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Help for Depressed Teens on the Autism Spectrum

"The older my teenage son gets, the more depressed he seems to be. I think something may be going on at school that he is hiding from us (perhaps not getting the acceptance from his 'friends' that he wants to like him - IDK). Any suggestions? Anyone else have a teen with ASD who seems depressed 24/7?"

Teens with Asperger’s (AS) and High-Functioning Autism (HFA) are particularly vulnerable to mental health problems (e.g., depression, anxiety). One study found that 65% of their sample of patients with AS presented with symptoms of a psychiatric disorder. However, the inability of AS and HFA teens to communicate feelings of distress can also mean that it is often very difficult to diagnose depression.

Likewise, because of their impairment in non-verbal expression, they may not appear to be depressed. This can mean that it is not until depression is well developed that it is recognized (e.g., in the form of aggression, alcoholism/drug abuse, increased obsessional behavior, paranoia, refusal to go to school/work/college, refusal to leave home, threatened/attempted/actual suicide, and total withdrawal).

In addition, teens with AS or HFA leaving home and going to college frequently report feelings of depression. As one young man said, "I had to deal with anger, frustration, and depression that I had been keeping inside since high school."

Depression in these young people is often related to a growing awareness of their disorder, a sense of being different from their friends, and an inability to form relationships or take part in social activities successfully. Personal accounts by AS and HFA teens frequently refer to attempts to make friends, but with little success. One teen stated, "I just did not know the rules of what you were and were not supposed to do."

Some of these “special needs” teenagers have even been accused of harassment in their attempts to socialize, which only adds to their depression and anxiety. Rodney, a 19-year-old with AS had this to say: "I did not know how to approach girls and ask them to go out with me. I would just walk up and talk to them, whether they wanted to talk to me or not. Some accused me of harassment, but I thought that was the way everybody did it." The difficulties AS and HFA teens have with personal space can compound this sort of problem (e.g., they may stand too close or too far from the person they are talking to).

==> Discipline for Defiant Aspergers and High-Functioning Autistic Teens

Negative childhood experiences (e.g., peer-rejection, teasing, bullying, etc.) can also result in depression, as can a history of misdiagnosis. Another possibility is that the teenager is biologically predisposed to depression.

The depression in teens on the autism spectrum resembles that of teens without the disorder, although the content may be different. For instance, it may show itself through the AS or HFA teen’s particular preoccupations and obsessions.

If parents believe their autistic teen is suffering from depression, an attempt should be made to assess his or her mental state. Symptoms to look for would include:
  • aggression
  • agitation
  • changes in appetite (e.g., decreased appetite, weight loss, increased cravings for food, weight gain)
  • crying
  • disruptive or risky behavior
  • exaggerated self-blame or self-criticism
  • extreme sensitivity to rejection or failure
  • feelings of sadness
  • feelings of worthlessness
  • fixation on past failures
  • frequent absences from school
  • frequent complaints of unexplained body aches and headaches
  • frequent thoughts of death, dying or suicide
  • frequent visits to the school nurse
  • guilt
  • increased time spent with special interests to the point of addiction (e.g., spending most of the day playing video games)
  • increased/decreased activity
  • insomnia or sleeping too much
  • irritability, frustration or feelings of anger, even over small matters
  • isolation
  • loss of interest in, or conflict with, family and friends
  • loss of interest or pleasure in normal activities
  • neglected appearance (e.g., mismatched clothes and unkempt hair)
  • ongoing sense that life and the future are grim and bleak
  • poor school performance
  • restlessness (e.g., pacing, hand-wringing, an inability to sit still)
  • self-harm (e.g., cutting, burning, or excessive piercing or tattooing)
  • slowed thinking, speaking or body movements
  • the need for excessive reassurance 
  • tiredness and loss of energy
  • trouble thinking, concentrating, making decisions and remembering things
  • use of alcohol or drugs
  • worsening of autistic traits (e.g., increased proportion of echolalia, the reappearance of stimming, etc.)

It can be difficult to tell the difference between depression and the normal ups-and-downs that are just part of adolescence. Talk with your teenager. Try to determine whether he or she seems capable of managing uncomfortable emotions, or if life seems overwhelming. If depression symptoms continue or begin to interfere in his or her daily functioning, talk to a mental health professional trained to work with autistic teens. Your family physician is a good place to start, or your child’s school may recommend someone.

You are your adolescent's best advocate. Here are some important tips parents can use that may help lessen the symptoms of depression in their autistic teens:

1. AS and HFA adolescents may be reluctant to seek support when life seems overwhelming. Encourage your teen to talk to a family member or other trusted adult whenever needed.

2. As long as your teen’s “special interest” (e.g., playing video games) doesn’t interfere with his normal day-to-day functioning (e.g., doing homework, completing chores, taking care of personal hygiene, having a modicum of a social life, etc.), allow him full access to this particular interest. It is most likely a great depression and anxiety reducer.

3. Create an environment where your teen can share concerns while you listen.

4. Do your part to make sure your adolescent eats regular, healthy meals.

5. Education about depression can empower your adolescent and motivate her to stick to a treatment plan.

==> Discipline for Defiant Aspergers and High-Functioning Autistic Teens

6. Encourage your adolescent to carefully choose obligations and commitments, and set reasonable goals. Let him know that it's OK to do less when he feels down.

7. Even if your adolescent is feeling well, make sure she continues to take medications as prescribed.

8. Even light physical activity can help reduce depression symptoms.

9. Help your adolescent plan activities by making lists or using a planner to stay organized.

10. It can benefit you and other family members to learn about your adolescent's depression and understand that it's a treatable condition.

11. Journaling may help improve mood by allowing your adolescent to express and work through pain, anger, fear or other emotions.

12. Make sure your adolescent attends appointments, even if she doesn't feel like going.

13. Many AS and HFA adolescents judge themselves when they aren't able to live up to unrealistic standards (e.g., academically, in athletics, or in appearance). Let your teen know that it's OK not to be perfect.

14. Participation in sports, school activities, or a job can help keep your adolescent focused on positive things, rather than negative feelings or behaviors.

15. Positive relationships can help boost your adolescent's confidence and stay connected with others. Encourage him to avoid relationships with peers whose attitudes or behaviors could make depression worse.

16. Sleeping well is important for all adolescents, especially those with depression. If your adolescent is having trouble sleeping, ask your physician for advice.

17. Talk to your adolescent about the changes you're observing and emphasize your unconditional support.

18. Talking with other AS or HFA adolescents facing similar challenges can help your adolescent cope. Local support groups for depression are available in many communities. Also, support groups for teens with autism spectrum disorders and depression are offered online.

19. Work with your adolescent's therapist to learn what might trigger depression symptoms. Make a plan so that you and your adolescent know what to do if symptoms get worse. Also, ask family members or friends to help watch for warning signs.

20. Your adolescent may feel like alcohol or drugs lessen depression symptoms, but in the long run, they worsen symptoms and make depression harder to treat.

If all efforts to reduce your AS or HFA teen’s depression fail to produce effective results, medication may be a good last resort. However, they do not make an impact on the primary social impairments that underlie autism spectrum disorders. As with any treatment for depression, adjustments may have to be made to find the appropriate drug and dosage for that particular teenager.

Side effects should also be monitored and effort made to ensure that the advantages of treatment outweigh the disadvantages. Also, it is important to identify the cause of the depression, which may necessitate counseling, social skills training, or meeting up with peers with similar interests and values.

==> Discipline for Defiant Aspergers and High-Functioning Autistic Teens

Aspergers Children & Mental Health Issues

Individuals with autism or Aspergers are particularly vulnerable to mental health problems such as anxiety and depression, especially in late adolescence and early adult life (Tantam & Prestwood, 1999). Ghaziuddin et al (1998) found that 65 per cent of their sample of patients with Aspergers presented with symptoms of psychiatric disorder. However, as mentioned by Howlin (1997), "the inability of individuals with autism to communicate feelings of disturbance, anxiety or distress can also mean that it is often very difficult to diagnose depressive or anxiety states, particularly for clinicians who have little knowledge or understanding of developmental disorders". Similarly, because of their impairment in non-verbal expression, they may not appear to be depressed (Tantam, 1991).This can mean that it is not until the illness is well developed that it is recognized, with possible consequences such as total withdrawal; increased obsessional behavior; refusal to leave the home, go to work or college etc.; and threatened, attempted or actual suicide. Aggression, paranoia or alcoholism may also occur.

In treating mental illness in the patient with autism or Aspergers, it is important that the psychiatrist or other health professional has knowledge of the individual with autism being assessed. As Howlin (1997) says, "It is crucial that the physician involved is fully informed about the individuals usual style of communication, both verbal and non-verbal". In particular it is recommended, if possible, that they speak to the parents or care-givers to ensure that the information received is reliable, e.g., any recent changes from the normal pattern of behavior, whilst at the same time respecting the right of the person with autism to be treated as an individual. Wing (1996) asserts that psychiatrists should be aware of autistic spectrum disorders as they appear in adolescents and adults, especially those who are more able, if diagnostic errors are to be avoided. Attwood (1998) also stresses the importance of the psychiatrist being knowledgeable in Aspergers. Tantam and Prestwood (1999), however, state that treatments for anxiety and depression that are also effective for individuals without autism are effective for individuals with autism. They go on to say that practitioners and psychiatrists with no special knowledge of autism or Aspergers can be of considerable assistance in treating these conditions. Typically, however, it is of great advantage if the psychiatrist has experience of autism/Aspergers.

This post will concentrate on mental health in individuals with high-functioning autism or Aspergers although references will be made to autism per se where appropriate. Emphasis will be on depression, anxiety and obsessive compulsive disorder, but it is important to realize that individuals with Aspergers also experience other problems, such as impulsive behavior and mood swings. To date there has been little research in this area but, as Carpenter (2001) has found, these can sometimes be incapacitating. Treatment can include conventional mood stabilizing drugs, but helping the person to improve their self-awareness is also important.


Depression is common in individuals with Aspergers with about 1 in 15 individuals with Aspergers experiencing such symptoms (Tantam, 1991). Individuals with Aspergers leaving home and going to college frequently report feelings of depression as demonstrated by the personal accounts that can be found at As one young person says, "I also had to deal with anger, frustration, and depression that I had been keeping inside since high school". A study by Kim et al (2000) also found depression to be more common in children aged 10-12 years with high-functioning autism/Aspergers than in the general population of children of the same age.

Depression in individuals with Aspergers may be related to a growing awareness of their disability or a sense of being different from their peer group and/or an inability to form relationships or take part in social activities successfully. Personal accounts by young individuals with Aspergers frequently refer to attempts to make friends but "I just did not know the rules of what you were or were not supposed to do" Indeed, some individuals have even been accused of harassment in their attempts to socialize, something that can only add to their depression and anxiety; "I also did not know how to approach girls and ask them to go out with me. I would just walk up and talk to them, whether they wanted to talk to me or not. Some accused me of harassment, but I thought that was the way everybody did that."

The difficulties individuals with Aspergers have with personal space can compound this sort of problem. For example, they may stand too close or too far from the person to whom they are speaking.

Other precipitating factors are also seen in many individuals without autism who are depressed and include loneliness, bereavement or other form of loss, sexual frustration, a constant feeling of failure, extreme anxiety levels etc.

Childhood experiences such as bullying or abuse may also result in depression, as can a history of misdiagnosis. Another possibility is that the person is biologically predisposed to depression (Attwood, 1998). However, there are, of course, many other factors that may trigger the depression and this list should not be taken as exhaustive.

Tantam and Prestwood (1999) describe the depression of someone with Aspergers as taking the same form as in individuals without the condition, although the content of the illness may be different. For example, the depression might show itself through an individual’s particular preoccupations and obsessions and care must be taken to ensure that the depression is not diagnosed as schizophrenia or some other psychotic disorder or just put down to autism. It is important to assess the individual’s depression in the context of their autism, i.e. their social disabilities, and any gradual or sudden changes in behavior, sleep patterns, anger or withdrawal should always be taken seriously.

Symptoms of depression can be psychological (poor concentration/memory, thoughts of death or suicide, tearfulness); physical (slowing down or agitation, tiredness/lack of energy, sleep problems, disturbed appetite (weight loss or gain)); or affects of mood and motivation (e.g., low mood, loss of interest or pleasure, hopelessness, helplessness, worthlessness, withdrawal or bizarre beliefs etc.) Individuals with depression can also experience periods of mania.

Lainhart and Folstein (1994) cite three approaches that need to be made in diagnosing depression in a person with autism. The first concerns a deterioration in cognition, language, behavior or activity. The complaint is rarely couched in terms of mood. Secondly, it is important to take the patients history to establish their baseline, patterns of activity and interests. It is this pattern with which the presenting patterns can be compared. Thirdly, an attempt should be made to assess the patient’s mental state, both directly and through the parent or care-giver, if present. Examples would include reports of crying, difficulties in separating from their parent/care-giver for an interview, increased/decreased activity, agitation or aggression. There may be evidence of new or increased self-injury or worsening autistic features, such as increased proportion of echolalia or the reappearance of hand-flapping.

Attwood (1998) also refers to the inability that some individuals with Aspergers have in expressing appropriate and subtle emotions. They may, for example, laugh or giggle in circumstances where other individuals would show embarrassment, discomfort, pain or sadness. He stresses that this unusual reaction, for example after a bereavement, does not mean the person is being callous or is mentally ill. They need understanding and tolerance of their idiosyncratic way of expressing their grief.

In treating depression, medications used in general practice may be prescribed (Carpenter, 1999). It is important to realize, however, that such agents do not make an impact on the primary social impairments that underlie autism. See Gringras (2000) for a discussion on the use of psychopharmacological prescribing for children with autism or Santosh and Baird (1999) for a analysis of psycho pharmacotherapy in children and adults with intellectual disability (including autism). As with any treatment for depression, adjustments may have to be made to find the appropriate drug and dosage for that particular person. Side effects should also be monitored and effort made to ensure the benefits of the treatment outweigh the penalties (Carpenter, 1999). It is also important to identify the cause for the depression and this may involve counseling (see below), social skills training, or meeting up with individuals with similar interests and values.


Anxiety is a common problem in individuals with autism and Aspergers. Grandin (2000) writes that, at puberty, fear was her main emotion. Any change in her school schedule caused intense anxiety and the fear of a panic attack. Anxiety attacks started shortly after her first menstrual period. Muris et al (1998) found that 84.1% of children with pervasive developmental disorder met the full criteria of at least one anxiety disorder (phobia, panic disorder, separation anxiety disorder, avoidant disorder, overanxious disorder, and obsessive compulsive disorder). This does not necessarily go away as the child grows older. Attwood (1998) states that many young adults with Aspergers report intense feelings of anxiety, an anxiety that may reach a level where treatment is required. For some individuals, it is the treatment of their anxiety disorder that leads to a diagnosis of Aspergers.

Individuals with Aspergers are particularly prone to anxiety disorders as a consequence of the social demands made upon them. As Attwood (1998) explains, any social contact can generate anxiety as to how to start, maintain and end the activity and conversation. Changes to daily routine can exacerbate the anxiety, as can certain sensory experiences.

One way of coping with their anxiety levels is for persons with Aspergers to retreat into their particular interest. Their level of preoccupation can be used a measure of their degree of anxiety. The more anxious the person, the more intense the interest (Attwood, 1998). Anxiety can also increase the rigidity in thought processes and insistence upon routines. Thus, the more anxious the person, the greater the expression of Aspergers. When happy and relaxed, it may not be anything like as apparent.

One potentially good way of managing anxiety is to use behavioral techniques. For children, this may involve teachers or parents looking out for recognized symptoms, such as rocking or hand-flapping, as an indication that the child is anxious. Adults and older children can be taught to recognize these symptoms themselves, although some might need prompting. Specific events may also be known to trigger anxiety e.g., a stranger entering the room. When certain events (internal or external) are recognized as a sign of imminent or increasing anxiety, action can be taken for example, relaxation, distraction or physical activity.

The choice of relaxation method depends very much on the individual and many of the relaxation products available commercially can be adapted for use for individuals with autism/Aspergers. Young children may respond to watching their favorite video. Older children and adults may prefer to listen to calming music. There is much music on the market, both from specialist outfits and regular music stores that is written specifically to bring about a feeling of tranquility. It is important the person does not have social demands, however slight, made upon them if they are to benefit. It is also important that they have access to a quiet room. Other techniques include massage (this should be administered carefully to avoid sensory defensiveness), aromatherapy, deep breathing and using positive thoughts. Howlin (1997) suggests the use of photographs, postcards or pictures of a pleasant or familiar scene. These need to be small enough to be carried about and should be laminated in order to protect them. Howlin also stresses the need to practice whichever method of relaxation is chosen at frequent and regular intervals in order for it to be of any practical use when anxieties actually arise.

An alternative option, particularly if the person is very agitated, is to undertake a physical activity (Attwood, 1998). Activities may include using the swing or trampoline, going for a long walk perhaps with the dog, or doing physical chores around the home.

Drug treatment may be effective for anxiety. Individuals may respond to buspirone, propranilol or clonazepam (Santosh and Baird, 1999) although Carpenter (2001) finds St. Johns Wort, benzodiazepines and selective serotonin reuptake inhibitors (SSRI) antidepressants to be more effective. As with all drug treatments it may take time to find the correct drug and dosage for any particular person. Such treatment must only be conducted through a qualified medical practitioner.

Whatever method is chosen to reduce anxiety, it is crucial to identify the cause of the anxiety. This should be done by careful monitoring of the precedents to an increase in anxiety and the source of the anxiety tackled.

Obsessive compulsive disorder—

Obsessive compulsive disorder (OCD) is described as a condition characterized by recurring, obsessive thoughts (obsessions) or compulsive actions (compulsions) (Thomsen, 1999). Thomsen goes on to say that obsessive thoughts are ideas, pictures of thoughts or impulses, which repeatedly enter the mind, whereas compulsive actions and rituals are behaviors which are repeated over and over again.

Baron-Cohen (1989) argues that the stereotypic obsessive action seen in children with autism differs from the child with OCD. As Thomsen (1999) explains, the child with autism does not have the ability to put things into perspective. Although terminology implies that certain behaviors in autism are similar to those seen in OCD, these behaviors fail to meet the definition of either obsessions or compulsions. They are not invasive, undesired or annoying, a prerequisite for a diagnosis of OCD. The reason for this is that individuals with (severe) autism are unable to contemplate or talk about their own mental states. However, OCD does appear often to coincide with Aspergers, although there is very little literature examining the relationship between the two (Thomsen, 1999).

Szatmari et al (1989) studied a group of 24 children. He discovered that 8% of the children with Aspergers and 10% of the children with high-functioning autism were diagnosed with OCD. This compared to 5 per cent of the control group of children without autism but with social problems. Thomsen el at (1994) found that in the children he studied, the OCD continued into adulthood.

Individuals with Aspergers can sometimes respond to conventional behavioral treatment to help reduce the symptoms of OCD. However, as with anyone, this will only be effective if the person wants to stop their obsessions. An alternative is use medication to reduce the anxiety around the obsessions, thus enabling the person to tolerate the frustration of not carrying out their obsession (Carpenter, 2001).


There is no evidence that individuals with autistic conditions are any more likely than anyone else to develop schizophrenia (Wing, 1996).

It is also important to realize that individuals have been diagnosed as having schizophrenia when, in fact, they have Aspergers. This is because their odd behavior or speech pattern, or the persons strange accounts or interpretations of life, are seen as a sign of mental illness, such as schizophrenia. Obsessional thoughts can become quite bizarre during mood swings and these can be seen as evidence of schizophrenia rather than the mood disorder that actually are. However, should someone with Aspergers experience hallucinations or delusions that they find distressing, conventional antipsychotic medications can be prescribed? However, it is recommended that only the newer atypical antipsychotics are used, as individuals with Aspergers often have mild movement disorders (Carpenter, 2001). Cognitive behavior therapy and other psychological management methods may be effective.

Psychological Treatments—

A primary psychological treatment for mood disorders is cognitive behavioral therapy as it is effective in changing the way a person thinks and responds to feelings such as anxiety, sadness and anger, addressing any deficits and distortions in thinking (Attwood, 1999). Hare and Paine (1997) list ways in which the therapy can be adapted for use with individuals with Aspergers: having a clear structure e.g., protocols of turn-taking; adapting the length of sessions therapy might have to be very brief e.g., 10-15 minutes long; the therapy must be non-interpretative; the therapy must not be anxiety provoking as any arousal of emotion during therapy may be very counterproductive; group therapy should not be used. It is also important that the therapist has a working knowledge and understanding of Aspergers in a counseling setting i.e., the difficulty individuals have dealing things emotionally, finding it best to deal with things intellectually. The therapist and client can work towards explicit operational goals, the focus being on concrete and specific symptoms. Attwood (1999) gives a succinct overview of the components of the counseling process. Hare and Paine (1997) stress that such therapy is not a treatment or even an amelioration of the characteristics of Aspergers itself. It merely opens the psychotherapeutic door for individuals with such a diagnosis.


Catatonia is a complex disorder covering a range of abnormalities of posture, movement, speech and behavior associated with over- as well as under-activity (Rogers, 1992; Bush et al, 1996; Lishman, 1998).

There is increasing research and clinical evidence that some individuals with autism spectrum disorders, including Aspergers, develop a complication characterized by catatonic and Parkinsonian features (Wing and Shah, 2000; Shah and Wing, 2001; Realmuto and August, 1991).

In individuals with autistic spectrum disorders, catatonia is shown by the onset of any of the following features:

a. difficulty in initiating completing and inhibiting actions
b. increased passivity and apparent lack of motivation
c. increased reliance on physical or verbal prompting by others
d. increased slowness affecting movements and/or verbal responses

Other manifestations and associated behaviors include Parkinsonian features including freezing, excitement and agitation, and a marked increase in repetitive and ritualistic behavior.

Behavioral and functional deterioration in adolescence is common among individuals with autistic spectrum disorders (Gillberg and Steffenburg, 1987). When there is deterioration or an onset of new behaviors, it is important to consider the possibility of catatonia as an underlying cause. Early recognition of problems and accurate diagnosis are important as it is easiest to manage and reverse the condition in the early stages. The condition of catatonia is distressing for the individual concerned and likely to exacerbate the difficulties with voluntary movement and cause additional behavioral disturbances.

There is little information on the cause or effective treatment of catatonia. In a study of referrals to Elliot House who had autistic spectrum disorders, it was found that 17% of all those aged 15 and over, when seen, had catatonic and Parkinsonian features of sufficient degree to severely limit their mobility, use of speech and carrying out daily activities. It was more common in those with mild or severe learning disabilities (mental retardation), but did occur in some who were high functioning. The development of catatonia, in some cases, seemed to relate to stresses arising from inappropriate environments and methods of care and management. The majority of the cases had also been on various psychotropic drugs.

There is very little evidence about effective treatment and management of catatonia. No medical treatment was found to help those seen at Elliot House (Wing and Shah, 2000). There are isolated reports of individuals treated with anti-depressive medication and electro-convulsive therapy (ECT) (Realmuto and August, 1991; Zaw et al, 1999).

Given the scarcity of information in the literature and possible adverse side effects of medical treatments, it is important to recognize and diagnose catatonia as early as possible and apply environmental, cognitive and behavioral methods of the management of symptoms and underlying causes. Detailed psychological assessment of the individuals, their environment, lifestyle, circumstances, pattern of deterioration and catatonia are needed to design an individual program of management. General management methods on which to base an individual treatment program are discussed in Shah and Wing (2001).


Individuals with Aspergers can experience a variety of mental health problems, notably anxiety and depression, but also impulsiveness and mood swings. They may be misdiagnosed as having a psychotic disorder and it is therefore important psychiatrists treating them are knowledgeable about autism and Aspergers. Conventional drug treatment can be used to treat depression, anxiety and other disorders. Behavioral treatments and therapies can also be effective. However, any treatment must be careful tailored to suit an individual and overseen by a qualified practitioner. However, any psychotropic medicine should be used with extreme caution and strictly monitored with individuals with autism due to their susceptibility to movement disorders, including catatonia.

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


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• Tantam D. and Prestwood S. (1999) A mind of one's own: a guide to the special difficulties and needs of the more able person with autism or Asperger syndrome.
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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…

Overcoming the "EQ Deficit": Help for People with Aspergers and High-Functioning Autism

While much of what I'm about to talk about applies to both men and women, this post is going to lean more toward addressing the male-version of Aspergers and High-Functioning Autism...

Men with Aspergers and High Functioning Autism suffer from a phenomenon called “mind-blindness,” which is a cognitive condition where the person is unable to attribute mental states to self and others. As a result of this condition, he is often unaware of others' mental states and has difficulty attributing beliefs and desires to others.

Lacking in this ability to develop a mental awareness of what is in the mind of his partner, the Aspergers man is often viewed as emotionally detached.

"Emotional intelligence" is in many ways the opposite of mind-blindness. Emotional intelligence (EQ) matters just as much as intellectual ability (IQ) when it comes to happiness and success in life. Emotional intelligence helps one build stronger relationships, succeed at work, and achieve career and personal goals.

So the “fix” (so to speak) for the Aspergers man would be to replace mind-blindness with emotional intelligence. But is this even possible? The answer is: it depends.

If the man is willing to seek treatment from a therapist (preferably one who specializes in Autism Spectrum Disorders), then chances are he will successfully work around his weaknesses and capitalize on his strengths. On the other hand, if the man refuses to acknowledge his mind-blindness issue (which is easy to do since a blind mind will have trouble seeing itself), then he will likely suffer the negative consequences associated with being out of touch -- and out of step -- with the world around him. Like a bicyclist with two flat tires, the Aspergers man’s progress will be slow and shaky.

==> Living With Aspergers: Help for Couples

Emotional intelligence is:
  • the ability to appreciate complicated relationships among different emotions
  • the ability to comprehend emotion language
  • the ability to detect and decipher emotions in faces, pictures, voices, and cultural artifacts, including the ability to identify one's own emotions
  • the ability to harness emotions to facilitate various cognitive activities (e.g., thinking and problem solving)
  • the ability to identify, assess, and control the emotions of oneself, of others, and of groups

Perceiving emotions represents a basic aspect of emotional intelligence, as it makes all other processing of emotional information possible. The emotionally intelligent person can capitalize fully upon his changing moods in order to best fit the task at hand. Understanding emotions encompasses the ability to be sensitive to slight variations between emotions, and the ability to recognize and describe how emotions evolve over time. The emotionally intelligent person can harness emotions, even negative ones, and manage them to achieve intended goals.

Emotional intelligence consists of four attributes:

1. Relationship management: Knowing how to develop and maintain good relationships, communicate clearly, inspire and influence others, work well in a team, and manage conflict.

2. Self-awareness: Recognizing one’s emotions and how they affect one’s thoughts and behavior, knowing one’s strengths and weaknesses, and having self-confidence.

3. Self-management: Being able to control impulsive feelings and behaviors, managing emotions in healthy ways, taking initiative, following through on commitments, and adapting to changing circumstances.

4. Social awareness: Understanding the emotions, needs, and concerns of other people, picking up on emotional cues, feeling comfortable socially, and recognizing the power dynamics in a group or organization.

The first step to improving emotional intelligence is to learn how to relieve stress. Uncontrolled stress impacts the Aspergers man’s mental health, making him vulnerable to anxiety and depression. If he is unable to understand and manage his emotions, he will be open to mood swings, which makes it very difficult for him to form strong relationships, and can leave him feeling lonely and isolated.

Emotional intelligence can help him navigate the social complexities of the workplace, lead and motivate others, and excel in his career. In fact, when it comes to gauging job candidates, many companies now view emotional intelligence as being as important as technical ability and require EQ testing before hiring.

By understanding his emotions and how to control them, the Aspergers man is better able to express how he feels – and understands how others are feeling. This allows him to communicate more effectively and forge stronger relationships, both at work and in his personal life.

Emotional intelligence consists of five key skills:
  1. The ability to connect with others through nonverbal communication
  2. The ability to quickly reduce stress
  3. The ability to recognize and manage one’s emotions
  4. The ability to resolve conflicts positively and with confidence
  5. The ability to use humor and play to deal with challenges

These five skills of emotional intelligence can be learned, but there is a difference between learning about emotional intelligence and applying that knowledge to one's life. Just because the Aspergers man knows he “should” do something doesn’t mean he will – especially if he becomes overwhelmed by stress, which can hijack his best intentions.

In order to permanently change behavior in ways that stand up under pressure, he will need to learn how to take advantage of the powerful emotional parts of his brain that remain active and accessible even in times of stress. This means that he can’t simply read about emotional intelligence in order to master it. Rather, he has to experience and practice the skills in his everyday life.

==> Living With Aspergers: Help for Couples

EQ Skill #1: Paying Attention to Nonverbal Communication—

Often, “what” somebody says is less important than “how” he or she says it or the other nonverbal signals that are sent out (e.g., the gestures a person makes, the way he sits, how fast or how loud he talks, how close he stands to others, how much eye contact he makes, etc). In order to hold the attention of others and build connection and trust, the Aspergers man needs to be aware of – and in control of – this body language. He also needs to be able to accurately read and respond to the nonverbal cues that other people send.

Messages don’t stop when someone stops speaking. Even when a person is silent, he or she is still communicating nonverbally. The Aspergers man needs to think about what he is transmitting as well, and if what he says matches what he feels. Nonverbal messages can produce a sense of interest, trust, excitement, and desire for connection – or they can generate fear, confusion, distrust, and disinterest.

Tips for improving nonverbal communication:

Successful nonverbal communication depends on one’s ability to manage stress, recognize one’s own emotions, and understand the signals one is sending and receiving. When communicating, the Aspergers man needs to:
  • Pay attention to the nonverbal cues he is sending and receiving (e.g., facial expression, tone of voice, posture and gestures, touch, timing and pace of the conversation).
  • Make eye contact, which will communicate interest and maintain the flow of a conversation, and help gauge the other person’s response.
  • Focus on the other person. If the Aspergers man is planning what he is going to say next, daydreaming, or thinking about something else, he is almost certain to miss nonverbal cues and other subtleties in the conversation.

EQ Skill #2: Quickly Reducing Stress—

High levels of stress can overwhelm the mind and body, getting in the way of one’s ability to accurately “read” a situation, to hear what someone else is saying, to be aware of one’s own feelings and needs, and to communicate clearly. Being able to quickly calm down and diffuse stress helps one stay balanced, focused, and in control – no matter what challenges are faced or how stressful a situation becomes.

Tips for reducing stress:
  • The best way to reduce stress quickly is by engaging one or more of the senses: sight, sound, smell, taste, and touch. Each person responds differently to sensory input, so the Aspergers man needs to find things that are soothing and/or energizing to him. For example, if he is a visual person, he can relieve stress by surrounding himself with uplifting images. If he responds more to sound, he may find a wind chime, a favorite piece of music, or the sound of a water fountain helps to quickly reduce his stress levels.
  • Everyone reacts differently to stress. If the Aspergers man tends to become angry or agitated under stress, he will respond best to stress relief activities that quiet him down. If he tends to become depressed or withdrawn, he will respond best to stress relief activities that are stimulating. If he tends to freeze (speeding up in some ways while slowing down in others), he needs stress relief activities that provide both comfort and stimulation.
  • Recognize what stress feels like. How does your body feel when you’re stressed? Are your muscles or stomach tight or sore? Are your hands clenched? Is your breath shallow? Being aware of one’s physical response to stress will help regulate tension when it occurs.

EQ Skill #3: Managing Emotions—

Being able to connect to one’s emotions (i.e., having a moment-to-moment awareness of your emotions and how they influence your thoughts and actions) is the key to understanding self and others. Many Aspergers men are disconnected from their emotions – especially strong core emotions like sadness, fear and joy. But although we can distort, deny, or numb our feelings, we can’t eliminate them. They’re still there, whether we’re aware of them or not. Unfortunately, without emotional awareness, we are unable to fully understand our own motivations and needs, or to communicate effectively with others.

How in touch are you with your emotions?
  • Are your emotions accompanied by physical sensations that you experience in certain places of your body (e.g., lower back, stomach, chest, etc.)?
  • Can you experience intense feelings that are strong enough to capture both your attention and that of others?
  • Do your emotions factor into your decision making?
  • Do you pay attention to your emotions?
  • Do you experience feelings that flow (i.e., encountering one emotion after another as your experiences change from moment to moment)?
  • Do you experience discrete feelings and emotions (e.g., anger, sadness, fear, joy), each of which is evident in subtle facial expressions?

If any of these experiences are foreign to you, then your emotions may be turned down or off. In order to be emotionally healthy and emotionally intelligent, you must reconnect to your core emotions, accept them, and become comfortable with them.

EQ Skill #4: Resolving Conflicts Positively--

Disagreements and misunderstandings are to be expected in relationships. Two people can’t possibly have the same needs, beliefs, and expectations at all times. However, that is not a bad thing. Resolving conflict in healthy, constructive ways can strengthen trust between people. When conflict isn’t perceived as threatening or punishing, it fosters freedom, creativity, and safety in relationships.

Tips for resolving conflict:
  • Choose your arguments. Arguments take time and energy, especially if you want to resolve them in a positive way. Consider what is worth arguing about and what is not.
  • End conflicts that can't be resolved. It takes two people to keep an argument going. You can choose to disengage from a conflict, even if you still disagree.
  • Forgive. Other people’s hurtful behavior is in the past. To resolve conflict, you need to give up the urge to punish or seek revenge.
  • Stay focused in the present. When you are not holding on to old hurts and resentments, you can recognize the reality of a current situation and view it as a new opportunity for resolving old feelings about conflicts.

EQ Skill #5: Using Humor and Play to Deal with Challenges--

Humor, laughter, and play are natural solutions to life’s problems. They lighten burdens and help keep things in perspective. A good hearty laugh reduces stress, elevates mood, and brings the nervous system back into balance. It’s never too late to develop and embrace your playful, humorous side. The more you joke, play, and laugh – the easier it becomes. Playful communication broadens emotional intelligence and helps the individual:
  • Become more creative. When we loosen up, we free ourselves of rigid ways of thinking and being, allowing us to get creative and see things in new ways.
  • Simultaneously relax and become more energized. Playful communication relieves fatigue and relaxes the body, which allows the person to recharge and accomplish more.
  • Smooth over differences. Using gentle humor often helps us say things that might be otherwise difficult to express without creating an argument.
  • Take hardships in stride. By allowing us to view our frustrations and disappointments from new perspectives, laughter and play enable us to survive annoyances, hard times, and setbacks.

In order to develop playful communication, the Aspergers man needs to:
  • find enjoyable activities that loosen him up and help him embrace his playful nature
  • play with animals, babies, young children, and outgoing people who appreciate playful banter
  • set aside regular, quality playtime

In a nutshell, the Aspergers man can begin to replace mind-blindness with emotional intelligence – with the assistance of a qualified professional – by doing the following:
  1. Acknowledging his negative feelings, looking for their source, and coming up with a way to solve the underlying problem 
  2. Avoiding people who invalidate him or don't respect his feelings 
  3. Being honest with himself
  4. Developing constructive coping skills for specific moods
  5. Examining his feelings rather than the actions or motives of other people
  6. Getting up and moving when he is feeling down
  7. Learning to relax when his emotions are running high
  8. Listening twice as much as he speaks
  9. Looking for the humor or life lesson in a negative situation
  10. Paying attention to non-verbal communication (e.g., watch faces, listen to tone of voice, take note of body language)
  11. Showing respect by respecting other people's feelings
  12. Taking responsibility for his own emotions and happiness

Most of you have heard that “there is no cure for Aspergers Syndrome.” And technically, that’s correct. But, emotional intelligence can be taught. And some people with Aspergers – both male and female – who have received quality treatment from a qualified professional have lost their Aspergers diagnosis after a few years of intensive therapy. That is, after being re-tested, they did not meet the criteria for Aspergers Syndrome any longer. The same can be true for you. So, what are you waiting for?

==> Skype Counseling for Struggling Couples Affected by Asperger's and HFA 

==> Living With Aspergers: Help for Couples

Behavioral Interventions for Aspergers Clients

The diagnostic criteria for Aspergers as outlined in DSM IV TR [1] includes in “criterion A” a description of some of the qualitative impairments in social interaction. The list of characteristics includes:

• Failure to develop peer relationships appropriate to developmental level
• Lack of social or emotional reciprocity
• Marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction

Clinical experience and autobiographies confirm that such people have considerable difficulty with the understanding and expression of nonverbal behaviors and social reciprocity. Regarding peer relationships, when we observe and assess the social play and friendship skills of kids with Aspergers, we recognize a delay in the conceptualization of friendship. The youngster may have an overall intellectual ability within the normal range, but their understanding of friendship skills resembles a much younger youngster. It is not simply a matter of developmental delay, however. There are aspects that are conspicuously unusual for any of the developmental stages [2]. At present, we can only speculate what the consequences may be for a youngster who fails to develop peer relationships that are appropriate for their developmental level, but inevitably there will be lasting effects in several aspects of cognitive, social, and emotional development. When playing in a group, kids learn the value of alternative perspectives and solutions in problem solving. They acquire increasingly sophisticated and successful strategies to resolve conflict and the interpersonal and team skills valued by employers.

Many of the characteristics valued in a close friend become the attributes associated with lasting personal relationships. Clinical experience also suggests that the social isolation of kids with Aspergers in the school playground can increase the youngster's vulnerability to being teased and bullied and a lack of close friends also can be a contributory factor in the development of childhood depression. A delay in social knowledge also can lead to anxiety in social situations that may develop into social phobia, school refusal, and agoraphobia. Thus, we achieve cognitive and affective growth within our circle of friends. It is inevitable that impaired peer relationship skills can result in significant psychopathology.

The DSM IV description of Aspergers includes reference to an association between Aspergers and several secondary mental disorders, including depressive and anxiety disorders. The presence of a secondary mood disorder unavoidably adds to the already considerable difficulty coping with everyday life for people with Aspergers. We are, however, only just beginning to develop effective remedial programs to improve peer relationships, emotional reciprocity, nonverbal communication, and mood [3]. This article examines two frameworks for behavioral interventions, namely the developmental stages in friendship skills, with remedial strategies for each stage, and modifications to Cognitive Behavior Therapy, to accommodate the unusual profile of cognitive skills of people with Aspergers.

The developmental stages in the concept of friendship –

Before considering programs to improve the general understanding of the concept of friendship and specific friendship skills, it is important to determine the youngster's stage of friendship development [4], [5]. Unfortunately, there are no standardized tests to measure friendship skills as there are for language skills, motor development, and cognitive abilities. Assessments can be made by analysis of the individual's answers to specific questions, however, and observation of their interactions with peers. The questions can include:

• How do you make friends?
• What do friends do?
• What makes a good friend?
• What makes you a good friend?
• Who are your friends at school?
• Why do we have friends?
• Why is (name) your friend?

Before the age of 3 years, kids interact with members of their family, but their concept of peers is often one of rivalry for possessions rather than friendship. If another youngster comes to their house, they may hide their favorite toys or become agitated if they have to take turns and share. There may be some parallel play, imitation, and intellectual curiosity in observing and copying what other kids are doing, as it may be fun and may impress a parent, but the youngster does not have the interpersonal insights and skills we associate with the reciprocal elements of being a friend. The first indicators of friendship occur at approximately the age of 3 years.

Stage 1: 3–6 years –

From the ages of 3 to 6 years there is a functional and egocentric conceptualization of friendship. When asked why a particular youngster is their friend, a youngster's reply usually is based on proximity (lives next door, sits at same table) or possessions (they have toys that the youngster admires or wants to use). Toys and play activities are the focus of friendship and the youngster gradually moves from engaging primarily in parallel play to recognizing that some games and activities cannot happen unless there is an element of sharing and turn taking. Cooperation skills are limited, however; the main characteristic of this age group is one-way and egocentric (he helps me or she likes me). Conflict is typified by demands, ultimatums, and physical force.

If a youngster from 3–4 years is asked what they did today, they tend to describe what they played with, whereas after the age of approximately 4 years they start to include who they played with. Social play gradually becomes more than just the construction and completion of the activity. Friendships are transitory, however, and the youngster has their own agenda of what to do and how to do it.

Remedial programs for stage 1 –

If one uses behavioral or learning theory terms, kids with Aspergers need to identify the relevant stimuli or cues and appropriate responses [6]. For example, in stage one, kids learn the cues to join a group of kids without causing disruption or annoyance. An activity can be to brainstorm with the youngster the entry cues, such as someone giving a welcoming gesture or facial expression, a pause in the activity or conversation, or an appropriate act such as returning the ball. These ‘acts’ of the social ‘play’ can be ‘rehearsed’ by identifying a few kids who are keen to help the friendship skills of the youngster with Aspergers. They can be informed that he or she is learning the cues and rules for joining in their play.

The youngster with Aspergers will be trying to join in (under the guidance of an adult) and to recognize the relevant cue. When this occurs they can help the youngster with Aspergers identify the cue and intellectually process the response by momentarily freezing their actions, thereby isolating the cue. This gives the youngster time to identify the cue (which can be pointed out by the adult) and to decide what to say or do in response, perhaps with a prompt and encouragement from the adult. Their response and the entry are then successfully completed. The procedure of identifying the cues in contrived settings and practicing appropriate responses (rehearsal) can be used for many friendship skills. The adult acts as a mentor or stage director, giving guidance and encouragement. It is important that the attitude from adults is one of discovery and guidance so that the youngster with Aspergers does not perceive the activity as being critical of their ability and a public recognition of their social errors.

Young kids with Aspergers may demonstrate more mature interaction skills with adults than with their peers. It is important that adults, especially moms and dads, observe the natural play of the youngster's peers, noting the games, equipment, rules, and language. They can then practice the same play with the youngster but with an adult ‘acting’ as their peer. This includes using what the author describes as ‘youngster speak,’ namely the speech of kids rather than adults. It is important that the adult role-plays examples of being a good friend, and also situations that illustrate unfriendly acts, such as disagreements and teasing. Appropriate and inappropriate responses can be enacted to provide the youngster with a range of responses.

Moms and dads can borrow or buy duplicate equipment that is used at school or is popular with their peers. Once the youngster has rehearsed with an adult who can easily modify the pace of play and amount of instruction, they can have a ‘dress rehearsal’ with another youngster, perhaps an older sibling or mature youngster in their class who can act as a friend to provide further practice before the skills are used openly with their peer group. Another strategy to learn the relevant cues, thoughts, and behavioral script is to write Social Stories that can be used by the youngster to improve their social understanding and abilities [7].

Stage 2: 6–9 years—

At this stage the youngster starts to recognize that they need a friend to play certain games and that that friend must like those games. They become more aware of the thoughts and feelings of their peers and how their actions and comments can hurt, physically and emotionally. The youngster is prepared to sometimes inhibit their intentions and to accept and incorporate the influences, preferences, and goals of their friends in their play. There is less of a dominant/submissive quality, and helping, especially mutual help, is one of the indices of friendship at this stage. A friend may be chosen because of similar interests, and aspects of their friend's character are recognized (he's fun to be with); yet when asked who is their friend, they may nominate someone who is known to be popular rather than a mutually recognized friendship.

The concept of reciprocity (she comes to my party and I go to hers) and the genuine sharing of resources and being fair become increasingly important. When managing conflict, the youngster's view is that the offender must retract the action and a satisfactory resolution is perhaps described as “an eye for an eye.” The concept of responsibility and justice is based on who started the conflict, not what was subsequently done or how it ended. At approximately 8 years of age, the youngster develops the concept of a best friend as not only their first choice for social play, but also as someone who helps in practical terms (he knows how to fix the computer) and in times of emotional stress (she cheers me up when I'm feeling sad).

Remedial programs for stage 2—

In stage 2, kids develop greater cooperation skills when playing with their peers and develop more constructive means of dealing with conflict. It is important that the youngster with Aspergers experiences more cooperative than competitive games. In competitive games there are winners and losers and strict rules. The youngster with Aspergers can require considerable tuition using Social Stories to understand the concepts of being fair and gracious in defeat. Clearly the youngster's recognition of the relevant cues and responses for cooperative play are acknowledged and encouraged.

Specific aspects of cooperative play that need to be recognized, however, are identifying and contributing to the common goal, accepting suggestions rather than being autocratic or indifferent, and giving guidance and encouragement. The youngster acknowledges that when functioning as a cooperative and cohesive group, some activities and goals are easier and quicker to achieve. Role play games can be used to illustrate appropriate and inappropriate actions with some time taken to explain why, in a logical and empathic sense, certain actions are considered friendly or not friendly. The unfriendly actions that are particularly relevant for kids with Aspergers are interruptions, failure to recognize personal body space, inappropriate touch, and coping with mistakes.

During stage 2, there is an increase in social cognition that enables the youngster to benefit from published training programs designed to improve Theory of Mind skills [8]. Programs on Theory of Mind skills also can help the youngster distinguish between accidental and intentional acts. The youngster may consider only the act from their perspective and not consider the cues that would indicate it was not deliberate. Educational programs on emotions also can help the youngster identify the cues that indicate the emotional state of their friend and themselves. The intention is to develop their empathy skills so that they can be recognized as a caring friend.

Finally in stage 2, the author has noted that there can be different coping mechanisms used by females with Aspergers in comparison with males. Females with Aspergers are more likely to be interested observers of the social play of other females and to imitate their play at home using dolls, imaginary friends, and by adopting the persona of a socially able female. This solitary practice of the social play of their peers can be a valuable opportunity to analyze and rehearse friendship skills. Some females with Aspergers can develop a special interest in reading fiction that may be age-appropriate or classic literature. This also provides an insight into thoughts, emotions, and social relationships. It is also noticeable that other females can be more maternal than males and can facilitate the inclusion of a female with Aspergers within an established group of friends. Their social difficulties can be accommodated and guided by peers who value the role of mother or educator. The female with Aspergers also may be popular because she is honest and consistent and less likely to be spiteful.

Stage 3: 9–13 years—

In the third stage, a friend is not simply someone who helps; they are chosen because of special attributes in their abilities and personalities. A friend is someone who genuinely cares and has complimentary attitudes, ideas, and values. There is a strong need to be liked by their peers and a mutual sharing of experiences and thoughts. With such self-disclosure, there is the recognition of being trustworthy and seeking advice not only for practical problems but also for interpersonal issues. There is a need for companionship and greater selectivity and durability in the friendship alliances. At this stage, there is a distinct gender split and peer pressure becomes increasingly important. Peer group acceptance and values become more important than the opinion of moms and dads. Friends also support each other in terms of managing emotions. If the youngster is sad, close friends will cheer them up, or if angry, calm them down to prevent the individual from getting into trouble.

When conflicts occur, friends will use more effective repair mechanisms. They can be less “heated,” with reduced confrontation and more disengagement, admitting making a mistake and recognizing it is not simply a matter of winner and loser. A satisfactory resolution can actually strengthen the relationship. The friend is forgiven and the conflict is put in perspective. These qualities of interpersonal skills that are played out in friendships are the foundation of interpersonal skills for adult relationships.

Remedial programs for stage 3—

In stage 3, there is usually a clear gender preference in the choice of friends. The activities and interests of males, who may be playing team games or sports, may be considered of little value to the male with Aspergers. They also are likely to be less able than their peers in team games and ball skills that may lead to teasing and bullying by males who can be notoriously intolerant of someone who is different. When the male with Aspergers approaches females, they can be more readily included in their activities, and females can be more patient, maternal, and supportive. One of the consequences of being more welcomed by females than by males and spending more time playing with females than males is that the male with Aspergers can imitate the prosody and body language of their female friends. This can result in further isolation and torment from male peers. The youngster needs a balance of same and opposite gender friends, and some social engineering could be necessary to ensure acceptance by both groups.

During stage 3 there is a strong desire for companionship rather than functional play, and the youngster with Aspergers can feel lonely and sad if their attempts at friendship are unsuccessful [9], [10]. They need tuition and guidance, but this may be achieved by discussion with supportive peers and adults. Individual kids who have a natural rapport with a youngster with Aspergers can be guided and encouraged to be a mentor in the classroom, playground, and in social situations. Their advice may be accepted as having greater value than that of moms and dads or a teacher. It is also important to encourage their friends or peers to help them regulate their mood, stepping in and helping the individual calm down if they are becoming agitated or tormented. Friends may need to provide reassurance if the individual is anxious and to cheer them up when sad. The youngster with Aspergers also needs advice and encouragement to be reciprocal with regard to emotional support, and must be taught how to recognize the signs of distress or agitation in their friend and how to respond.

At this stage, the existing remedial programs use strategies to develop teamwork rather than friendship skills. To be attending a program on teamwork skills for sports or employment may be considered more acceptable to the young teenager with Aspergers, who may be sensitive to any suggestion that they need remedial programs to have friends. Another strategy to help the adolescent who is sensitive to being publicly identified as having few friends is to adapt speech and drama classes.

Liane Holliday-Wiley, in her book “Pretending To Be Normal”, describes how she improved her social skills by observation, imitation, and acting [11]. This is an appropriate and effective strategy, especially in stage 3. The individual with Aspergers can learn and practice conversational scripts, self-disclosure, body language, facial expression, and tone of voice for particular situations, and role-play people they know who are socially successful. The adolescent or adult with Aspergers sometimes uses this strategy naturally; however, it is important to ensure that they choose good role models to portray.

Stage 4: 13 years to adult –

In the previous stage there can be a small core of close friends, but in stage 4 the breadth and depth of friendship increases. There can be different friends for different needs, such as comfort, humor, or practical advice. A friend is defined as someone who “accepts me for who I am” or “we think the same way about things.” A friend provides a sense of personal identity and is compatible with one's own personality. An important aspect of the quality of friendship is the ability to accept the self before being able to relate to others at an adult level; otherwise friendships can be manipulated as a means of resolving personal issues. There are less concrete and more abstract definitions of friendship with what may be described as autonomous interdependence. The friendships are less possessive and exclusive and conflict resolved with self-reflection, compromise, and negotiation.

Remedial programs for stage 4—

Because of the developmental delay in the conceptualization of friendship, when the individual with Aspergers reaches stage 4, they have usually left high school and seek friends through work and recreational pursuits. Attempts to change a relationship from colleague or work mate to friend can present some challenges to the young adult with Aspergers. A mentor at work who understands their unusual profile of friendship skills can provide guidance and act as a confidante and advocate. The mentor also can help determine the degree of genuine interest in friendships from the colleague. Sometimes people with Aspergers assume that a friendly act, smile, or gesture has greater implications than was intended. There can be a tendency to develop an intense interest or infatuation with a particular individual. This topic may dominate their time and conversation and can lead to behavior such as stalking.

Conversely, the individual with Aspergers can be desperate to have a friend and may become the recipient of financial, physical, or sexual abuse, through failing to recognize that the other individual's intentions are not honorable. The two-way misinterpretation of signals and intentions can lead to mutual confusion. Relationship counseling can be suggested, but at present counselors often have limited knowledge and experience regarding Aspergers [12]. An interesting development in recent years is older and more mature adults with Aspergers providing guidance and counseling through group counseling sessions organized by adult support groups. These groups are often formed by concerned moms and dads and people with Aspergers who want to meet like-minded people. They meet on a regular basis to discuss topics that range from employment issues to personal relationships.

The Internet has become the modern equivalent of the dance hall in terms of an opportunity for young people to meet. The great advantage of this form of communication to the individual with Aspergers is that they often have a greater eloquence to disclose and express their inner self and feelings through typing rather than conversation. In social gatherings, the individual is expected to be able to listen to and process the other individual's speech (often against a background of other conversations), to immediately reply, and simultaneously analyze nonverbal cues, such as gestures, facial expression, and tone of voice. When using the computer, the individual can concentrate on social exchange using a visual rather than auditory medium.

As in any other situation, the individual with Aspergers may be vulnerable to others taking advantage of their social naivety and desire to have a friend. The individual with Aspergers needs to be taught caution and to not provide personal information until they have discussed the Internet friendship with someone they trust. Genuine and long-lasting friendships can develop over the Internet based on shared experiences, interests, and mutual support. It is an opportunity to meet like-minded people who accept the individual because of their knowledge rather than their social persona. The individual with Aspergers is somewhat egocentric and eccentric but can prove an honest, loyal, and knowledgeable friend.

Mood disorders –

When one considers the diagnostic criteria for Aspergers and the effects of the disorder on the individual's adaptive functioning in a social context, one would expect such people to be vulnerable to the development of secondary mood disorders. The current research indicates that approximately 65% of adolescent patients with Aspergers have an affective disorder that includes anxiety disorders [13], [14], [15], [16], [17], [18] and depression [16]. There is also evidence to suggest an association with delusional disorders [19], paranoia [20], and conduct disorders [21]. We know that comorbid affective disorders in adolescents with Aspergers are the rule rather than the exception, but why should this population be more prone to affective disorders?

Research has been conducted on the family histories of kids with autism and Aspergers and has identified a higher than expected incidence of mood disorders [22], [23], [24], [25]. People with Aspergers could be vulnerable to a genetic predisposition to mood disorders. When one also considers their difficulties with regard to social reasoning, empathy, verbal communication, profile of cognitive skills, and sensory perception, however, they are clearly prone to considerable stress as a result of their attempts at social inclusion. Chronic levels of stress can precipitate a mood disorder. Thus, there may be constitutional and circumstantial factors that explain the higher incidence of affective disorders.

The theoretic models of autism developed within cognitive psychology and research in neuropsychology also provide some explanation as to why such people are prone to secondary mood disorders. The extensive research on Theory of Mind skills confirms that people with Aspergers have considerable difficulty identifying and conceptualizing the thoughts and feelings of other people and themselves [26], [27], [28], [29], [30]. The interpersonal and inner world of emotions seems to be uncharted territory for people with Aspergers.

Research on executive function in subjects with Aspergers suggests characteristics of being disinhibited and impulsive, with a relative lack of insight that affects general functioning [31], [32], [33], [34]. Impaired executive function also can affect the cognitive control of emotions. Clinical experience indicates there is a tendency to react to emotional cues without cognitive reflection. Research with subjects with autism using new neuroimaging technology also has identified structural and functional abnormalities of the amygdala [35], [36], [37], [38], which is known to regulate a range of emotions, including anger, fear, and sadness. Thus, we also have neuroanatomic evidence that suggests there will be problems with the perception and regulation of the emotions.

Managing anxiety, depression, and anger –

When clinicians diagnose a secondary mood disorder, they need to know how to modify standard psychologic treatments to accommodate the unusual cognitive profile of people with Aspergers. As the primary psychologic treatment for mood disorders is cognitive behavior therapy (CBT), this article now examines such modifications based on our knowledge of the disorder and preliminary clinical experience.

CBT has been designed and refined over several decades and has proven to be effective in changing the way an individual thinks about and responds to feelings such as anxiety, sadness, and anger [39], [40]. CBT focuses on aspects of cognitive deficiency in terms of the maturity, complexity, and efficacy of thinking, and cognitive distortion in terms of dysfunctional thinking and incorrect assumptions. Thus, it has direct applicability to patients with Aspergers who are known to have deficits and distortions in thinking.

The therapy has several components, the first being an assessment of the nature and degree of mood disorder using self-report scales and a clinical interview. The subsequent stage is affective education with discussion and exercises on the connection between cognition, affect, and behavior, and the way in which people conceptualize emotions and construe various situations. Subsequent stages are cognitive restructuring, stress management, self-reflection, and a schedule of activities to practice new cognitive skills. Cognitive restructuring corrects distorted conceptualizations and dysfunctional beliefs. The individual is encouraged to establish and examine the evidence for or against their thoughts and build a new perception of specific events. Stress management and cue controlled relaxation programs are used to promote responses incompatible with anxiety or anger. Self-reflection activities help the individual recognize their internal state, monitor and reflect on their thoughts, and construct a new self-image. A graded schedule of activities is also developed to allow the individual to practice new abilities that are monitored by the therapist.

Assessment –

There are several self-rating scales that have been designed for kids and adults with specific mood disorders that can be administered to patients with Aspergers. There are specific modifications that can be used with this clinical group, however, as they may be more able to accurately quantify their response using a numeric or pictorial representation of the gradation in experience and expression of mood. Examples include an emotion “thermometer,” bar graphs, or a “volume” scale. These analogue measures are used to establish a baseline assessment and are incorporated in the affective education component. To minimize word retrieval problems, multiple-choice questions can be used in preference to open-ended, sentence-completion tasks. A pictorial dictionary of feelings also can be used as additional cues for a diary or logbook completed during the therapy by the patient.

The assessment includes the construction of a list of behavioral indicators of mood changes. The indicators can include changes in the characteristics associated with Aspergers, such as an increase in time spent engaged in solitude or their special interest, rigidity, or incoherence in their thought processes, or behavior intended to impose control in their daily lives and over others. This is in addition to conventional indicators such as a panic attack, comments indicating low self worth, and episodes of anger. It is essential to collect information from a wide variety of sources, as kids and adults with Aspergers can display quite different characteristics according to their circumstances. For example, there may be little evidence of a mood disorder at school but clear evidence at home. Moms and dads and educators also can complete a daily mood diary to determine whether there is any cyclical nature to, or specific triggers for, mood changes.

The clinician also needs to assess the coping mechanisms and vocabulary of emotional expression of the individual with Aspergers. Although there are no standardized tests to measure such abilities, some characteristics have been identified by clinical experience. For example, discussion with moms and dads can indicate that the youngster displays affection, but the depth and range of expression is usually limited and immature for their chronologic age. Their reaction to pleasure and pain can be atypical, with idiosyncratic mannerisms that express feeling excited, such as hand flapping, or a stoic response to pain and punishments.

Examples of characteristics that moms and dads may be concerned about are a lack of apparent gratitude or remorse and paradoxic and atypical responses to particular situations. For example, the youngster may giggle when expected to show remorse [41] and be remarkably quick in resolving grief. They also may misinterpret gestures of affection, such as a hug, with the comment that the squeeze was perceived as uncomfortable and not comforting. Their emotional reactions also can be delayed, perhaps with an expression of anger some days or weeks after the event.

Their coping or emotional recovery mechanisms need to be assessed and can include characteristics such as retreating into solitude, increasing time spent engaged in a special interest, reading fantasy literature, and playing computer games. Some people internalize their reaction with self-blame and low self-esteem, whereas others externalize their reaction, becoming critical of others and developing an arrogant and intolerant personality. The former may show signs of depression and anxiety, whereas the latter are often referred for problems with anger management. Different emotions can prevail at particular times of the day, however, for example, being anxious before school and angry when returning home. It is also valuable to assess not only how the youngster repairs their own feelings but also how they repair the feelings of others. Research suggests that people with Aspergers use fewer of the available cues in facial expression and body language to infer emotional states [42].

The clinician needs to assess the individual's ability to identify the cues of emotional states in others and to know when specific words and actions are anticipated, for example, providing gestures and words of affection when a family member or friend is sad or reassurance when they are anxious. Questions can be asked, such as “How would you know when your mother is feeling sad?” and “What would you do if she were crying?” Another area of assessment is their awareness of the impact of their own mood state and associated behavior on the thoughts and feelings of others, namely an assessment of empathy. Unfortunately we do not have any standardized tests to measure empathy; accordingly, most information is obtained from discussion with the individual with Aspergers and their family for examples of a relative lack of empathic response.

Affective education—

Affective education is the next stage in a course of CBT and an essential component for those with Aspergers. The main goal is to learn why we have 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 therapist, but a useful starting point is happiness or pleasure. A scrapbook can be created that illustrates the emotion. For young 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, for example, a photograph of a rare lizard for an individual with a special interest in reptiles. For adults, the book can illustrate the pleasures in their life, with a list based on the song My Favorite Things. The content also can include the sensations that may elicit the feeling, such as aromas, tastes, and textures. The scrapbook can be used as a diary to include compliments, and records of achievement, such as 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 the therapy is conducted in a group, the books can be compared and contrasted. Talking about trains may be an enjoyable experience for one participant but perceived as remarkably boring or dominating for another. Part of the education is to explain that although this topic may create a feeling of well being in the one participant, their attempt to cheer up another individual by talking about trains may not be a successful strategy, perhaps producing a response that they did not expect. One of the interesting aspects that the author has noticed is that individuals with Aspergers tend to achieve enjoyment primarily from knowledge, interests, and solitary pursuits, and less from social experiences, in comparison with other client groups. They are often at their happiest when alone.

The affective education stage includes the therapist describing and the individual discovering the salient 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 include not identifying which cues are relevant or redundant, and misinterpreting cues. The therapist uses a range of games and resources to “spot the message” and explain the multiple meanings; for example, a furrowed brow can mean anger or bewilderment, or may be a sign of aging skin. A loud voice does not automatically mean that an individual 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 therapist can construct a model “thermometer,” “gauge,” or volume control, and can use a range of activities to define the level of expression. For example, they 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 the individual shares the same definition or interpretation of words and gestures and to clarify any semantic confusion. Clinical experience has indicated that some individuals with Aspergers can use extreme statements such as “I am going to kill myself” to express a level of emotion that would be more moderately expressed by another individual. During a program of affective education, the therapist often has to increase the individual'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 such as auditory EMG and GSR machines. The individual and those who know them well can create a list of their physiologic, cognitive, and behavioral cues that indicate their increase in emotional arousal. The degree of expression can be measured using one of the special instruments used in the program, such as the emotion thermometer. One of the aspects of the therapy is to help the individual perceive their “early warning signals” that indicate emotional arousal that may need cognitive control; perhaps, using a metaphor, they can be the warning lights and instruments on a car dashboard.

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. After exploring happiness, the next topic explored would be sadness; feeling relaxed would be explored before a project on feeling anxious. The individual is encouraged to understand that certain thoughts or emotions are “antidotes” to other feelings, for example, some strategies or activities associated with feeling happy may be used to counteract feeling sad.

Some people with Aspergers 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 therapist can use prose in the form of a “conversation” by typing questions and answers on a computer screen or techniques such as comic strip conversations that use figures with speech and thought bubbles [7]. 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 individual and therapist.

Other activities to be considered in affective education are the creation of a photograph album that includes pictures of the individual and family members expressing particular emotions, or video recordings of the individual expressing their feelings in real-life situations. This can be particularly valuable to demonstrate their behavior when expressing anger. Another activity entitled “Guess the message” can include the presentation of specific cues, such as a cough as a warning sign or a raised eyebrow to indicate doubt. It is also important to incorporate the individual's special interest in the program. For example, the author has worked with people whose special interest has been the weather and has suggested that their emotions are expressed as a weather report. There are several kids reading books that have a particular emotion as a theme and self-help books for adolescents with specific mood disorders that can be used as a form of bibliotherapy. We also now have books and computer programs that provide a social and emotional curriculum that includes activities for affective education for kids with Aspergers [43], [44].

Cognitive restructuring –

Cognitive restructuring enables the individual to correct distorted conceptualizations and dysfunctional beliefs. The process involves challenging their current thinking with logical evidence and ensuring the rationalization and cognitive control of their emotions. The first stage is to establish the evidence for a particular belief. People with Aspergers can make false assumptions of their circumstances and the intentions of others. They have a tendency to make a literal interpretation, and a casual comment may be taken out of context or may be taken to the extreme. For example, a young teenage male with Aspergers was once told his voice was breaking. He became extremely anxious that his voice was becoming faulty and decided to consciously alter the pitch of his voice to repair it. The result was an artificial falsetto voice that was incongruous in a young man. A teenage female with Aspergers overheard a conversation at school that implied that a female must be slim to be popular. She then achieved a dramatic weight loss in an attempt to be accepted by her peers.

We are all vulnerable to distorted conceptualizations, but people with Aspergers are less able to put things in perspective, seek clarification, and consider alternative explanations or responses. The therapist encourages the individual to be more flexible in their thinking and to seek clarification, using questions or comments such as “Are you joking?” or “I'm confused about what you just said.” Such comments also can be used when misinterpreting someone's intentions such as, “Did you do that deliberately?” and to rescue the situation after the patient has made an inappropriate response with a comment such as, “I'm sorry I offended you,” or “Oh dear, what should I have done?”

To explain a new perspective or to correct errors or assumptions, comic strip conversations can help the individual determine the thoughts, beliefs, knowledge, and intentions of the participants in a given situation [7]. This technique involves drawing an event or sequence of events in storyboard form with stick figures to represent each participant, and speech and thought bubbles to represent their words and thoughts. The individual and therapist use an assortment of fibro-tipped colored pens, with each color representing an emotion. As they write in the speech or thought bubbles, the individual's choice of color indicates their perception of the emotion conveyed or intended. This can clarify the individual's interpretation of events and the rationale for their thoughts and response. This technique can help the individual identify and correct any misperception and determine how alternative responses might affect the participants' thoughts and feelings.

One common effect of misinterpretation is the development of paranoia. Our knowledge of impaired Theory of Mind skills in the cognitive profile of kids with Aspergers suggests a simple explanation. The youngster can have difficulty distinguishing between accidental or deliberate intent. Other kids will know from the context, body language, and character of the individual involved that the intent was not to cause distress or injury. People with Aspergers, however, can focus primarily on the act and the consequences: “He hit me and it hurt, so it was deliberate,” whereas other kids would consider the circumstances: “He was running, tripped, and accidentally knocked my arm.” There may need to be training in checking the evidence before responding and developing more accurate “mind reading” skills.

Cognitive restructuring also includes a process known as “attribution retraining.” The individual may blame others exclusively and not consider their own contribution, or they can excessively blame themselves for events [2]. One aspect of Aspergers is a tendency for some individuals to adopt an attitude of arrogance or omnipotence where the perceived focus of control is external. Specific people are held responsible and become the target for retribution or punishment. These people have considerable difficulty accepting that they themselves have contributed to the event. The opposite can occur, however, when the individual has extremely low self-esteem and feels personally responsible, which results in feelings of anxiety and guilt. There also can be a strong sense of what is right and wrong and conspicuous reaction if others violate the social “laws” [2]. The youngster may be notorious as the class “policeman,” dispensing justice but not realizing what is within their authority. Attribution retraining involves establishing the reality of the situation, the various participants' contributions to an incident, and determining how the individual can change their perception and response.

Cognitive restructuring also includes activities that are designed to improve the individual's range of emotional repair mechanisms. The author has extended the use of metaphor to design programs that include the concept of an emotional toolbox to “fix the feeling.” Patients know that a toolbox usually includes a variety of tools to repair a machine, and discussion and activities are used to identify different types of “tools” for specific problems associated with emotions.

One type of emotional repair tool can be represented by a hammer, which signifies physical “tools” such as going for a walk or run, bouncing on a trampoline, or crushing empty cans for recycling. The intention is to repair emotions constructively by a safe physical act that increases the heart rate. One individual explained how a game of tennis “takes the fight out of me.” A paintbrush can be used to represent relaxation tools that lower the heart rate, such as drawing, reading, or listening to calming music. A two-handle saw can be used to represent social activities or people who can help repair feelings. This can include communication with someone who is known to be empathic and able to dispel negative feelings. This can be by spoken conversation or typed communication, enabling the individual to gain a new perspective on the problem and providing some practical advice. A picture of a manual can be used to represent thinking tools that are designed to improve cognitive processes. This includes phrases that encourage reflection before reaction. Evan, a young man with Aspergers, developed his “antidote to poisonous thoughts.”

The procedure is to provide a comment that counteracts negative thoughts, for example, “I can't cope” (negative or poisonous thought) “but I can do this with help” (positive thought or antidote). The individual also is taught that becoming emotional can inhibit their intellectual abilities in a particular situation that requires good problem-solving skills. When frustrated, one needs to become “cool” and less rigid in one's thinking to solve the problem, especially if the solution requires social cognition.

There is a discussion of inappropriate tools (with the comment that one would not use a hammer to fix a computer) to explain how some actions, such as violence and thoughts such as suicide, are not appropriate emotional repair mechanisms. For example, one individual would slap himself to stop negative thoughts and feelings. Another tool that could become inappropriate is to retreat into a fantasy world (perhaps imagining they are a superhero), or to plan retaliation. The use of escape into fantasy literature and games can be a typical tool for ordinary adolescents but is of concern when this becomes the exclusive coping mechanism; the border between fantasy and reality may be unclear and the thinking becomes delusional. Cognitive restructuring can be used to return to concrete thinking.

Also of concern is when daydreams of retaliation to teasing and bullying are expressed in drawings, writing, and threats. Although this is a conventional means of emotional expression, there is a concern that the expression is misinterpreted as an intention to carry out the fantasy or indeed may be a precursor to retaliation using weapons. Unusual tools also are discussed. For example, during a group CBT session on sadness, a teenage female explained that, “Crying doesn't work for me, so I get angry.” Clinical experience suggests that tears may be rare as a response to feeling sad, with a more common response to sadness being anger. The program includes the development of a range of conventional means of emotional expression and repair mechanisms and an explanation as to why some of their reactions are misinterpreted by others.

Clinical experience also has indicated that humor and imagination can be used as thinking tools. Those with Aspergers are not immune to the benefits of laughter, can enjoy jokes typical of their developmental level, and can be remarkably creative with puns and jokes [45]. One tool or mechanism that seems to be unusual is that of being quick at resolving grief and serious tragedies. This characteristic can be of concern to the individual's family, who expect the classic signs of prolonged and intense grieving; they consider the individual as uncaring, yet the rapid recovery is simply a feature of Aspergers.

Other interesting characteristics are the inclusion of talking to pets as a social tool, sometimes in preference to talking to friends, and the positive effects on mood from helping someone. This strategy can be effective for individuals with Aspergers who also need to be needed and can improve their mood by being of practical assistance. Finally, the concept of a toolbox can be extremely helpful in enabling the individual with Aspergers not only to repair their own feelings but also to repair the feelings of others. They often benefit from tuition in learning what tools to use to help friends and family and which tools others use, so that they may borrow tools to add to their own emotional repair kit.

Stress management –

People with Aspergers are prone to greater stress in their daily lives than their peers. Social interaction, especially with more than one individual, in which they have to identify, translate, and respond to social and emotional cues and cope with unexpected noise levels, inevitably increases stress to a point where the individual's coping mechanisms may collapse. A stress assessment based on our knowledge of Aspergers will help the clinician determine what are the natural and idiosyncratic stressors for the individual [46]. Subsequently, an effective stress management program can be designed as an essential component of CBT.

Traditional relaxation procedures using activities to encourage muscle relaxation and breathing exercises can be taught to individuals with Aspergers as a counter conditioning procedure, but one must also consider the circumstances in which they are particularly prone to stress. Environmental modification can significantly reduce stress. This can include reducing noise levels, minimizing distractions, and having a safe area for periods of solitude to relax or concentrate on schoolwork. If the clinician recognizes that a particular event is a major cause of stress, then it would be wise to consider whether the source of stress could be avoided, for example, recommending the temporary suspension of homework. At school, one option for the youngster who becomes stressed in the playground is to be able to withdraw to the school library, or for the worker who is anxious about socializing during the lunch break, to complete a crossword puzzle or go for a walk. Another source of stress for kids and adults is unexpected changes in work demands or circumstances. They may need advance preparation and time to adjust their work schedule.

Cue-controlled relaxation is also a useful component of a stress management plan. One strategy is for the individual to have an object in their pocket that symbolizes or has been classically conditioned to elicit feelings of relaxation. For example, a teenage female with Aspergers was an avid reader of fiction, her favorite book being The Secret Garden. She kept a key in her pocket to metaphorically open the door to the secret garden, an imaginary place where she felt relaxed and happy. A few moments touching or looking at the key helped her to contemplate a scene described in the book and to relax and achieve a more positive state of mind. Adults can have a special picture in their wallet such as a photograph of a woodland scene, which reminds the individual of the solitude and tranquility of such a place


In conventional CBT programs, the individual is encouraged to self-reflect to improve insight into their thoughts and feelings, promoting a realistic and positive self-image and enhancing the ability to self-talk for greater self-control. The concept of self-consciousness may be different for people with Aspergers, however. There may be a qualitative impairment in the ability to engage in introspection. Research evidence, autobiographies, and clinical experience have confirmed that some individuals with Aspergers and high functioning autism can lack an “inner voice” and think in pictures rather than words [47], [48]. They also have difficulty translating their visual thoughts into words. As an adolescent with Aspergers explained in relation to how visualization improves his learning (a picture is worth a thousand words), “I have the picture in my mind but not the thousand words to describe it.” Some have an “inner voice” but have difficulty disengaging mind and mouth, and vocalize their thoughts to the confusion or annoyance of those near them. Obviously, the therapy needs to accommodate such unusual characteristics.

The modifications include a greater use of visual material and resources using drawings, role-play, and metaphor, and less reliance on spoken responses. It is interesting that many individuals have a greater ability to develop and explain their thoughts and emotions using other expressive media, such as typed communication in the form of e-mail or a diary, music, art, or a pictorial dictionary of feelings [3].

When talking about themselves, young adults with autism and Aspergers do not anchor their self-attributes in social activities and relationships or use as wide a range of emotions in their descriptions as their peers [49]. They are less likely to describe themselves in the context of their relationships and interactions with other people. The self-reflection component of CBT may have to be modified to accommodate a concept of self primarily in terms of physical, intellectual, and psychologic attributes.

The therapy includes programs to adjust the individual's self image to be an accurate reflection of their abilities and the neurologic origins of their disorder. Some time needs to be allocated to explaining the nature of Aspergers and how the characteristics account for their differences. The author recommends that as soon as the youngster or adult has the diagnosis of Aspergers, the clinician needs to carefully and authoritatively explain the nature of the disorder to their family, but the youngster also must receive a personal explanation. This is to reduce the likelihood of inappropriate compensatory mechanisms to their recognition of being different and concern as to why they have to see psychologists and psychiatrists.

They also may be concerned as to why they have to take medication and receive tuition at school that is not given to their peers. Over the last few years, there have been several publications and programs developed specifically to introduce the youngster or adolescent to their diagnosis. The choice of which book or program to use is determined by the clinician, but it is important that the explanations are accurate and positive. The individual will perceive the diagnosis as it is presented. If the approach is pessimistic, the reaction can be to trigger a depression or to reject the diagnosis and treatment. The clinician also can recommend the individual read some of the autobiographies written by kids [50], [51] and adults [52], [53]. The subsequent discussion is whether and how to tell other people of the diagnosis, especially extended family, neighbors, friends, and colleagues.

When an accurate perception of self has been achieved, it is possible to explore cognitive mechanisms to accommodate their unusual profile of abilities, which the author describes as their talents and vulnerabilities, and to consider the directions for change in self-image. One approach is using the metaphor of a road map with alternative directions and destinations [54], and a Personal Construct Assessment [55].


Once the individual has improved their cognitive strategies to understand and manage their moods at an intellectual level, it is necessary to start practicing the strategies in a graduated sequence of assignments. The first stage is for the therapist to model the appropriate thinking and actions in role-play with the individual, who then practices with the therapist or other group members, vocalizing thinking to monitor their cognitive processes. A form of graduated practice is used, starting with situations associated with a mild level of distress or agitation. A list of situations or triggers is created from the assessment conducted at the start of the therapy, with each situation written on a yellow Post-It note. The individual uses the thermometer or measuring instrument originally used in the affective education activities to determine the hierarchy or rank order of situations. The most distressing are placed at the upper level of the instrument. As the therapy progresses, the individual and therapist work through the hierarchy using fading or systematic desensitization using a schedule of graduated exposure to encourage the individual to be less emotionally reactive [56].

After practice during the therapy session, the individual has a project to apply their new knowledge and abilities in real-life situations. The therapist obviously needs to communicate and coordinate with those who are supporting the individual in real-life circumstances. After each practical experience, therapist and individual consider the degree of success, using activities such as comic strip conversations to debrief, reinforcement for achievements, and a “boasting book” or certificate of achievement. It also helps to have a training manual for the individual that includes suggestions and explanations. The manual becomes a resource for the individual during the therapy but is easily accessible information when the therapy program is complete. One of the issues during the practice will be generalization. People with Aspergers tend to be rigid in terms of recognizing when the new strategies are applicable in a situation that does not obviously resemble the practice sessions with the psychologist. It is necessary to ensure that strategies are used in a wide range of circumstances and no assumption made that once an appropriate emotion management strategy has proved successful, it will continue to be used in all settings.

The duration of the practice stage depends on the degree of success and list of situations. Gradually the therapist provides less direct guidance and support to encourage confidence in independently using the new strategies. The goal is to provide a template for current and future problem, but it will probably be necessary to maintain contact with the individual for some time to prevent relapse.

Aspects of CBT can be incorporated into conventional family therapy [57] and social skills groups [58], and can be conducted as the primary psychologic treatment. Other specialists may be consulted during the program, especially if the individual has signs of attention deficit disorder, Tourette syndrome, and specific learning problems. Predictors of a successful outcome may include the complexity and degree of expression of the mood disorder and diagnostic characteristics, the intellectual capacity of the individual, and their circumstances and support. Two positive predictors that have been recognized by the author from clinical experience are a sense of humor and imagination.

Finally our scientific knowledge in the area of psychologic therapies and Aspergers is remarkably limited. We have case studies [59], but at present, no systematic and rigorous independent research studies that examine whether CBT is an effective treatment with this clinical population. This is despite the known high incidence of mood disorders, especially among adolescents with Aspergers. As a matter of expediency, a clinician may decide to conduct a course of CBT based on the known effectiveness of this form of psychologic treatment in the general population. We have yet to establish whether it is universally appropriate, however, and to confirm the modifications to accommodate the unusual characteristics and profile of abilities associated with Aspergers.

Best Comment:

Three months ago I wrote that son, 27, was finally getting his own apartment about 15 minutes away from our house.

As usual, I have a pattern of unrealistic hopes and dreams that clash with hard cold reality. I am thrilled that son has made it three months, that is a huge milestone. But there have been bumps, big and small.

Small bump: I thought I anticipated and prepared for every possible thing that could he could encounter, but I forgot about this one: adjusting the thermostat! For one thing he doesn't feel cold or heat in the same way we do and for another, seventy-two degrees has no more meaning for him than thirty-two degrees. It is just a word. So that was a huge shock when we saw his first utility bill and it was as much as for our much larger house. So, up went another sign tacked right above the thermostat listing "at-home" temperatures, "going out" temperatures and settings. It complements the reminder by the front door with a checklist for keys, phone etc, and the one over the light switch in the bedroom reminding night time meds and routines, and the one in the bathroom to brush teeth and shave. His apartment is practically wallpapered with the reminders.

Funny bump: the second month in the apartment, he had a light bulb burn out and called the maintenance man! In retrospect, not sure he had ever changed a light bulb while living at home. But, now he has a package of them tucked in the pantry shelf and the knowledge of how to change one now.

Huge bump: he informed us after the fact that he'd filed a police report on someone he met online, someone living in a state thousands of miles away with a "goth" appearance who had threatened him after chatting.

Month one was a honeymoon. I was congratulating myself on how well he was doing, keeping up with his stuff. Month two was a disaster. Losing keys, losing cell phone, losing wallet, oversleeping and missing the bus for work. Month three is a mix.

We had to take back his newly-purchased, used truck for violating the "no eating while driving rule." And the "no cell phone while driving rule" and, as it turned out, he started a nasty habit of smoking little cigars in the truck, too, and burned six holes in the vinyl floor (slightly distracting!). Again, he managed to come up with a brand new contingency that I had not prepared for.

So, all the talks with all his support group and mentors about distracted driving and his sincere-sounding promises to "never do that" went out the window. He didn't follow thru with that at all, so we confiscated his transportation. That was hard for him. Most of our conversations ended up with one of us hanging up on the other. Lots of announcements that it "is his life and I should butt out." At one point, we were visiting him for about the second or third time. Apartment was a disaster with empty food containers everywhere but in the garbage. Spilled Ramen noodles and rice on the floor…as I suggested it should be cleaned up, he suggested that "why didn't we just leave?" So, we just stood up and walked out the door with a "see ya." I think he was shocked and that was the intended purpose.

So here we are ending month three. I am trying to let him handle his problems and difficulties more and more. It would be so nice, however, if I felt he learned from them, but he seldom seems to.

We are gradually working out an uneasy phone relationship. He is bored and very lonely, despite the fact he spent 95% of his time here last year in his room, he had us around. And now it is just him. He has one friend and do they do little together. So I constantly feel guilty that we should be his friend group and do more and more stuff with him socially. I get frustrated that he calls more than five times a day with NOTHING to say…holding a conversation with the other end and his one word answers when I am busy and he is bored is draining! I have pointed him towards a social group here for Aspies, not interested. He quit the orchestra he was in (and seemed to love) for no reason he could articulate. I have sent him info on churches, and on and on and on.

So, I am holding my breath…he would be so much happier in a supported living environment. But that doesn't exist in our county, though I am working trying to make it happen someday. However, I need one "right now!" I have a step daughter that is helping a little bit with taking him to grocery and bringing him over for dinner occasionally and I am very grateful for that. I feel like I should be more grateful that he is out and living on his own…but again, my expectations were a lot higher. He still has no job, does two volunteer positions where he's been for MONTHS and even though they say what a great job he's doing, they can't seem to find enough money to hire him for even four hours a week. So that contributes to being bored and being on a very small income.

In reading this over, I feel very mean and petty. I should be more grateful with what he is able to do…and hopefully, he will be able to find a job. I should count my blessings more and not complain so much. But today I just feel like venting at the unfairness of it all!

But what do I do, how do I cope with a child who has had all this special schooling, therapies out the wazoo, thousands of dollars in counseling…and it seems to have made little difference in his outcome. Bang, bang, bang…that is me banging my head against the wall!


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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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How to Prevent Meltdowns in Children on the Spectrum

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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Parenting Children and Teens with High-Functioning Autism

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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Highly Effective Research-Based Parenting Strategies for Children with Asperger's and HFA

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