Complications of the Aspergers Diagnosis: Help for Clinicians

When moms and dads look for assistance for their Aspergers youngster, they encounter diverse opinions (e.g., “he'll outgrow it” … “leave him alone” … “it's no big deal” … “he just wants attention” ...and so on). Many therapists try to work with the Aspergers youngster as if his disorder is like other developmental disorders, but it's very different. Generally, there's a profound misunderstanding by many people regarding the needs of these special children.

For the unskilled, identifying the defining features of Aspergers as outlined below can be challenging, and misdiagnosis tends to occur frequently:

• A lack of emotional empathy
• Clumsy, un-coordinated movements
• Intense absorption in certain subjects
• Limited ability to establish relationships
• Naïve, inappropriate, one-sided social interactions
• Odd postures
• Pedantic, repetitive speech
• Poor non-verbal communication

Diagnosis is further complicated by the fact that an Aspergers youngster or adolescent has many of the same features present in other disorders. These numerous features are often misinterpreted, overlooked, under-emphasized, or overemphasized. Consequently, a youngster may obtain a variety of diagnoses over time or from various therapists. For instance, if the Aspergers child shows a high level of ADHD-like signs and symptoms, this may be the sole diagnosis he gets. However, many ADHD characteristics are also common in Aspergers kids. The same holds true if obsessive or compulsive behaviors are exhibited - the youngster will get tagged with OCD rather than Aspergers.

The following traits are also generally seen in Aspergers children in varying degrees. However, simply because these traits exist does not mean that the youngster ought to be diagnosed in a different way. These traits ought to be noted as significant features of Aspergers:

• Anxiety
• Difficulty with pragmatic language skills
• Hyperlexia (advanced word recognition skills)
• Motor deficits
• Oppositional defiant disorder (ODD)
• Sensory difficulties
• Social skills deficits

Therapists who do not have much knowledge about Aspergers have a problem identifying the defining characteristics. For instance, social skill deficits might be noted by a therapist, but then these deficits are often downplayed since the youngster or adolescent seems to be having appropriate conversations with other people or appears to be interested in others. But with an Aspergers youngster, the conversations aren't usually reciprocal, therefore the youngster should be carefully observed to determine if there is true back-and-forth conversation. Additionally, many Aspergers kids are interested in other people, but the diagnostician must clarify if the objects of their interest are age appropriate (e.g., Do they connect to friends in an age-appropriate manner? Can they maintain relationships over a period of time, or do they end as the novelty wears off?). These are the kinds of observations and queries that must be asked to guarantee a proper diagnosis.

Another illustration of an overlooked area may be the “narrow routines or rituals” which are supposed to be present. This doesn't always show itself as obsessive-compulsive behavior in the usual sense (e.g., repetitive hand-washing or neatness), but instead in the insistence on the need for rules about numerous problems and circumstances. These types of kids might not throw temper tantrums over their need for rules, but may require them as much as the person who has a meltdown whenever a rule is violated. Essentially, there isn't any solitary profile of the standard Aspergers child.

Due to these subtleties and technicalities, the single most significant consideration in diagnosis is that the therapist making the initial diagnosis be familiar with Autistic Spectrum Disorders - in particular, Aspergers. They should have previously diagnosed numerous kids. To make a correct, initial diagnosis demands the following:

1. An evaluation by an occupational therapist acquainted with sensory integration issues may provide additional and useful information.

2. It is essential to incorporate a speech and language assessment, as individuals with Aspergers will display impairments in the pragmatics and semantics of vocabulary, in spite of having sufficient receptive and expressive vocabulary. This can also serve to make moms and dads aware of any abnormal vocabulary patterns the youngster shows that will interfere in later social situations. Once again, these oddities might not be acknowledged if the therapist isn't acquainted with Aspergers.

3. The youngster ought to see a specialist or developmental pediatrician (again, someone familiar with Autistic Spectrum Disorders) for a comprehensive neurological examination to rule out other health conditions and to assess the need for prescription medication. The physician might recommend additional medical testing (e.g., blood, urine, fragile X, hearing).

4. Both parents and the Aspergers child should have sessions with a therapist in which the youngster is very carefully observed to see exactly how he responds in various situations. This is accomplished through play or talk sessions in the therapist's office and by discussions with the parents. The therapist may ask the parents to complete checklists or questionnaires to gain a better understanding of the youngster's behaviors at home and school. If the youngster is in school, the therapist may call the youngster's teacher or ask him to complete additional checklists. The checklists or questionnaires used should be ones that are appropriate for children with Aspergers.

5. Another important factor is to determine the IQ level of the Aspergers youngster. An average or above-average IQ is necessary for a diagnosis of Aspergers.

Help for Clinicians—

Kids can begin to show signs of Aspergers by the age of 3. However, because most kids with ASPERGERS are of average or above average intelligence, the condition may not be noticed until later. When a youngster begins to develop socially and is placed in a school or playgroup setting, symptoms of Aspergers may become more apparent. In some cases, ASPERGERS is not diagnosed until adolescence (especially in girls).

Most experts agree that Aspergers symptoms can vary greatly. In general, each youngster who has the disorder has his or her own unique set of symptoms. Kids with ASPERGERS usually have a combination of the following symptoms:

• Unusual speech patterns with regard to tone, pitch, or accents
• Unusual sensitivity to sound, light, or touch
• Strong aversion to change or spontaneity
• Strong attachment to routine
• Obsessive interest in one topic which they may talk about excessively
• Late development of motor skills or a lack of physical coordination
• Inability to sense other people's needs for personal space
• Inability to read non-verbal social cues and other people's feelings
• Inability to be empathetic
• Extreme difficulty with peer relationships and social situations
• Difficulty understanding their feelings
• Below average handwriting
• Awkward, repetitive gestures, body postures or facial expressions
• Average or above average vocabulary skills
• Above average memory skills

Kids who have Aspergers may show any or all of these symptoms to various degrees. However, all kids with the disorder generally have particular difficulty with social relationships.

Kids who have mild symptoms of Aspergers may simply be labeled as eccentric and not receive appropriate care and attention. It is also common for kids with the disorder to become targets of teasing, ridicule, harassment, or bullying. As a result, kids with Aspergers are at increased risk for developing depression and other mental illnesses.

Moms and dads who suspect their youngster may have Aspergers should talk with his or her pediatrician about their observations and concerns. To rule out other conditions that may be causing the youngster's symptoms, the health care provider will perform a complete physical examination and may perform x-rays and blood tests. If no physical cause for the youngster's symptoms is found, he or she may be referred to a health professional that specializes in developmental disorders in kids.

A thorough diagnosis and evaluation are important for determining the most effective treatments for the youngster. Diagnosis of ASPERGERS can be performed by one or more of the following health care professionals:

• Pediatric neurologist
• Developmental pediatrician
• Child/adolescent psychologist
• Child/adolescent psychiatrist

Diagnosis of the conditions involves taking a complete medical history of the youngster, usually based on the observations and recollections of the parents and other family members. Input from other caregivers or teachers who have had contact with the youngster are also helpful.

The medical history includes information about:

• how the youngster expresses his or her feelings
• the family's medical history
• the infancy period of the youngster
• the pregnancy
• the youngster’s social interactions with peers, siblings, and other family members
• the youngster's development of motor skills, language development, and interests
• the youngster's early (preschool) development

In addition to a medical history, a communication assessment may be performed. This test is used to gather information about the youngster's communication skills, including the following:

• Speech (e.g., clarity, volume, pitch)
• Non-verbal communication (e.g., gestures, glances)
• Non-literal language (e.g., humor, irony)
• Formal language (e.g., vocabulary, sentence structure, comprehension)
• Conversation skills (e.g., turn-taking, sensitivity to cues, ability to follow typical rules of conversation)

In kids who have Aspergers, formal language often is an area of strength, and other forms of communication are usually areas of difficulty.

The Aspergers Comprehensive Handbook