For years, psychiatrists have debated how to classify and subdivide the category of Pervasive Developmental Disorder (PDD). Pervasive Developmental Disorder is a category that contains several specific diagnoses. Children with PDD have problems with the social interaction and often show delays in several other areas. These other areas may include language, coordination, imaginative activities, and intellectual functioning. The degree of severity can vary tremendously in the various forms of PDD.
Autism is one of the more severe forms of PDD. A child with Autism has marked difficulty relating to others. He or she frequently has delayed or absent speech and may be mentally retarded.
Aspergers (also referred to as ‘high-functioning autism’) is on the milder end of PDD. Kids with Aspergers generally have normal intelligence and normal early language acquisition. However, they show difficulties with social interactions and non-verbal communications. They may also show perseverative or repetitive behaviors.
Preschool: A preschool aged Aspergers kid might show difficulty understanding the basics of social interaction. He or she may have difficulty picking up social cues. He may want friends but be unable to make or keep any friends.
Elementary School: One often hears the phrase, “poor pragmatic language skills.” This means that the child cannot use the right tone and volume of speech. He may stand too close or make poor eye contact. He may have trouble understanding age-appropriate humor and slang expressions. Many are clumsy and have visual-perceptual difficulties. Learning difficulties, subtle or severe, are common. The Aspergers kid may become fixated on a particular topic and bore others with frequent or repetitive talk even when the other kids have given clear signals that they are no longer interested in the topic. Some have difficulties tolerating changes in their daily routine. Change must be introduced gradually.
Middle and High School: This may be the most difficult time for a youngster with Aspergers. Those with milder forms of the disorder may first come to treatment when they are in middle school. In adolescence, social demands become more complex. Subtle social nuances become important. Some may show an increase in oppositional or aggressive behavior. Children with Aspergers have difficulty understanding which of their peers might want to be a friend. A socially marginal boy might try to date the most popular girl in his class. He will probably experience rejection. He is unaware that some other girl might accept his invitation. Because of his social naiveté, he may not realize when someone is trying to take advantage of him. He can be especially vulnerable to manipulation and peer pressure.
Adulthood: There is less information on Aspergers in adulthood. Some people with mild Aspergers are able to learn to compensate. They become indistinguishable from everyone else. They marry, hold a job and have kids. Other people live an isolated existence with continuing severe difficulties in social and occupational functioning. People with Aspergers often do well in jobs that require technical skill but little social finesse. Some do well with predictable repetitive work. Others relish the challenge of intricate technical problem solving. I knew a man, now deceased, who had many of the characteristics of Aspergers. He lived with his mother and had few social contacts. When he visited relatives, he did not seem to understand how to integrate himself into their household routine. When the relatives would explain the situation to him, he was able to accept it. However, he was unable to generalize this to similar situations. Although he was a psychologist, his work involved technical advisory work, not face-to-face clinical sessions.
Associated Difficulties: Aspergers may be associated with learning difficulties and attention deficit disorder. Indeed, many kids and teenagers with Aspergers have previously been diagnosed with ADHD instead of Aspergers. Children with ADHD may have difficulty with social interaction, but the primary difficulties are inattention, hyperactivity and impulsivity. In children with Aspergers, the social awkwardness is a greater concern. As children with Aspergers enter adolescence, they become acutely aware of their differences. This may lead to depression and anxiety. The depression, if not treated, may persist into adulthood.
Treatment for Aspergers—
Medications: There is no one specific medication for Aspergers. Most are on no medication. In other cases, we treat specific target symptoms. One might use a stimulant for inattention and hyperactivity. An SSRI such as Paxil, Prozac or Zoloft might help with obsessions or perseveration. The SSRIs can also help associated depression and anxiety. In children with stereotyped movements, agitation and idiosyncratic thinking, we may use a low dose antipsychotic such as risperidone.
Social Skills Training: This is one of the most important facets of treatment for all age groups. I often tell moms and dads and teachers that the child needs to learn body language as an adult learns a foreign language. The youngster with Aspergers must learn concrete rules for eye contact, social distance and the use of slang. Global empathy is difficult, but they can learn to look for specific signs that indicate another individual’s emotional state. Social skills are often best practiced in a small group setting. Such groups serve more than one function. They give people a chance to learn and practice concrete rules of interpersonal engagement. They may also be a way for the participant to meet others like himself. Children with Aspergers do best in groups with similar children. If the group consists of street-wise, antisocial peers, the Aspergers child may retreat into himself or be dominated by the other members.
Educational Interventions: Because Aspergers covers a wide range of ability levels the school must individualize programming for each child with Aspergers. Educators need to be aware that the student may mumble or refuse to look him in the eye. Educators should notify the child in advance about changers in the school routine. The youngster may need to have a safe place where he can retreat if he becomes over-stimulated. It may be difficult to program for a very bright student with greater deficits. In one case, a student attended gifted classes but also had an aide to help her with interpersonal issues. That student is now in college. Kids with Aspergers are often socially naive. They may not do well in an “emotionally disturbed” class if most of the other kids are aggressive, street-wise and manipulative. I have seen some do well when placed with other students with pervasive developmental disorders. Some do well in a regular classroom with extra support. This extra help might include an instructional assistant, resource room or extra training for the primary teacher.
Psychotherapy: Children with Aspergers may have trouble with a therapist who insists that they make an early intense emotional contact. The therapist may need to proceed slowly and avoid more emotional intensity than the patient can handle. Concrete, behavioral techniques often work best. Play can be helpful in a limited way if the therapist uses it to teach way of interaction of the therapist uses play as a break from an emotionally tense if it is used to lower emotional tension. Grown-ups and kids may also do well in group therapy. Support groups can also be helpful.
Moms and dads play an important role in helping their Aspergers children. These young people will require time and extra nurturance. It is important to distinguish between willful disobedience and misunderstanding of social cues. It is also important to sense when the Aspergers kid is entering emotional overload so that one can reduce tension. They may need to prepare the youngster for changes in the daily routine. One must choose babysitters carefully. Moms and dads may have to take an active role in arranging appropriate play dates for the “Aspie.” Some moms and dads seek out families with similar kids. Kids with Aspergers often get along with similar playmates. Moms and dads should help educators understand the world from the Aspergers kid’s unique point of view. Parenting an adolescent with Aspergers can be a great challenge. The socially naive adolescent may not be ready for the same degree of freedom as his peers. Often moms and dads can find a slightly older adolescent who can be a mentor. This person can help the adolescent understand how to dress, and how to use the current slang. If the mentor attends the same school, he can often give clues about the cliques in that particular setting.
Grown-ups with Aspergers may benefit from group therapy or individual behavioral therapy. Some speech therapists have experience working with grown-ups on pragmatic language skills. Behavioral coaching (a relatively new type of intervention) can help the man or woman with Aspergers organize and prioritize his daily activities. Grown-ups may need medication for associated problems such as depression or anxiety. It is important to understand the needs and desires of that particular adult. Some do not need treatment. They may find jobs that fit their areas of strength. They may have smaller social circles, and some idiosyncratic behaviors, but they may still be productive and fulfilled.
