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Showing posts sorted by relevance for query emotional behavioral. Sort by date Show all posts

Help for Bullied Asperger’s and HFA Children Who Become Bullies Themselves

A large body of research has documented the difficulties associated with being bullied – and with bullying other kids. Young people who are bullied suffer more anxiety, depression, loneliness, post-traumatic stress – and have a heightened risk of suicide. Kids who bully are more likely than other youngsters to experience peer-rejection, conduct problems, anxiety, academic difficulties, and engage in rule-breaking behavior.

Recent research has shown that a substantial number of kids with Asperger’s (AS) and High-Functioning Autism (HFA) who have been a victim of bullying become bullies themselves at some point. A distinguishing feature of AS and HFA children is that they struggle to control their emotions. For example, they may unintentionally prompt kids to bully them again by reacting very emotionally to teasing, threats or physical aggression, and may have similar problems controlling feelings of anger and frustration, predisposing them to retaliatory aggression.

Given that these young people experience a broader range of behavioral and emotional difficulties than do “typical” kids, it is not surprising that AS and HFA victims of bullying experience anxiety, depression, peer-rejection, a lack of close friendships, and the cognitive and social difficulties often apparent in bullies themselves (e.g., a greater acceptance of rule-breaking behavior, hyperactivity, a tendency toward reactive aggression, etc.).

In addition, these victims are at greater risk for psychiatric disorders and criminal offenses in young adulthood than are kids dealing with only one of these problems. Also, they have proven to be less responsive to a comprehensive school-based program for kids with severe emotional disturbances. As a result, it is of the utmost importance that they receive support and services that address the full spectrum of their needs.

Programs designed to address emotional and behavioral problems associated with being bullied:

1. Self-control techniques have been used in the treatment of both aggressive and anxious kids with AS and HFA. Given the difficulty these children have controlling their emotions, it is advisable to make this deficit a key target of interventions. “Special needs” kids develop better self-control over their emotions by learning to recognize the physical signs of anxiety or anger (e.g., muscle tension) by practicing positive self-talk (e.g., “I should stop, take a few deep breaths, and think before I act”) and utilizing relaxation techniques (e.g., muscle relaxation, deep breathing) to reduce emotional arousal and delay an immediate response to a stressful situation. This will provide careful reflection (e.g., problem solving, cognitive restructuring) prior to taking retaliatory action.

2. Problem-solving skills training is another strategy common to programs targeting behavioral or emotional problems. AS and HFA kids are helped to think of several possible solutions to a given problem, and to reflect on the positive and negative consequences of each in order to choose the technique that will maximize positive consequences in both the short- and long-term. Kids who are bullied – and then bully others in return – rely too heavily on aggressive solutions, whereas anxious or depressed youngsters often default to avoiding their difficulties.

Problem-solving skills training can be used in either case to broaden the repertoire of constructive coping techniques and enhance decision-making. Decreasing depression and anxiety related to being bullied would be helpful in itself for victims, but it may have the added benefit of reducing negative moods that render AS and HFA kids vulnerable to engaging in explosive, emotional and reactive aggression.

3. Cognitive restructuring has been used to deal with aggression, anxiety, and depression in AS and HFA children. The central feature of this technique is to identify thoughts that increase anger, anxiety or sadness, challenge their accuracy, and replace them with thoughts that are more realistic and less destructive. For example, a child may learn to recognize that his anxiety rises when he assumes that all of his peers would “think he is dumb” if he were to give an incorrect answer in class. Instead, he may be encouraged to take a more realistic view, recognizing that everyone makes mistakes, and that when other people make mistakes, he does not usually think badly of them. To reinforce this concept, the child may use some positive self-talk (e.g., “It’s OK to make mistakes, because it’s how we all learn”).

Applied to behavioral difficulties, cognitive restructuring techniques are often used to emphasize that there is more than one way to explain the actions of other kids. For example, since kids who are bullied – and then subsequently become bullies themselves – do not often give their peers the benefit of the doubt. They may be inclined to see teasing as cruel, which would increase anger and the likelihood of an aggressive response. However, it is equally likely that teasing may be good-natured, and in teaching AS and HFA kids to be open to this possibility, the number of peer conflicts that result in episodes of bully-like behavior may be reduced.

As a therapist who has worked with families affected by autism spectrum disorders over the years, what I see most often is that many AS and HFA kids who have been bullied by peers in elementary and middle school tend to become bullies themselves around the high school years. But, they usually do not bully their peers at school, rather they find easier targets to misplace their aggression. This is usually parents (especially single mothers) and younger siblings. In other words, they bring their frustration and aggression home with them and take it out on family members.

AS and HFA children who are victims or bullying face a complicated array of social and emotional challenges, and it is crucial that concerned moms and dads, educators, and mental health providers recognize the full extent of their difficulties, and tailor interventions to match their complex needs. More research is needed to create and evaluate programs that integrate cognitive-behavioral techniques for the treatment of both behavioral and emotional problems associated with bullying. Until that happens, parents, educators and clinicians can broaden the focus of existing school-based and clinic-based interventions by applying the strategies listed above. 

More resources for parents of children and teens with High-Functioning Autism and Asperger's:

==> How To Prevent Meltdowns and Tantrums In Children With High-Functioning Autism and Asperger's

==> Parenting System that Significantly Reduces Defiant Behavior in Teens with Aspergers and High-Functioning Autism

==> Launching Adult Children with Asperger's and High-Functioning Autism: Guide for Parents Who Want to Promote Self-Reliance

==> Teaching Social Skills and Emotion Management to Children and Teens with Asperger's and High-Functioning Autism

==> Parenting Children and Teens with High-Functioning Autism: Comprehensive Handbook

==> Unraveling The Mystery Behind Asperger's and High-Functioning Autism: Audio Book

==> Parenting System that Reduces Problematic Behavior in Children with Asperger's and High-Functioning Autism

"Emotionally Fragile" Children with Asperger's & High-Functioning Autism

"Any tips for dealing with a very fragile and overly sensitive child on the autism spectrum ...he's a chronic worrier to say the least and will go back and forth between being extremely shy or very aggressive?"

As some parents may have discovered, many young people with Asperger’s (AS) and High Functioning Autism (HFA) are “emotionally fragile” (to coin a term). In other words, these individuals have great difficulty coping with day-to-day stressors, and exhibit unusually withdrawn or aggressive behaviors as a defense mechanism.

Emotional fragility is most prevalent in school-age AS and HFA kids. It can manifest itself in many ways, all of which are challenging for the youngster, parents, and teachers. These young people often exhibit a variety of symptoms that cause school psychologists to misdiagnose them with depression, bipolar disorder, or some other disorder. A wrong diagnosis can often lead to the youngster being placed in inappropriate special education classes, or even being treated with the wrong medication.

Traits of Emotional Fragility —

1. An emotionally fragile AS or HFA youngster may become socially anxious and withdrawn in public. When faced with risks or decisions, however trivial, he may become tense and fearful. He may have extremely poor self-esteem, and may seem to have a distorted sense of reality, usually preferring to live in his own fantasy world. These kids will often internalize their feelings and emotions, and have difficulty talking about them when asked. Occasionally they may act out and hurt others out of fear and a desire to be left alone.

2. Emotional fragility often causes AS and HFA kids to regress developmentally. They may behave as though they were much younger, even to the point of seeming overly dependent on others. As these kids become older, they may be at risk for substance abuse, although due to their lack of social skills, they may be less likely to use drugs in a peer-group context.

3. An AS or HFA child with emotional fragility usually has some degree of difficulty at school. A “typical” child will be able to follow a teacher's instructions independently, and will have no problem asking for help if needed. The emotionally fragile youngster will have difficulty carrying out these same age-appropriate instructions, and may be fearful of asking for help. This can create an inability to learn on the same level as other peers of the same age, which causes the youngster to view school as a source of misery and confusion. This often leads to poor grades and excessive absences.

4. Emotional fragility can have detrimental effects on a youngster's ability to make friends and interact with others. A “typical” youngster will be able to approach a group of his peers, converse, and join in their activities. The emotionally fragile youngster will be consistently rejected or ignored by these peers due to a lack of appropriate social skills, and may even be taunted or called names. This youngster may be viewed as immature or "weird" by his peer group.

Warning Signs—

Some of the most common warning signs of emotional fragility are a loss of interest in school, depression, social withdrawal, hyperactivity, sleep problems or fatigue. However, these are just a few of the most common warning signs. It is also important to keep in mind that just because a youngster has some of these behaviors doesn't necessarily mean that she is emotionally fragile. All kids experience these things at different points in their lives. Parents should only be concerned if their youngster is displaying any of the associated behaviors over a prolonged period of time.

The most difficult part of determining eligibility for special education services is deciding if the child is emotionally fragile, or has a behavior disorder (one can often look like the other).

Let’s draw a distinction between the two along the following domains:
  1. Affective Reactions— Emotional Fragility: disproportionate reactions, but not under child’s control. Behavior Disorder: intentional with features of anger and rage; explosive.
  2. Aggression— Emotional Fragility: hurts self and others as an end. Behavior Disorder: hurts others as a means to an end.
  3. Anxiety— Emotional Fragility: tense; fearful. Behavior Disorder: appears relaxed; cool.
  4. Attitude toward School— Emotional Fragility: school is a source of confusion or angst; does much better with structure. Behavior Disorder: dislikes school, except as a social outlet; rebels against rules and structure.
  5. Conscience— Emotional Fragility: remorseful; self-critical; overly serious. Behavior Disorder: little remorse; blaming; non-empathetic.
  6. Developmental Appropriateness— Emotional Fragility: immature; regressive. Behavior Disorder: age appropriate or above.
  7. Educational Performance— Emotional Fragility: uneven achievement; impaired by anxiety, depression, or emotions. Behavior Disorder: achievement influenced by truancy, negative attitude toward school, avoidance.
  8. Interpersonal Dynamics— Emotional Fragility: poor self-concept; overly dependent; anxious; fearful; mood swings; distorts reality. Behavior Disorder: inflated self-concept; independent; underdeveloped conscience; blames others; excessive bravado.
  9. Interpersonal Relations— Emotional Fragility: inability to establish or maintain relationships; withdrawn; social anxiety. Behavior Disorder: many relations within select peer group; manipulative; lack of honesty in relationships.
  10. Locus of Disorder— Emotional Fragility: affective disorder; internalizing. Behavior Disorder: conduct disorder, externalizing.
  11. Peer Relations and Friendships— Emotional Fragility: difficulty making friends; ignored or rejected. Behavior Disorder: accepted by a same delinquent or socio-cultural subgroup.
  12. Perceptions of Peers— Emotional Fragility: perceived as bizarre or odd; often ridiculed. Behavior Disorder: perceived as cool, tough, charismatic.
  13. Risk Taking— Emotional Fragility: avoids risks; resists making choices. Behavior Disorder: risk-taker; daredevil.
  14. School Attendance— Emotional Fragility: misses school due to emotional or psychosomatic issues. Behavior Disorder: misses school due to choice.
  15. School Behavior— Emotional Fragility: unable to comply with teacher requests; needy or has difficulty asking for help. Behavior Disorder: unwilling to comply with teacher requests; truancy; rejects help.
  16. Sense of Reality— Emotional Fragility: fantasy; na├»ve; gullible; thought disorders. Behavior Disorder: street-wise; manipulates facts and rules for own benefit.
  17. Social Skills— Emotional Fragility: poorly developed; immature; difficulty reading social cues; difficulty entering groups. Behavior Disorder: well developed; well attuned to social cues.
  18. Substance Abuse— Emotional Fragility: less likely; may use individually. Behavior Disorder: more likely; peer involvement.

Accommodations for Emotionally Fragile AS and HFA Children: Tips for Parents and Teachers—

1. AS and HFA kids with emotional fragility are often achieving academically below their “typical” peers in reading, writing, and arithmetic. Accommodation: early detection and intervention is the best strategy; set up personalized goals and strategies so that the youngster can find success.

2. Kids with emotional fragility may appear easily distracted, less attentive, and have poor concentration. Accommodation: by setting up an environment and materials that are stimulating, these kids can stay more engaged and interested; set clear rules and expectations with visual stimulating material.

3. Some young people with emotional fragility may be blame others, manipulate situations, and even bully others. Accommodation: use behavior contracts; use a highly structured environment; stay consistent in expectations; set limits and boundaries; develop a cue word for the youngster to note inappropriate behavior; clearly post rules.

4. AS and HFA kids who are emotionally fragile often have skewed views of their long term possibilities and desires. Accommodation: include these children in the planning process and IEP so they can visualize and voice their goals; it can also be helpful for them to note the goals it will take to get there.

5. Youngsters with emotional fragility may present extra challenges to parents in the form of outbursts and disobedience. Accommodation: parents should not give into this as it only validates the youngster’s behavior; instead parents need to challenge their child to keep him learning new skills.

6. Children with emotional fragility may have difficulty establishing a variety of relationships. Accommodation: use seating arrangement to encourage social interaction; use role-playing situations; set up goals aimed at social interactions.

7. Children with emotional fragility often have low self-esteem, high stress points, and may engage in self-injurious behaviors. Accommodation: be aware of your speech and non-verbal cues when talking to the child; establish a quiet cool off area; provide time for relaxation techniques; teach and put in place self-monitoring and self-control techniques; teach self-talk to relieve stress and anxiety.

8. AS and HFA children with emotional fragility are often truant from school and disruptive when present. Accommodation: communicate with moms and dads so similar strategies and expectations are used at home.

Additional Strategies to Assist Emotionally Fragile AS and HFA Children—

1. Create a new behavior to replace the behavior you want to change. If the AS/HFA youngster is aggressive toward others while working in a group, you may want him to take turns or talk in a quiet tone of voice while in a group. Remember to create an alternative behavior that is directly observable.

2. Establish rewards and/or consequences for behaviors. Overall, it's more effective to reward the positive behavior that you are trying to increase than to punish the behavior you are trying to decrease. If the behavior does not pose an immediate threat to you, the AS/HFA youngster or other kids, or does not disrupt the entire group lesson, try to ignore the disruptive behavior while rewarding the positive behavior.

3. Identify the behavior you want to change. Keep a written record of the behaviors the AS/HFA youngster exhibits during social and independent play and academic activity (e.g., "I want Julie to play without pushing other kids …or to remain quiet during a test …or to stay seated during a lesson"). Once you describe the youngster's behavior in terms of observable actions, you will be able to monitor and mediate the behavior.

4. Provide plenty of opportunities to practice new behaviors. AS and HFA children with emotional fragility usually have difficulty working with others whether they are aggressive or withdrawn. You will want to set up social situations where the youngster can practice taking turns in a group or with a partner, and sharing and talking appropriately.

5. Role-play and hold conflict-resolution meetings so the AS/HFA youngster can practice and discuss alternative responses to social situations.

6. Teach the youngster to monitor progress independently. Have charts in folders, in a locker, or at home where she can document progress in achieving a particular behavioral goal. Have her write or verbally explain why a certain behavior is unacceptable and what behavior she can do to change it.


Children with emotional fragility often have an early diagnosis among school districts. This is because educators initiate the referral process among concerns over behavior in class. Often, the DSM is used by a school psychologist, whom may conduct interviews and distribute surveys as part of the social-emotional evaluation.

When it is determined that the child is emotionally fragile, he should receive an Individualized Education Plan (IEP). Children can also receive specific behavioral plans such as a 504 in the state of California. This often includes goals towards appropriate behavior, productive coping strategies and academic skills. Effective services should focus on these, and can mandate an educational assistant for support in regular education classes, access to a resource room for individualized instruction, medication management provided by a mental health professional, as well as individual counseling.

Emotionally fragile children are often considered at-risk for dropping out of school, suicide, criminal activity, as well as being diagnosed with a learning disability. Nonetheless, with the appropriate supports in place, these young people have been shown to have enormous potential to succeed.

More resources for parents of children and teens with High-Functioning Autism and Asperger's:

==> How To Prevent Meltdowns and Tantrums In Children With High-Functioning Autism and Asperger's

==> Parenting System that Significantly Reduces Defiant Behavior in Teens with Aspergers and High-Functioning Autism

==> Launching Adult Children with Asperger's and High-Functioning Autism: Guide for Parents Who Want to Promote Self-Reliance

==> Teaching Social Skills and Emotion Management to Children and Teens with Asperger's and High-Functioning Autism

==> Parenting Children and Teens with High-Functioning Autism: Comprehensive Handbook

==> Unraveling The Mystery Behind Asperger's and High-Functioning Autism: Audio Book

==> Parenting System that Reduces Problematic Behavior in Children with Asperger's and High-Functioning Autism

Affective Education for Children and Teens on the Autism Spectrum

A major part of emotional development in “typical” (i.e., non-autistic) kids and teens is how they recognize, label, and control the expression of their feelings in ways that generally are consistent with social norms (i.e., emotional control). Self-regulation of feelings includes recognition and description of feelings. Once a youngster can articulate an emotion, the articulation already has a somewhat regulatory effect.

Typical kids are able to use various strategies to self-regulate as they develop and mature. They begin learning at a young age to control certain negative feelings when in the presence of grown-ups, but not to control them as much around friends. By about age 4, they begin to learn how to alter how they express feelings to suit what they feel others expect them to express.

By about age 7 to 11 years, “typical” kids are better able to regulate their feelings and to use a variety of self-regulation skills. They have likely developed expectations concerning the outcome that expressing a particular feeling to others may produce – and have developed a set of behavioral skills to control how they express their feelings. By the teenage years, they adapt these skills to specific social relationships (e.g., they may express negative feelings more often to their mom than to their dad because they assume their dad will react negatively to displays of emotion). “Typical” teens also have heightened sensitivity to how others evaluate them.

Unfortunately, young people on the autism spectrum do not develop emotionally along the same lines and time-frame as “typical” children do. Children with Asperger’s (AS) and High-Functioning Autism (HFA), after all, have a “developmental disorder” – their emotional age is younger than their chronological age. Thus, they must be taught emotion management and social skills. Affective education (i.e., teaching children about emotions) is an effective way to accomplish this goal.

==> How To Prevent Meltdowns and Tantrums In Children With High-Functioning Autism and Asperger's
Affective education is a crucial stage in a course of Cognitive Behavioral Therapy (CBT) and an essential component for children and teens with AS and HFA. The main goal is to learn why one has emotions, their use and misuse, and the identification of different levels of expression.

A basic principle is to explore one emotion at a time as a theme for a project. The choice of which emotion to start with is decided by the Cognitive Behavioral therapist, but a useful starting point is happiness or pleasure. A scrapbook can be created that illustrates the emotion. For younger kids, this can include pictures of people expressing the different degrees of happiness or pleasure, but can be extended to pictures of objects and situations that have a personal association with the feeling, (e.g., a photograph of a rare rock for a child with a special interest in rock collecting).

For older teens, the scrapbook can illustrate the pleasures in their life. The content also can include the sensations that may elicit the feeling (e.g., aromas, tastes, textures). The scrapbook can be used as a diary to include compliments, and records of achievement (e.g., certificates and memorabilia). At a later stage in therapy, the scrapbook can be used to change a particular mood, but it also can be used to illustrate different perceptions of a situation.

If therapy is conducted in a group, the scrapbooks can be compared and contrasted. Talking about dinosaurs may be an enjoyable experience for one group member, but perceived as terribly boring for another. Part of affective education is to explain that, although this topic may create a feeling of well-being in the one participant, his attempt to cheer up another person by talking about dinosaurs may not be a successful strategy (perhaps producing a response that he did not expect).

One of the interesting aspects noticed is that group members with AS and HFA tend to achieve enjoyment primarily from knowledge, interests, and solitary pursuits, and less from social experiences, in comparison with “typical” group members. They are often at their happiest when alone.

Affective education includes the clinician describing – and the AS or HFA child discovering – the prominent cues that indicate a particular level of emotional expression in facial expression, tone of voice, body language, and context. The face is described as an information center for emotions. The typical errors that young people on the autism spectrum make include not identifying which cues are relevant or redundant, and misinterpreting cues. The clinician uses a range of games and resources to “spot the message” and explain the multiple meanings (e.g., a furrowed brow can mean anger or bewilderment, or may be a sign of aging skin; a loud voice does not automatically mean that a person is angry).

Once the key elements that indicate a particular emotion have been identified, it is important to use an “instrument” to measure the degree of intensity. The clinician can construct a model “thermometer,” “gauge,” or volume control, and can use a range of activities to define the level of expression. For instance, the clinician can use a selection of pictures of happy faces and place each picture at the appropriate point on the instrument.

During the therapy, it is important to ensure that the AS or HFA child shares the same definition or interpretation of words and gestures and to clarify any semantic confusion. Clinical experience has indicated that some young people on the spectrum can use extreme statements (e.g., “I am going to kill myself”) to express a level of emotion that would be more moderately expressed by a “typical” child or teen. During a program of affective education, the clinician often has to increase the AS or HFA child's vocabulary of emotional expression to ensure precision and accuracy.

The education program includes activities to detect specific degrees of emotion in others – but also in oneself – using internal physiologic cues, cognitive cues, and behavior. Technology can be used to identify internal cues in the form of biofeedback instruments (e.g., auditory EMG and GSR machines). The AS or HFA child – and those who know him well – can create a list of physiologic, cognitive, and behavioral cues that indicate an increase in emotional arousal. The degree of expression can be measured using one of the special instruments used in the program (e.g., the emotion thermometer). One of the aspects of the therapy is to help the child perceive his “early warning signals” that indicate emotional arousal that may need cognitive control.

When a particular emotion and the levels of expression are understood, the next component of affective education is to use the same procedures for a contrasting emotion. For example, after exploring happiness, the next topic explored could be sadness; feeling relaxed could be explored before a project on feeling anxious. The child is encouraged to understand that certain thoughts or emotions are “antidotes” to other feelings (e.g., some activities associated with feeling happy may be used to counteract feeling sad).

Some young people with AS and HFA can have considerable difficulty translating their feelings into conversational words. There can be a greater eloquence, insight, and accuracy using other forms of expression. The clinician can use prose in the form of a “conversation” by typing questions and answers on a computer screen, or by using certain techniques (e.g., comic strip conversations that use figures with speech and thought bubbles). When designing activities to consolidate the new knowledge on emotions, one can use a diary, e-mail, art, or music as a means of emotional expression that provides a greater degree of insight for both the child and clinician.

Other activities to be considered in affective education are the creation of a photograph album that includes pictures of the child and family members expressing particular emotions, or video recordings of the child expressing her feelings in real-life situations. This can be particularly valuable to demonstrate her behavior when expressing anger.

Another activity entitled “Guess the message” can include the presentation of specific cues (e.g., a cough as a warning sign, a raised eyebrow to indicate doubt, etc.). It is also important to incorporate the AS or HFA child's special interest into the program (e.g., a child whose special interest is the weather can express his emotions as a weather report).

==> Parenting System that Significantly Reduces Defiant Behavior in Teens with Aspergers and High-Functioning Autism

Emotional Flooding—

The opposite of emotional control is emotional flooding, which is characterized as overwhelming and intense feelings that can't be controlled. During an episode of emotional flooding, the autistic child's rational mind is disconnected, his nervous system is saturated, and his prefrontal cortex ceases to exercise its controlling function. Flooding may turn into panic and fear, fight or flight. It takes a long time to come down from this heightened state, and afterward, the "special needs" youngster is often completely drained to the point of exhaustion.

Here is a 7-step plan that parents can use to deal with emotional flooding in their AS or HFA child:

1. Create signals your AS or HFA youngster can use to let you know he is about to have an episode of emotional flooding. Signals can give these kids a tool to put some space in between the reaction and their response. One 11-year-old boy with AS came up with the word “burning” to use when he felt himself getting ready to spin out-of-control. He would shout “burning, burning, burning.” His sister knew this was the signal to back off, and his mom knew this was the signal to intervene. It worked for him by giving him a few seconds before his emotions took over.

2. When your child is flooding, don’t leave him alone – but don’t try to take away his uncomfortable emotions either. If you have an AS or HFA adolescent, give him some distance until he is ready to talk.  With a younger kid, wait and listen for a shift in the intensity, and then step-in to help soothe. Sometimes you can directly ask if your child needs help to feel better (e.g., “I notice you are really upset. Do you need some help to calm down?”). If your child is not ready, he will let you know. But if he is ready, you will get a nod yes, at which point you can make some moves to soothe. When an AS or HFA youngster is out-of-control emotionally, she needs your help to get her equilibrium back. You can’t problem solve until this has been accomplished. This is true even if the emotional flooding has occurred as a result of some disciplinary measure.

3. Understand the difference between emotional flooding and a child’s drama-driven display that is created to get something. If you have a youngster that you really feel uses emotional flooding strategically to get a particular response out of you, then back off until the intensity dies down, and then offer some assistance (but don’t give in to an unreasonable demand). If your youngster is using flooding manipulatively, and she is not successful in getting the results she is after, she will eventually stop. The goal here is to help your youngster learn to self soothe and problem solve.

4. Help your youngster move from (a) acting out intense emotions to (b) labeling and describing them verbally. Words help to diffuse and give a youngster some tools to begin regulating emotions. The better able your youngster is at describing in detail her emotional state or reactions, the better she can regulate them.

5. Never attempt to suppress negative emotions. No child can help the feelings he has. He can only learn how to best manage them. Getting rid of negative emotions prematurely just sends them underground, where they can gain intensity and explode later during an unrelated event.

6. Try to figure out what the trigger is for your child’s emotional flooding. Sometimes triggers are obvious (e.g., reactions to change of routine). But, sometimes out-of-control behavior is a reaction to something that isn’t so obvious in the current situation.  For example, an AS or HFA youngster who has been repeatedly rejected and/or teased by peers may be overly-sensitive to even the slightest hint of criticism from parents.

7. When emotional flooding has run its course and the child is calm, parents can attempt to address the problem in question. Encourage your child to talk, and then reflect back to him what you heard (i.e., provide feedback). In this stage of the game, it’s more important that your child feels understood than for you to correct his way of thinking. Let him play out the scenario, and then show you understand his point of view. After you have accomplished this, you can start helping him to come up with a solution to the problem that caused him to “flood” in the first place.

More resources for parents of children and teens with High-Functioning Autism and Asperger's:

==> How To Prevent Meltdowns and Tantrums In Children With High-Functioning Autism and Asperger's

==> Parenting System that Significantly Reduces Defiant Behavior in Teens with Aspergers and High-Functioning Autism

==> Launching Adult Children with Asperger's and High-Functioning Autism: Guide for Parents Who Want to Promote Self-Reliance

==> Teaching Social Skills and Emotion Management to Children and Teens with Asperger's and High-Functioning Autism

==> Parenting Children and Teens with High-Functioning Autism: Comprehensive Handbook

==> Unraveling The Mystery Behind Asperger's and High-Functioning Autism: Audio Book

==> Parenting System that Reduces Problematic Behavior in Children with Asperger's and High-Functioning Autism


•    Anonymous said… I needed this today. My so. Had an "emotional flooding" moment and let me know that kids walk away from him or ignore him completely when he tries to talk to them. How do i get services for social and cognitive behavior help at age 14?
•    Anonymous said… I wish we could have found people that actually knew how to do this. My daughter is now 22 and things have not gotten any easier. We put her in 3 different places when she was younger and none of them helped at least not long term.
•    Anonymous said… I would like to know if anyone here has a HFA adult age now that cusses them out constantly and nothing at all is ever their fault.
•    Anonymous said… My daughter is 18 and heading to college in the fall. I've always wanted her to be able to get this kind of help. I've tried in my own way, but it's hard. So nervous to let her go. Don't give up smile emoticon
•    Anonymous said… Once my son got to high school...he became more discerning of people's motives. After a while he could care less what anyone said or thought about him (negatively ). He had a few friends in Anime Club and pretty much ignored the bullies.
•    Anonymous said… So very true!! It breaks my heart every time our son THINKS a kid is either making fun of him, when he or she is not and it's just "typical kid banter". Or like recently, when a boy at his middle school was taking GREAT advantage of him because he knew how desperately our son wanted friends. He just didn't see the insincere behavior and thought it was what friendship is supposed to be. Just killed me when he figured it out after we talked to him about the "bad thing" that happened. frown emoticon But there is a bright spot to this. It can be taught and learned, understanding certain social cues and how to watch for them. He's getting there. It's just that, for so many others, this sort of thing is instinctive. For our kiddos, we have to help them, point things out, role play, help them learn it. Merry Christmas everyone!!!
•    Anonymous said… That's is all we all can do with a child with Aspergers is try in our own way. What worked yesterday may not work today so we just keep trying. smile emoticon
•    Anonymous said… This is exactly my son too
•    Anonymous said… You are not alone, my son is 11. Place after place he went and all they would do is CBT. Now we live where there is an Autism center and he's too old, their age cut off is 8.
•    Anonymous said…. It's hard when you just want to make everything ok. Milan is not on the spectrum but he struggles socially and it's so hard to watch or answer why his five year old brother has so many friends and party invites

Please post your comment below…

Children on the Autism Spectrum and Emotional Dysregulation

Emotional dysregulation is a term used in the mental health community to refer to an emotional response that is poorly modulated and does not fall within the conventionally accepted range of emotive response. Emotional dysregulation may be referred to as labile mood or mood swings.

Possible manifestations of emotional dysregulation include behavioral outbursts (e.g., destroying or throwing objects, aggression towards self or others, anger and rage, etc.). These variations usually occur in seconds to minutes or hours. Emotional dysregulation can lead to behavioral problems and can interfere with a child’s social interactions and relationships at home and school.

Emotional dysregulation is quite common in Aspergers and High-Functioning Autistic (HFA) children. In my practice, the most frequently asked question by parents is: “What do I do when my child loses control of his emotions?” When emotional dysregulation is occurring, the best reaction is to ensure the safety of all concerned. Know that this behavior is not planned, but instead is most often caused by subtle and perplexing triggers. When the behavior happens, everyone in its path feels pain – especially the Aspergers youngster.

When Your Aspergers or HFA Child Experiences Emotional Dysregulation:

1. Acknowledge your youngster’s effect on you. Many HFA kids will calm down if you acknowledge their impact — and get angrier if you don't. You might stop and say something like, "I've stopped the car (or "I am off the phone") and you have my full attention." Then, ask questions like, "What don't I understand?"

2. Avoid physical power struggles. Using your size and strength only exacerbates the problem. Imagine your youngster is feeling furious and picks up a stick. If you grab it before he has time to give it up voluntarily, he might try to hit you with it. Instead, you can avert danger and acknowledge your youngster’s power by saying, "Please put that down. You could hurt someone you love." (Obviously you would never allow someone to hurt or be hurt.)

3. Don't extend your child’s dysregulated state with too much discussion. If your youngster is feeling out of control or in a rage, a lot of talking may not help – in fact, it could prolong the problem.

4. It's natural for HFA children to sometimes have big feelings. You haven't done something wrong if your youngster has an occasional blow-up or melt-down. Moms and dads should only worry if the youngster is chronically, constantly out of control.

5. Keep breathing and stay relaxed. It's hard not to tense up when your youngster is getting out of control, but if you stay relaxed, he's more likely to follow. Sometimes we start holding our breath when things get tense. Instead, inhale, exhale and then talk through your own feelings in a clear and (if necessary) firm way.

6. Keep your own strong feelings separate from your child’s behavior. While it's often important to show your youngster what you feel, entering into his dysregulated state with your own anger will only escalate the situation. Take a breath, speak calmly, even leave the room and give yourself a time out if you need to.

7. Let the emotional dysregulation run its course as long as no one is being hurt. This is really crucial. A youngster who is filled with raw feelings may not know how to manage them. But he may feel reassured by your calmer presence. Then, you get back to the business of communicating.

8. Let your youngster express negative feelings without judging him. Imagine if every time you were upset, some bigger, taller, frowning person looked down at you and said, "Don't feel that way," or "Don't tell me that." Would you feel like calming down - or acting out?

9. Reflect your youngster’s feelings. You might say, "I can see how frustrated you are. Can you tell me what made you feel that way?" ("What" is always more important than "Why" — it asks for specifics.)

10. Seek professional help if you see a repeated, chronic pattern that you can't figure out. If your child’s destructive behavior escalates and becomes increasingly difficult to deal with, and if nothing works over a period of weeks or months, there may be an underlying issue that needs professional help. You can find a referral through a doctor, guidance counselor at your youngster’s school, a friend, neighbor, community center or place of worship.

11. Set limits that your youngster will find comforting. A limit is not a punishment. Limits may help your youngster learn how to calm himself down. Aspergers and HFA children find the “setting of limits” comforting and soothing. They need to know that you (the parent) are in control.

12. Slow down the process by saying, "I need a moment to think about this." If your youngster is starting to lose control, you can slow things down by giving feedback. You might say, "I can see you're upset. Let's talk."

13. Try not to take your youngster’s strong feelings personally. Many moms and dads feel frustrated or personally attacked if their youngster explodes at them. Don't take his strong feelings personally. “I hate you” is not actually a personal statement. What your youngster really may be saying is “I hate being out of control.”

14. Try to avoid threats in the heat of the moment. The moment you make irrational threats with punishments that do not suit the occasion, you are not talking about the topic anymore. In the heat of the moment, if you say, “If you throw that toy – I’ll ground you,” then the youngster may start to fight the grounding, and the original issue is lost.

15. Try to comfort your youngster physically. Each kid on the autism spectrum reacts to emotional dysregulation differently. Some will want to be held, others want to be left alone. If it seems right, you might try holding your youngster, if he will let you. If your child struggles ferociously, let go as long as no one will get hurt.

More resources for parents of children and teens with Asperger's and High-Functioning Autism:

Aspergers Children Who Are Physically Abused


My asperger son is almost 16. He doesn't live with me. He's told me on numerous occasions that he's being physically abused. When I've reported it, they either accuse me of coaching him, or accuse him of lying, or of not being able to get him to focus enough to report the abuse. Years ago I did get one report of abuse substantiated, (because of bruises) however, nothing was done about it, and my son is still ignored. If someone could please help me to get help for my son, or just help my son, I would greatly appreciated it. I love him, and I want him to be safe and happy. He doesn't deserve abuse just because he isn't like other kids.


In the USA, an estimated 906,000 kids are victims of abuse & neglect every year, making abuse as common as it is shocking. Whether the abuse is physical, emotional, sexual, or neglect, the scars can be deep and long-lasting, often leading to future abuse. You can learn the signs and symptoms of abuse and help break the cycle, finding out where to get help for the kids and their caregivers.

Facts about abuse and neglect—

How could anyone abuse a defenseless child? Most of us can’t imagine what would make an adult abuse a child. The worse the behavior is, the more unimaginable it seems. Yet sadly, abuse is much more common than you might think. Abuse cuts across social classes and all ethnicities. And the abuse overwhelmingly is at the hands of those who are supposed to be protecting the child- the parents.

What is abuse?

Abuse happens in many different ways, but the result is the same- serious physical or emotional harm. Physical or sexual abuse may be the most striking types of abuse, since they often unfortunately leave physical evidence behind. However, emotional abuse and neglect are serious types of abuse that are often more subtle and difficult to spot. Child neglect is the most common type of abuse.

How can abuse happen?

There are many complicated factors that lead to abuse. Risk factors for abuse include:
  • Alcohol or drug abuse. Alcohol and drug abuse lead to serious lapses in judgment. They can interfere with impulse control making emotional and physical abuse more likely. Due to impairment caused by being intoxicated, alcohol and drug abuse frequently lead to child neglect.
  • Domestic violence. Witnessing domestic violence in the home, as well as the chaos and instability that is the result, is emotional abuse to a child. Frequently domestic violence will escalate to physical violence against the child as well.
  • History of abuse. Unfortunately, the patterns we learn in childhood are often what we use as parents. Without treatment and insight, sadly, the cycle of abuse often continues.
  • Stress and lack of support. Parenting can be a very time intensive, difficult job. Moms and dads caring for kids without support from family, friends or the community can be under a lot of stress. Teen parents often struggle with the maturity and patience needed to be a parent. Caring for a child with a disability, special needs or difficult behaviors is also a challenge. Caregivers who are under financial or relationship stress are at risk as well.

The lasting effects of abuse—

All types of abuse and neglect leave lasting scars. Some of these scars might be physical, but emotional scarring has long lasting effects throughout life, damaging a child’s sense of self and ability to have healthy relationships.

You can make a difference—

One of the most painful effects of abuse is its tendency to repeat itself. One of every three abused or neglected kids will grow up to become an abusive parent. You may be reluctant to interfere in someone’s family, but you can make a huge difference in a child’s life if you do. The earlier abused kids get help, the greater chance they have to heal from their abuse and not perpetuate the cycle.

Physical abuse: Warning signs and how to help—

Many physically abusive parents and caregivers insist that their actions are simply forms of discipline, ways to make kids learn to behave. But there’s a big difference between giving an unmanageable youngster a swat on the backside and twisting the child’s arm until it breaks. Physical abuse can include striking a youngster with the hand, fist, or foot or with an object, burning, shaking, pushing, or throwing a child; pinching or biting the child, pulling a youngster by the hair or cutting off a child’s air. Another form of abuse involving babies is shaken baby syndrome, in which a frustrated caregiver shakes a baby roughly to make the baby stop crying, causing brain damage that often leads to severe neurological problems and even death.

Warning signs of physical abuse—
  • Behavioral signs. Other times, signs of physical abuse may be more subtle. The youngster may be fearful, shy away from touch or appear to be afraid to go home. A child’s clothing may be inappropriate for the weather, such as heavy, long sleeved pants and shirts on hot days.
  • Caregiver signs. Physically abusive caregivers may display anger management issues and excessive need for control. Their explanation of the injury might not ring true, or may be different from an older child’s description of the injury.
  • Physical signs. Sometimes physical abuse has clear warning signs, such as unexplained bruises, welts, or cuts. While all kids will take a tumble now and then, look for age-inappropriate injuries, injuries that appear to have a pattern such as marks from a hand or belt, or a pattern of severe injuries.

Is physical punishment the same as physical abuse?

Physical punishment, the use of physical force with the intent of inflicting bodily pain, but not injury, for the purpose of correction or control, used to be a very common form of discipline. Most of us know it as spanking or paddling. Many of us may feel we were spanked as kids without damage to body or psyche. The widespread use of physical punishment, however, doesn’t necessarily make it a good idea. The level of force used by an angry or frustrated parent can easily get out of hand and lead to injury. Even if it doesn’t, what a youngster learns from being hit as punishment is less about why conduct is right or wrong than about behaving well — or hiding bad behavior — out of fear of being hit.

Emotional abuse—

“Sticks and stones may break my bones but words will never hurt me”. This old saying could not be farther from the truth. Emotional abuse may seem invisible. However, because emotional abuse involves behavior that interferes with a child’s mental health or social development, the effects can be extremely damaging and may even leave deeper lifelong psychological scars than physical abuse.

Emotional abuse takes many forms, in words and in actions.

Words. Examples of how words can hurt include constant belittling, shaming, and humiliating a child, calling names and making negative comparisons to others, or constantly telling a youngster he or she is “no good," "worthless," "bad," or "a mistake." How the words are spoken can be terrifying to a youngster as well, such as yelling, threatening, or bullying.

Actions. Basic food and shelter may be provided, but withholding love and affection can have devastating effects on a child. Examples include ignoring or rejecting a child, giving him or her the silent treatment. Another strong component of emotional abuse is exposing the youngster to inappropriate situations or behavior. Especially damaging is witnessing acts that cause a feeling of helplessness and horror, such as in domestic violence or watching another sibling or pet be abused.

Signs of emotional abuse—

Behavioral signs. Since emotional abuse does not leave concrete marks, the effects may be harder to detect. Is the youngster excessively shy, fearful or afraid of doing something wrong? Behavioral extremes may also be a clue. A youngster may be constantly trying to parent other kids for example, or on the opposite side exhibit antisocial behavior such as uncontrolled aggression. Look for inappropriate age behaviors as well, such as an older youngster exhibiting behaviors more commonly found in younger kids.

Caregiver signs. Does a caregiver seem unusually harsh and critical of a child, belittling and shaming him or her in front of others? Has the caregiver shown anger or issues with control in other areas? A caregiver may also seem strangely unconcerned with a child’s welfare or performance. Keep in mind that there might not be immediate caregiver signs. Tragically, many emotionally abusive caregivers can present a kind outside face to the world, making the abuse of the youngster all the more confusing and scary.

Sexual abuse—

Sexual abuse, defined as any sexual act between an adult and a child, has components of both physical and emotional abuse. Sexual abuse can be physical, such as inappropriate fondling, touching and actual sexual penetration. It can also be emotionally abusive, as in cases where a youngster is forced to undress or exposing a youngster to adult sexuality. Aside from the physical damage that sexual abuse can cause, the emotional component is powerful and far reaching. The layer of shame that accompanies sexual abuse makes the behavior doubly traumatizing. While news stories of sexual predators are scary, what is even more frightening is that the adult who sexually abuses a youngster or adolescent is usually someone the youngster knows and is supposed to trust: a relative, childcare provider, family friend, neighbor, teacher, coach, or clergy member. Kids may worry that others won’t believe them and will be angry with them if they tell. They may believe that the abuse is their fault, and the shame is devastating and can cause lifelong effects.

Signs of sexual abuse—
  • Behavioral signs. Does the youngster display knowledge or interest in sexual acts inappropriate to his or her age, or even seductive behavior? A youngster might appear to avoid another person, or display unusual behavior- either being very aggressive or very passive. Older kids might resort to destructive behaviors to take away the pain, such as alcohol or drug abuse, self-mutilation, or suicide attempts.
  • Caregiver signs. The caregiver may seem to be unusually controlling and protective of the child, limiting contact with other kids and adults. Again, as with other types of abuse, sometimes the caregiver does not give outward signs of concern. This does not mean the youngster is lying or exaggerating.
  • Physical signs. A youngster may have trouble sitting or standing, or have stained, bloody or torn underclothes. Swelling, bruises, or bleeding in the genital area is a red flag. An STD or pregnancy, especially under the age of 14, is a strong cause of concern.

Sexual abuse: The online risk—

Kids who use the Internet are also vulnerable to Internet predators. Among the warning signs of online sexual abuse are these:
  • You find pornography on your child's computer.
  • Your youngster becomes withdrawn from the family.
  • Your youngster receives phone calls or mail from people you don't know, or makes calls to numbers that you don’t recognize.
  • Your youngster spends large amounts of time online, especially at night, and may turn the computer monitor off or quickly change the screen on the monitor when you come into the room.

Child neglect—

Child neglect is the most frequent form of abuse. Neglect is a pattern of failing to provide for a child's basic needs, endangering a child’s physical and psychological well-being. Child neglect is not always deliberate. Sometimes, a caregiver becomes physically or mentally unable to care for a child, such as in untreated depression or anxiety. Other times, alcohol or drug abuse may seriously impair judgment and the ability to keep a youngster safe. The end result, however, is a youngster who is not getting their physical and/or emotional needs met.

Warning signs of child neglect—
  • Behavioral signs. Does the youngster seem to be unsupervised? School kids may be frequently late or tardy. The youngster might show troublesome, disruptive behavior or be withdrawn and passive.
  • Caregiver signs. Does the caregiver have problems with drugs or alcohol? While most of us have a little clutter in the home, is the caregiver’s home filthy and unsanitary? Is there adequate food in the house? A caregiver might also show reckless disregard for the child’s safety, letting older kids play unsupervised or leaving a baby unattended. A caregiver might refuse or delay necessary health care for the child.
  • Physical signs. A youngster may consistently be dressed inappropriately for the weather, or have ill-fitting, dirty clothes and shoes. They might appear to have consistently bad hygiene, like appearing very dirty, matted and unwashed hair, or noticeable body odor. Another warning sign is untreated illnesses and physical injuries.

What to do if a youngster reports abuse—

You may feel overwhelmed and confused if a youngster begins talking to you about abuse. It is a difficult subject and hard to accept, and you might not know what to say. The best help you can provide is calm, unconditional support and reassurance. Let your actions speak for you if you are having trouble finding the words. Remember that it is a tremendous act of courage for kids to come forward about abuse. They might have been told specifically not to tell, and may even feel that the abuse is normal. They might feel they are to blame for the abuse. The youngster is looking to you to provide support and help- don’t let him or her down.

Avoid denial and remain calm. A common reaction to news as unpleasant and shocking as abuse is denial. However, if you display denial to a child, or show shock or disgust at what they are saying, the youngster may be afraid to continue and will shut down. As hard as it may be, remain as calm and reassuring as you can.

Don’t interrogate. Let the youngster explain to you in his/her own words what happened, but don’t interrogate the youngster or ask leading questions. This may confuse and fluster the youngster and make it harder for them to continue their story.

Reassure the youngster that they did nothing wrong. It takes a lot for a youngster to come forward about abuse. Reassure him or her that you take what is said seriously, and that it is not the child’s fault.

Reporting abuse and neglect—

Reporting abuse seems so official. Many people are reluctant to get involved in other families’ lives. However, by reporting, you can make a tremendous difference in the life of a youngster and the child’s family, especially if you help stop the abuse early. Early identification and treatment can help mitigate the long-term effects of abuse. If the abuse is stopped and the youngster receives competent treatment, the abused youngster can begin to regain a sense of self-confidence and trust. Some moms and dads may also benefit from support, parent training and anger management.

Reporting abuse: Myths and Facts—
  • I don’t want to interfere in someone else’s family. The effects of abuse are life long, affecting future relationships, self esteem, and sadly putting even more kids at risk of abuse as the cycle continues. Help break the cycle of abuse.
  • It won’t make a difference what I have to say. If you have a gut feeling that something is wrong, it is better to be safe than sorry. Even if you don’t see the whole picture, others may have noticed as well, and a pattern can help identify abuse that might have otherwise slipped through the cracks.
  • They will know it was me who called. Reporting is anonymous. In most states, you do not have to give your name when you report abuse. The abuser cannot find out who made the report of abuse.
  • What if I break up someone’s home? The priority in youngster protective services is keeping kids in the home. A abuse report does not mean a youngster is automatically removed from the home - unless the youngster is clearly in danger. Support such as parenting classes, anger management or other resources may be offered first to parents if safe for the child.

Abuse Hotlines: Where to call to get help or report abuse—

If you suspect a youngster is in immediate danger contact law enforcement as soon as possible.
  • To get help in the U.S., call: 1-800-4-A-CHILD (1-800-422-4453) – Childhelp National Abuse Hotline
  • To get help for child sexual abuse, call: 1-888-PREVENT (1-888-773-8368) – Stop It Now
  • 1-800-656-HOPE Rape, Abuse & Incest National Network (RAINN)

Abuse prevention—

Reducing the incidence of abuse is a matter of intervention and education.


In some cases, as in cases of extreme cruelty, sexual abuse, and severe alcohol and drug abuse, kids are safer away from the caregiver. Not all abusive moms and dads intend harm to their kids, however. Some moms and dads need help to realize that they are hurting their kids, and can work on their problems. Some examples include:
  • Alcohol and drug abuse. Alcohol and drug abusers may be so focused on their addiction that they are hurting their kids without realizing it. Getting appropriate help and support for alcohol and drug abuse can help moms and dads focus back on their kids.
  • Domestic violence. A mother might be trying to do her best to protect her kids from an abusive husband, not realizing that the kids are being emotionally abused even if they are not physically abused. Helping a mother leave an abusive relationship and getting supportive counseling can help stop these kids from being abused.
  • Untreated mental illness. A depressed mother might not be able to respond to her own needs much less her kid’s. A caregiver suffering from emotional trauma may be distant and withdrawn from her kids, or quick to anger without understanding why. Treatment for the caregiver means better care for the kids.

In some cases, you might be able to provide support for parents/caregivers who need help yourself. What if a parent or caregiver comes to you? The key is not to be self-righteous or judgmental, which can alienate caregivers, but offer support and concrete offers of help, such as helping them connect with community resources. If you feel that your safety or the safety of the youngster would be threatened if you try to intervene, leave it to the professionals. You may be able to provide more support later after the initial professional intervention.


Some caregivers have not learned the skills necessary for good parenting. Teen parents, for example, might have unrealistic expectations about how much care babies need or why toddlers can be so prone to tantrums. Other times, previous societal and cultural expectations of good child raising may not be considered so today. In previous generations and in many cultures, for example, strict physical discipline was considered to be essential in teaching a youngster to behave. Education can greatly help caregivers who need information on raising kids. Parenting classes can not only be effective for teen parents, but for parents who themselves were abused and need to learn new parenting patterns. Education on managing stress and building healthier relationships also helps caregivers.

Kids need education as well to help protect against abuse. They need to know that abuse is never their fault and is never “OK”. Teaching a youngster about inappropriate touch and that they should never keep secrets that make them uncomfortable can help prevent sexual abuse.

For caregivers—

Do you see yourself in some of these descriptions, painful as it may be? Do you feel angry and frustrated and don’t know where to turn? Caring for kids can be very difficult. Don’t go it alone. Ask for help if you need it. If you don’t have a friend or family to turn to, call the abuse hotline, 1-800-4-A-CHILD, yourself. The hotline is also designed to get you support and find resources in the community that can help you.

The Aspergers Comprehensive Handbook

Medical Treatment for Aspergers

This post discusses strategies that assist in medication treatment of people with Aspergers and high functioning autism. Elsewhere, there are recent reviews offering detailed information on medications used for HIGH FUNCTIONING AUTISM and ASPERGERS [1]. The objective here is to discuss the logic and organization of medication treatments for symptoms of ASPERGERS and ways to decide which medications may be useful.

ASPERGERS and HIGH FUNCTIONING AUTISM have moved from being esoteric, “boutique” conditions into the mainstream of child and adolescent psychiatric practice. Diligent practitioners recognize they must be informed about the diagnosis, course, and treatment of these disorders. Recent epidemiologic studies suggest a prevalence of approximately 19–67/10,000 people for autism spectrum disorders [2], [3], [4]. Moreover, autism spectrum disorders are no longer the exclusive province of specialists. A typical child and adolescent psychiatric practice is likely to see individuals from the roughly 50%–60% of the PDD population who are “high functioning,” that is, they have good functional semantic language skills and average or greater IQ. Many people with these disorders have mood and behavioral problems [5], and moderate to severe symptoms certainly lead moms/dads to seek treatment with a child and adolescent psychiatrist. Reports from education departments suggest children with these conditions represent a large influx of new special education children [6] and place a heavy demand on education systems.

Although there has been an effort to identify features that differentiate HIGH FUNCTIONING AUTISM and some ASPERGERS [7], [8], it is premature to be confident about this distinction [9], [10], [11], [12]. Specifically, longitudinal studies have not demonstrated differences in prognosis [9], [13]; it is possible that the outcome can overlap [11]. There is no evidence that the groups show a different response to interventions for social skills development or that there are differences in basic information processing [14], [15], [16], [17], [18]. Furthermore, there is no evidence that the two disorders exhibit genetic specificity or different recurrence risks. There are no differences in neuropathology that have been demonstrated [19]. This discussion therefore considers both “high functioning” groups together under the designation ASPERGERS. For the purposes of pharmacologic treatment this is particularly justifiable because no studies have reported differences in medication responses in those people with HIGH FUNCTIONING AUTISM compared with those with ASPERGERS.

Core features and the mechanics of pharmacologic treatment—

It is essential for anyone who takes responsibility for pharmacologic treatment to understand the phenomenology and course of ASPERGERS (discussed elsewhere in this issue). The specific features of ASPERGERS exhibited by a patient influence the treatment one chooses and how the treatment is assisted for that patient (and family). The nature of ASPERGERS introduces specific and sizable challenges, particularly when using pharmacologic treatments. Building a relationship and gaining the patient's trust can be hard to accomplish; individuals often feel forced to take medication and commonly recoil from the idea of medication treatment. Understandably, many individuals are so frightened of the effects of medications that they cannot put those fears aside enough to try one. The amount of anxiety that makes it appropriate to consider medication for a patient can also interfere with him or her adhering to a prescription. Despite the enormous interference or distress their symptoms generate, many individuals cannot put aside their worries about the medication. The family and a trusted physician may be the only individuals the patient will allow to counter these fears. Usually, creating a therapeutic framework for medication treatment that achieves this rapport requires time and several visits [20].

Many of the difficulties with anger, perseveration, or anxiety are more distressing to those around the patient than to the patient himself (or herself). People with ASPERGERS commonly lack the ability to perceive the signals of comfort or pleasure of others or, once acquired, to use others' emotions to guide their behaviors. Lacking this ability, individuals struggle with the initial fears related to taking medication or entering into other therapy that might help them get along with others. Often they cannot see why they should be required to take a medication simply because others are upset. Threatening an unpleasant consequence is often ineffective. People with ASPERGERS can be willing to accept dreadful consequences rather than yield control to someone else, compromise a rigidly held rule, contain a pressing urge, or tackle managing an anxious feeling.

Another hurdle is the shortcomings individuals have in identifying their own internal mood states and emotions. As a result, the clinician may be unable to gauge whether individuals experience less subjective anxiety, sadness, or anger. The patient's psychological “comfort” may not be available to the clinician for rating improvement. To monitor progress, the clinician is compelled to draw on multiple observations, rely more or less exclusively on the patient's somatic experience, and to use highly concrete measures with individuals. Treating adult individuals who are living independently and are unwilling to allow others to participate in their treatment is particularly challenging.

An associated obstacle is the deficits ASPERGERS people have perceiving and understanding other individual's intentions, wishes, or needs. The blindness to others often contributes to the ASPERGERS person's inability to grasp how their reactions contributed to a bad result; more often they believe they are being persecuted. The bona fide teasing and persecution that are a common part of their day-to-day experience only adds to this. For the person with ASPERGERS, it may be impossible to tell the difference. Nevertheless, the person with ASPERGERS is likely to be oblivious to how their actions contributed to a chain of events that ended in an outburst or aggression, or even to believe that the outcome should be averted in the future. This blindness also produces a tendency to accuse those around them of causing problems; faulting others is highly characteristic and is a direct result of the primary disorder. This should not to be confused with the more common psychological defenses of avoiding responsibility and assigning blame that are used by more socially skillful, typical agemates.

Many people with ASPERGERS display profound weaknesses in the ability to observe sequences of events and transactions accurately and in understanding the “logical” responses of those around them. ASPERGERS kids can be highly concrete; the “big picture” of behaviors and emotions is often lost to an excessive attention to small changes in circumstances or minor details. They often have a flawed sense of proportion. For example, premeditated, forceful, retaliation may be viewed as a justified response to someone else's small blunder.

In addition, ASPERGERS people often are rigid in their behaviors with inflexible routines, dedication to unnecessary rules, or ritualized behaviors. Sometimes these may be no more than a minor irritation to others, but when severe, they can obstruct action and exasperate those around them. Severe rigidity can be highly frustrating to others, and attempts to counter it may produce aggressive reactions from the patient. For all this, such individuals may perceive that “if only individuals let me do what I want” there would be no problems at all. ASPERGERS individuals are not merely immature ordinary kids or adolescents.

In addition to these, several other obstacles are related to the state of the field. First, no pharmacologic agent influences the core pragmatic social deficits such as misinterpreting cues or failure to appreciate social cues and nuances. As a result, there is no one algorithm to follow that targets the primary source of impairment or the greatest source of difficulty for the patient. Second, there is an absence of high quality, valid studies of the efficacy of different pharmacologic agents for specific symptoms in this population. Most of the studies are case reports or small-scale, open, unblinded trials [1]. This requires the clinician to take findings from studies of other disorders in the hope that the results translate to ASPERGERS. This presumption is entirely theoretic at this point. Much of the time, a clinician has no way to gauge the patient's response in comparison with other people with this condition; global functioning may or may not be meaningfully improved. A third obstacle is the absence of treatment and outcome studies of ASPERGERS with comorbid conditions.

For example, it may be erroneous to presume that mood dysregulation and the response to mood stabilizers in the context of ASPERGERS is identical to bipolar disorder in an otherwise ordinary adolescent. Nearly all treatment studies of other childhood disorders exclude people with PDD spectrum disorders. Consequently, when a patient appears in the clinician's consulting room, unless one has the luxury of a previous relationship and sense of that patient's baseline functioning, one cannot know what the individual looks like when the comorbid condition is “resolved.” Most of the core social impairments are likely to remain, although functional gains are possible.

Treatment strategies—

In response to these challenges, there are strategies that therapists can adopt that increase their chance of success. A prominent characteristic of the care of individuals with ASPERGERS is the need for therapists to integrate behavioral and pharmacologic treatments [21]. Thus, treatment strategies must embrace nonpharmacologic and pharmacologic interventions. The strategies shared by both interventions are genuinely complementary. Behavioral and pharmacologic care must establish realistic expectations, optimize the home and school (or work) environment, implement strong parental collaboration, and focus on specific symptom clusters.

It is most important to establish realistic expectations about the effect of medication (and other treatments). Many individuals are drawn to pharmacologic treatment with the expectation that the response will be rapid and complete. Excessively positive expectations may be intrinsic to ASPERGERS, but they also can be related to the anxiety that one is hoping to alleviate. In any case, anxious ASPERGERS individuals often are unable to cope with the constraints that treatments are imperfect and require time. Even for individuals with more common disorders, rigidly holding to over-optimistic expectations can undermine treatment under the best of circumstances. For individuals with ASPERGERS, having such expectations may be exceptionally likely. More than others, people with ASPERGERS may require the relief that comes from things being predictable and uncomplicated. They may be highly anxious about treatments that take time and give mixed results.

For people with ASPERGERS more than others, achieving a different outcome from the one that was anticipated may be harder to endure. Many individuals also have the mistaken idea that their symptoms will remit more quickly with pharmacologic treatment than with behavioral psychotherapies. It is therefore important for the clinician and the patient to understand that there are no “magic bullets,” nor any “quick fixes” when it comes to treating these symptoms.

People with ASPERGERS also may be more prone to side effects. Typical kids and adolescents may experience these as more of a nuisance than a source of major impairment, but people with ASPERGERS often find even minor side effects hard to tolerate. The exquisite and atypical sensory world of people with ASPERGERS means that they may experience a greater variety and rate of these kinds of side effects. When side effects appear, they often outstrip the patient's ability to follow conventional advice “to just ignore it.” We do not know if the actual amount of discomfort is greater or if the means for self-soothing, distraction, or rationalization are insubstantial.

In either case, some ASPERGERS people cannot tolerate some medications because of “minor” side effects that individuals who do not have ASPERGERS handle with relative ease. In addition, they may be less likely to report side effects, or may allude to them in a manner that makes it much harder to detect them. Therapists may be misled by comments that are offered in a flat, toneless manner, suggesting minor uneasiness for the patient when in fact they are extremely distressing. Similarly, highly concrete individuals may not report side effects because the clinician does not ask about each specific one. Some individuals stop their medication without telling the clinician in order to extricate themselves from the discomfort of side effects or having to talk about them.

Although therapists frequently believe environmental and educational interventions can be helpful, physicians often rely on medication. This may be the request of the patient and others in his or her life, but it may not serve the patient in all circumstances.

A large 15-year-old youth with HIGH FUNCTIONING AUTISM attending a day school program displayed average receptive language but weak expressive language abilities. He was referred with the expressed request to increase the dose of his neuroleptic medication after showing increased agitation, irritability, and physical behavior at school. It seemed that these behaviors increased sharply over 3 weeks. He had been sent home several times in the last month following noncompliance with requests, outbursts of anger, and knocking over furniture. When asked, program staff did not remark on any precipitants. The patient's moms/dads reported an increase in anxiety at home. Discussion with the patient's moms/dads revealed that this young man had been expressing concerns over an impending labor strike at his program. He had reiterated, in an echoic way, conversations occurring in his presence among staff about the prospects for abrupt cessation of the program. At home he was tearful, apologetic, and anxious. Staff members at the program were unaware that he grasped their remarks or that the comments might influence him. When they explained that he would be given advance warning of any changes and he would continue to receive services in other ways, his agitation, outbursts, and irritability ended.

Thus, pharmacotherapy certainly has a place in an overall treatment plan, but physicians must be particularly mindful that educational and behavioral supports are the mainstays of treatment for these conditions. Medication can augment services, but when educational and other services are inadequate or unavailable, pharmacotherapy cannot make up the difference. Similarly, acute behavior changes usually should lead one to implement educational and behavioral supports that may be helpful before adding pharmacotherapy, except in uncommon circumstances that are discussed in detail later.

Parental collaboration is necessary to accomplish adequate medication treatment for ASPERGERS. This goes well beyond helping a patient make the necessary changes in his daily routine that taking a medication imposes and assuring his adherence to a medication regimen. The nature of ASPERGERS itself places additional demands on moms/dads and caretakers to participate in the treatment. Most individuals with ASPERGERS are weak intrinsically in their abilities to perceive their actions or feelings, recall them accurately, compare them at one time with another time, or observe a pattern of emotional or behavioral responses to events or a context. Kids and adolescents with ASPERGERS, to a greater extent than typical kids and adolescents, cannot grasp or respond to the intentions, needs, and desires of others. At an elemental level, they have only a modest awareness of the difficulties their symptoms create for themselves and those around them.

Thus, moms/dads play a crucial role in monitoring the patient by providing information to the physician, administering medication, observing for side effects, and noting behavioral and emotional effects. On the one hand, therapists might imagine that medication treatment for kids with ASPERGERS might be simpler if one chose to meet with only a parent. Safe use of these medications requires that the patient inform his or her doctor about side effects, however, and have the chance to voice any worries he or she harbors. It is equally true that kids with ASPERGERS tend to be self-centered and limited in their focus, which undermines the value of their subjective reports of overall functioning and improvement. As a result, objective reports of behavior, mood, and general functioning are needed. Taken altogether, a vital objective of the treatment relationship is gaining a sturdy, reliable, comfortable, knowledgeable collaboration with the individuals' moms/dads and with the individuals.

All ASPERGERS treatment is only relatively specific now. This will be so until research identifies the specific neurochemical or genetic defects that produce ASPERGERS and discovers a biologic or behavioral treatment that targets those defects. To make treatment specific, the psychopharmacologist cannot merely prescribe whatever is new or untested. Decisions about which agents to use should be based on what is likely to be most helpful for the individual patient's symptoms. A symptom-focused method means that the clinician is seeking the patterns of behavior in his or her specific patient with ASPERGERS that are creating obstacles to optimal educational and social experiences. It is an imperfect process and forces therapists to assess what can be achieved with educational and behavioral treatments, and to be knowledgeable about what symptoms medications are capable of ameliorating. The clinician's goal is a reduction in the specific symptoms that interfere with functioning. It is extremely unlikely that current medications will increase skills, but they may reduce the interference a patient experiences and allow him to use the skills he possesses.

Establishing treatment priorities—

The quantity, scale, and range of difficulties experienced by ASPERGERS people can be perplexing. Everyone involved, the patient, family, and clinician, can be swept up in this complexity. The first challenge is to create the hierarchy of symptoms and the problems they create. Often, difficulties fall into a cluster of symptoms. The primary task of the clinician is to determine which symptoms should be targeted first. Box 1 suggests the questions and order of consideration when approaching this quandary. Although no clinical trials have used combined approaches, it is likely that combined modalities will be a part of the youngster's care outside the consulting room. Creating a hierarchy of specific symptoms lends itself to behavioral and pharmacologic modalities. In coordinating services, simultaneously directing behavioral and pharmacologic treatments to the same symptoms may well enhance the response.

Box 1: Considerations for establishing treatment priorities—

1. Symptoms that threaten the safety of patient, family members, or others

2. Symptoms that generate subjective distress for the patient

3. Symptoms that are sources of adversity in the family's life

4. Symptoms that jeopardize sustained educational progress

Safety is the most compelling reason that ASPERGERS individuals are referred for pharmacotherapy. Aggression and violent outbursts are common in people with ASPERGERS [22], [23], and people with ASPERGERS commonly engage in other types of dangerous behaviors such as throwing or destroying objects [23]. Moreover, there are features of the disorder that make aggression and self-injury harder to control. Among other reasons, deficits in abilities to soothe and comfort themselves, the comparative insignificance of others' distress, rigid adherence to patterns or behaviors, deficits in generalizing from one circumstance to another, and the tendency to engage in repetitive and stereotyped behaviors may contribute to this intractability. As a result, the safety to individuals and those around them are the highest priority.

A patient's subjective distress takes center stage once safety is not a primary worry. Relief of suffering in itself is a worthy objective, but focusing on the distress of ASPERGERS individuals goes beyond this generic physician mandate. ASPERGERS individuals who are sad, anxious, or continually irritable are thwarted in their ability to learn, monitor themselves, and “read” their environment. Their emotions override their abilities to perceive events and think through the solutions to everyday problems; they cannot respond with the necessary flexibility to the rapidly changing demands of the social world. As a result, subjective distress closes off opportunities to learn information, increase social relating, and gain new social skills. A patient in continual distress is likely to be unable to demonstrate his or her actual abilities.

The effects of an ASPERGERS youngster's symptoms on a family are diverse, and some symptoms can be exceptionally taxing. Adverse effects on a family can be difficult to isolate and harder still to quantify. (Volumes could be written on the effect of ASPERGERS on families.) Clearly, some symptoms exhibited by ASPERGERS kids exceed what families can manage and may jeopardize a youngster remaining at home. Symptoms that imperil a youngster living at home deserve the most strenuous efforts to avert institutional or foster placements. The way a family adapts to a youngster with ASPERGERS grows out of a complex interplay of the youngster's constitutional factors, such as his skills, deficits, and temperament, and the measure of limitations and demands of other family members that must be met. Cultural influences and community responses also can have a potent moderating or amplifying effect. Certainly the way moms/dads and siblings adapt to a youngster's limitations and demands is a factor in the youngster's overall adaptation.

The clinician may be required to decide which contributions to an adverse family environment warrant family treatment, couples treatment, or further psychoeducational interventions, and which are likely to benefit from pharmacotherapy. A common misjudgment is using medications to treat the patient's symptoms when a parent's depression or anxiety is a major contribution to family strain. Frequently, high levels of parental distress lead therapists to prescribe for the youngster rather than educate moms/dads and recommend that they obtain treatment. This is not to advocate that family members must be infinitely adaptable to impairing symptoms in a youngster or that family problems are always the result of parental disorders. The point is that family distress has many sources. Using medication may reduce a patient's inflexibility, instability, and anxiety, and thereby enhance life at home for everyone. If the relentless stress of raising a youngster with ASPERGERS has fueled depression or an anxiety disorder in a parent, or inflamed conflicts in a marriage, however, usually treating only the youngster is insufficient. To treat clinical disorders in a parent or the tensions between partners, it is most likely that specific treatment is needed.

Similar to the risk for being unable to continue living at home, some behaviors can jeopardize a good educational placement. For example, when minor daily schedule changes lead a youngster to display aggression, withdrawal, or severe tantrums, if the school placement is at risk then there may be a role for medication to supplement vigorous behavioral efforts. This is particularly relevant when the program previously met a youngster's needs and then no longer is able to because of increasing symptoms or new symptoms that programmatic changes cannot reduce. On the other hand, not every program is ideal for every student. Some school placements do not fit the youngster's needs well and on occasion there are requests for medication that are based on a misunderstanding of the patient and his or her disorder. Medication should not be used to force a fit to a school program that poorly matches a patient's needs. Discussions with educators, moms/dads, special education administrators, and autism resource staff at the school often are necessary to sort out important medication decisions.

Characterizing symptoms—

Behavioral and pharmacologic treatments of ASPERGERS share a basic principle—a detailed characterization of the specific symptoms is needed to select the proper intervention. In part this is an outgrowth of the integration of behavioral and pharmacologic approaches. However, even if the integration of behavioral supports and biologic interventions were not necessary, these symptom details would be needed. A careful analysis of symptoms is important because the choice of interventions is influenced by symptom characteristics. Furthermore, the wide array of symptoms engenders an inclination of those closest to the youngster to lose sight, over time, of the intervention targets. When observers turn their attention to a new troubling cluster of symptoms, a treatment that has been effective may be reinterpreted as ineffective. Being attentive to symptom characteristics permits the clinician to measure effects and introduce thoughtful responses. The most important characteristics to consider are shown in Box 2.

Box 2: Characteristics of symptoms—

1. Distribution

2. Intensity

3. Onset: Time and Location

4. Duration

5. Ameliorating Factors

6. Aggravating Factors

7. Trends: upward or downward

The distribution of behaviors is a term for the frequency of symptoms over time. It may be self-evident, but it is worth underscoring that for most individuals, the frequency of symptoms changes within days, weeks, and months. Thus, having a good awareness of the course of a symptom is important for monitoring medication effects. The early, short-term effects of a medication may not be the most reliable ones for predicting the overall effect that medication delivers. Frequency also usually is related to settings and circumstances. Aggression or perseverative behaviors often increase or emerge under certain circumstances, such as when there are many individuals talking or when there are crowds. Consequently, for behaviors that are episodic it is useful to rate the behavior at the time when it is most frequent or likely to surface, rather than a general rating throughout the day, week, or month.

Furthermore, when symptoms are concentrated to specific times or places, one should first consider behavioral or educational interventions carefully. It may be that greater direction for certain activities, a break from interaction, or modifying the expectations for the patient in an activity will go a long way toward reducing maladaptive behaviors. Similarly, the risk for side effects should match the frequency of a behavior. If a symptom arises rarely, then it does not make sense to use an agent that carries a high risk for serious side effects or is highly likely to produce side effects that have the potential to make the patient uncomfortable.

Intensity is a measure of the energy or concentration the patient uses when engaging in the behavior. It also can be helpful to base this rating on the ease with which a patient may be redirected to another, different line of behavior. The onset of symptoms is often related to a time and a location. The ability to know when and where symptoms surface, or under what circumstances they surface, is helpful in rating progress. In addition, if a symptom only arises in one setting then this might lead one to consider intensive behavioral interventions first. More generalized behaviors might lend themselves more to pharmacologic treatments, because it can be difficult to maintain uniform responses across many different settings for behavioral interventions. Duration is self-explanatory. Aggravating and ameliorating factors can indicate what triggers a behavior or what sustains it.

The reason to consider the trend of a behavior, that is, whether it is increasing or decreasing, is that an intervention that is introduced as a behavior is winding down may be wrongly considered as having helped. Often, individuals or their families seek treatment when a behavior is peaking in severity. For episodic conditions, by the time a clinician intervenes, the behavior may be cycling down by itself. It is therefore often helpful to wait before intervening, to learn about the pattern and characteristics of a behavior. Of course, this cannot be considered when the risks to safety or jeopardy to other aspects of the patient's wellbeing prevent the clinician from taking this time. If there is some doubt about whether symptoms may respond to behavioral treatment, or if one is unsure whether things have improved or remained the same, a clinician is advised to wait. Increasing doses or starting new medications should only go forward if one is sure that symptoms are worse or improved to a small degree.

A 12-year-old boy with ASPERGERS was brought to treatment for picking and scratching behaviors that had become a part of his nighttime routine before going to bed. Each night he would scratch or dig at his legs. After extensive efforts to learn about the pattern of his behaviors, it seemed that these behaviors were influenced by the course of interactions at school during the day. Although the patient himself did not make the connection between being teased or having disagreements with classmates and his self-picking, it was possible to use medication and relaxation techniques to reduce the intensity and duration of these behaviors. In addition, the patient's moms/dads were able to talk with him in the early evening about specific events from throughout the day that might create distress before he went to bed. Over time the behaviors were significantly reduced, although they did not disappear altogether.

Deciding on modality priorities—

The integration of behavioral and pharmacologic treatment can place therapists in the predicament of deciding whether to pursue behavioral or pharmacologic treatment. There are patient and symptom characteristics that should enter the equation. Individuals who work hard with a behavioral support system are obviously ones who should be treated vigorously in this manner. Other individuals resist behavioral work or have circumstances that do not lend themselves to behavioral treatments. For example, it may be difficult to use behavioral treatments at home with frail caretakers who may be physically intimidated during attempts to ignore maladaptive behaviors.

As indicated earlier, there are some scenarios in which the clinician might request a more thorough application of behavioral treatment before engaging in pharmacotherapy. The features that indicate vigorous behavioral treatment are those that are more infrequent, highly setting- or circumstance-specific, and moderately (or less) intense. It is important to consider whether behavioral treatments have been conducted properly, were of sufficient duration, and were provided with sufficient intensity. A history of well conducted but unsuccessful behavioral treatments suggests that one should move to medication along with behavioral supports.

Six symptom clusters—

For simplicity, six clusters of symptoms are discussed. Throughout this discussion the emphasis has been on specific symptoms and this is an important feature to emphasize. If a patient repetitively seeks elastic objects to stretch and chew, then that symptom is the one to be targeted; for this discussion it would fall into repetitive behaviors and inflexibility. The monitoring of that symptom, however, means that the clinician and others are all tracking perseverative behavior with elastic—not every repetitive behavior that the patient may display. The clusters that follow are only a convenient way of talking about pharmacologic treatments for the common kinds of behaviors that impede the lives of individuals who have ASPERGERS. These clusters are hardly comprehensive and there certainly could be more. These were chosen because they are common reasons to seek pharmacotherapy for people with ASPERGERS.


Aggression is seldom an isolated problem and is particularly complex in people with ASPERGERS [23]. It is important to understand that aggressive behavior is not always associated with just one condition and can have highly varied sources. An array of theoretic models has been proposed to understand aggressive behavior in people with ASPERGERS [24]. There are promising biologic models that suggest the behavior arises from alterations in dopaminergic reward mechanisms [25], and cognitive models, suggesting that such acts are an outcome of conditioned learning [26], [27]. Tantrums and physical aggression are often responses to a variety of circumstances and occur in the context of diverse emotions [23]. It has become fashionable to consider aggression as prima facie evidence of bipolar disorder, particularly when ASPERGERS people are distractible, restless, and have chronically decreased need for sleep. It is increasingly important to consider, however, whether features of bipolar illness appear together and depart from chronic baseline functioning.

It is also relevant if they are associated with pharmacologic (eg, serotonin reuptake inhibitor) side effects. It is useful to know the circumstances preceding and following aggressive outbursts before selecting a pharmacologic agent. For example, when aggression is a response to anxiety or frustration, the most helpful interventions target those symptoms and the circumstances that produce them rather than exclusively focusing on aggressive behavior. Unfortunately, the request for treatment typically follows a crisis and the press for a rapid, effective end to the behaviors may not permit the gathering of much data or discussion. Nevertheless, it is not appropriate to “always” begin with one agent or another. Moving to a more “surefire” agent too quickly may mean that the patient takes on cardiovascular, endocrinologic, and cognitive risks that might be otherwise avoided. There are reports in support of using serotonin reuptake inhibitors (SRIs) [28], [29], [30], [31], [32], [33], [34] (Table 1), alpha-adrenergic agonists [35] (Table 2), beta-blocking agents [36], [37] (Table 3), “mood stabilizers,” (or anticonvulsants) [38] (Table 3), and neuroleptics [39], [40], [41], [42], [43], [44], [45] (Table 4) for aggressive behavior. When a clinician has the luxury of time, the support of family, and collaboration with staff where the individual is working or attending school (or living), then an agent that is safer, but perhaps takes a longer time to work or is a little less likely to help, can be tried. It does seem that those agents with a greater likelihood of success pose greater risks [22], [46]. The most evidence supports use of dopamine blocking agents (neuroleptics) for aggression [22] (Table 4), but the side effects and long-term risks from these agents are greater than others listed earlier.


People with ASPERGERS are particularly vulnerable to anxiety [47], [48]. This vulnerability may be an intrinsic feature of ASPERGERS [49] through specific neurotransmitter system defects [50], a breakdown in circuitry related to extinguishing fear responses [51], or a secondary consequence of their inability to make social judgments [15], [16], [17] throughout development. The social limitations of ASPERGERS make it difficult for people with the disorder to develop coping strategies for soothing themselves and containing difficult emotions. Limitations in their ability to grasp social cues and their highly rigid style act in concert to create repeated social errors. They are frequently victimized and teased by their peers and cannot mount effective socially adaptive responses. Limitations in generalizing from one situation to another also may contribute to repeating the same social gaffs. Furthermore, the lack of empathy severely limits skills for autonomous social problem solving. For higher functioning people, there is sufficient grasp of situations to recognize that others “get it” when they do not. For others there is only the discomfort that comes from somatic responses that are disconnected from events and experience.

Several agents have been tried for treatment of anxiety. There is no reason to suspect that people with ASPERGERS are less likely to respond to the medications used for anxiety in people without ASPERGERS. Thus, SRIs [28], [29], [30], [31], [32], [33], [34], [52] (Table 1), buspirone [53] (Table 3), and alpha-adrenergic agonist medications such as clonidine or guanfacine all have been tried [35] (Table 2). The best evidence to date supports use of selective serotonin reuptake inhibitors (Table 1). It is also true that people with ASPERGERS may be more vulnerable to side effects and to exhibit unusual side effects. Disinhibition is particularly prominent and can be seen with any of the serotonin reuptake inhibitors; in some circles this is regarded as evidence of bipolar “switching,” although there are no studies to suggest that among people with ASPERGERS this reaction is a portent of later nonmedication-related mania. Similarly, excessive doses may produce an amotivational syndrome [54].


Depression seems to be common among ASPERGERS people in adolescence and adulthood [55]. Many of the same deficits that produce anxiety may conspire to generate depression. The relationship between serotonin functioning and depression has been explored in detail [56], [57], [58], [59]. There is also good evidence that serotonin functions may be impaired in people with ASPERGERS [60] and which suggest that depression and ASPERGERS would be more likely. Another possibility is that the basic circuitry related to frontal lobe functions in depression may be affected in people with ASPERGERS [61]. In addition, deficits in social relationships and responses that permit one to compensate for disappointment and frustration may fuel a vulnerability to depression [15], [16], [17], [55]. There is some genetic evidence suggesting that depression and social anxiety are more common among first-degree relatives of autistic people [62], even when accounting for the subsequent effects of stress.

The medications that are useful for depression in typical kids and adolescents should be considered for people with ASPERGERS who display symptoms of depression. It exceeds the scope of this discussion to detail the diverse forms depression may take in people with ASPERGERS or the complexities of how one might make the diagnosis of depression in people with comorbid ASPERGERS. It should be pointed out, however, that because some features of depression and ASPERGERS overlap, it is important to track that the changes in mood are a departure from baseline functioning. Thus, the presence of social withdrawal in a person with ASPERGERS should not be considered a symptom of depression unless there is an acute decline from that person's baseline level of functioning.

A second important point is that the core symptoms of depression should arise together. Thus, the simultaneous appearance of symptoms such as sleep and appetite changes, irritability, sadness, loss of pleasure in activities, decreased energy, further withdrawal from interactions, and self-deprecating statements would point to depression. An additional important point is that individuals who display affective and vocal monotony are at higher risk for having their remarks minimized. Higher functioning people can make suicidal statements in a manner that suggests an off-hand remark, without emotional impact. When comments are made this way, therapists and others may underestimate them. In people with ASPERGERS, the content of such comments may be more crucial than the emotional emphasis with which they are delivered.

Agents that are useful for treatment of depression in people with ASPERGERS are serotonin reuptake inhibitors (Table 1). There also may be indications for considering tricyclic agents with appropriate monitoring of ECG, pulse, and blood pressure (Table 5). There are no agents that have been shown to be particularly more beneficial for depressive symptoms in people with ASPERGERS. Thus, the decision as to which agents to use is determined by side effect profiles, previous experience, and, perhaps, responses to these medications in other family members.

Hyperactivity and inattention:

Hyperactivity and inattention are common in ASPERGERS people, particularly in early childhood [5], [63], [64]. Differential diagnostic considerations are paramount, particularly in the context of ASPERGERS [63]. Hyperactivity and inattention is seen in a variety of other disorders, such as developmental receptive language disorders, anxiety, and depression. Thus, the appearance of inattention or hyperactivity does not point exclusively to attention deficit hyperactivity disorder (ADHD). The compatibility of the patient and his or her school curriculum is particularly important when evaluating symptoms of hyperactivity and inattention. There is a risk that a school program that is poorly matched to the individual's needs, by overestimating or underestimating a youngster's abilities, may be frustrating, boring, or unrewarding. If the verbal or social demands exceed what he or she can manage, they may produce anxiety or other problems that mimic inattention or induce hyperactivity.

Virtually every variety of medication has been tried to reduce hyperactive behavior and increase attention. The best evidence at this point supports dopamine blocking agents [39], [40], [41], [42], [43], [44], [45], [46] (Table 4), stimulants [65] (Table 6), alpha-adrenergic agonists [35] (Table 2), and naltrexone [66], [67], [68] (Table 3).

Inflexibility and behavioral rigidity:

Symptoms of inflexibility or behavioral rigidity are often difficult to quantify and yet often introduce some of the most disruptive chronic behaviors exhibited by individuals with ASPERGERS. These can be manifest by difficulties tolerating changes in routine, minor differences in the environment (such as changes in location for certain activities), or changes to plans that have been previously laid out. For some people this inflexibility can lead to aggression, or to extremes of frustration and anxiety that thwart activities. Families and school staff may find themselves “walking on eggshells” in an effort to circumvent any extreme reaction from brittle individuals. In addition, the individuals themselves may articulate their anxiety over fears that things will not go according to plan or that they will be forced to make changes that they cannot handle. Sometimes these behaviors are identified as “obsessive-compulsive” because of the patient's need for ritualized order or nonfunctional routine. This is a phenomenologic error, as OCD has features that can be differentiated from PDD spectrum disorders [69].

Nevertheless, the idea that OCD and these “needs for sameness” might share some biologic features is attractive. It is not known now whether these symptoms are produced by disturbances in the same cortico-striatal-thalamo-cortical circuitry that is believed to produce OCD [70]. The model of obsessive-compulsive disorder, however, has suggested that use of SRI agents might be useful in ameliorating this problem [28], [33]. Whether the effect of SRI agents on this symptom cluster is mediated by a general reduction in anxiety [48] or is specific for “needs for sameness” is not known. An alternative hypothesis suggests that the impairment might be located in circuitry subserving reward systems that rely on norepinephrine and dopamine [24], [71]. If so, this would point to study of other agents and systems in future investigations.

To add further support to this hypothesis, reports from studies of alpha-adrenergic agents like clonidine [35] and guanfacine also suggest a decrease in these rigid behaviors. These short-term trials do not establish whether the benefits were sustained over a longer time, however. Agents that have been most useful are SRIs (Table 1), but there may be a role for dopamine blocking agents for refractory symptoms [43], [44], [45] (Table 4).

Stereotypies and perseveration:

Stereotyped movements and repetitive behaviors are a common feature of ASPERGERS [64]. As with behavioral rigidity and inflexibility, similar models for stereotypy and obsessive-compulsive disorder have been proposed [72]. Stereotypy also may be closely related to tic disorders and Parkinson disease, however, in which repetitive behaviors emerge from impairment in dopaminergic [73] and glutamaturgic systems [74]. There are also interesting analogs to L-dopa toxicity in Parkinson disease [75].

The treatments for stereotyped movements and perseveration closely parallel those for behavioral inflexibility and the two clusters are often grouped together in studies of treatment efficacy. Thus, serotonin reuptake inhibitors (Table 1) and alpha-adrenergic agonists may be helpful (Table 2). In addition, the hypothesis that dopamine might play a role suggests that dopaminergic blocking agents should be added to the possibilities (Table 4). Reports from studies of olanzapine [41], risperidone [42], [43], [44], and ziprasidone [45] suggest this is warranted.

Complementary and alternative medicine:

The pharmacologic treatment of ASPERGERS people is in a very early stage. As a result of more organized and systematic investigation, the field is making advances in the discovery of more effective treatments [76]. A large gap remains, however, between the need for effective treatments and the effectiveness of the known agents. When there is such a disparity, opportunities for scientifically unfounded, anecdotal experience or highly biased efforts to capture the attention of moms/dads, physicians, and educators are great. In the case of ASPERGERS, one can cite many examples; the recent experience with secretin [77], [78], [79], [80] is one. This does not mean that everything about secretin in autism is now understood, only that is unreasonable to recommend secretin for ASPERGERS [81]. A similar point might be made for the variety of dietary and nutritional therapies—in the absence of carefully designed, scientifically valid, controlled studies, it is hard to justify recommending specific treatments.

Nevertheless, therapists still have to answer families who ask about trying novel treatments. Among investigators and concerned practitioners, broad guidelines have been suggested (Klin, personal communication). The first is that treatments should be safe. A variety of diets and mineral supplements are apparently safe, but some can be toxic; the frequency of toxic reactions should be spelled out and signs of toxicity should be thoroughly comprehended. More extraordinary interventions such as neurosurgery obviously are not reversible. The second guideline is that treatments should be affordable. At the height of the secretin rush, some practitioners were charging many hundreds of dollars for medication and supplies that totaled less than fifty dollars.

For most families, these treatments are not covered by insurance and money that goes to novel treatment is not available for other services. The third guideline is that novel treatments should not interfere with a youngster's participation in daily programs or treatments that are known to be helpful. Focusing on communication and social enhancement through education should be the first priority of every multimodal treatment plan. Attending school, having a detailed evaluation, and receiving behavioral supports that promote socialization and communication should not be curtailed by the pursuit of novel somatic, dietary, and complementary medical treatments.


The treatment of complex, polymorphous disorders like ASPERGERS always brings a particular challenge to pharmacotherapy. Additionally, the specific characteristics presented by ASPERGERS introduce unique complications to patient care and place unusual demands on a clinician's skill and experience. To provide safe and effective treatment, the clinician must understand the core features of the disorder and the manifestations of the condition in his or her patient. Furthermore, a thorough understanding of the family, school, and community resources and limitations is necessary.

Once an assessment has been made, focusing on target symptoms provides a crucial framework for care. Knowing manifestations of symptoms and characterizing their distribution and behavior in that patient is most important. For individuals with ASPERGERS it is particularly essential to coordinate behavioral and pharmacologic objectives. The target symptoms should be tracked carefully and placed into a priority system that is based on the risks and disability they create for the patient. The skill of pharmacotherapy also means setting out realistic expectations, keeping track of the larger systems of care at school and home, and collaboration with moms/dads and care providers.

There is an expanding range and pace of biologic and intervention research into ASPERGERS. The genetic work has produced exciting leads that are likely to be helpful to future generations [82], [83], [84], but the task of therapists is to tend to today's individuals. As we discover more about the complex neural circuitry subserving repetitive behaviors, reward systems, and social cognition, there are good reasons to believe our treatments will become more sophisticated and specific. Psychopharmacology is also moving to design medications that target more specific populations of receptor and brain functions. This is likely to produce medicines that have fewer side effects, are more effective, and are more symptom-specific.

Pharmacotherapy is not the ultimate treatment for ASPERGERS but it has a definite place. Medication can be a critical element in a comprehensive treatment plan. There is a wider range of medications with more specific biologic effects than ever before. For individuals with ASPERGERS these newer agents are safer and less disruptive. When paired with therapists who are becoming more skilled at recognizing and managing symptoms, individuals have a greater opportunity to reach their potential and lead pleasurable lives.

My Aspergers Child: Preventing Meltdowns in Aspergers Children


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My child has been rejected by his peers, ridiculed and bullied !!!

Social rejection has devastating effects in many areas of functioning. Because the ASD child tends to internalize how others treat him, rejection damages self-esteem and often causes anxiety and depression. As the child feels worse about himself and becomes more anxious and depressed – he performs worse, socially and intellectually.

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Meltdowns are not a pretty sight. They are somewhat like overblown temper tantrums, but unlike tantrums, meltdowns can last anywhere from ten minutes to over an hour. When it starts, the Asperger's or HFA child is totally out-of-control. When it ends, both you and your child are totally exhausted. But... don’t breathe a sigh of relief yet. At the least provocation, for the remainder of that day -- and sometimes into the next - the meltdown can return in full force.

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Parenting Defiant Teens on the Spectrum

Although Aspergers [high-functioning autism] is at the milder end of the autism spectrum, the challenges parents face when disciplining a teenager on the spectrum are more difficult than they would be with an average teen. Complicated by defiant behavior, the teen is at risk for even greater difficulties on multiple levels – unless the parents’ disciplinary techniques are tailored to their child's special needs.

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Older Teens and Young Adult Children with ASD Still Living At Home

Your older teenager or young “adult child” isn’t sure what to do, and he is asking you for money every few days. How do you cut the purse strings and teach him to be independent? Parents of teens with ASD face many problems that other parents do not. Time is running out for teaching their adolescent how to become an independent adult. As one mother put it, "There's so little time, yet so much left to do."

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Two traits often found in kids with High-Functioning Autism are “mind-blindness” (i.e., the inability to predict the beliefs and intentions of others) and “alexithymia” (i.e., the inability to identify and interpret emotional signals in others). These two traits reduce the youngster’s ability to empathize with peers. As a result, he or she may be perceived by adults and other children as selfish, insensitive and uncaring.

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Become an expert in helping your child cope with his or her “out-of-control” emotions, inability to make and keep friends, stress, anger, thinking errors, and resistance to change.

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My Aspergers Child - Syndicated Content