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Aspergers: Aggression, Anxiety, Depression, Hyperactivity, Inflexibility and Repetitive Behaviors

In this article, we will discuss the major symptoms associated with Aspergers and High Functioning Autism…

Aggression—

Aggression is seldom an isolated problem and is particularly complex in kids with Aspergers (high functioning autism) [23]. It is important to understand that aggressive behavior is not always associated with just one condition and can have highly varied sources. An array of theoretic models has been proposed to understand aggressive behavior in children with Aspergers [24]. There are promising biologic models that suggest the behavior arises from alterations in dopaminergic reward mechanisms [25], and cognitive models, suggesting that such acts are an outcome of conditioned learning [26], [27]. Tantrums and physical aggression are often responses to a variety of circumstances and occur in the context of diverse emotions [23]. It has become fashionable to consider aggression as prima facie evidence of bipolar disorder, particularly when Aspergers kids are distractible, restless, and have chronically decreased need for sleep. It is increasingly important to consider, however, whether features of bipolar illness appear together and depart from chronic baseline functioning. It is also relevant if they are associated with pharmacologic (eg, serotonin reuptake inhibitor) side effects. It is useful to know the circumstances preceding and following aggressive outbursts before selecting a pharmacologic agent. For example, when aggression is a response to anxiety or frustration, the most helpful interventions target those symptoms and the circumstances that produce them rather than exclusively focusing on aggressive behavior.

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

Anxiety—

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

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

Depression—

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

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

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

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

Hyperactivity and Inattention—

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

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

Inflexibility and Behavioral Rigidity—

Symptoms of inflexibility or behavioral rigidity are often difficult to quantify and yet often introduce some of the most disruptive chronic behaviors exhibited by patients with Aspergers. These can be manifest by difficulties tolerating changes in routine, minor differences in the environment (such as changes in location for certain activities), or changes to plans that have been previously laid out. For some kids this inflexibility can lead to aggression, or to extremes of frustration and anxiety that thwart activities. Families and school staff may find themselves “walking on eggshells” in an effort to circumvent any extreme reaction from brittle patients. In addition, the patients themselves may articulate their anxiety over fears that things will not go according to plan or that they will be forced to make changes that they cannot handle.

Sometimes these behaviors are identified as “obsessive-compulsive” because of the patient's need for ritualized order or nonfunctional routine. This is a phenomenologic error, as OCD has features that can be differentiated from PDD spectrum disorders [69]. Nevertheless, the idea that OCD and these “needs for sameness” might share some biologic features is attractive. It is not known now whether these symptoms are produced by disturbances in the same cortico-striatal-thalamo-cortical circuitry that is believed to produce OCD [70]. The model of obsessive-compulsive disorder, however, has suggested that use of SRI agents might be useful in ameliorating this problem [28], [33]. Whether the effect of SRI agents on this symptom cluster is mediated by a general reduction in anxiety [48] or is specific for “needs for sameness” is not known. An alternative hypothesis suggests that the impairment might be located in circuitry subserving reward systems that rely on norepinephrine and dopamine [24], [71]. If so, this would point to study of other agents and systems in future investigations.

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

Stereotypies and Perseveration—

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

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

Complementary and Alternative Medicine—

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

Nevertheless, clinicians still have to answer families who ask about trying novel treatments. Among investigators and concerned practitioners, broad guidelines have been suggested (Klin, personal communication). The first is that treatments should be safe. A variety of diets and mineral supplements are apparently safe, but some can be toxic; the frequency of toxic reactions should be spelled out and signs of toxicity should be thoroughly comprehended. More extraordinary interventions such as neurosurgery obviously are not reversible. The second guideline is that treatments should be affordable. At the height of the secretin rush, some practitioners were charging many hundreds of dollars for medication and supplies that totaled less than fifty dollars. For most families, these treatments are not covered by insurance and money that goes to novel treatment is not available for other services. The third guideline is that novel treatments should not interfere with a youngster's participation in daily programs or treatments that are known to be helpful. Focusing on communication and social enhancement through education should be the first priority of every multimodal treatment plan. Attending school, having a detailed evaluation, and receiving behavioral supports that promote socialization and communication should not be curtailed by the pursuit of novel somatic, dietary, and complementary medical treatments.

Summary—

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

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

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

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



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The connection between Semantic Pragmatic Disorder and Aspergers Syndrome

Has anyone found any direct combination of Aspergers Syndrome and Specific Learning Disability? Have a small girl of 5 yrs who displays these traits.

Aspergers may be associated with learning difficulties and attention deficit disorder. Indeed, many kids and teens with Aspergers have previously been diagnosed with AD/HD instead of Aspergers. Children with AD/HD may have difficulty with social interaction, but the primary difficulties are inattention, hyperactivity and impulsivity. In children with Aspergers, the social awkwardness is a greater concern. As kids with Aspergers enter adolescence, they become acutely aware of their differences. This may lead to depression and anxiety. The depression, if not treated, may persist into adulthood.

Also, what is the connection between Semantic Pragmatic Disorder and Aspergers Syndrome??


==> First, we'll look at SPG...

Semantic Pragmatic Disorder—

HISTORY—

Semantic-Pragmatic Disorder was originally defined in the literature on Language Disorder in 1983, by Rapin and Allen, although at that time it was classified as a syndrome. They referred to a group of kids who presented with mild Autistic features and specific semantic pragmatic language problems.

In babyhood, moms & dads often described them as model babies or by contrast babies who seemed to cry too much. Many of these kids babbled little or very late and went on using 'jargon' speech much longer than other kids of the same age. Their first words were late and learning language was a hard slog. Some had other speech disorders too. Problems were usually first identified between 18 months and 2 years when the youngster had few if any real words.

Many moms & dads wondered if their kids were deaf at first because they did not appear to respond to speech. Assessment found that most kids had good hearing, although some did have otitis media and had grommets fitted to ensure maximum hearing.

The problem usually proved to be one of listening and processing the meaning of language instead. Many of the kids ignored their names early on but would hear the telephone or the door bell and even respond to the rustle of a sweet paper. Early on in their lives, Semantic-Pragmatic Disordered kids were found to have comprehension problems finding it difficult to follow instructions which were not part of the normal routine. Comprehension problems usually improved or responded well to speech therapy so that by the age of four years, many of the kids appeared to be functioning superficially, very well.

By the time these kids reached school, staff and moms & dads were aware that there was something "different" about them, but they couldn't quite put their finger on it. Sometimes the kids would appear to follow very little conversation, while at other times they could give a detailed explanation of an event. Later on in school they were often good at math, science, and computers but had great difficulty in writing a coherent sentence or playing with other kids. They were also unable to share and take turns. They could appear aggressive, selfish, bossy, over confident, shy or withdrawn. Many, therefore, were singled out as behavior problems and subjected to behavioral regimes which did not always work and left the youngster confused about what he was supposed to be doing. As one 6 year old Semantic-Pragmatic Disordered youngster said to his mother, "I don't want to be naughty".

Current Thinking—

Today we have a better understanding of the Disorder. We know that Semantic-Pragmatic Disordered kids have many more problems than just speaking and understanding words, so we call it a communication disorder rather than a language disorder. We think that the difficulty for kids with SEMANTIC PRAGMATIC DISORDER may be in the way they process information. Kids with SEMANTIC PRAGMATIC DISORDER find it more difficult to extract the central meaning or the saliency of an event. They tend to focus on detail instead; for example the sort of youngster who finds the duck hidden in the picture but fails to grasp the situation or story in the picture or the youngster who points out the spot on your face before saying 'hello'.

Extracting information from around us is something we do all the time. We are always looking for similarities and differences so that we can understand and anticipate. Kids who find it difficult to extract any kind of meaning will find it even more difficult to generalize and grasp the meaning of new situations. They will therefore cling on to keeping events the same and predictable. Maintaining sameness, by following routines slavishly, insisting on eating certain foods or wearing particular articles of clothing or developing obsessional interests are all characteristics of kids with SEMANTIC PRAGMATIC DISORDER Because these kids have difficulty extracting meaning both aurally and visually, the more stimulating the environment becomes the more difficult they find extracting information. Because people have minds which allow them to behave independently they are much less predictable and more difficult to understand than objects or machines. Kids with SEMANTIC PRAGMATIC DISORDER are often more sociable with friends at home or in a formal 1:1 assessment situation than in a busy classroom. Carers may be puzzled by the apparent discrepancy.

Listening and Understanding Language—

Because kids with SEMANTIC PRAGMATIC DISORDER find it difficult to focus their listening, they are easily distracted by noises outside the classroom or someone talking on the other side of the room. They may butt in on conversations which have nothing to do with them. They are often described by staff as inattentive or impulsive. They may find loud noise in the classroom distressing and may comment on this. Sometimes when kids with SEMANTIC PRAGMATIC DISORDER are trying very hard to concentrate they may not hear speech at all and ignore general instructions in the classroom while they are trying to work. Many class teachers say they sometimes have to stand in front of their kids with SEMANTIC PRAGMATIC DISORDER or touch them before they respond.

Although many kids with SEMANTIC PRAGMATIC DISORDER do very well; sometimes way above their age level on formal language assessments, this does not mean that they do not have comprehension difficulties. What it does mean is that our methods of testing are not tapping the right areas, or the ones we are using are not standardized yet.

Their difficulties in understanding language are usually fairly subtle by the time they are 5. Kids with SEMANTIC PRAGMATIC DISORDER can often respond to long instructions like, "put the blue pen under the big book", because the objects are there, because it is here and now in time, and because bright kids with SEMANTIC PRAGMATIC DISORDER usually have very little difficulty in understanding visible concepts like size, shape and color and can be well ahead of their peers. The other very important point is this kind of language does not require knowledge about the person giving the instruction.

Kids with SEMANTIC PRAGMATIC DISORDER would find comments and questions like "Where did you come from then?,.. What are you doing later?" "That was very clever of you!", much more difficult. This language requires more than listening and understanding words. You need to understand what the speaker was thinking and intending. You need to understand non literal expressions and time concepts too.

SEMANTIC PRAGMATIC DISORDER kid’s understanding usually breaks down in a busy classroom when the teacher starts to chat, tell jokes, or makes a few sarcastic remarks. Kids with SEMANTIC PRAGMATIC DISORDER often feel very uncomfortable at this point because they take everything literally. If other kids become aware of this, they can learn to tease and take advantage.

Because kids with SEMANTIC PRAGMATIC DISORDER have difficulty in understanding what other people are thinking when they are talking, they cannot understand when people are lying or deceiving them. Many moms & dads of kids with SEMANTIC PRAGMATIC DISORDER have reported to us that their kids have had their lunches taken off them or parted with pocket money and returned home unable to give a clear account of what happened.

Talking—

As well as subtle comprehension problems kids with SEMANTIC PRAGMATIC DISORDER have difficulties with talking too. These are not always picked up by moms & dads or staff because so often they chat fluently. It is the particular way in which they use language which identifies them as a group. That is, they have specific Pragmatic Difficulties.

Kids with SEMANTIC PRAGMATIC DISORDER have a different style of learning language; they seem to learn more by memorizing than knowing what the individual words really mean; so they cannot use language with the same range and flexibility as other kids. Kids with SEMANTIC PRAGMATIC DISORDER remember whole chunks of adult phrases and because they are not sure which bits are more important than others they learn everything accurately including the intonation and the accent of the speaker! Sometimes you can hear yourself talking. All in all they seem to say a lot more than they really understand. Some kids with SEMANTIC PRAGMATIC DISORDER use a flat or 'sing-songy' voice when they are echoing other people's language.

Kids with SEMANTIC PRAGMATIC DISORDER often remember to use this echoed language appropriately so they can sound very grown up which contrasts dramatically with their social immaturity. However, when you ask them to give you an account of an event or discuss a picture story which they have not rehearsed, you find them groping for original words and the whole account is very disjointed. One mum described how her son of 5 would tell everyone off in his class including the teacher using her words but could never explain what he had done at school or ask the teacher for help.

When you analyze the content of a SEMANTIC PRAGMATIC DISORDER youngster's speech, you find a disappropriate amount of echoed social phrases and very little about how people feel or think. SEMANTIC PRAGMATIC DISORDER kid’s delayed social development means that they do not make distinctions between people. Adults, kids, teachers and moms & dads are treated the same so when Adam said "don't talk to me like that" to a visitor, he was understandably thought to be very rude, when in fact he was simply repeating what had been said to him. SEMANTIC PRAGMATIC DISORDER kid’s inappropriate or immature use of language can be very embarrassing. They say things like, "why has that lady got such a big nose", or they give the family secret away to the very person you had intended it to be kept from. It is easy to see why adults find kids with SEMANTIC PRAGMATIC DISORDER so exasperating at times.

Problems with talking really show up at a conversational level for kids with SEMANTIC PRAGMATIC DISORDER First of all their delayed social development means that like younger kids, they are much more interested in themselves than other people so they tend to choose topics about themselves, their family or their special interests. Because they have insufficient understanding of their conversational partner, they tend not to understand that she might not be interested in their latest obsession and because the SEMANTIC PRAGMATIC DISORDER youngster has no idea what is pertinent in his story and what is not, when he is able to describe past events, he tends to give an over detailed account and fails to read the signals of boredom in his listener. He may, on the other hand believe that his listening partner shares his thoughts exactly. He thus assumes common knowledge and fails to put his partner sufficiently in the picture and requests for information may bring one word answers only.

On top of these problems so far described, the SEMANTIC PRAGMATIC DISORDER youngster may misunderstand what his conversation partner intended so he may give rather bizarre answers or he may, if he is skilful enough, change the topic and gear it back to what he understands and keep talking just to shut his partner out. Conversation can take on very strange meanings, if you are not aware of the SEMANTIC PRAGMATIC DISORDER youngster's difficulty.

Understanding how others think—

Some S.P.D kids become skilled at talking about pictures or sequences of pictures but you find them only able to give you the bare facts. Their inability to describe people's thoughts and intentions within the picture mean they cannot be creative or abstract in their account or they cannot infer or make sensible predictions. They cling to the observable features of the picture without dealing with the implied underlying meaning.

The SEMANTIC PRAGMATIC DISORDER youngster's difficulty in seeing the world through other people's eyes or understanding that other people think differently from himself, is often described as a youngster who does not have a 'theory of mind'.

There has been a lot of research recently into when kids develop a 'theory of mind'. Researchers have used false belief stories and deception tasks (which tests the youngster's ability to understand that people who do not share the same knowledge will behave differently) to determine when kids develop this skill. Researchers think that four year olds have quite good understanding of minds but that kids on the Autistic Continuum * find this more difficult.

Most 'core' Autistic kids never acquire a complex theory of mind where as SEMANTIC PRAGMATIC DISORDER do seem to but later than other skills at the same developmental stage. This lack of social 'nous' above all else makes life difficult for the SEMANTIC PRAGMATIC DISORDER youngster. They find it difficult to make friends with kids of their own age and tend to gravitate towards younger or much older kids unless of course there are other kids with SEMANTIC PRAGMATIC DISORDER in the class - when they seem to be attracted to each other like magnets. We think that kids with SEMANTIC PRAGMATIC DISORDER need to spend time together so they can feel on a par with each other and not constantly at the mercy of more sophisticated peers.

We think teachers should explain to other kids, in simple terms, why it is the SEMANTIC PRAGMATIC DISORDER youngster cannot conform and to keep an eye on his vulnerability both inside and outside of the classroom.

Creative Play—

Researchers have also suggested that the difficulty kids with SEMANTIC PRAGMATIC DISORDER have in playing creatively and in mentalizing has a common cognitive origin. The ability to separate one’s own thinking from that of another person may start at birth and develop through simple turn taking and shared attention games. Even breast feeding, humpty dumpty or peek-a-boo requires turn taking and mentalizing.

At about 18 months, kids take a leap forward in their mentalizing, they are able to think even more abstractly and they can switch from abstract to concrete thinking very easily. For example, they can pretend a toy cup is a telephone, but they also understand that the toy cup is a cup.

Toddlers' teddies take on extra meanings when they become people who are taken to bed, fed and even used to fight kid’s battles for them. Three year olds know how to switch from pretend to reality and develop story lines with their friends when they say, "Let’s pretend you are .....".

Kids with SEMANTIC PRAGMATIC DISORDER, on the other hand, find this kind of abstract thinking much more difficult. This makes their play less creative so that a tower of bricks is always a tower of bricks until someone else tells him otherwise. Kids with SEMANTIC PRAGMATIC DISORDER tend to flit from toy to toy or play repetitively. They show more interest in real activities like water, motor play, operating machines, tidying up and stacking toys. Many kids with SEMANTIC PRAGMATIC DISORDER understand representation i.e. that a toy cup stands for a real cup and they will often perform the appropriate action on the toy. They are not however pretending. The youngster who is really pretending is taking on the role of someone else and using their persona to develop a story line.

Many bright kids with SEMANTIC PRAGMATIC DISORDER try to solve the mystery of pretence by copying other peoples' pretence or copying moms & dads actions in the same detailed way they copy their speech. Some kids with SEMANTIC PRAGMATIC DISORDER copy exerts from TV programs exactly, and some people actually think kids with SEMANTIC PRAGMATIC DISORDER are being creative when in fact they are simply copying in detail. We call this kind of play functional play. This inability to separate pretence from reality can pose problems for some kids watching t.v. Although most kids with SEMANTIC PRAGMATIC DISORDER prefer cartoon programs, many, as they mature, enjoy films too. We would suggest that as far as possible you limit access to programs which contain violence and that you explain what is real and what is not.

This inability to be creative is usually extended to drawing skills too. Many kids with SEMANTIC PRAGMATIC DISORDER are late acquiring representational drawing skills. Many have to be taught how to draw a face and they can only repeat it in a particular way. Some kids with SEMANTIC PRAGMATIC DISORDER will only copy draw and some will only draw objects related to their obsessional interests. One youngster we knew would only draw pyramids, another drew horses. Very few, except the most able, can draw a picture story which is not the same each time.

Motor Difficulties—

Some kids with SEMANTIC PRAGMATIC DISORDER have fine motor difficulties. They find handwriting very difficult. They often need specialized help in making the correct letter shapes.

Some kids with SEMANTIC PRAGMATIC DISORDER have mild gross motor difficulties too, not always noticed early on except they are sometimes described as walking with an 'odd gait'. They are late riding bikes, find gym work difficult and take little interest in rule based games like football. Perceptual difficulties too can interfere with performance on practical skills, e.g. the sort of youngster who tells you how to prepare a 3 course meal but cannot put the beans on the toast.

Memory Skills—

Many bright kids with SEMANTIC PRAGMATIC DISORDER have exceptional memory skills which compensate for their communication problems. Many have a detailed memory for past events which other members of the family have long forgotten. Most have a detailed memory for social phrases as mentioned. Many have a memory for routes and can direct moms & dads long distances by car! Some have an excellent memory for reading, others remember tunes.

Academic Performance—

In the classroom, academic performance tends to be patchy. First of all, the SEMANTIC PRAGMATIC DISORDER youngster's egocentricity means that he can only understand topic work from his own perspective. Refusing to do work may signal the work has no meaning for him and may suggest to the teacher and moms & dads that they need to supplement class work with more concrete shared experience. Kids with SEMANTIC PRAGMATIC DISORDER often have excellent number concepts and teachers and moms & dads are puzzled by the youngster's slowness in grasping how to do 'sums'. It seems they find the abstract symbols of adding + and subtracting - rather meaningless unless they are allowed to make their own. Later on, they often fail to understand the value of money or tell analogue time - unless of course either one happens to be an obsessional interest.

We think these difficulties can be remediated if addressed early on. Kids with SEMANTIC PRAGMATIC DISORDER usually manage fairly well during infant classes and it is often not until junior level, when help has not been available that obstacles seem to be met. At junior level, the major problems are handwriting and creative writing.

We would suggest that if handwriting is still unintelligible at nine years, there is little point in persisting with further handwriting practice and that it may be more sensible to encourage development of written skills through the use of word processors.

Creative writing, rather like pretend play, is something which may remain inflexible. Many kids with SEMANTIC PRAGMATIC DISORDER find it easier to regurgitate their own experiences or retell stories. One youngster we know is so accomplished at memorizing stories and interweaving them into new ones that he has actually won prizes for creative writing!

Some kids with SEMANTIC PRAGMATIC DISORDER learn to read very early but not necessarily with understanding. We call this hyperlexia. Other kids find reading and writing a hard slog and we call this dyslexia. As yet we cannot predict which kids will fall into which group.

SEMANTIC PRAGMATIC DISORDER is therefore a complex disorder not yet fully understood. Except we now know that most of the problems experienced by these kids have something to do with abstract thinking and mentalizing; but just like any group of kids, they are all different. They have their individual personality and their individual abilities, which mean they have individual needs.

School Placements—

Some kids have moderate learning difficulties on top of their SEMANTIC PRAGMATIC DISORDER problems and do best in special schools, but many kids are brighter than average and can do very well in mainstream education; particularly if they have the support of a helper or spend time in a language unit or a language school. We think that as our understanding of the disorder improves then we shall be able to provide an educational environment which best meets their needs.

For bright kids with SEMANTIC PRAGMATIC DISORDER, we think that the most important question is, "What is it that makes the SEMANTIC PRAGMATIC DISORDER youngster unique?" He has a different style of learning which is equally valid but it does necessitate a special understanding and a different approach. If we are to maintain his self esteem and reduce his anxiety to levels that allow him to learn, then we should perhaps start from the premise of what can this youngster do, rather than what can't he do.

With a clear understanding of his skills and his needs, our expectations should become more realistic and our interventions less punitive. The SEMANTIC PRAGMATIC DISORDER youngster may not show embarrassment when he has violated a class social rule but he will feel a failure if he is saturated with labels of 'naughty', 'silly' and 'no common sense'. He simply needs to know what is acceptable and what is unacceptable.

Bright kids with SEMANTIC PRAGMATIC DISORDER are usually very quick at picking up rules if they are spelt out and will stick to them much more slavishly than the rest of the class. The secret of good teaching is perhaps to anticipate when these rules may need revision. Kids with SEMANTIC PRAGMATIC DISORDER often perform best in small, orderly 'old fashioned' styled classrooms.

Growing Up—

We haven't followed any of language unit kids with SEMANTIC PRAGMATIC DISORDER into adulthood yet, but we do know that the kids whose problems have been identified early and whose behavior and communication problems have been recognized as part of the learning disorder tend to integrate best at least up to senior level. Some kids have managed the transition to senior school well and one we expect to go to university. Other kids however bright would simply be too vulnerable to cope socially at comprehensive school even though much of the academic work would be within their scope. We hope that in time some specialist facility may be offered locally at senior school for those who need it.

What we are sure of at this stage, is that kids with SEMANTIC PRAGMATIC DISORDER do have problems recognizing what is sociably acceptable and unacceptable and that they should not be educated with kids whose primary diagnosis is E.D.B (Emotional Disturbed Behavior). We believe that SEMANTIC PRAGMATIC DISORDER kid’s behavior problems escalate in the presence of conduct disorders.

We have also found that some kids with SEMANTIC PRAGMATIC DISORDER who find it difficult to cope in a busy mainstream class are out performed by similar kids in special school, particularly if there is high Speech Therapy input and if the school has a genuine interest in developing a service for kids with Semantic Pragmatic Difficulties.

Echoed speech, comprehension problems and refusal to co-operate are all behaviors minimized in the appropriate setting.

Kids with SEMANTIC PRAGMATIC DISORDER will probably benefit most from an adapted curriculum where teachers and speech therapists work alongside each other to provide an integrated academic and communication program.

Kids with SEMANTIC PRAGMATIC DISORDER often do well if they spend time with kids who are equally or less socially sophisticated than themselves. They need social peers as well as intellectual ones. Kids who will encourage or insist on interaction rather than kids who ignore.

Kids with SEMANTIC PRAGMATIC DISORDER need extra talking practice, not less. With help, kids with SEMANTIC PRAGMATIC DISORDER will overcome most of their language comprehension problems but if their conversation is to be timely and appropriate they need to 'know' who their conversational partner is.

Autistic Continuum—

This phrase refers to all kids who share the same specific cognitive deficit resulting in problems with sociability, language and pretence. At the severe end of the continuum, we have kids labeled as Autistic, Core Autistic or Classically Autistic.

At the other end of the continuum, we have kids with milder problems who may have diagnostic labels of Semantic-Pragmatic Disorder or Autistic Spectrum Disorders.

Autistic Spectrum Disorders—

This recently adopted phrase refers to kids who fall some way between normality and Autism but outside Core Autism. Labels like Atypical Autism, Aspergers Syndrome, or Semantic-Pragmatic disorder are often used and they all describe similar communication difficulties to a greater or lesser degree. All kids on the Autistic Continuum including those with Core Autism have Semantic-Pragmatic difficulties with language and they should all be viewed in the context of Autism. That is they share the same triad of difficulties, with sociability, pretence and language.

Kids with SEMANTIC PRAGMATIC DISORDER are the group who are sociably the most able but who have much more difficulty early on at least learning basic language skills. But whose difficulties we suspect in adulthood will blur into the realms of mild eccentricity.

Kids with Aspergers Syndrome tend to have more problems with socializing than kids with Semantic Pragmatic Disorder but are generally earlier fluent speakers. There seems to be a pay off between early comprehension skills and sociability. As kids mature, it is often difficult to specify what label best fits. Many kids improve dramatically and diagnostic labels can change.

Labeling or not—

There is an argument, at least in the early years, particularly for more able kids, to use less specific diagnostic labels like Autism and simply to describe kids who may well improve dramatically in the pre-school years as falling within the 'Autistic Continuum' or as having an Autistic Spectrum Disorder.

Specific labels, however, can be useful, at the school stage of development both for research and for planning resources. There is clearly an enormous difference between a youngster with severe learning difficulties and Autism and a youngster of superior intelligence with a Semantic-Pragmatic Disorder. When we are describing kids on the Autistic Continuum, we must also be clear in our own minds about whether we are simply describing levels of sociability or whether we are also describing more generalized learning difficulty. The two do not necessarily go hand in hand.

As a rule of thumb, however, kids with Semantic Pragmatic Disorders as a group have less generalized learning difficulties than Autistic Kids.

Origins of Semantic-Pragmatic Difficulty—

We now think there is a family link between these Autistic Spectrum Disorders. We have sometimes found that having identified one youngster on the Autistic Continuum, another youngster in the family has been found to have milder communication problems too, particularly if they are male.

Moms & dads ask why? Well as you have probably deduced, the evidence is now pointing to a disorder which is genetic in origin. Autistic Spectrum Disorders are sometimes associated with other genetic disorders like Fragile X Syndrome, Retts Syndrome and Tuberousclerosis.

We think the problem is much more complex than one parent passing on a problem. Just like two hearing moms & dads can produce a profoundly deaf youngster, we think that two healthy moms & dads can produce a youngster with a communication disorder.

Some moms & dads of kids with SEMANTIC PRAGMATIC DISORDER describe eccentric relatives or others with psychiatric illness, but this is by no means always the case. We still have much to learn about genes and inheritance. What we can say is, boys are much more likely to have communication problems than girls: something in the ratio of 6:1.

Some moms & dads describe difficult birth histories and wonder if brain damage at birth could have been responsible. Well it is possible, but unlikely that a brain injury could be so specific. We think that in the majority of cases, the genetic makeup of the youngster makes him more vulnerable at birth.

If the same partners are contemplating extending their families after discovering they have a youngster with Autism and Semantic-Pragmatic Difficulties, we would recommend they sought Genetic counseling first.

Prognosis—

Semantic-Pragmatic Disorder is not an illness like Diabetes. It is a developmental disorder which improves with age. Rates of progress are probably dependent on overall intelligence and the support of carers. At centers like Heathlands, carers hope to maximize on such improvement by providing support and guidance throughout childhood.

Until about 10 years ago, we were only able to recognize the most handicapped kids with Autism. Kids were either Autistic or they were not Autistic. This meant that many able kids on the continuum with very mild and specific learning difficulties were excluded from a diagnosis and subsequent help. Many were dismissed as eccentric or language disordered or as having behavior problems, leaving moms & dads with much unresolved guilt.

Today we have extended the boundaries to include those kids with only mild social difficulties, some of whom may be able to extend their special interest and abilities to outperform their peers in mainstream.

The gloomy picture of Autism and Mental Handicap once painted is not something that necessarily follows. If you are a parent and you have been given this article to read, you should feel reasonably optimistic.

TELL TALE SIGNS—

(These are the features we have observed in many of our kids but not all in one youngster!)

Early Developmental 0-2 years:

1. "Golden" baby
2. A loner.
3. Didn't always look at you properly or enough when talking to you.
4. Didn't babble much.
5. Didn't take teddy to bed.
6. Difficult toddler with no sense of danger.
7. Fussy eater
8. Inappropriate response to sensory stimuli (e.g. touching, pain, noise)
9. Late pointing to share knowledge.
10. Late recognizing himself in a mirror or in a photograph.
11. Late talking
12. No boundaries.
13. Not interested in baby games.
14. Over clingy or wandered off too easily.
15. Thought he was deaf.

Nursery age development 2-4 years:

1. Appears to have a receptive language disorder.
2. Better conversation at home than at school.
3. Cannot play or negotiate with other kids
4. Cannot share.
5. Can't initiate pretend games with other kids.
6. Difficulty cutting out.
7. Doesn't build much with lego or tends to build the same.
8. Echoes people’s conversations, stories and t.v. programs.
9. Good at jigsaws, colors, numbers, shapes.
10. Has to be prompted to use social greetings like 'hello' and 'goodbye'.
11. Late drawing representationally. Prefers scribble if left.
12. Loves music and has a good memory for tunes
13. Never asks for help - too independent.
14. Obsessional interests like cars, dinosaurs and Michael Jackson!
15. Only interacts at a rough and tumble or chase level.
16. Only watches cartoon t.v. or animal programs
17. Prefers 'helping' with real activities like operating machinery or washing up.
18. Prefers to 'read' his own story (usually Thomas the Tank Engine).
19. Pretend is only action on object and doesn't have a storyline.
20. Rarely dresses up.
21. Tantrums persisting.
22. Very active - doesn't settle to play for long.
23. Wouldn't settle at playgroup and had to be removed.

School Age development:

1. Appears rude or can say things that embarrass you.
2. Approaches people inappropriately by kissing them or wrapping his arm around them or standing too close.
3. Cannot cope in crowds like assembly or parties.
4. Can't follow topic work in the classroom.
5. Can't get his ideas on paper.
6. Can't tell you what he did at school without shared knowledge.
7. Difficulty coping with school dinners (e.g. food fads, slow eater, surrounding noise, conversational expectations).
8. Distractible in the classroom.
9. Does not see himself as a member of a group.
10. Doesn't ask the teacher for help.
11. Doesn't exchange eye contact or facial expression appropriately.
12. Doesn't like football or complex rule based games.
13. Doesn't really follow the storyline of a book.
14. Doesn't take turns in conversation.
15. Doesn't understand abstract concepts like: tomorrow, next week, guess, wish.
16. Doesn't use much gesture like shrugging shoulders.
17. Excellent number concepts but difficulty with + or - or telling the time or value of money.
18. Fluent speaker but only wants to talk about things important to him.
19. Follows his own interests rather than the class.
20. Follows rules slavishly, and expects everyone else too.
21. Good memory for places and events.
22. Has no special friend but dominates some kids or plays on his own.
23. Has to be told how to behave.
24. Late reader or 'super' reader.
25. Literal understanding doesn't know when you are being sarcastic or joking.
26. Naive and unable to see deception in others.
27. Obsessional questioning. Answers don't satisfy him.
28. Poor handwriting
29. Seems much more childish for his age than his intelligence would suggest.
30. Sounds like a grown up sometimes.
31. Under performing at school.

Summarizing Difficulties—

Social/Emotional Delay and Disorder:

• Approaches kids and adults inappropriately.
• Childish.
• Demands a lot of adult attention.
• Difficulty making friends of his own age.
• Does not understand status.
• Doesn't recognize the difference between good and bad behavior unless told.
• Doesn't understand other people’s intentions.
• Egocentric.
• Feels bad about himself if he makes a mistake but doesn't feel embarrassment.
• Little empathy
• Naive

Language Disorder:

• Confuses he/she
• Conversation can sound too grown up or rude.
• Difficulty establishing shared attention and joint reference.
• Disproportional early vocabulary of nouns to verbs.
• Doesn't initiate conversation appropriately.
• Doesn't use language sociably and tends not to bother about social greetings.
• Early listening and comprehension problems.
• Easily distracted.
• Late talking and late pointing reverentially.
• Later on few words to describe thoughts, feelings and intentions of others.
• May have other language problems like fluency or speech disorder.
• Not interested in or able to follow topics outside his own experience.
• Over uses social phrases or non-specific pronouns e.g. 'over there'.
• Poor Auditory discrimination so he may misuse words e.g. 'cartoon' for 'carton'.
• Quiet baby.
• Single track attention in a busy room.
• Sometimes appears deaf.
• Talks nonstop about his own interests.
• Uses a flatter or exaggerated intonation pattern.
• Uses time labels incorrectly. Words like 'yesterday' can mean any period back in time.

Play skills:

• Can't share easily.
• Can't share pretence or develop story lines.
• Difficulty in following rules of games like tag, hide and seek or football.
• Finds it difficult to develop to and fro games with adults e.g. throwing and catching a ball. Hide and Seek.
• Good at lego and jigsaws.
• Likes playing on his own repetitively.
• Only plays chase or rough and tumble with other kids.
• Prefers real activities to pretend.
• Prefers self chosen activity and resists adult direction.
• Some anxiety about playing in the playground, particularly if there is no apparatus or objects to play with.

Academic Skills:

• Difficulties in playground. May result in anxious behavior just before break times with reappearance in classroom at playtimes.
• Difficulties with: handwriting, creative stories, reading comprehension, spelling and mathematical representation.
• Follows his own interests.
• Good at number, science and computers.
• Interprets topics from his own perspective.
• Only works when he wants to and appears to have no motivation for some work.
• Refuses to conform.

Motor Skills:

• Fine Motor Difficulties make practical skills like scissors, drawing, handicraft difficult.
• Gross Motor Difficulties makes riding bikes, swimming, dressing and rule based games like football difficult.

Sensory Difficulties:

• Many have a heightened awareness of smell or taste and may refuse certain foods. Others have a diminished awareness of hunger and may only eat if told.
• Some are late acquiring an interest in sensory exploration and continue to need this kind of play activity more than other kids of the same age and ability.
• Some avoid touching certain materials particularly sticky or wet substances.
• Some kids have a heightened awareness of loud noise. Others ignore loud noise and focus on peripheral sound.
• Some kids seem to have a diminished awareness of pain 'bravely' picking themselves up after serious accidents and only displaying signs of distress after observing the visible signs of hurt e.g. blood

Sameness:

This is not usually a major problem for kids with SEMANTIC PRAGMATIC DISORDER Overplaying with toys or over drawing are usually a sign of anxiety and that something in the environment needs changing - like a Speech and Language Therapist talking too much!

Over activity:

This is a feature shared by other kids with learning difficulties and may serve to confuse the diagnosis.

Initially, however, kids with Semantic-Pragmatic difficulties have very good concentration (sometimes too much) for self chosen activities like watching cartoon videos or playing with sand and water but become 'hyperactive' with more adult directed activity. Activity levels usually increase with complexity of tasks, complexity of environment, and expectations of failure. Over activity levels usually decrease with age and confidence but are hardly ever reduced by increased physical activity. Some moms & dads have found an association between food additives and levels of activity and while restricted diets do help, the problem is rarely solved this way.

Helping Kids with SEMANTIC PRAGMATIC DISORDER—

Social Development:

a. Provide a certain amount of predictability to reduce anxiety

b. Give a simple explanation to the other kids in the class (in mainstream).

c. Allow him to work in small groups or in a small class.

d. Facilitate his interactions with other kids. Do not allow him to opt out by holding your hand in the playground or dominating one youngster.

e. Give clear rules of how to behave without negative judgments. It is not healthy to be constantly told you are 'silly' or 'naughty'. When you do not know what it is you are doing wrong.

f. If he can't cope outside, give him special tidying or sorting jobs e.g. library.

g. If he hits out when thwarted, you may need to monitor him for a few days, if you want to stop this. While he may not be intentionally aggressive, he will not have sufficient empathy to know how hard to hit. His behavior could be a danger to other kids.

h. Encourage sharing, first by identifying his needs, secondly, by reflecting the other youngster's needs and thirdly by insisting he shares.

i. Make dinner time a pleasant experience. He may need an adult to sit with him.


Language:

a. Provide him with suitable conversation partners.

b. Give the youngster time to reply.

c. Acknowledge the youngsters communication even if it is inappropriately done and even if he cannot have his way.

d. Aim to teach him more appropriate strategies

e. Keep the class as orderly as possible with 'noise' to a minimum.

f. Make sure he knows what to do and what to do next.

g. If you want him to follow a general classroom instruction make sure you say his name.

h. Invite moms & dads into school on a weekly basis.

i. Talk slowly in simple sentences and do not bombard him with questions. When he asks a question make sure you are responding to his intentions rather than just the words otherwise you may be on the road to developing repetitive questioning in him.

j. If you want him to take a message home (however simple) write it down for him.

k. Use gesture or visual props when introducing new topics. Always work from shared practical experience first. This is a crucial element of teaching if knowledge is to be generalized and cannot be over emphasized.

l. Inform moms & dads which topics are being covered so they can supplement with extra hands on experience too.

m. Home school diary to help conversation and writing skills.

n. If his language doesn't make sense don't respond to what he says. Think of what he means to tell you. (his intentions)

o. Reflect what you think the youngster means when he echoes adult language, e.g. "I think it is getting awfully late", might mean "Adam is worried,. Adam doesn't understand". Hopefully this kind of comment if it matches the youngster's thinking will help him use the right words next time and reduce questioning.

p. If the youngster is involved in confrontation with another youngster, it is often helpful to reflect what the other youngster is thinking too, e.g. "Adam wants the pen". "David says it's mine".

q. Because kids with SEMANTIC PRAGMATIC DISORDER are so inflexible in thought, we suggest you tune into their thinking first. If you say what they are thinking first then the SEMANTIC PRAGMATIC DISORDER youngster is much more likely to listen. Then you can switch to what you want to say. Avoid dealing with situations by opening with a question:- e.g. "What's happening Peter?" is expressing your feelings and doesn't match what it is the youngster is thinking. Matching your words to the youngster's thoughts is called mapping. We think that mapping allows the youngster to build up a vocabulary of useful words which should have maximum meaning. If words have meaning then they should be used much more flexibly.

r. Over use specific vocabulary which youngster finds difficult. Pay particular attention to teaching opposites - e.g. he/she put/take upstairs/downstairs

s. Choose 2 or 3 words each week and ask moms & dads to do the same. Choose vocabulary from programs like living language particularly words of space, quantity, personal feelings and time.

t. Avoid sarcasm. Explain if you do.

u. Take care when you say "X is not good for you" (he may never eat it again!)

v. If you are doing 'news' work, encourage him to bring in visual props like pictures to help him talk about the 'there and then'.


Play skills:

a. Encourage sensory exploration and 'Wendy House' play

b. Help him vary his play, beyond set routines

c. Help youngster interact in playground.

d. Facilitate role play based on real life experience with props. e.g. reenact his birthday party or a trip to McDonalds using the empty cartons etc..

e. Help creative drawing and building - again based on real life visits and photos and video recordings.

f. Start group activities like story time or action rhymes with an activity he can do to hold his interest immediately.

g. Facilitate turn taking and anticipatory games through youngster centered play.

h. Encourage simple rule based games like hide and seek.


Academic Help:

a. Do not be deceived by his memory skills, make sure he 'understands'.

b. Use his visual skills and sense of order to develop understanding.

c. Extra help with correct letter formation.

d. Help him write sentences based on what the youngster has just done - with props e.g. written sequence of a practical activity.

e. If he has any obsessive or special interests, rather than ignoring them, it may be possible for him to develop them so he incorporates some useful knowledge.

f. Spelling rules - taught systematically.

g. Reading - help comprehension by reading the story to youngster first, and then discussing the text and asking him questions which require him to infer or predict but be prepared to give him the answers. Finally, ask the youngster to read the story to you.

h. Allow him to read some books above his comprehension level if he is hyperlexic so he feels as good as the other kids in the class.

i. If he is finding reading difficult, make him his own reading book with photographs based on himself and his family.

j. Exemption from topic work which may be too complex e.g. Religious or Historical projects. It may not be sensible for example to work on topics like the Romans if he does not understand what 'last week' means.


Math:

a. Help him translate mathematical problems like "If I have two sweets and you give me two more" into higher levels of representation e.g. 2+2 (make sure he understands the link).

b. Explain symbols + If these are difficult for him let him make his own and change them gradually.

c. Systematic help with 'time' based on school routine. Make sure you have a clock with numbers (one hand at a time).

d. Value of money (real money). Allow him pocket money as soon as he is old enough.

e. Make sure he understands the difference between words like:
• a few / a lot
• more / more than
• each / all / both
• how many / count
• 15 /50

f. If he is having problems with 'base 10' concepts. He may need to have special help with understanding concepts like eleven (one T. one) or twenty-three (two T. three) etc.

g. He may need extra help with estimating and measuring.


Self Esteem:

Find something he can do better than the rest of the group. If he can become the class artist or computer expert then he will gain the respect of his peers.


==> Next, we will look at Aspergers...

Aspergers Syndrome—

For years, psychiatrists have debated how to classify and subdivide the category of Pervasive Developmental Disorder (PDD). Pervasive Developmental Disorder is a category that contains several specific diagnoses. People with PDD have problems with the social interaction and often show delays in several other areas. These other areas may include language, coordination, imaginative activities, and intellectual functioning. The degree of severity can vary tremendously in the various forms of PDD. Autism is one of the more severe forms of PDD. An child with Autism has marked difficulty relating to other human beings. He or she frequently has delayed or absent speech and may be mentally retarded. Aspergers is on the milder end of PDD. People with Aspergers generally have normal intelligence and normal early language acquisition. However, they show difficulties with social interactions and non-verbal communications. They may also show perseverative or repetitive behaviors.

The Young Child: A preschool aged youngster might show difficulty understanding the basics of social interaction. He or she may have difficulty picking up social cues. He may want friends but be unable to make or keep any friends.

Elementary School Aged Child: One often hears the phrase, “poor pragmatic language skills.” This means that the child cannot use the right tone and volume of speech. He may stand too close or make poor eye contact. He may have trouble understanding age-appropriate humor and slang expressions. Many are clumsy and have visual-perceptual difficulties. Learning difficulties, subtle or severe, are common. The youngster may become fixated on a particular topic and bore others with frequent or repetitive talk even when the other Kids have given clear signals that they are no longer interested in the topic. Some have difficulties tolerating changes in their daily routine. Change must be introduced gradually.

The Adolescent: This may be the most difficult time for an child with Aspergers. Those with milder forms of the disorder may first come to treatment when they are in middle school. In adolescence, social demands become more complex. Subtle social nuances become important. Some may show an increase in oppositional or aggressive behavior. People with Aspergers have difficulty understanding which of their peers might want to be a friend. A socially marginal boy might try to date the most popular girl in his class. He will probably experience rejection. He is unaware that some other girl might accept his invitation. Because of his social naiveté, he may not realize when someone is trying to take advantage of him. He can be especially vulnerable to manipulation and peer pressure.

Adulthood: There is less information on Aspergers in adulthood. Some people with mild Aspergers are able to learn to compensate. They become indistinguishable from everyone else. They marry, hold a job and have Kids. Other people live an isolated existence with continuing severe difficulties in social and occupational functioning. People with Aspergers often do well in jobs that require technical skill but little social finesse. Some do well with predictable repetitive work. Others relish the challenge of intricate technical problem solving. I knew a man, now deceased, who had many of the characteristics of Aspergers. He lived with his mother and had few social contacts. When he visited relatives, he did not seem to understand how to integrate himself into their household routine. When the relatives would explain the situation to him, he was able to accept it. However, he was unable to generalize this to similar situations. Although he was a psychologist, his work involved technical advisory work, not face-to-face clinical sessions.

Associated Difficulties: Aspergers may be associated with learning difficulties and attention deficit disorder. Indeed, many Kids and teenagers with Aspergers have previously been diagnosed with AD/HD instead of Aspergers. People with AD/HD may have difficulty with social interaction, but the primary difficulties are inattention, hyperactivity and impulsivity. In people with Aspergers, the social awkwardness is a greater concern. As people with Aspergers enter adolescence, they become acutely aware of their differences. This may lead to depression and anxiety. The depression, if not treated, may persist into adulthood.

Treatment for Aspergers—

Medications: There is no one specific medication for Aspergers. Some are on no medication. In other cases, we treat specific target symptoms. One might use a stimulant for inattention and hyperactivity. An SSRI such as Paxil, Prozac or Zoloft might help with obsessions or perseveration. The SSRIs can also help associated depression and anxiety. In people with stereotyped movements, agitation and idiosyncratic thinking, we may use a low dose antipsychotic such as risperidone.

Social Skills Training: This is one of the most important facets of treatment for all age groups. I often tell moms & dads and teachers that the person needs to learn body language as an adult learns a foreign language. The person with Aspergersmust learn concrete rules for eye contact, social distance and the use of slang. Global empathy is difficult, but they can learn to look for specific signs that indicate another person’s emotional state. Social skills are often best practiced in a small group setting. Such groups serve more than one function. They give people a chance to learn and practice concrete rules of interpersonal engagement. They may also be a way for the participant to meet others like himself. People with Aspergers do best in groups with similar people. If the group consists of street-wise, antisocial peers, the Aspergers child may retreat into himself or be dominated by the other members.

Educational Interventions: Because Aspergers covers a wide range of ability levels the school must individualize programming for each student with Aspergers. Teachers need to be aware that the student may mumble or refuse to look him in the eye. Teachers should notify the student in advance about changers in the school routine. The student may need to have a safe place where he can retreat if he becomes over stimulated. It may be difficult to program for a very bright student with greater deficits. In one case, a student attended gifted classes but also had an aide to help her with interpersonal issues. That student is now in college. Kids with Aspergers are often socially naive. They may not do well in an Emotionally Disturbed class if most of the other students are aggressive, street-wise and manipulative. I have seen some do well when placed with other students with pervasive developmental disorders. Some do well in a regular classroom with extra support. This extra help might include an instructional assistant, resource room or extra training for the primary teacher.

Psychotherapy: People with Aspergers may have trouble with a therapist who insists that they make an early intense emotional contact. The therapist may need to proceed slowly and avoid more emotional intensity than the patient can handle. Concrete, behavioral techniques often work best. Play can be helpful in a limited way if the therapist uses it to teach way of interaction of the therapist uses play as a break from an emotionally tense if it is used to lower emotional tension. Adults and Kids may also do well in group therapy. Support groups can also be helpful.

Moms & dads play an important role in helping their youngster or teenager. This youngster or teenager will require time and extra nurturance. It is important to distinguish between willful disobedience and misunderstanding of social cues. It is also important to sense when the youngster is entering emotional overload so that one can reduce tension. They may need to prepare the youngster for changes in the daily routine. One must choose babysitters carefully. Moms & dads may have to take an active role in arranging appropriate play dates for the younger youngster. Some moms & dads seek out families with similar Kids. Kids with Aspergers often get along with similar playmates. Moms & dads should help teachers understand the world from the youngster’s unique point of view. Parenting an teenager with Aspergers can be a great challenge. The socially naive teenager may not be ready for the same degree of freedom as his peers. Often moms & dads can find a slightly older teenager who can be a mentor. This person can help the teenager understand how to dress, and how to use the current slang. If the mentor attends the same school, he can often give clues about the cliques in that particular setting.

Adults may benefit from group therapy or individual behavioral therapy. Some speech therapists have experience working with adults on pragmatic language skills. Behavioral coaching, a relatively new type of intervention, can help the adult with Aspergers organize and prioritize his daily activities. Adults may need medication for associated problems such as depression or anxiety. It is important to understand the needs and desires of that particular adult. Some adults do not need treatment. They may find jobs that fit their areas of strength. They may have smaller social circles, and some idiosyncratic behaviors, but they may still be productive and fulfilled.


References—

1. Aarons and Gittons 1992 Autism - A guide for parents and professionals.
2. Aarons and Gittons Dec. 91 Autism as a context. Bulleting No. 476.
3. Bishop and Rosenbloom 87 Childhood Language Disorders : Classification and overview in language development and disorder.
4. Bishop D. 89 Autism, Aspergers Syndrome and Semantic Pragmatic Disorder. Where are the boundaries? British Journal of Disorders of Communication 24
5. Child language teaching and therapy Vol 1 No. 1
6. Ed. Yule and Rutter. Pub. Mac Keith Press
7. Frith 89 Autism : Explaining the Enigma. Blackwell
8. Frith 91 Autism and Asperger Syndrome. Cambridge
9. Granberg 85 Some problems in the Early stages of teaching numbers to language handicapped children.
10. Hughes Martin 86 Children and number difficulties in learning mathematics. Blackwell.
11. Leinonesse and Smith BR 92 Clinical Pragmatics.
12. Neuropsychology of language, reading and spelling New York : Academic Press
13. Rapin L & Allen D. 83 Development Language Disorders Nostologic consideration. JN U. Kirk Ed.
14. Wilson A. 92 Do Semantic Pragmatic Disordered children have a Theory of mind? (MSC research project in press)
15. Wing C. 1992 Autistic Continuum Disorders.


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