

However, if you decide to try the diet, it is important to do as much research as possible before you start and to consult your physician. You may find your physician is not supportive as this approach is not, as yet, widely accepted by the medical profession, although some physicians may be sympathetic.

Another diet followed is the Feingold Diet which eliminates all artificial colors, preservatives, flavors, etc. and encourages fresh, natural foods.

Vitamin supplements may be used, and fish oil supplements are cited as particularly beneficial, although this is still a matter of debate. It makes sense to feed any youngster a healthy, additive free diet, and thankfully the medical profession is now acknowledging the effects of diet on behavior.

As with any other diet you may introduce to a child with Aspergers, it is wise to consult your primary medical practitioner and to extensively research it via books, the web, and through talking with other children who have used the diet.

Do not remove whole food groups from your youngster’s diet or introduce large doses of vitamins and minerals without specific medical advice.

What is the best treatment option for defiant teens with Asperger’s and High-Functioning Autism?

Although there is no single treatment that is right for all teens on the autism spectrum, available supports and treatments include:
  • Dietary interventions
  • Occupational therapy
  • Medication
  • Experiential therapy
  • Physical activity and exercises designed to improve motor skills and coordination
  • Physical therapy
  • Special education services pursuant to the Individuals with Disabilities Education Act, including an Individualized Education Program (IEP)
  • Role modeling
  • Recreational therapy
  • Psychotherapy
  • Speech therapy

The frustration of not being able to express themselves, combined with social challenges, leads some Asperger’s teens to develop behavioral problems or become depressed or anxious. Treatment should address these needs as well as help the teenager manage his or her other symptoms.

In some cases, the teen may need more specialized, in-depth services than a public school can provide. Therapeutic boarding schools that specialize in autism spectrum disorders and learning disabilities are highly effective alternatives. In a highly structured setting, under the guidance of teachers and staff with specialized training and experience, these young people develop the skills they need to maximize their potential. Therapeutic boarding schools offer:
  • Social skills training
  • Small class sizes and favorable teacher-student ratios
  • Minimal distractions in an environment conducive to learning
  • Education and training on self-advocacy
  • Extracurricular activities tailored to each teen’s interests
  • Family involvement
  • Hands-on learning opportunities
  • High level of personalized attention
  • Consistent routines and predictable schedules
  • Communication and life skills development

Also, summer camps for teenagers with Asperger’s and high functioning autism are a shorter term option that has proven beneficial (and fun).

Discipline for Defiant Aspergers Teens

Aspergers Children and "Low Frustration Tolerance"

"I was just wondering, my daughter who is 9 (diagnosed as asd, as our doctor doesn’t like to put them into one category, but says if she did my child would be Aspergers!) doesn't have aggressive meltdowns, it’s more a crying depressive meltdown. Like I just had to ask her to tidy her room, and was explaining that if she picked up her things she wouldn’t have to tidy it this much. While I was telling her (I never shout or swear, i promise) she was crying, whilst putting things away, getting frustrated with drawers and things. I then came back after doing other things in the house, and found her just lying on the floor of her room with her comfort blanket. She is now watching a film in her room, took off her clothes and is in bed with one of the blinds shut. I asked her what was wrong…But she never seems to know how she is feeling, and just says she is ill. She said I had told her to do too many things. (Plus we had just been to the super market half an hour before) does this sound like a meltdown of some sort? She is never aggressive...just emotionally unbalanced, cries easy, often seems depressed. I hope someone can help. I am worried I might be handling things wrong!"

It may seem like they over-react to the small things that happen, but it is a fact that kids with Aspergers and high functioning autism have little emotional control and get frustrated easily. That's where they need your help and the help of others qualified in the area of emotions.

Ask yourself these questions about your Aspergers child's frustration: 
  • Does she throw things and hurt people?
  • Does she withdraw to someplace she feels safe?
  • Does she yell and cry?
  • How does your youngster show her frustration?
  • What do you do when she gets frustrated?
  • Do you give her time alone to try to deal with it?
  • Do you take it personally, or do you jump in to soothe her when she is on the brink of crying?
  • Is it best to talk about the issue or let it go?

Kids with Aspergers and high functioning autism have a low toleration for frustration. This frustration comes from a lack of understanding of their feelings. They are unable to identify and express what they are feeling, so they lump all the 'bad' feelings together. The parents see the overflow of 'bad' feelings come out at once. It's important that we don't take them personally, even when they seem as though they are directed at us. Aspergers kids want to tell us what is on their mind, but most of the time they don't know how to say it properly, or they misinterpreted their thoughts altogether.

So what can moms and dads do to help their Aspergers youngsters with frustrations?

If the youngster is exhibiting threatening behavior and seems unable to control it, then getting her to work with a professional is the best approach if she doesn't already have one. Many times, a therapist can provide coping techniques for the youngster to deal with her feelings. Also, a therapist can provide the parent with valuable insight and tools for helping the youngster deal with her feelings. There are also medications that a doctor can prescribe to help calm these outbursts and let the youngster think it through.

A child who is obviously frustrated but not particularly threatening or violent still needs help, and parents can provide that through on the fly discussions. An older youngster can be reasoned with on what triggered the outburst and how she can deal with it the next time. It's important that these discussions be held calmly and rationally. If the youngster feels accused or threatened, then she will not be receptive to what the mother or father has to say. It may help to have a therapist facilitate these types of conversations.

The bottom line is if your Aspergers youngster appears to have a low tolerance for frustration and it is happening more frequently, then she needs help understanding what it happening to her. This kind of help can come from a number of places, and the most important players are the parents. Don't take it personally, rather understand that your child is literally brimming over with 'bad' emotions and doesn't fully realize what she is doing.

My Aspergers Child: How to Prevent Meltdowns and Tantrums in AS and HFA Children

 
COMMENTS:

•    Anonymous said... I'm reminding myself that when Quinlan has a bay day no matter how frustrated or upset I am, he's 100 times more frustrated and upset. Woosah
•    Anonymous said... I had to do that reminder a few times myself today. Calm usually is easy for me, but not always.
•    Anonymous said... I'm normally calm and laid back. I think yesterday was one of those challenging days. Today has been nice and calm. With the occasional texture panic. ;) Thank you for letting me know, I'm not the only parent reminding themselves.
•    Anonymous said... On days when I'm at my whits end and I'm in my room crying, I remind myself that at least I can take a break. He can't. He always has Asperger's...
•    Anonymous said... Very well said. I'm so glad I finally found other moms who understand our daily struggles and joys.
•    Anonymous said... Thank you. I have selfishly held the attitude that even though others can take a break, I can't because I always have a son with Asperger's.... but what about him? stabbed me right in the gut. I mean it - thank you.
•    Anonymous said… Have the same issues with my son who is 8 with Aspergers - he just can't process so much at once, and gets shut down. Finding the balance is hard but I'm ever hopeful - this year is better than last year, new challenges but we know more too. x Good luck and remember it's a learning curve for both of you. x
•    Anonymous said… I found the Speechie and Ot helped with managing such sensory overload and executive function/organizing issues. Breaking down tasks, visual step by step and lists help to build the habit.
•    Anonymous said… it sound like sensory overload at the store. Lucky you for the meltdowns. Once you understand how the sensory funnel works you will figure how to avoid the overloads
•    Anonymous said… My 13 year old is exactly the same
•    Anonymous said… My adoptive teen is not aggressive but he is more of a quite depressive mode. He does have the capability of deceptive explosive behavior, If he is bullied by others. Otherwise, he shuts down!!!
•    Anonymous said… My daughter is like this as well. Even a statement like tidy your toys is to vague for her. She needs specific put your stuffed animals in the basket or whatever it is. She can't break it down into smaller tasks on her own. I have found that putting pictures on drawers help a little so she can see what goes there. To her it isn't messy and she sees no need to clean it so that's why giving specific tasks helps. At least with her maybe it will help you to. I know of we go out I can't ask anything from her for a minimum of thirty minutes because it is to much for her. Being around people is to demanding and exhausting for her. Hope that this helps at all.
•    Anonymous said… My son can become frozen if I ask him to do more than one thing at a time. He will flop onto his bed and bury himself in his blankets and squeal. Someitmes he paces back and forth not knowing what to do with himself and will scream or grab his hair. He is twelve and this is not always his reaction but if he is trying to concentrate on something like building lego or whatever and I ask him to put his shoes on, feed the chickens, and wash his hands, this is enough to put him out of sorts. Sometimes I ask him to brush his hair and he brushes his teeth smile emoticon He does not always have the headspace to hear what I am saying sometimes because he is always thinking of really intricate and detailed things and it takes time for him to find his way back to the world where people are making demands of him.
•    Anonymous said… My son is 8 and would do something similar in the same situation. Try breaking the job down into much smaller jobs. We give him a list to work through so he can cross of what he has done and see that there is an end to it. Does that make sense?
•    Anonymous said… My son is more this way as well.
•    Anonymous said… My son is the exact same way!! Those are his meltdowns. He just shuts down and cries. He never knows why he has them.
•    Anonymous said… My son is the same way. I will admit though, that my son is pretty manipulating when it comes to doing chores. He can be aggressive and have meltdowns, especially if I ask or tell him to do something like clean his room. He has also developed a depressive attitude with low self esteem which hurts so badly as a patent. Anyway, I've found it goes a lot smoother if I tell him instead specifically what he needs to do one thing at a time. So instead of telling him to clean his room, I'll ask him to put his toys in his closet and also offer to help him with something else, say, put his books away. If I want him to run the vacuum, I'll tell him that I'll dust. It also helps if I plan a room for us to do together. This way it doesn't seem to overwhelm him as much. Hope this helps.
•    Anonymous said… My son started school two weeks ago, he has just turned five. I find we get a mixture of absolute emotional helplessness to extreme anger and aggression. The aggression is always followed by emotional turmoil and upset and the need to feel squeezed. I have realised that his meltdowns vary and I also realise that he also cannot process more than one task at hand. One reason I know this is because he is very intelligent and has always been very 'forward' academically in comparison to his peers, yet, now he is at school I he is not really displaying any real high level of intelligence . His teacher explained to me ( when discussing something else) that gabriel often makes mistakes even when she knows he knows the answer , he also seems eager to please and rushes , this is particularly the case when there are seven or so children taking part in an an activity around a table , once there is only he, or one other child left at the table with the teacher he answers accurately all the time . He often needs to be asked a question twice, the first time to process he is being asked something and to get over the feeling of pressure or stress of being asked and then the second or third time to actually answer the question. Please don't misunderstand me, it is not of great importance that he is seen as being highly intelligent at school, I refer to this point because it has helped me understand how he functions and why he acts in certain ways. I think the difference is that he is completely overloaded and can't process what he is doing whilst at the same time watching and listening to the other children. He also doesn't respond under pressure and can actually look completely vacant as though you aren't even there let alone have asked him something . If I give him a small list of say two or three things to do he will despair. He will demonstrate sheer frustration without even attempting anything. This is true of any direction I give him that follows further instructions . He becomes frustrated so easily too, especially if it's something asked of him that is not within his usual routine. I do find that he responds better with one thing given to him at a time with the next introduced after. I also have to put a real enthusiastic positive emphasis on everything . He also cries so easily , is emotionally all over the place a lotOf the time but particularly when tired or feeling exhausted . He often complains of tired legs a lot which seems to distract him from anything else that I need him to concentrate on . He says they are heavy when he lifts them. His anxiety issues can also be at different levels from one day to the next dependant on other factors such as tiredness and how sensitive he is on a particular day.
•    Anonymous said… My son who is 12 now thrives on structure, written out step by step responsibilities for the day he can check off when completed. Helps him keep a routine and doesn't get overwhelmed. My daughter who I also suspect is on the spectrum deals with emotional anxieties. Cries very easily and can not seem to control it. Anxiety medication has helped both my children with their sensory issues that can change on a day to day basis.
•    Anonymous said… Probably over loaded. Sounds like my son. The shopping was probably enough to overload her-all the sensory overload! Maybe a break after shopping b4 any tasks may help in future...X
•    Anonymous said… The phrase "low frustration tolerance" has always described my 9 yr old Aspie. Emotional and intense follow right behind. We are always teaching strategies for recognizing emotions, identifying those big feelings as they're coming (instead of after they overflow), etc. It's a skill we will always be practicing, I think.
•    Anonymous said… Yes, this is what I would see with my daughter - more of a shutdown than a meltdown. I didn't recognize it for what it was for a long time (because her younger brother was having over the top meltdowns) and only got her diagnosed at sixteen. Good for you for being so attuned to your daughter! And if it helps, my daughter was the same with her room and now it's completely organized and when it gets out of hand she can do it herself.
•    Anonymous said… You are not alone. I have a nineteen yr old on the spectrum who has some of the same issues. Lots of love and patience!! Keep your chin up Momma! Find a good network of parents for support!
•    Anonymous said… Your beautiful girl sounds just like my beautiful girl (also aged 9) who can get overwhelmed at the simplest of tasks or become stressed at the most benign of issues. There is no right or wrong way, as some days she copes better than others. We work hard to support her to become more resilient and confident - she has self esteem issues also - and when she has a "wobble" (our name for those wee episodes) we let the dust settle and then talk it through. The task still gets done, but we often have to break it down into more manageable chunks and explain the reasons why the task must be done. It's a toughie.....we acknowledge and appreciate the challenges that she faces, but we must also do our best to teach her lessons and skills that often come more easier to typical kids. Bad behaviour isn't tolerated and she still has to conform to rules and social norms, but our discipline regime (for want of a better phrase) is a little more gentle than the one we applied with her brother. Good things to note is that there are way more upsides with Maia, as she is sweet, creative, kind, funny, smart and sparkly.....I flippin love her!!!
 
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How can I bottle break him without causing him extra stress?

"My son Jacob has aspergers (high functioning). He turned 3 years old several months ago, but still is in diapers and takes a bottle. How can I bottle break him without causing him extra stress?"

In general, Aspergers kids can try a cup at 6 months and be weaned off the bottle around 12 to 18 months. It does vary from child to child, and it is up to the mother to decide when to encourage the change from bottle to cup. The things to look out for are when the baby can sit up for themselves; obviously drinking from a cup is going to be near impossible when baby is still lying on his back. Also, your baby should be taking bottle feeds at regular times. You should also be noticing that your Aspergers child starts to show a real interest in the food of others.

Aspergers kids being bottle fed are more likely to suffer from tooth decay. So, it is important to not allow your him to carry on bottle feeding longer than is necessary, but don't force the issue - remember, weaning your Aspergers child of bottle feeding is a gradual process. As your youngster develops, the nutrients he requires change. He will not get these nutrients from bottle feeding alone whereas he will get more than he needs from solids. Finally, Aspergers kids who delay the transition from formula to solids may have difficulty developing appropriate feeding skills.

How do you wean your Aspergers child off the bottle?
  • At age 8 to 10 months, substitute a 'sippy' cup for a bottle at one feeding during the day. Choose a feeding when the Aspergers child usually drinks just a little, rather than a major mealtime. Use this same feeding time to use the cup every day for a week. Remember, routine is key.
  • Be patient. Help your Aspergers child to hold the cup and tip a small amount of liquid into the child's mouth.
  • Consistency is key to successful weaning. Be sure to give the Aspergers child the cup at the designated feeding time and don't switch back to the bottle at this feeding.
  • Gradually introduce the cup at another feeding, slowly decreasing the number of bottles the Aspergers child receives.
  • Some Aspergers kids may need to suck as a way for them to control their behavior. This sets their mood to accomplish certain tasks such as sleeping, concentrating and running. Some Aspergers kids may continue to suck on a pacifier or bottles of plain water for the first few years.
  • Wean your Aspergers child during a relatively stress-free time. It is not a good idea to start when a new sibling has just arrived or when the family is moving to a new house.

What can you do to make weaning easier?
  • Be a positive role model and drink from a cup with your Aspergers child.
  • Buy cups with handles, spouted lids or baby cups with straws to make drinking easier.
  • Offer other comforts such as a soft blanket or stuffed animal or play soothing music.
  • Spend extra time cuddling with your Aspergers child during the weaning process.


How To Get Other Family Members To Accept Your Child's Diagnosis

"I'm a stay-at-home mom. My husband works out of town and is only home on weekends. My question is how can I get my husband and in-laws to accept our daughter’s diagnosis? They claim I am just 'making this up' and that it's really a behavior problem with her – not a 'disorder'."

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High-Functioning Autism and Associated Disorders

“We’re in the process of having our son assessed for high functioning autism. We’ve had numerous problems in the past that have brought us to this point. The doc said he believes our son may have several ‘comorbid’ conditions as well. What does this mean? What other ‘conditions’ might there be?”

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Why does a child with Aspergers have a short attention span?

Kids with Aspergers frequently exhibit problems associated with other special needs (e.g., attention problems and obsessive/compulsive disorders). Researchers and practitioners are unsure whether these behaviors are a part of Aspergers or are comorbid, (i.e., related) disorders.

The characteristics of Aspergers include difficulties in social communication, sensory problems and organizational difficulties. All of these combined will certainly affect their ability to sustain concentration for any length of time.

For example, a room may be too bright, noisy, too many pictures, etc., which are all distractions and high stimulation. This means that certain sights, noises, tastes and textures can bother a child more than they would a child without Aspergers.

Aspergers kids will often not fully understand what is being said to them and will often misinterpret crucial verbal and non-verbal information. They also find it difficult to give consistent eye contact as this sometimes interferes with their ability to take in new information.


Individual Education Plan for Aspergers Children

Question

How can I get help in obtaining services that are supposedly out there and available? My son’s ISSP (IEP) looks fantastic on paper, but in reality, most of the services are not obtainable due to extremely long wait lists or shortage of workers to completely fill the positions.

Answer

Developing a relationship with your son’s school and creating an acceptable IEP, or Individual Education Plan, is very important. “How Well Does Your IEP Measure Up?” by Diane Twachtman-Cullen and Jennifer Twachtman-Reilly is a book that can help you grow to be a valuable member of your son’s IEP team, giving you insight into the IEP process. You’ll learn about often-neglected areas that should be addressed during the IEP meeting.

Your son’s school has obviously been cooperative, working with you and acknowledging his disabilities. However, without follow-through, all you have is a stack of papers. By law, your son is entitled to FAPE or a free, appropriate public education due to his diagnosis of Asperger’s Syndrome. His IEP is a legal document. Your son’s school is legally responsible to uphold the contents of his IEP. There are procedures in place to protect all parties involved in the education plan. However, someone has to initiate these procedures.

At the time of your son’s IEP meeting, his IEP team leader should have reviewed your state’s laws and your rights as a parent of a child with special needs. You should have been given a copy of your state’s FAPE procedures and parent’s rights handbook. Now is the time to review this handbook and determine your first step.

You must initiate a legal procedure called due process. Once you file due process, you will have the opportunity to show proof that the school system is not fulfilling your son’s services as set in his IEP. Your parent handbook will outline the steps you must take to begin due process in your state. You, as the parent, are responsible for holding the school system accountable.

Preserving your relationship with your son’s school is very important. Even if you file for due process, your son will remain in their care until the process is resolved. You will want to be comfortable with this arrangement. Remember to maintain neutral communication. While this is a personal matter in your life, this is not a personal attack. Moreover, it doesn’t have to become one.

Contact your state’s special education advocacy support group. This group is in place to support the families of special needs kids by offering information and advocacy training services at no charge. This group can guide you through the legal process of receiving FAPE for your son.

Aspergers Students: Navigating Through the Educational System

"Please give me some ideas on how I can work with my son's school (he is high functioning with Aspergers). We are starting to have some academic and behavior problems with him, have tried to educate his teacher about things that set him off and calm him down, but no one seems willing to try anything different, treating our son as though he had no special issues."

If you are wondering how to navigate through the system in order to get your Aspergers (high functioning autism) youngster educated you are not alone. Our kids don't fit so neatly into the main stream educational system. They are often too high functioning for some programs and still need more assistance than other programs offer. While they are in desperate need of socialization, too much is often detrimental. One on one for academics is perfect but does not provide enough stimulation and a classroom environment is just the opposite. The first step is to look at all of our options without leaving any out, even the ones we absolutely reject right off the bat. Taking a good look at every option, the good and bad ones will give us the education we need to come up with creative solutions.

Gather as much facts about every option. Public Schools, private schools, home school support schools, home schooling at home, public online virtual schools, private online virtual schools and of course the laws in your state. Ask every question you can think of. The squeaky wheel gets the grease. Ask around, look online and don't let fear rule your decisions. With all my heart I wanted my son to go to the school that was attached to my home church and fear kept me from looking at other viable options for much longer than was necessary.

Leave yourself open to new ideas. My son went to private school till 5th grade. It was absolute torture trying to keep up. Finally when it became obvious that it was no longer working I decided to home-school. It has been a fabulous experience for us both and I wish I had been brave enough to try it sooner. I purchased curriculum, set up schedules and after about a month I put it all in a box and started to concentrate on the things that my son needed most and we worked on those. I went from traditional to eclectic lickety split. I found online games, videos, typing programs, online spelling programs, vocabulary software, online reading programs and we worked on things till he learned them, however long it took. We took piano lessons, art lessons and swimming lessons. We spent 6 months on Math facts. On days that one thing wasn't working we switched to something else. Life is too short. As a result my son reads wonderfully and loves to learn. That was middle school. During that time we also found a wonderful home school support school.

Now that he is starting High School he is taking some classes online and going part time to a nearby Christian High School. Technically he is still homeschooled so he will also be attending a Home School support school. At some point we will use an umbrella school to consolidate his High School Credits in order to get a High School Diploma or he may graduate from the High School he is attending. Every year is different and I have learned to always have a plan A, plan B & even a plan C. These days though I am certain that it will all come together. Fear no longer rules my decisions.

Tips—

1. After getting the facts, think over your options carefully and talk them over with carefully selected people who are sensitive to your situation. I often use counseling services when I get stuck on the tough decisions. Remember: If you have a plan A, a plan B and a plan C it’s easier to move on if something doesn't work out like it seemed it might. Allowing ourselves to think out of the box has been a freeing experience.

2. I am always careful to explain any changes with my son well in advance and prepare him for each transition as best as possible. I also try to anticipate anything that may cause him anxiety or that needs to be addressed a head of time. One example is I always show him around any new setting to make sure he knows his way around very well and knows who to ask if he needs help. I check in often to make sure he is settled in and make sure I am available if I am needed. My son is a special gift to me and I never take that gift for granted.

3. Obviously every option is not right for everyone. That is why it is so important to get the facts not only about your options but the facts about your families strengths, weaknesses, resources and support options.


COMMENTS:

•    Anonymous said… Awesome! We are on much the same journey... 5 years in therapeutic schools and finally having the courage to listen... and on year two of homeschooling. It's been a blessing for us all as we grow and change and learn... anything is possible! Not perfect - but better! Thank you - this was exciting and encouraging to read. :) Peace!
•    Anonymous said… great article... we are on much the same journey t midde school part.thank you! :)
•    Anonymous said… Homeschooling successfully...
•    Anonymous said… I got the school to provide my son with the work and a tutor to do homeschooling to take some of the pressure off of me but they only tutor him an hour a day and he is going into 6th grade so I still need to work with him a few hours a day.He has begged me not to send him back ..he hates it.The pyschologists disagree with me and think he needs to be in school for social ization but I think the type of socialization in school is usually neagative anyway so he's not missing anything. I am going to put him into a social group with kids he can relate to.But back to the topic ,I was in the same boat with schools saying he needed to be in the mainstream classroom since he was so intelligent…but its not just about intelligence,what about his anxiety and sensory issues...they just don't get it and don't want to either:(
•    Anonymous said… I had to yell beg scream and cry for 4 years to get my son an IEP... even failing all his classes for the same exec function disability reason for years didnt get the point across .... *sigh* "but he is so smart"..... yes and he forgets everything including his coat even in -20 degree weather .... he needs help... *sigh* a very long bitter battle to finally get him the services he was entitled to for years. hopefully not too late to do some good .
•    Anonymous said… thinking we will do home schooling,
•    Anonymous said… We're homeschooling too

*   Anonymus said... Hopefully you have an IEP for your son. If not obtain this and ask the person doing the screening to include things that help your son behaviorally. If you have it down on paper, from a professional, sometimes it helps. I'm a counselor (my husband is a teacher) and we have a child on the spectrum but even with all our skills it took FOREVER to get the school to understand that children on the spectrum need different things. When we finally got their by in things started to change slowly, but it takes extreme patience (baby steps too), and good understanding from administrators (tolerance for children with special needs). Get everything down in writing when you suggest something to the school. This helps for follow up and just keep plugging away. When our child went to that school district my good friend and I we would utilize each other to bounce ideas, letters, and strategies off of each other before sharing them with the school district. If it weren't for her there were days that would have been tougher! So try to find others in the district that are in the same position as you are and work together. There is power in numbers. Good luck! We ended up moving when things were getting better and are in a district that is COMPLETELY different. It is so validating!

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Symptoms and Treatments for Aspergers and HFA

There are various symptoms that can be seen in a youngster with Aspergers (AS) or High Functioning Autism (HFA). Parents can use a checklist to closely observe their kids when they are fairly young. Children on the autism spectrum:
  • often lack motor skills
  • often speak in an odd tone or pitch
  • adhere to routines and have repetitive habits
  • have difficulty interacting at a social level
  • are often unable to make a coordinated plan
  • fail to get the undertone of a speaker
  • have difficulty empathizing because they have a hard time understanding the feelings of others
  • have narrowed interest fields and are often focused on one particular subject or topic

There is no treatment for AS or HFA as such, but there are many ways in which a parent can help his or her youngster to cope with this disorder. Often times, there is an additional disorder found in the child, which worsens the situation. Fortunately, medication is used to help the child deal with these comorbid conditions.

There are several medicines and therapies that have been discovered so far that help to control the symptoms of AS and HFA as well as comorbid conditions (e.g., ADHD, anxiety, depression). Certain medicines are prescribed by the physicians to bring ADHD under control; however, many of them show side effects such as twitches, trouble sleeping, loss of appetite, stomach aches, and  headaches. Fortunately, most of these side effects subside within a few weeks.

There are programs conducted in various schools that help the youngster by training him and helping him understand social cues and non-verbal language. In these training sessions, a communication specialist can always be brought in to help the youngster with social communication and social interaction skills. With proper training, these "special needs" kids can easily learn about the social cues, which is often taught in a way that one is taught a foreign language. They can also be taught to speak in a natural pitch and rhythm, and they can be trained to understand the various communication gestures like tone of voice, undertone like sarcasm and irony, eye contact and much more.

There are certain behavioral training procedures and therapies that have been adopted in order to train kids on the spectrum when it comes to behavioral disorders. These therapies help to curb such habits as interrupting, obsessions, anger and other emotional outburst. Cognitive behavior therapy appears to be a very effective method for changing unwanted behavior in AS and HFA children and teens.

Why do Aspergers kids behave in an obsessive manner?

It is very common for a youngster with Aspergers to become fascinated by a special interest that dominates his time. It is important to recognize what the fascination may provide for this youngster before attempting to eliminate it or control access to it. The fascination or obsession may provide the order and consistency he craves. It may also provide a method of relaxation.

Rather than try to eliminate these altogether (which is almost impossible), create a plan that uses these unusual interests as a reward for completed tasks. For example, if you ask the youngster to complete a task that he is familiar with and in which he can be successful. Then give him time on the interest as a reward. This way your kid will learn to manage and control the obsession better.


Aspergers: A Clinical Account

The many patterns of abnormal behavior that cause diagnostic confusion include one originally described by the Austrian psychiatrist, Hans Asperger (1944, 1968, 1979). The name he chose for this pattern was 'autistic psychopathy' using the latter word in the technical sense of an abnormality of personality. This has led to misunderstanding because of the popular tendency to equate psychopathy with sociopathic behavior. For this reason, the neutral term Aspergers is to be preferred and will be used here.

Not long before Aspergers original paper on this subject appeared in 1944, Kanner (1943) published his first account of the syndrome he called early infantile autism. The two conditions are, in many ways, similar, and the argument still continues as to whether they are varieties of the same underlying abnormality or are separate entities.

Whereas Kanner's work is widely known internationally, Aspergers contribution is considerably less familiar outside the German literature. The only published discussions of the subject in English known to the present author are by Van Krevelen (1971), Isaev & Kagan (1974), Mnukbin & Isaev (1975) (translation from Russian), Wing (1976), Chick et al (1979), Wolff & Barlow (1979) and Wolff & Chick (1980). In addition, a book by Bosch in which autism and Aspergers are compared, originally appearing in German in 1962, has been translated into English (Bosch, 1962). A paper given by Asperger in Switzerland in 1977 has appeared in an English version (Asperger, 1979). Robinson & Vitale (1954) and Adams (1973) gave clinical descriptions of kids with behavior resembling Aspergers, but without referring to this diagnosis.

In the present paper the syndrome will be described, illustrated with case histories, and the differential diagnosis and classification discussed. The account is based on Aspergers descriptions and on 34 cases, ranging in age from 5 to 35 years, personally examined and diagnosed by the author. Of these, 19 had the history and clinical picture of the syndrome in more or less typical form and 15 showed many of the features at the time they were seen, though they did not all have the characteristic early history (see below). Six of those in the series were identified as a result of an epidemiological study of early childhood psychoses in the Camberwell area of south-east London (Wing & Gould, 1979). The rest were referred to the author for diagnosis - 11 by their moms and dads, through the family doctor, two by head teachers and 15 by other psychiatrists.

The following general description includes all the most typical features. But, as with any psychiatric syndrome identifiable only from a pattern of observable behavior, there are difficulties in determining which are essential for diagnosis. Variations occur from person to person and it is rare to find, in any one case, all the details listed below.

The Clinical Picture—

Illustrative case histories based on those of kids and grown-ups seen by the present author are to be found in the Appendix. Throughout the paper, the numbers in parentheses refer to these histories.

Aspergers description of the syndrome:

Asperger noted that the syndrome was very much more common in boys than in girls. He believed that it was never recognized in infancy and usually not before the third year of life or later. The following description is based on Aspergers accounts.

Speech-

The youngster usually begins to speak at the age expected in normal kids, whereas walking may be delayed. A full command of grammar is sooner or later acquired, but there may be difficulty in using pronouns correctly, with the substitution of the second or third for the first person forms (No. 1). The content of speech is abnormal, tending to be pedantic and often consisting of lengthy disquisitions on favorite subjects (No.2). Sometimes a word or phrase is repeated over and over again in a stereotyped fashion. The youngster or grown-up may invent some words. Subtle verbal jokes are not understood, though simple verbal humor may be appreciated.

Non-verbal communication-

Non-verbal aspects of communication are also affected. There may be little facial expression except with strong emotions such as anger or misery. Vocal intonation tends to be monotonous and droning, or exaggerated. Gestures are limited, or else large and clumsy and inappropriate for the accompanying speech (No. 2). Comprehension of other people's expressions and gestures is poor and the person with Aspergers may misinterpret or ignore such non-verbal signs. At times he may earnestly gaze into another person's face, searching for the meaning that eludes him.

Social interaction-

Perhaps the most obvious characteristic is impairment of two-way social interaction. This is not due primarily to a desire to withdraw from social contact. The problem arises from a lack of ability to understand and use the rules governing social behavior. These rules are unwritten and unstated, complex, constantly changing, and affect speech, gesture, posture, movement, eye contact, choice of clothing, proximity to others, and many other aspects of behavior. The degree of skill in this area varies among normal people, but those with Aspergers are outside the normal range. Their social behavior is naive and peculiar. They may be aware of their difficulties and even strive to overcome them, but in inappropriate ways and with signal lack of success. They do not have the intuitive knowledge of how to adapt their approaches and responses to fit in with the needs and personalities of others. Some are over-sensitive to criticism and suspicious of other people. A small minority have a history of rather bizarre antisocial acts, perhaps because of their lack of empathy. This was true of four of the present series, one of whom injured another boy in the course of his experiments on the properties of chemicals.

Relations with the opposite sex provide a good example of the more general social ineptitude. A young man with Aspergers observes that most of his contemporaries have girl friends and eventually marry and have kids. He wishes to be normal in this respect, but has no idea how to indicate his interest and attract a partner in a socially acceptable fashion. He may ask other people for a list of rules for talking to girls, or try to find the secret in books (No. 1). If he has a strong sex drive he may approach and touch or kiss a stranger, or someone much older or younger than himself, and, as a consequence, find himself in trouble with the police; or he may solve the problem by becoming solitary and withdrawn.

Repetitive activities and resistance to change-

Kids with this syndrome often enjoy spinning objects and watching them until the movement ceases, to a far greater extent than normal. They tend to become intensely attached to particular possessions and are very unhappy when away from familiar places.

Motor co-ordination-

Gross motor movements are clumsy and ill-co-ordinated. Posture and gait appear odd (No.1). Most people with this syndrome (90% of the 34 cases mentioned above) are poor at games involving motor skills, and sometimes the executive problems affect the ability to write or to draw. Stereotyped movements of the body and limbs are also mentioned by Asperger.

Skills and interest-

Those with the syndrome in most typical form have certain skills as well as impairments. They have excellent rote memories and become intensely interested in one or two subjects, such as astronomy, geology, the history of the steam train, the genealogy of royalty, bus time-tables, prehistoric monsters, or the characters in a television serial, to the exclusion of all else. They absorb every available fact concerning their chosen field and talk about it at length, whether or not the listener is interested, but have little grasp of the meaning of the facts they learn. They may also excel at board games needing a good rote memory, such as chess (No.2), and some have musical ability. Seventy-six per cent of the present author's series had special interests of this kind. However, some have specific learning problems, affecting arithmetical skills, reading, or, as mentioned above, writing.

Experiences at school-

This combination of school and communication impairments, and certain special skills gives an impression of marked eccentricity. The kids may be mercilessly bullied at school, becoming, in consequence, anxious and afraid (Nos. I and 2). Those who are more fortunate in the schools they attend may be accepted as eccentric 'professors', and respected for their unusual abilities (No.4). Asperger describes them as unsatisfactory students because they follow their own interests regardless of the teacher's instructions and the activities of the rest of the class (Nos. 3 and 4). Many eventually become aware that they are different from other people, especially as they approach adolescence, and, in consequence, become over-sensitive to criticism. They give the impression of fragile vulnerability and a pathetic childishness, which some find infinitely touching and others merely exasperating.

Modifications of Aspergers account-

The present author has noted a number of additional items in the developmental history, not recorded by Asperger, which can sometimes be elicited by appropriate questioning of the moms and dads. During the first year of life there may have been a lack of the normal interest and pleasure in human company that should be present from birth. Babbling may have been limited in quantity and quality. The youngster may not have drawn attention to things going on around him in order to share the interest with other people. He may not have brought his toys to show to his moms and dads or visitors when he began to walk. In general, there is a lack of the intense urge to communicate in babble, gesture, movement, smiles, laughter and eventually speech that characterizes the normal baby and toddler (No.3).

Imaginative pretend play does not occur at all in some of those with the syndrome, and in those who do have pretend play it is confined to one or two themes, enacted without variation, over and over again. These may be quite elaborate, but are pursued repetitively and do not involve other kids unless the latter are willing to follow exactly the same pattern. It sometimes happens that the themes seen in this pseudo-pretend play continue as preoccupations in adult life, and form the main focus of an imaginary world (see the case history of Richard L. in Bosch, 1962).

There are also two points on which the present author would disagree with Aspergers observations. First, he states that speech develops before walking, and refers to 'an especially intimate relationship with language' and 'highly sophisticated linguistic skills'. Van Krevelen (1971) emphasized this as a point of differentiation from Kanner's early childhood autism, in which, usually, walking develops normally, or even earlier than average, whereas the onset of speech is markedly delayed or never occurs. However, slightly less than half of the present author's more typical cases of Aspergers were walking at the usual age, but were slow to talk. Half talked normally but were slow to walk, and one both walked and talked at the expected times. Despite the eventual good use of grammar and a large vocabulary, careful observation over a long enough period of time discloses that the content of speech is impoverished and much of it is copied inappropriately from other people or books (No.3). The language used gives the impression of being learned by rote. The meanings of long and obscure words may be known, but not those of words used every day (No.5). The peculiarities of non-verbal aspects of speech have already been mentioned.

Secondly, Asperger described people with his syndrome as capable of originality and creativity in their chosen field. It would be more true to say that their thought processes are confined to a narrow, pedantic, literal, but logical, chain of reasoning. The unusual quality of their approach arises from the tendency to select, as the starting point for the logical chain, some aspect of a subject that would be unlikely to occur to a normal person who has absorbed the attitudes current in his culture. Usually the result is inappropriate, but once in a while it gives new insight into a problem. Asperger also believed that people with his syndrome were of high intelligence, but he did not quote the results of standardized intellectual tests to support this. As will be seen from the case histories in the Appendix, the special abilities are based mainly on rote memory, while comprehension of the underlying meaning is poor. Those with the syndrome are conspicuously lacking in common sense.

It must be pointed out that the people described by the present author all had problems of adjustment or superimposed psychiatric illnesses severe enough to necessitate referral to a psychiatric clinic. Nine had left school or further education. Of these, three were employed, three had lost their jobs, and three had not obtained work. The author is also acquainted, through their moms and dads who are members of The National Society for Autistic Kids, with a few young adults reported to have some or all of the features of Aspergers, and who are using their special skills successfully in open employment. It would be inappropriate to give precise numbers or to include these in the series, because the author does not have access to case histories or assessment. For this reason, the series described here is probably biased towards those with more severe handicaps.

Course and Prognosis—

The published clinical descriptions are of kids and young adults. No studies of the course and prognosis in later life are available.

Asperger emphasized the stability of the clinical picture throughout childhood, adolescence and at least into early adult life, apart from the increase in skills brought about by maturation. The major characteristics appear to be impervious to the effects of environment and education. He considered the social prognosis to be generally good, meaning that most developed far enough to be able to use their special skills to obtain employment. He also observed that some who had especially high levels of ability in the area of their special interests were able to follow careers in, for example, science and mathematics.

As Bosch (1962) pointed out, it is possible to find people with all the features characteristic of Aspergers other than normal or high intelligence. This applied to 20% of the series described here. If these are accepted as belonging to the same diagnostic category, then Aspergers rather hopeful view of the prognosis has to be modified to take such cases into account (see the case history of J.G., Appendix No.5).

The prognosis is also affected by the occurrence of superimposed psychiatric illnesses. Clinically diagnosable anxiety and varying degrees of depression may be found, especially in late adolescence or early adult life, which seem to be related to a painful awareness of handicap and difference from other people (Nos. 2 and 3). Wolff & Chick (1980), in a follow-up study of 22 people with Aspergers, reported one who appeared to have a typical schizophrenic illness and another in whom this diagnosis was made, but less convincingly. Five of the 22 had attempted suicide by the time of early adult life.

The present author's series included 18 who were aged 16 and over at the time they were seen. Of these, four had an affective illness; four had become increasingly odd and withdrawn, probably with underlying depression; 1 had a psychosis with delusion and hallucinations that could not be classified; I had had an episode of catatonic stupor; one had bizarre behavior and an unconfirmed diagnosis of schizophrenia; and two had bizarre behavior, but no diagnosable psychiatric illness. Two of the foregoing had attempted suicide and one had talked of doing so. These two were referred because of their problems in coping with the demands of adult life.

Though it appears that the risk of psychiatric illness in Aspergers is high, it is difficult to draw firm conclusions because of the nature of the samples that were studied. The 13 people mentioned above, before they were seen by the present author, had been referred to adult services because of superimposed psychiatric conditions, so the series was highly biased. Wolff's cases were somewhat less selective since they were referred as kids and followed up into adult life, but, even so, they were clinic and not population based. Asperger (1944) noted that only one of his 200 cases developed schizophrenia. The true prevalence of psychiatric illnesses can be calculated only from an epidemiological study, including people with the syndrome not referred to psychiatric services.

Even in the absence of recognizable psychiatric disorder, adolescence may be a difficult time. The development of partial insight and increasing sexual awareness can cause much unhappiness (No. I) and may lead to socially unacceptable behavior. Peculiarities which may be ignored in a small child become very obvious in a young adult.

The degree of adjustment eventually achieved appears to be related to the level and variety of skills available and also to the temperament of the individual concerned. Good self-care, a special ability that can be used in paid employment, and a placid nature are needed if a person with Aspergers is to become socially independent.

Aetiology and Pathology—

Asperger (1944) considered his syndrome to be genetically transmitted. He reported that the characteristics tended to occur in the families, especially the fathers of those with the syndrome. Van Krevelen (1971) stated that, in many cases, the antecedents for generations back had been highly intellectual. In the present author's series, 55% had fathers who were in professional or managerial occupations, but the personalities of the moms and dads were not studied systematically. In many cases, the mother alone was seen. The purpose of the interview was to discuss the problems of the youngster, not to investigate the moms and dads. Including only those concerning whom some tentative conclusions could be drawn (from clinical impressions or evidence from other sources), it appeared that 5 out of 16 fathers and 2 out of 24 mothers had, to a marked degree, behavior resembling that found in Aspergers. No features of the clinical picture appeared to be associated with higher or lower social class, level of education of the moms and dads, or their personalities.

It is difficult to interpret the findings on social class, since the cases referred to clinics having a special interest in such problems are a selected group, with a strong bias towards higher social class and intellectual occupations in the moms and dads. Schopler et al (1979) and Wing (1980) noted a similar bias in the fathers of classically autistic kids referred to clinics, which was not reflected in less selected groups with the same diagnosis. The findings concerning the moms and dads' personalities have to be treated with caution because of the way they were obtained and the lack of any comparison group.

The syndrome can be found in kids and adults with history of pre-, pen- or post-natal conditions, such as anoxia at birth, that might have caused cerebral damage. This was true of nearly half of those seen by the present author (Nos. 3 and 4). Mnukhin & Isaev (1975) considered that the behavior pattern was due to organic deficiency of brain function.

Emotional causes or abnormal child-rearing methods have been suggested, especially where the moms and dads or siblings show similar peculiarities to the patient, but there is no evidence to support such theories.

Detailed epidemiological studies, based on total populations, are needed in order to establish which, if any, of these aetiological factors are relevant.

No specific organic pathology has been identified. No particular abnormalities of face or body have been reported. In childhood the physical appearance is usually, but by no means always, normal. In adolescence and adult life, the inappropriate gait, posture and facial expression produce an impression of oddness.

In general, on psychological assessment, tests requiring good rote memory are performed well, but deficits are shown with those depending on abstract concepts, or sequencing in time. Visuo-spatial abilities vary and the scores on testing may be markedly lower than those for expressive speech (No.4). The results of psychological testing will be described in more detail elsewhere.

Epidemiology—

As already mentioned, no detailed, large-scale epidemiological studies have been carried out, so that the exact prevalence of Aspergers is unknown. A major difficulty in designing such a study would be the establishment of criteria for distinguishing the syndrome from other similar conditions, as will be discussed later.

Wing & Gould (1979) carried out a study in which all the mentally and physically handicapped kids aged under 15 in one area of London were screened in order to identify cases of early childhood psychosis and severe mental retardation. In this study, two kids (0.6 per 10,000 aged under 15) showed most of the characteristics of Aspergers, though they were in the mildly retarded range on intelligence tests, and 4 (1.1 per 10,000) could have been diagnosed as autistic in early life, but came to resemble Aspergers later. There were a total of 35,000 kids aged under 15 in the area.

Wing & Gould did not use methods designed to identify mild cases of Aspergers, so that any kids who were attending normal school and had not come to the attention of the educational, social or medical services would not have been discovered. The prevalence rate for the typical syndrome given above is almost certainly an underestimate.

The syndrome appears to be considerably more common in boys than in girls. Asperger originally believed it to be confined to males, though he modified this view later (personal communication). Wolff & Barlow (1979) mentioned that the clinical picture could be seen in girls. In their series the male:female ratio was 9:1. In the present author's series there were 15 boys and 4 girls with the syndrome in fairly typical form, and 13 boys and 2 girls who had many of the features. The girls tended to appear superficially more sociable than the boys, but closer observation showed that they had the same problems of two-way social interaction.

Differential Diagnosis—

As with any condition identifiable only from a pattern of abnormal behavior, each element of which can occur in varying degrees of severity, it is possible to find people on the borderlines of Aspergers in whom diagnosis is particularly difficult. Whereas the typical case can be recognized with ease by those with experience in the field, in practice it is found that the syndrome shades into eccentric normality, and into certain other clinical pictures. Until more is known of the underlying pathology, it must be accepted that no precise cut-off points can be defined. The diagnosis has to be based on the full developmental history and presenting clinical picture, and not on the presence or absence of any individual item.

Normal variant of personality-

All the features that characterize Aspergers can be found in varying degrees in the normal population. People differ in their levels of skill in social interaction and in their ability to read nonverbal social cues. There is an equally wide distribution in motor skills. Many who are capable and independent as adults have special interests that they pursue with marked enthusiasm. Collecting objects such as stamps, old glass bottles, or railway engine numbers are socially accepted hobbies. Asperger (1979) pointed out that the capacity to withdraw into an inner world of one's own special interests is available in a greater or lesser measure to all human beings. He emphasized that this ability has to be present to marked extent in those who are creative artists or scientists. The difference between someone with Aspergers and the normal person who has a complex inner world is that the latter does take part appropriately in two-way social interaction at times, while the former does not. Also, the normal person, however elaborate his inner world, is influenced by his social experiences, whereas the person with Aspergers seems cut off from the effects of outside contacts.

A number of normal adults have outstandingly good rote memories and even retain eidetic imagery into adult life. Pedantic speech and a tendency to take things literally can also be found in normal people.

It is possible that some people could be classified as suffering from Aspergers because they are at the extreme end of the normal continuum on all these features. In others, one particular aspect may be so marked that it affects the whole of their functioning. The man described by Luria (1965), whose visual memories of objects and events were so vivid and so permanent that they interfered with his comprehension of their significance, seemed to have behaved not unlike someone with Aspergers. Unfortunately, Luria did not give enough details to allow a diagnosis to be made.

Even though Aspergers does appear to merge into the normal continuum, there are many cases in whom the problems are so marked that the suggestion of a distinct pathology seems a more plausible explanation than a variant of normality.

Schizoid personality-

The lack of empathy, single-mindedness, odd communication, social isolation and over-sensitivity of people with Aspergers are features that are also included in the definitions of schizoid personality (see review by Wolff & Chick, 1980). Kretschmer (1925) outlined some case histories of so-called schizoid adults, one or two of which were strongly reminiscent of this condition, although he did not provide sufficient detail to ensure the diagnosis. For example, one young man had no friends at school, was odd and awkward in social interaction, always had difficulty with speech, never took part in rough games, was oversensitive, and very unhappy when away from home. He thought out fantastic technical inventions and, together with his sister, invented a detailed imaginary world.

There is no question that Aspergers can be regarded as a form of schizoid personality. The question is whether this grouping is of any value. This will be discussed below in the section on classification.

Schizophrenia-

Adults with Aspergers may be diagnosed as suffering from schizophrenia. The differential diagnosis of schizophrenia has been discussed elsewhere (J.K.Wing, 1978). The main difficulty arises from the fact that schizophrenia has been defined loosely by some and strictly by other workers.

If a loose definition of schizophrenia is accepted, based only on characteristics such as social withdrawal and speech disorder, then a case could perhaps be made for including Aspergers in this group. As with schizoid personality, the question is whether doing so has any advantages. Poverty of social interaction and abnormalities of speech can have many different causes, so the diagnosis of chronic or simple schizophrenia tends to cover a variety of conditions having little in common with each other.

Careful observation of speech in Aspergers discloses differences from thought blocking and the 'knight's move' in thought described by Bleuler (1911). In Aspergers, speech may be slow, and there may be irrelevant or tangential replies to questions, but these problems are due partly to a tendency to become stuck in well-worn conversational grooves rather than to produce new ideas. Utterances are always logical, even if they are unrelated to the question, or originated from an unusual point of view. Thus one young man, when asked a general knowledge question about organized charities, said 'They do things for unfortunate people. They provide wheelchairs, stilts and round shoes for people with no feet'. There is a marked contrast between the vague woolliness of schizophrenic thought and the concrete, pedantic approach found in Aspergers.

The term schizophrenia can be used more strictly. It can be confined to those who have, currently or in the past, shown the florid first-rank symptoms described by Schneider (1971). In this case, the differentiation of Aspergers rests on accurate definition of the clinical phenomena. Unless they have a superimposed schizophrenic illness, people with Aspergers do not experience thought echo, thought substitution or insertion, thought broadcast, voices commenting on their actions, voices talking to each other, or feelings that external forces are exerting control over their will, emotions or behavior. The young man, L.P. (Appendix No. 2), when asked if he had such experiences, gave the matter long and careful thought and then said, 'I believe such things to be impossible'.

During clinical examination it is necessary to be aware that comprehension of abstract or unfamiliar concepts is impaired in Aspergers. Those with the more severe form of the handicap may have a habit of answering 'yes' to any question they do not understand, this being the quickest way to cut short the conversation. Some may also pick up and repeat phrases used by other people, including other patients in a hospital ward, making diagnosis even more difficult.

Other psychotic syndromes-

The tendency found in people with Aspergers to sensitivity and over-generalization of the fact that they are criticized and made fun of may, if present in marked form, be mistaken for a paranoid psychosis. Those who are pre-occupied with abstract theories or their own imaginary world may be said to have delusions or hallucinations. One boy, for example, was convinced that Batman would arrive one day and take him away as his assistant. No rational argument could persuade him otherwise. This type of belief could be called a delusion, but is probably better termed an 'over-valued idea'. It does not have any specific diagnostic significance, since such intensely held ideas can be found in different psychiatric states.

Severe social withdrawal, echopraxia and odd postures may be noted. These may become more marked at times, and then they could be regarded as catatonic phenomena. Such catatonic symptoms can be associated with various conditions (including encephalitis) and, on their own, should not be considered as indicative of schizophrenia.

Obsessional neurosis-

Repetitive interests and activities are part of Aspergers, but the awareness of their illogicality and the resistance to their performance characteristic of the classic case of obsessional neurosis are not found in the former It would be of interest to investigate the relationship between Aspergers, obsessional personality, obsessional illness, and post-encephalitic obsessional conditions.

Affective conditions-

The quietness, social withdrawal, and lack of facial expression in Aspergers might suggest a depressive illness. Shyness and distress when away from familiar surroundings could make an anxiety state a possible diagnosis, or excited talking about a rather fantastic grandiose, imaginary world might bring to mind hypomania. However, the full clinical picture and the early developmental history should clarify the diagnosis.

More difficult problems occur when affective illnesses are superimposed on Aspergers. Then a double diagnosis has to be made on the history and present state.

Early childhood autism-

Asperger acknowledged that there were many similarities between his syndrome and Kanner's early infantile autism. Nevertheless, he considered they were different because he regarded autism as a psychotic process, and his own syndrome as a stable personality trait. Since neither psychotic process nor personality trait has been defined empirically, little more can be said about whether they can be distinguished from each other.

Van Krevelen (1971) and Wolff & Barlow (1979) agreed with Asperger that his syndrome should be differentiated from autism. They differ in their accounts of the distinguishing features and the impression gained from their papers is that, although there are some differences, the syndromes are more alike than unalike. The variations could be explained on the basis of the severity of the impairments, though the authors quoted above would not agree with this hypothesis. Thus the autistic youngster, at least when young, is aloof and indifferent to others, whereas the youngster with Aspergers is passive or makes inappropriate one-sided approaches. The former is mute or has delayed and abnormal speech, whereas the latter learns to speak with good grammar and vocabulary (though he may, when young, reverse pronouns), but the content of his speech is inappropriate for the social context and he has problems with understanding complex meanings. Non-verbal communication is severely impaired in both conditions. In autism, in the early years, there may be no use of gesture to communicate. In Aspergers there tends to be inappropriate use of gesture to accompany speech. In both conditions, monotonous or peculiar vocal intonation is characteristic. The autistic youngster develops stereotyped, repetitive routines involving objects or people (for example, arranging toys and household objects in specific abstract patterns, or insisting that everyone in a room should cross the right leg over the left), whereas the person with Aspergers becomes immersed in mathematical abstractions, or amassing facts on his special interests. Abnormal responses to sensory input - including indifference, distress and fascination - are characteristic of early childhood autism and form the basis of the theories of perceptual inconstancy put forward by Ornitz & Ritvo (1968) and of over-selectivity of attention suggested by Lovaas et al (1971). These features are associated with greater severity of handicap, and lower mental age. They are not described as typical of Aspergers, and they are rarely seen in older autistic people with intelligence quotients in the normal range.

The one area in which this type of comparison does not seem to apply is in motor development. Typically, autistic kids tend to be good at climbing and balancing when young. Those with Aspergers, on the other hand, are notably il1-co-ordinated in posture, gait and gestures. Even this may not be a particularly useful point of differentiation, since kids who have typical autism when young tend to become clumsy in movement and much less attractive and graceful in appearance by the time of adolescence (see DeMyer, 1976, 1979 for a discussion of motor skills in autism and autistic-like conditions).

Bosch (1962) considered that Aspergers and autism were variants of the same condition. This author pointed out that, although Asperger and Van Krevelen (1971) listed features in the early history which they thought distinguished the two conditions, in practice these did not cluster into two groups often enough to justify the differentiation. The youngster in Appendix No. 6 illustrates this problem (see also Everard 1980).

Classification—

Asperger regarded the syndrome he described as a disorder of personality that could be distinguished from other types of personality abnormalities although he recognized the similarities to early childhood autism. Wolff & Barlow (1979) argued that it should be classified under the heading of schizoid personality. In support of this view, Wolff & Chick (1980) reviewed the literature in which schizoid characteristics are described. As discussed above, the syndrome can be placed in this group, and further work in this field would be of interest, but, at the moment, classification under this heading has no useful practical implications. Although Wolff & Chick have listed five features, operationally defined, that they regard as core characteristics of schizoid personality, this term, as generally used, is so vague and ill-defined a concept that it covers a wide range of clinical pictures in addition to Aspergers. The aim should be not to enlarge, but to separate sub-groups from the broad category and thus to increase diagnostic precision. Furthermore, the word schizoid was originally chosen to underline the relationship of the abnormal personality to schizophrenia. The latter can occur in a person with Aspergers, but, as already discussed, there is no firm evidence of a special link between this syndrome and schizophrenia, strictly defined. To incorporate such an untested assumption into the name of the condition must give rise to confusion.

The reasons for personality variations are so obscure that classifying Aspergers under this heading does not lead to any testable hypotheses concerning cause, clinical phenomena, pathology or management. A more limited, but more productive, view of the problem is to consider it as a consequence of impairment of certain aspects of cognitive and social development.

As mentioned above, Wing & Gould (1979) carried out an epidemiological study of all mentally or physically handicapped kids in one area of London, in an attempt to identify all those with autism or autistic-like conditions, whatever their level of intelligence. The results confirmed the following hypothesis. Certain problems affecting early child development tend to cluster together: namely, absence or impairment of two-way social interaction; absence or impairment of comprehension and use of language, non-verbal as well as verbal; and absence or impairment of true, flexible imaginative activities, with the substitution of a narrow range of repetitive, stereotyped pursuits. Each aspect of this triad can occur in varying degrees of severity, and in association with any level of intelligence as measured on standardized tests.

When all kids with this cluster of impairments were examined, it was found that a very few resembled the description given by Asperger and some had typical Kanner's autism. A number could, tentatively, be classified as having syndromes described by authors such as De Sanctis (1906, 1908), Earl (1934), Heller (see Hulse, 1954) and Mahler (1952), although the definitions given by these writers were not precise enough for easy identification. The remainder had features of more than one of these so-called syndromes and under the general, but unsatisfactory, heading of early childhood psychosis. The justification for regarding them as related is that all the conditions in which the triad of language and social impairments occurs, whatever the level of severity, are accompanied by similar problems affecting social and intellectual skills. Furthermore, individuals with the triad of symptoms all require the same kind of structured, organized educational approach, although the aims and achievements of education will vary from minimal self-care up to a university degree, depending on the skills available to the person concerned.

This hypothesis does not suggest that there is a common gross aetiology. This is certainly not the case, since many different genetic or pre-, peri- or post-natal causes can lead to the same overt clinical picture (Wing & Gould, 1979). It is more likely that all the conditions in which the triad occurs have in common impairment of certain aspects of brain function that are presumably necessary for adequate social interaction, verbal and non-verbal communication and imaginative development. It is possible that these are all facets of one underlying in-built capacity - that is, the ability actively to seek out and make sense of experience (Ricks & Wing, 1975). Included in this would be the innate ability to recognize other human beings as distinct from the rest of the environment and of special importance. If this basic skill were diminished or absent, the effects on development would be profound, as is the case in all early childhood psychoses.

The full range of clinical material can be sub-divided in many different ways, depending on the purpose of the exercise, but no aetiological classification is possible as yet. Sub-grouping on factors such as level of intelligence (Bartak & Rutter, 1976) or on degree of impairment of social interaction (DeMyer, 1976; Wing & Gould, 1979) has more useful practical implications for education and management than any based on the eponymous syndromes mentioned above.

In the light of this finding, is there any justification for identifying Aspergers as a separate entity? Until the aetiologies of such conditions are known, the term is helpful when explaining the problems of kids and adults who have autistic features, but who talk grammatically and who are not socially aloof Such people are perplexing to moms and dads, teachers and work supervisors, who often cannot believe in a diagnosis of autism, which they equate with muteness and total social withdrawal. The use of a diagnostic term and reference to Aspergers clinical descriptions help to convince the people concerned that there is a real problem involving subtle, but important, intellectual impairments, and needing careful management and education.

Finally, the relationship to schizophrenia of Aspergers, autism and similar impairments can be reconsidered. Although they are dissimilar in family history, childhood development and clinical pictures, both groups of conditions affect language, social interaction and imaginative activities. The time of onset and the nature of the disturbances are different, but there are similarities in the eventual chronic defect states that either may produce. It is not surprising that autism and schizophrenia have, in the past, been confused. Progress has been made in separating them and it is important to continue to improve precision in diagnosis, despite the many difficulties met in clinical practice.

Management and Education—

There is no known treatment that has any effect on the basic impairments underlying Aspergers, but handicaps can be diminished by appropriate management and education.

Both kids and adults with this syndrome, like all those with the triad of language and social impairments, respond best when there is a regular, organized routine. It is important for moms and dads and teachers to recognize the subtle difficulties in comprehension of abstract language, so that they can communicate with the youngster in ways he can understand. The repetitive speech and motor habits cannot be extinguished, but, with time and patience, they can be modified to make them more useful and socially acceptable. Techniques of behavior modification as used with autistic kids can possibly be helpful if applied with sensitivity. However, Asperger (1979) expressed considerable reservations about using these methods with kids with his syndrome who are bright enough to be aware of and, as Asperger put it, 'to value their freedom'.

Education is of particular importance because it may help to develop special interests and general competence sufficiently to allow independence in adult life. The teacher has to find a compromise between, on the one hand, letting the youngster follow his own bent completely, and, on the other, insisting that he conform. She also has to ensure that he is not teased and bullied by the rest of the class. There is no type of school that is particularly suitable for those with Aspergers. Some have performed well in schools for normal kids, while others have managed better in schools for various kinds of handicaps. Educational progress depends on the severity of the youngster's impairments, but also on the understanding and skill of the teacher.

Most people with Aspergers who settle in open employment have jobs with a regular routine. They also have sympathetic employers and workmates who are willing to tolerate eccentricities. In many instances, work has been found by moms and dads who persevere in approaching employers, despite all the difficulties.

Finding appropriate living accommodation also presents problems. Living with moms and dads is the easiest solution, but cannot last forever. Hostels or lodgings with a helpful landlady are the most usual answer. Tactful supervision may be needed to ensure that rooms are kept clean and tidy and clothes are changed regularly.

Superimposed psychiatric illnesses, if they occur, should be treated appropriately. Emotional distress in adolescents and young adults due to partial insight may be reduced to some extent by counseling from someone who has a full understanding of the syndrome. Such counseling consists mainly of explanation, reassurance and discussion of fears and worries. The counselor has to adopt a simple and concrete approach in order to stay within the limits of the client's understanding. Psychoanalysis, which depends upon the interpretation of complex symbolic associations, is not useful in this condition.

Moms and dads, in their youngster's early years, are usually confused and distressed by his strange behavior. They need a detailed explanation of the nature of his problems if they are to understand and accept that he is handicapped.


Appendix—

Case histories:

As mentioned above, the following case histories are those of people who have been referred to psychiatric services. The high achievers mentioned by Asperger (1944) are not represented.

Case l-

This is a typical example of the syndrome.

Mr K.N. first presented as a psychiatric out-patient when he was aged 28, complaining of nervousness and shyness.

As a baby he was always placid and smiling and rarely cried. He used to lie in his pram for hours, laughing at the leaves on the trees. His mother remembered he did not point things out for her to look at, in contrast to his sister. He continued to be quiet and contented as a toddler. If other kids took his toys he did not protest. Walking was somewhat delayed and he was slow in acquiring self-care skills, though not enough for his moms and dads to worry.

He began to talk around one year of age. He had several words at this time, but, after seeing and hearing a car crash which startled him, he stopped talking and did not begin again until he was three years old. His moms and dads thought his understanding of speech was normal. K. developed good grammar, though he referred to himself in the third person till 4-5 years old. He has never been communicative. Even as an adult he gives information only if questioned and then replies as briefly as possible. His facial expression and gestures are limited, and his voice is monotonous.

As a youngster he was attached to his mother, he never made any friends, and he was much teased at school. He remains a shy and socially isolated person though he would like to be able to make social contacts.

K. had no stereotyped movements, but has always been ill-co-ordinated and very poor at games. He does not swing his arms when he walks. He attended a private school and did well in subjects needing a good rote memory, such as history and Latin, but fell behind at the stage when comprehension of abstract ideas became necessary. He was in the army for a short time, but was not allowed to take part in marches and parades because of his clumsiness and inability to do the right thing at the right time. He was discharged because of these peculiarities.

K. did not object to changes imposed by others, but he was, and still is, orderly in his own daily routines and in arranging his own possessions.

From early in his life he liked toy buses, cars and trains. He amassed a large collection and would notice at once if a single item were missing. He would also make models with constructional kits. He played with such toys, on his own, for as long as he was allowed to continue. He had no other pretend play and never joined in with other kids. The interest in means of transport has remained with him. In his spare time he reads factual books on the subject, watches cars and trains and goes on trips to see trains with fellow train-enthusiasts. He has no interest in fiction or any other type of non-fiction.

K. has been employed for many years in routine clerical work. He enjoys his job and his hobby, but is very sad and anxious because he is aware of his own social ineptness and would like to have friends and to marry. He writes many letters to advice columns in magazines, hoping for help with these problems. His concern over what he terms his 'shyness' finally made him ask for help from a psychiatrist.

The WAIS gave K. an IQ in the dull normal range, with similar verbal and non-verbal scores. He was particularly poor at sub-tests needing comprehension of a sequence of events.

Case 2-

The second case history is also typical, but complicated by severe depression with onset in early adult life.

Mr L.P. was admitted to a psychiatric hospital at age 24 because of a suicide attempt. He was born four weeks premature and had feeding problems in the first week or two. He was an easy, placid, rather unresponsive baby who rarely cried. He acquired motor and self-care skills, but his moms and dads later realized that he passed these milestones more slowly than his sister, though they did not worry at the time. His father had a vague premonition that there was something odd about L. but not enough to seek advice.

He did not begin to speak until he was three years old, but this was attributed to the fact that the family was bilingual. However, by the time he went to school he was speaking in long, involved, pedantic sentences that sounded as if they had come from books. He tended to interpret words in odd ways. For example, when hearing someone described as 'independent' he thought this meant they always jumped in at the deep end of the swimming pool. He still takes jokes very seriously. He used to ask the same questions over and over again, regardless of the answers he was given. He did not initiate or join in conversations except by repetitive questioning.

L. remained placid and obedient throughout his childhood. He rarely initiated any activity, but waited to be told what to do. As a small child he used to rock himself when unoccupied. He had no imaginative play. He went to normal school, but did not join in with the other kids and had no friends until he was about 14 years old. Then he did begin to mention one or two companions and referred to them as friends, but has lost touch since.

He was bullied at school and remembers it as an unhappy time.

L. has always been concerned that his possessions should be orderly and that the daily routine should be followed exactly.

He is poor at games needing gross motor skills and at tasks requiring hand-eye co-ordination. His posture and gait are markedly odd. His face has a faintly bewildered expression that rarely changes. He uses large, jerky, inappropriate gestures to accompany speech. The odd impression he conveys is exacerbated by his old-fashioned choice of clothing.

L.' s memory is excellent and this enabled him to pass exams in subjects that can be learnt by rote. He is a very good chess player and enjoys taking part in matches. He can read well and enjoys books on physics and chemistry, concerning which he has memorized a large number of facts. He is particularly interested in time. He wears two watches, one set at Greenwich Mean Time and one at local time, even when these are the same.

His major problem is his social ineptitude. He will, for example, go on talking about his special subjects despite the most obvious signs of boredom in his audience. He makes inappropriate, often quite irrelevant, remarks in company and appears gauche and childish. He is painfully aware of his deficiencies, but is unable to acquire the skills necessary for social interaction. Nevertheless, he is kind and gentle and, if he realizes someone is ill or unhappy, he will be most sympathetic and do his best to help.

Since leaving school he has been employed as a filing clerk, and lives in a hostel.

L.'s moms and dads did not seek psychiatric help when he was a youngster, but he has been in contact with psychiatric services since reaching adolescence. On the first occasion he had become agitated because of worries about sex. On the second, he was anxious and losing sleep because of a minor change in his routine at work. On the third he was admitted as an in-patient following attempted suicide, once again precipitated by the possibility of re-organization in the office where he works. He tried to drown himself, but failed because he is a good swimmer. He then tried to strangle himself, without success. Commenting on this he said 'The trouble is I am not a very practical person'. At admission he was disheveled in appearance, deeply distressed and sad. His speech was painfully slow with long pauses between phrases. Its content was coherent, although, in his replies to questions, L. tended to add information that was correct, and related to the subject in hand, but not relevant in the context. For example, when asked about relations with his father L. said 'My father and I get on well. He is a man who likes gardening'.

L. blamed himself for all his problems, describing himself as an unpleasant person, whom no one could like and who could not manage his own life. He said he had heard people saying things about him such as 'L. is stupid', 'L. is a bad person', 'L. is a chemistry fanatic'. Careful questioning and subsequent observation showed that these were misinterpretations of overheard conversations and never occurred when L. was alone. For the first two admissions, the referring agency diagnosed an anxiety state, and for the third, schizophrenia. The final diagnosis was Aspergers complicated by anxiety and depression (not schizophrenia).

L. scored in the average range on the WAIS, his verbal being rather higher than his performance score, mainly because of his large vocabulary.

Case 3-

The third case history is that of a boy where abnormality was recognized from infancy.

B.H. is aged 10. He was delivered by forceps and had difficulty with breathing and cyanosis after birth, remaining in special care for two weeks. He was a large, placid baby, who would lie without moving for long periods. He was not eager to use gestures, to clap or to wave goodbye. His mother was worried about him from the beginning, partly because of the difficult birth and partly because of his behavior.

His moms and dads were certain that he replied 'Yes' appropriately to questions at 11 months. At around 14 months he began to speak in a fluent, but incomprehensible 'language' of his own.

He made no effort to crawl, but one day, aged 17 months, he stood up and walked. He learnt to crawl after this.

He retained his own language until aged three years, when he started to copy clearly words he heard, and then went on to develop understandable speech. His comprehension of language has always lagged behind his expression. By the age of four he could read. His moms and dads said they did not teach him - he presumably learnt from the television. At the age of five he had a reading age of nine years, but his comprehension was poor.

In his early years, B. remained quiet and passive, showing little emotion of any kind. He seemed to prefer a regular routine, but did not react at all to changes. He was not demanding and gave no trouble.

B. did not develop imaginative pretend play at the usual age. At the age of about six years he became fascinated with means of transport, read all about them and learn all the technical terms. He enacts actions involving cars, aero planes and so on, but never with other kids.

He appears clumsy and ill-co-ordinated, has problems with buttons and laces, and is afraid of climbing.

B. attends a special school. When first admitted he ignored the other kids and carried on with his usual preoccupations. He appeared astounded when the teacher indicated that he should obey her instructions and follow the rest of the class. Gradually he began to fit in and to make active social approaches, though in a naive and inappropriate fashion. He has difficulty in following the rules of any game.

He speaks in a pedantic style, in an accent quite unlike that of his local environment. For example, he referred to a hole in his sock as 'a temporary loss of knitting'. Many of his phrases are, like this one, inappropriately adapted quotations from television or books.

B. is now aware of and sensitive to other people's criticism, but appears unable to learn the rules of social interaction.
When tested at age seven, he had a word recognition age of 12 years, scored at his age level on performance tasks, but was well below this on tests needing recall and comprehension of language.

Case 4-

In the following example of the syndrome, the diagnosis is complicated by a history of illness and psychological stress in early life, and by visual impairment.

Miss F.G. is aged 26. Pregnancy and delivery were normal, but F. had a series of illnesses and operations, including a subdural hemorrhage of unknown aetiology and correction of strabismus before the age of three years. She has poor eyesight and has to peer very closely to see, but can read, write and type.

F. talked fluently at an early age, and had a large vocabulary. Her moms and dads thought she was developing normally until the operation on her eyes at 2 1/2 years. Following this she was socially withdrawn for several months. No detailed description could be obtained, but her mother was quite certain that there was a marked change in behavior. Despite the problems of social interaction, F.'s speech remained clear, with good vocabulary and grammar. She always had a remarkable memory for anything she had heard or read, including any statistical information. F. gradually became more friendly and, by about three years of age, she was making social approaches to her moms and dads and others in the family. However, she did not interact much with other kids. She copied her mother's activities a little, but did not develop normal pretend play or social play.

Her main interests as a young child were drawing and, later on, reading. She also collected costume dolls, which she arranged in rows that must not be disturbed.

F. went to a normal comprehensive school. She loved history and geography, and would memorize facts in these subjects with ease, but her teacher reported that she would do no work in any subject that did not interest her, such as mathematics.

She was accepted at school but recognized as odd. Her conversation contained many long quotations from books and she also often made irrelevant remarks.

F. was never good at practical tasks. Her moms and dads tended to do things for her. They found that, if they asked her to do some task, she would begin, but soon stop and turn to her own preferred activity - usually reading a book.

After leaving school she obtained work as a typist. She proved an excellent copy typist and was outstandingly accurate at spelling. She made no friends with the other members of staff. After four years the pressure of work increased. F. became distressed and unable to cope. She left work and has been unemployed for three years. During this time she has been anxious and agitated and unable to do anything on her own. She spends her time reading and amassing facts. She tends to have childish temper tantrums if thwarted in any way.

The WAIS showed that F. had a verbal score in the average normal range, but performance was very much lower, being in the mildly retarded range. The verbal skills depended on her good vocabulary. She did poorly on any task where the elements bad to be organized into a coherent whole.

Case 5-

This is the history of a young man who showed the features of Aspergers, but who was mentally retarded and did not achieve independence as an adult.

Mr J. G. is aged 24 and attends a training centre for mentally retarded adults. J. was a quiet, unresponsive baby. He began to say a few words at the age of two, but did not walk until 21/2 years old. At first he echoed, used phrases repetitively and had poor pronunciation. He learnt to read at the age of 51/2 and always did well on reading tests, though his comprehension was poor. He knew many unusual or technical words, such as 'aeronautical' and 'pterodactyl' but would be puzzled by familiar ones such as 'yesterday'.

He was not aloof, but gentle and passive, tending to stand and watch other kids, wanting to join in but not knowing how. He was very affectionate towards his own family. At age 24 he is still unable to interact socially, though is happy to be a passive member of a group.

He is clumsy in gait and posture and slow on tests of manual dexterity. J.'s special interests are music and cars. He can recognize any make of car, even if shown only a small part of the whole vehicle.

He attended a special school for mentally retarded kids. He was described by his teacher as 'showing no initiative'. He was eventually placed in an adult training centre near his home, where he is happily settled.

His WAIS score at the age of 17 was on the borderline between mild and severe retardation, with the verbal level being very slightly better than the performance. His reading age was still well in advance of all other skills.

Case 6-

The following case history is of a boy who at first was classically autistic and later developed the characteristics of Aspergers.

C.B. is aged 13. His mother dates C.'s problems from the age of six months when his head was accidentally bruised. From this time he became socially aloof and isolated, and spent most of his time gazing at his hands which he moved in complicated patterns in front of his face. At one year old he began to watch the passing traffic, but still ignored people. He continued to be remote, with poor eye contact, until five years of age. He passed his motor milestones at the usual ages and, as soon as he was physically able, he spent hours running in circles with an object in his hand, and would scream if attempts were made to stop him. At the age of three he began to be able to recognize letters of the alphabet and rapidly acquired skill at drawing. He then drew the salt and pepper pots, correctly copying the names written on them, over and over again. For a time this was his sole activity. Following this he became fascinated with pylons and tall buildings and would stare at them from all angles and draw them.

He did not speak till the age of four, then for a long time used single words. After this, he acquired repetitive phrases and reversed pronouns. C. had many stereotyped movements as a young child, including jumping, flapping his arms and moving his hands in circles.

After the age of five, C.'s speech and social contact markedly improved. He attended a special school until aged 11, where they tolerated a range of bizarre, repetitive routines. At one point, for example, he insisted that all his class and the teacher should wear watches that he had made from plasticine before lessons could begin. Despite all the problems, he proved to have excellent rote memory, absorbed all that he was taught, and could reproduce facts verbatim when asked. C. was transferred to a normal comprehensive school at the age of II - He has good grammar and a large vocabulary, though his speech is naive and immature and mainly concerned with his own special interests. He has learnt not to make embarrassing remarks about other people's appearances, but still tends to ask repetitive questions. He is not socially withdrawn, but he prefers the company of adults to that of kids of his own age, finding it difficult to understand the unwritten rules of social interaction. He said of himself, 'I am afraid I suffer from bad sportsmanship'. He enjoys simple jokes but cannot understand more subtle humor. He is often teased by his classmates.

His main interest is in maps and road signs. He has a prodigious memory for routes and can draw them rapidly and accurately. He also makes large, complicated abstract shapes out of any material that comes to hand, and shows much ingenuity in ensuring that they hold together. He has never had pretend play but is deeply attached to his toy panda to which he talks as if it were an adult when he needs comfort.

His finger dexterity is good, but he is clumsy and ill-co-ordinated in large movements and therefore is never chosen by the other kids for sports and team games.

C. is of average intelligence on the WISC, with better verbal than performance skills. He does well on tasks needing rote learning, but his teachers are deeply puzzled and concerned about his poor comprehension of abstract ideas and his social naivety. They find him appealing but sadly vulnerable to the hazards of everyday life.

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