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Treating Children with Aspergers and Comorbid Bipolar Disorder

Kids and teenagers with pervasive developmental disorders, including Aspergers, often are seen by pediatricians, pediatric neurologists, child psychiatrists, and other professionals as having a variety of behavioral and emotional disturbances (1–3). Aggression and self-injury are among the most common problematic behaviors that come to the attention of clinicians. In some of these kids and teenagers, these disturbing behaviors are symptoms of a comorbid psychiatric condition. However, many clinicians continue to view them as part of the underlying developmental disorder. In consideration of the long-term disability associated with the pervasive developmental disorders and the absence of specific pharmacological treatments for the core deficits of this disorder, it is of paramount importance to recognize and treat comorbid psychiatric conditions in these kids, which can substantially improve functioning (2, 3).

This report summarizes a clinical case conference presented at McLean Hospital in Belmont, Mass. The presentation was used to inform clinicians about the occurrence of psychiatric disorders among developmentally disabled kids, with an emphasis on those with pervasive developmental disorders. It also serves as an illustration of how aggression and self-injury can be symptoms of comorbid psychiatric disorders and underscores the necessity of proper diagnostic formulation in these kids. For this youngster, the proper diagnosis was not recognized for years. Once he was diagnosed with comorbid bipolar disorder, appropriate treatment led to a decrease in problematic behaviors, an improvement in quality of life for the youngster, and a decrease in family burden.

CASE PRESENTATION—

Michael (not his real name) first came to the McLean outpatient department at the age of 13.5 years. He had just been discharged from inpatient hospitalization and required ongoing outpatient pharmacologic management. His mother stated that he had been diagnosed with Aspergers and despite numerous placements in therapeutic schools, hospitalizations, and medication trials, he continued to be violent and aggressive. None of the medications that he had tried had been effective, except thioridazine. Michael had been treated with thioridazine, 125 mg/day, for an extended period. Both parents, who were well educated, felt that their son did not simply have Aspergers, and they wanted to know what other diagnoses could be made. In addition, Michael’s parents were concerned about his current medication regimen because he had recently developed an unusual tongue movement, which was most prominent when he missed a dose of thioridazine.

At the initial evaluation, Michael had ongoing sleep disturbances, obsessions, sadness, irritability, and racing thoughts. He spoke in a loud, anxious manner. He washed all the clothes in the house in a frenzied and intense manner late into the night, even if the items were clean. Michael obsessed about a girlfriend who he reported was enrolled at a local public high school, although the girlfriend did not, in fact, exist. Michael also felt that God could transfer thoughts from one person to another and that God and other people could read his mind. Michael stated that something was "haywire" and that he felt like he was "unraveling." He could not follow his own thoughts and felt disorganized. Michael also stated that he felt he could see his dead uncle. He admitted to biting himself when he was upset.

His mother said that Michael had become more aggressive over the past few months. Without provocation, he had hit his younger siblings and struck out at people. In addition, his mother described him as being more perseverative than usual. He was extremely intrusive physically and engaged in some inappropriate touching. His mother stated that Michael’s whole family was gravely affected by his behavior. His siblings were afraid of him. His mother, who was a graduate student at the time, had missed many classes, and his father often had to leave work early in order to help with Michael.

His parents described him as quite silly and anxious at age 2.5 years. At age 4, Michael had become aggressive and had engaged in bizarre talk using repetitive nonsensical words. Michael was first hospitalized when he was 8 years old. Psychological testing at that time showed that he had some looseness of association and some breaks with reality. Psychotherapy notes at that time stated that he had "manic-like behaviors."

Since the age of 8, he had undergone numerous evaluations. He had a history of being fidgety, having grandiose and racing thoughts, exhibiting disorganized behavior, and being aggressive. Michael showed mood lability and had discrete episodes of hypomania, evidenced by silliness, hypersexuality, poor sleep, and perseverative and pressured obsessive ritualistic behaviors, such as washing clothes all night. He had received numerous diagnoses in the past, including conduct disorder, attention deficit hyperactivity disorder (ADHD), social learning disability, anxiety disorder, pervasive developmental disorders not otherwise specified, and Aspergers. The most consistent historical diagnosis given to Michael was pervasive developmental disorders not otherwise specified or Aspergers. However, none of the historical diagnoses had captured his symptom complex completely. One treating psychiatrist had entertained the possibility that Michael might have mood dysregulation and tried lithium to treat his symptoms, but no formal diagnosis of bipolar or affective disorder had been made.

The results of past neurologic evaluations, including an EEG and magnetic resonance imaging, had all been within normal limits. A test for fragile X syndrome had been negative. At 6 years old, Michael had psychological testing; his verbal IQ was 111, and his performance IQ was 97. He had difficulty grasping a pencil and was noted to have trouble placing pegs in a Peg-Board with only one hand. He had difficulty "reading" the emotional content in pictures in the Kid’s Apperception Test (which contains drawings of familiar social situations, such as a father sitting in a chair with a boy next to him). Michael routinely had difficulty labeling the feelings shown in the pictures accurately and had difficulty perceiving the social interactions that were taking place. The examiner felt that his inability to identify the feelings of others was causing Michael to misperceive what was going on socially in his environment. In addition, Michael was highly anxious and inattentive and had difficulty with self-control. He was seen as managing his anxiety by trying to control social situations in an effort to counter some of the social rejection he faced. The examiner concluded that Michael had a "social learning disability." At numerous subsequent psychological evaluations, Michael was noted to have disorganized thinking.

He had been prescribed a number of medications over the years. He was initially given imipramine but developed a glazed look and stomach aches, so it was discontinued. He had tried four selective serotonin reuptake inhibitors (SSRIs)—fluoxetine, clomipramine, sertraline, and paroxetine—all of which led to an increase in sleep disturbances, agitation, aggression, and, at times, homicidal ideation. In addition, he was given a low dose of methylphenidate (10 mg/day), which increased his agitation. A trial of perphenazine, up to 9 mg/day, caused side effects but no improvement. The psychiatrist who suspected an underlying mood disorder tried lithium, up to 600 mg/day. Lithium decreased Michael’s impulsivity and motor agitation; however, it was discontinued because it caused diarrhea.

Michael had been hospitalized just before his outpatient visit at McLean Hospital because of his worsening depressive symptoms and suicidal ideation. He was sad, could not concentrate, and did not want to attend his new school. Michael was intermittently suicidal and preoccupied with skunks and washing all the clothes in the house. In addition, he began experimenting with electrical appliances, and just before his last hospitalization, he had stuck a knife in an electrical socket.

While in the hospital, he had to be placed in the quiet room frequently because of his aggressive, inappropriately intrusive, and oppositional behaviors. At times Michael had to be placed in six-point restraints because he slammed his body repeatedly against the door of the quiet room. He underwent a short trial of paroxetine during this stay to address his depression and obsessiveness, but he became increasingly irritable, sad, sleepless, and aggressive on this regimen. Michael was discharged from the facility with a diagnosis of Aspergers and "rule out intermittent explosive disorder." His medications included clonidine, 0.25 mg/day, and thioridazine, 125 mg/day.

At the time of his initial evaluation, Michael lived with his supportive family. His mother and father, married for 16 years, were both in their late 30s at the time. His three siblings were all younger than Michael. His father had experienced episodes of major depression, which responded to pharmacologic treatment. An uncle had been diagnosed with ADHD, and a maternal grandfather had alcoholism. There was no family history of anxiety disorder, obsessive-compulsive disorder (OCD), developmental disorders, psychosis, or bipolar disorder. There was also no family history of neurological disorders.

Michael’s mother’s pregnancy was uncomplicated and went to full term; his birth weight was 7 lb, 10 oz. His mother did not use alcohol, illicit drugs, or prescription medications during pregnancy. He was slightly jaundiced at birth but did not require phototherapy. His mother breast-fed him for 15 months, and he gained weight normally. His mother described Michael as an infant as calm and cuddly and liking to be held. His sleep patterns were irregular from an early age. As an infant, Michael seemed to visually track objects in his crib, even if there was nothing there. As a toddler, Michael had only fair eye contact. He never had stereotypic movements. Michael had a tendency to be preoccupied with objects, particularly mechanical things, at times to the exclusion of people.

Michael’s parents noticed that Michael was different from other kids when he was 2 years of age. For example, although his speech development was timely, he tended to speak in a loud voice, with odd prosody. Although he was very bright and often had precocious speech, Michael spoke with pronominal reversals, repeated nonsensical words, and engaged in lengthy pedantic monologues regarding his circumscribed topics of interest. His motor development was timely. In addition, Michael had difficulty with fine motor skills and was noted at age 6 to have an awkward pencil grip while writing. He had little capacity for reciprocal interaction. Michael did not seem to have the capacity to understand other people’s feelings and had little capacity to empathize with others. He had difficulty making friends because he was controlling and bossy and wanted all the other kids to engage in his activity of choice while adhering strictly to his rules. He also had difficulty sharing and taking turns in a socially appropriate manner. Michael often preferred to be in the company of adults and related to adults better than to his peers. He had an odd preservative way of seeking comfort during times of distress, during which he would intrusively ask questions repeatedly.

Over the years, his focus of interest shifted. For example, as a preschooler, he was preoccupied with his stuffed animals and needed to line them up in a certain way; as a preadolescent, he was preoccupied with trains and collected all the train schedules that he could acquire; and as an adolescent, he focused more on mechanical items, such as electrical sockets and washing machines, with an intense inquisitiveness as to how they worked. In addition, he was very good with numbers as a young child and was able to do multiplication at age 6. He had extreme difficulty adjusting to changes in his routine and was very rigid in his insistence on adhering to his daily schedule.

Upon initial examination in our clinic, Michael appeared well dressed, well groomed, and eager to converse. He made brief eye contact but more often he looked around the room with darting eyes. He was quite fidgety. His speech was somewhat pedantic in style, pressured, and loud. He described his mood as "fine." His affect was irritable and labile, ranging from anger to sadness. His thought content was notable for grandiosity; he thought that he had the capacity to understand everyone in the world. He asserted that he had a girlfriend (who did not exist). Michael believed that he could read other people’s minds, that other people could take thoughts out of his head, and that other people could then turn his own thoughts against him. He felt that his younger siblings were intentionally trying to hurt him. He was not suicidal or homicidal at the time. His thought process was overly inclusive, perseverative, and, at times, circumstantial. There was no evidence for current auditory, visual, tactile, or olfactory hallucinations, although he stated that he had been conversing with a dead person just before his recent hospitalization. He did not have the capacity for reciprocal conversation. He also did not seem to understand that other people might have feelings separate from his.

Michael was given the following diagnoses: bipolar disorder (mixed, with psychotic features) and Aspergers, with features of OCD. Shortly after his initial outpatient evaluation, Michael was hospitalized at McLean because of ongoing agitation and unsafe behavior. His thioridazine and clonidine doses were slowly tapered, and he was given other medications, including valproate and propranolol. Both trials were of short duration and limited efficacy owing to side effects. Eventually, a combination of 1 mg b.i.d. of oral clonazepam, 2100 mg/day of lithium (1.0 mM), and 3 mg/day of risperidone led to a marked reduction in his behavioral symptoms. Over the next few months his mood normalized and his aggressive, extreme compulsive and disruptive behaviors stopped.

FOLLOW-UP—

Michael has not been hospitalized for several years now. In the intervening years, his risperidone has been slowly tapered to 1.5 mg/day, and his lithium dose has remained at 2100 mg/day. He has continued to do well with his medication regimen, with minor adjustments for occasional episodes of mild hypomania. During these hypomanic periods, Michael’s obsessiveness also increases, and it has become clear over the years that his obsessiveness cycles with his mood and is more of a manic preoccupation than the type of obsessiveness typically seen in kids with pervasive developmental disorders.

Michael currently attends a therapeutic day school that specializes in educating individuals with autistic spectrum disorders, where he receives psychotherapy, group therapy, behavioral and social pragmatic intervention, and vocational preparation. The professional staff at the school and at McLean Hospital are in regular contact regarding his progress.

His mother states that Michael is more responsible, he is helping appropriately around the house, he is trying to be a good big brother to his siblings, and he is an excellent driver. His siblings look up to him now and are not afraid of him. In addition, once Michael’s condition was stable, his mother was able to finish her graduate program and went back to work.

Although Michael’s impaired mood symptoms are currently under control, he continues to have difficulty in a number of areas: in peer relationships (he prefers the company of adults to peers), in his ongoing preservative way of seeking comfort when distressed, in his ongoing interest in circumscribed topics (although it is not as intense and pressured as when he is manic; Michael now has the capacity to be redirected from his obsessions), in his pedantic speech (although he is no longer pressured and disorganized), in the monotonous quality to his speech, in his ongoing difficulty understanding the feelings of others, in his awkward gross motor movements, and in his difficulty adjusting to change in his routine. Aside from these ongoing symptoms of underlying Aspergers, the only remaining issues are those that his mother feels are typically seen in adolescent boys, as he struggles to individuate from his parents. Michael was able to personally describe his other successes in an interview.

INTERVIEW WITH MICHAEL—

Michael: [Immediately after he was introduced, Michael eagerly went to the front of the room and began addressing the people attending the conference without any questions having been asked of him.] First of all, I started high school in August of [deleted]. I am going to get my high school diploma in [deleted]. So far, I’m doing very, very well, and when I get my diploma, I am probably going to go on to college or something like that, but I would like to share some of my improvements with you: I started this high school program, which does not end until [deleted]. I also now have a driver’s license [applause]. Thank you very much. This license says I can drive. [Michael held up his license for all to see.]

Also, I would like to share that despite walking out a couple of times, I now have a job as a cashier in a food grocery store. I had a job before this, but I quit in the middle of the day the first time. I had the job, then I called them later and said, "May I please come back?" and they said, "Sure," after a few days of thinking. I quit in the middle of the day a second time too and did not go back to that site. Now I have a different job at another food store; the old job was a food store job as well. At this job, I am the cashier making $6.40 an hour, for those that are interested.

I also want to say I am a very religious person, I’m very strong with God; I’m not going to get deeply into it, as it’s not very appropriate at this time. I just want to say I am very religious; I always have been.

Also, I have had no accidents since I got my license, and that shows a lot of ability to drive well.

Regarding this high school program issue, I have my hard times in this high school program in regards to making friends, but in general I have done well over all, and I thank God and I thank all for your help.

Dr. Jackson: Now, tell me when you had this job and you quit it on two occasions. The first job at the first grocery store did not go well?

Michael: Actually work-wise, I did a good job. I’m very good at being polite to customers and helping them out, but I had this one day when something went wrong. I said, "Good-bye, I’m leaving," and I left without any notice.

Dr. Jackson: So, it sounds like you are really doing well with your new job.

Michael: I like it a lot.

Dr. Jackson: You said you had some problems with making friends at work and at school?

Michael: Friendships have never been completely easy for me, but at my house, I have a lot of neighborhood friends because the kids in my school are obviously like me in some ways. They are not going to be happy and cannot offer the perfect friendship.

Dr. Jackson: Could you tell me about some of your friends in your neighborhood?

Michael: Well, I have this one friend. He is more my brother’s friend than mine, but he really helps me a lot because he said that I have a nice personality, and I do. I have a very nice personality. I’m very helpful and caring, every single day. For example, now I walk my dog to be helpful to the dog and to the family. Although, some days I might get off because I have something important, but most days I give my dog a very quick 3-mile walk.

Dr. Jackson: Do you have any hobbies?

Michael: I like to read the Bible, I like to go to church, I like to drive, and I like to work.

Dr. Jackson: How long have you been seeing Dr. Frazier?

Michael: I met Dr. Frazier for the first time....

This was weird, because I actually announced to my mom that I needed to go back in the hospital; she didn’t say I had to go back, I announced it. She said, "Well, if you say so, let’s go." So I went and that was my first time as an inpatient here and when I met Dr. Frazier.

I am too upset to think about that [the hospitalization]. But...do you want my honesty?

Dr. Jackson: Yes.

Michael: Well, the reason I wanted to go to the hospital was to visit all the people that I met the first time I was in the hospital.

Dr. Jackson: It also sounds like you were still having a difficult time.

Michael: I was still having a hard time, but I basically liked my first time in the hospital. About a month after I left the hospital, I said to myself, "I miss those people there...the staff. I would love to go back to see them." I knew that one way that was possible was to be hospitalized again, because you can’t go back to visit. So, I went back—I said, "Mom I need the hospital again. I’m going nuts" (even though I was really fine, and I wasn’t really that upset). I just thought I had to say something to convince her. I went back to the hospital, and I was only there for a day, then I was transferred here and started working with Dr. Frazier. That’s how I’m with her. When I was hospitalized here, I just wouldn’t stop running around.

Dr. Jackson: Do you remember what the hospital stay here was like?

Michael: Yes, I mean, like, I’m bipolar, and until I got on to this lithium, which protects me from it, I was really not doing well because sometimes, when I was really feeling low, I’d run into my mother and jump on her lap and start crying like my little brother. Once I met Dr. Frazier, she put me on lithium and I was fine, depression-wise. I still get depressed sometimes but not like before, and even when I am depressed...I can drive just fine.

Dr. Jackson: Mrs. [deleted], what changes have you observed since Michael was hospitalized 3 years ago?

Mrs. [deleted]: Before the hospitalization, we were at the end of our rope. Michael’s problems were dominating the family, frightening his siblings. Safety issues were a constant concern. My husband and I were looking into a residential placement. Now, Michael is a different person—responsible, hardworking, and a conscientious big brother.

DISCUSSION—

Aspergers is a developmental disorder that is on a diagnostic continuum with autism and falls under the category of pervasive developmental disorders. The American Psychiatric Association included this diagnosis in DSM-IV. The disorder is characterized by a paucity of empathy, naive and inappropriate interactions, a limited ability to form friendships with peers, pedantic and poorly intonated speech, egocentrism, poor nonverbal communication, intense absorption in circumscribed topics, and, at least in some patients, ill-coordinated movements. Although Aspergers is similar to autism in many respects, the distinguishing feature in individuals with the disorder is their relatively normal speech development. In addition, individuals with Aspergers are less likely to have stereotypical behaviors and tend to have normal intelligence. In fact, a delayed onset of language may be the only developmental variable that predicts diagnosis when kids with high-functioning autism and Aspergers are compared (4). The long-term outcome for individuals with Aspergers is generally more positive than for those with autism. For example, many individuals with Aspergers go on to college and start their own families. The disorder may have a later age at onset (>24 months) than autism. Before the publication of DSM-IV, Aspergers was often described as high-functioning form of pervasive developmental disorder and was coded as pervasive developmental disorders not otherwise specified.

Diagnosis-

An English study by Howlin and Asgharian (5) found that the diagnosis of Aspergers is often delayed in affected individuals, despite parents’ concerns about their kid’s abnormal social development, beginning around age 30 months. Kids with autism tended to be diagnosed around age 5.5 years on average, whereas those with Aspergers tended to be diagnosed around age 11 (5). Earlier diagnosis and appropriate intervention can optimize a youngster’s functioning. The American Academy of Child and Adolescent Psychiatry published practice parameters for the assessment and treatment of individuals with autism spectrum disorders (6). In addition, the Child Neurology Society and the American Academy of Neurology proposed a method for diagnosing and assessing autism that entails a dual-level approach: 1) routine developmental surveillance and 2) diagnosis and evaluation of autism. (Specific recommendations for each of these two levels are described in reference 7.)

Prevalence and Genetics-

Estimates of the prevalence rate for autism have varied somewhat over the past decade. Autism was thought to occur in 1 out of 2,000 kids and more recently has been estimated to occur in 1 out of 500 kids (1, 7). In a recent English survey of 15,500 kids (aged 2.5–6.5 years) (8), the prevalence rate for autism was found to be 16.8 per 10,000 kids and 45.8 per 10,000 kids for other pervasive developmental disorders.

The concordance rate for autism in monozygotic twins is 60%; the concordance rate for a broader autism phenotype is 90% (9, 10). In one study (11), the risk of recurrence for autism (i.e., the frequency of autism in subsequent siblings) was estimated at 6%–8%, or up to 200 times the risk in the general population. However, a more complicated analysis of the same data using a mixed-model method (i.e., a major gene model, a polygenic model, a sibling-effect model, and a mixed-model consisting of major-gene and shared-sibling effects) (12) estimated that the relative risk of recurrence of autism is only 4.5%, which is 65 times greater than the risk in the general population. The difference in concordance between monozygotic twins and dizygotic twins or first-degree relatives is consistent with the requirement for multiple interacting genes; a combination of three separate risk genes provides the most plausible model (13). Current genetic research in autistic spectrum disorders is directed at identifying genetic loci that may be associated with components of the disorder, such as social impairments, cognitive deficits, and obsessional traits (14).

As a component of autistic spectrum disorders, Aspergers has been estimated to occur in 8.4–10 of 10,000 kids in one study (1, 8). Aspergers may be highly heritable. For example, a recent familial aggregation study (15) demonstrated that in families of kids with pervasive developmental disorders (34 with two affected kids, 44 with one affected youngster, and 14 with an adopted youngster with pervasive developmental disorders), all components of the lesser variant of pervasive developmental disorders (or with traits like those in pervasive developmental disorders) were more common in biological relatives than nonbiological relatives, which confirmed the familial aggregation of the traits. Kids who had a greater risk of family members being affected were those with a higher level of functioning who came from families in which two kids were affected with pervasive developmental disorders (15). However, the genetics of Aspergers, in particular among the pervasive developmental disorders, have not been well studied. Future research needs to focus on the genetics specific to this disorder.

Comorbidity of Asperger’s and Bipolar Disorders-

Several investigators have described kids with mood lability who satisfy many of the diagnostic criteria for bipolar disorder in their prepubertal years (16–19). Kids with presumptive bipolar disorder exhibit mixed mood states, chronic irritability, rapid cycling, suicidality, and oppositionality. Kids with developmental disabilities have a two-to-six-times greater risk of experiencing comorbid psychiatric conditions than their developmentally normal peers (3, 20–22). The presence of comorbid affective disorders in these kids may more severely impair an individual with already limited cognitive functions and social skills (23). However, individuals with Aspergers and other developmental disabilities can suffer from treatable comorbid mood disorders for years, despite frequent medical assessments and developmental and psychiatric evaluations. The reasons for this delay in diagnosis of a comorbid mood disorder are complex and multiple. The symptoms of mood disorders can be masked by other symptoms or behaviors in the population with autistic spectrum disorders; for example, behaviors that are characteristic of or associated with autistic spectrum disorders (i.e., obsessiveness, stereotypies, hyperactivity, inattention, social intrusiveness, social withdrawal, aggression, and self-injurious behaviors) may become more pronounced, intense, or exaggerated during manic or depressive phases. The changes in these behaviors in individuals with both Asperger’s and bipolar disorders are usually episodic and occur within the context of a mood state and are responsive to effective treatments for mood disorders. Individuals with autistic spectrum disorder or Aspergerss have a limited ability for abstract thinking, restricted or odd expression of emotions in their faces, voices, or words, and limited capacity to understand the mental states and feelings of themselves or others. Most individuals with autistic spectrum disorders are very sensitive to changes in their environment, and their moods and behaviors shift in response to these changes (24).

Diagnosing Comorbid Bipolar Disorder-

Bipolar disorder should be entertained as a possible diagnosis when there is deterioration in cognition, language, behavior, or activity; when there is a clear pattern of fluctuation or cyclicity in activity, behavior, and interests (with "good times" and "bad times"); and when observed behavior indicates a mood problem. (As examples of the latter, an increase in crying, self-injury, sleep disturbances, and social withdrawal, a decrease in activity, and a loss of interest in activities of daily living may indicate depression; an increase in silliness, distractibility, poor judgment, intrusiveness, laughing, aggression, pressured speech, noncompliance, and agitation may represent symptoms of mania [24–26].)

Although more research needs to be done to delineate the similarities and differences in mood states between individuals with Aspergers and developmentally normal individuals, Sovner (25) (and with Parry [26]) proposed some criteria as a starting point. Sovner noted that there are four specific domains of functioning in individuals with developmental disorders that can be further affected by a comorbid affective illness, making the task of diagnostic formulation difficult. These four domains are intellectual distortion, psychosocial masking, cognitive disintegration, and baseline exaggeration (25).

Rates of the prevalence of comorbid pervasive developmental disorders, specifically Asperger’s and bipolar disorders, are difficult to ascertain as Aspergers is a relatively new diagnostic category that first appeared in DSM-IV, and the actual prevalence of pediatric bipolar disorder will be difficult to fully ascertain until the definition of bipolarity in kids is more fully agreed upon. However, in a population of kids evaluated by a pediatric psychopharmacology clinic, Wozniak and colleagues (27) reported that out of 727 kids, 52 met criteria for pervasive developmental disorders, 114 met criteria for mania, and 14 of 52 kids with pervasive developmental disorders met criteria for both pervasive developmental and bipolar disorders (which represented 2% of all referrals, 12% of the kids with bipolar disorder, and 27% of the kids with pervasive developmental disorders). Clearly, these data suggest that there was an overrepresentation of kids with pervasive developmental disorders in the overall group with bipolar disorder and an overrepresentation of kids with bipolar disorder in the group with pervasive developmental disorders. However, the study did not specifically represent individuals with Aspergers, and it is not clear how generalizable these data were to the group with general pervasive developmental disorders because they represented kids who were evaluated in a pediatric psychopharmacology clinic. To date, there is little known about the prevalence of mood disorders in a group of kids with Aspergers who were not specifically referred for treatment of serious behavioral problems.

There are a number of published case reports and studies that suggest an association between autistic spectrum disorders and bipolar disorder (27–31), although not all of these reports are explicit regarding the number of kids that actually had Aspergers because they predate DSM-IV. For example, Komoto and colleagues (28) described three autistic kids who also had an affective disorder and a positive family history of depression or bipolar disorder. Gillberg (29) described a patient with Aspergers and recurrent psychosis who had a family history of bipolar disorder. Lainhart and Folstein (24) reviewed all of the current published case reports regarding kids with autistic spectrum disorders and comorbid affective disorders (N=17). In a study of a group of patients with Aspergers who were followed into adolescence, Wing (30) found that nearly one-half of the patients developed affective disorders. In another study (31), kids with autistic spectrum disorders who had a family history of bipolar disorder were compared with kids with autistic spectrum disorders who had no a family history of bipolar disorder; clear differences in symptom profiles were seen in the two groups. The kids without a family history of bipolar disorder did not have marked cyclic variations in behavior, showed less florid agitation, fearfulness, and aggression, and were of lower functioning, whereas the kids with a family history of bipolar disorder showed extremes of affect, cyclicity, intense obsessive interests, neurovegetative disturbances, and regression after a period of normal or precocious development.

There is an accumulating body of literature that suggests that autism spectrum disorders may be associated with a family history of affective disorders (28–36); several of the studies indicate that there is a greater risk of bipolar disorder in family members of individuals with Aspergers, in particular. For example, a higher prevalence of affective disorders, especially bipolar affective disorder, was found in the families of about one-third of the individuals who were diagnosed with autism spectrum disorders (31, 32, 35). DeLong and Dwyer (33) found that relatives of probands with pervasive developmental disorders had a 4.2% prevalence of bipolar disorder (nearly five times greater than that expected in the general population) and that the prevalence was highest among relatives of probands with Aspergers (6.1% versus 3.3% for relatives of probands with autism). On the other hand, Gillberg (34) found rates of affective disorder in this group that were similar to those found in the general population. He found that four (17%) of 23 kids with Aspergers and three (13%) of 23 with autism had family histories of major affective disorders. On the other hand, Piven and colleagues (35) found that although major depression had a higher lifetime prevalence in the moms and dads of autistic probands (27%) than in the normal population, bipolar disorder did not. Finally, DeLong and Nohria (36) studied 40 kids with autistic spectrum disorder, 20 of whom had no identifiable neurological disorder that could account for their autism. A family history of affective disorders enriched by sevenfold the risk of autistic spectrum disorders in the group compared with those who did have an underlying neurological disorder, such as tuberous sclerosis or congenital rubella.

Neurobiology-

In 1978 Damasio and Maurer proposed a mesolimbic model of autism (37). More recently, Bachevalier (38) demonstrated deficits in social reciprocity and an increase in circumscribed behaviors in nonhuman primates who had had their amygdalo-hippocampal complexes lesioned during infancy. The amygdala is a critical component of the limbic or affective loop in the brain and has been implicated in both neuropathological and neuroimaging studies of Aspergers, autism, and bipolar disorder. The involvement of the amygdala and the limbic system and the apparent involvement of the right side of the brain in Aspergers suggest areas of overlap with bipolar disorder, which also has been described as involving dysfunction of the right hemisphere (39).

Treatment-

Unfortunately, despite the fact that there are medications that can help kids with mood disorders in the autistic spectrum, many kids are never diagnosed properly, nor do they come to the attention of mental health professionals. For example, in an epidemiological study (40), at least 41% of the kids who were developmentally disabled were affected by comorbid psychiatric disorders, but less than 10% of the kids with comorbid psychiatric disorders had seen a specialist.

There are numerous system biases and multiple issues that contribute to the lack of proper psychiatric diagnoses and treatment for kids with autistic spectrum disorders. These kids may suffer from two disorders, both carrying with them a societal prejudice. This prejudice partly influences medical professionals to the degree that psychiatric evaluation and treatment are often overlooked in these kids, which results in the phenomenon known as "diagnostic overshadowing," in which changes in mood and behavior are wrongly attributed to the individual’s developmental disorder rather than to a comorbid psychiatric condition (23). Owing to the individual’s poor communication and social skills, the expression of psychopathology (e.g., self-injurious behavior, aggression, and rocking) may be different from that of a cognitively and developmentally normal individual. Understanding the etiology of a disturbing behavior is extremely important.

The selection of medications for treating problematic behaviors requires careful observation of the youngster with an autistic spectrum disorder over a period of time, owing to the patient’s limited ability to express problems verbally and poor insight. In general, targeting symptoms of a psychiatric disorder, and not of an individual behavior, should be the basis of treatment with psychopharmacologic agents. For example, the individual behavior of self-injury may be a symptom of numerous psychiatric disorders. Proper formulation needs to occur before treatment is initiated.

It is important to emphasize that there are a limited number of controlled trials regarding the use of psychopharmacological interventions in this population. Therefore, pharmacological intervention should be chosen judiciously, and patients should be closely monitored for symptom improvement and side effects. Given that these patients are often treated with psychotropic medications, there is a crucial need for systematic controlled trials to establish both the safety and efficacy of pharmacological agents in kids with Aspergers and with developmental disabilities in general.

Historically, kids with developmental disabilities have been reported to have a higher rate of dyskinesias (29.7%) when treated with neuroleptics (41). However, when 16 neuroleptic-naive autistic kids were assessed at baseline for stereotypies, mannerisms, and dyskinetic movements, 25% were found to have abnormal movements (42). In addition, the raters in this study were unable to distinguish these abnormal baseline movements from the dyskinesias that other autistic kids had developed during treatment with neuroleptics. Nonetheless, tardive dyskinesia is a concern to clinicians, especially when they are considering use of typical antipsychotics in this population. Therefore, the atypical agents, with their lower (but not yet fully determined) risk of tardive dyskinesia, offer much promise for the pharmacotherapy of these kids and other pediatric populations (43–45).

Thioridazine is a typical antipsychotic agent that has been used historically in child psychiatry with relative frequency. Like the atypical agents, thioridazine has lower acute extrapyramidal side effects and some serotonin 5-HT2 receptor antagonism, which has made it an attractive agent for use in youth. However, thioridazine has recently been given a "black box" warning because of its tendency to cause prolongation of the QT interval on ECGs.

Risperidone, when used in kids with autistic spectrum disorders, leads to significant reduction of repetitive behaviors, aggression, impulsivity, and some elements of social relatedness (43). The effectiveness of risperidone was evaluated in a retrospective chart review of the treatment of kids with bipolar disorder who did not have pervasive developmental disorders. In this study (45), risperidone was extremely helpful in decreasing mania, psychosis, and aggression. In addition, studies using other atypical agents for the treatment of childhood bipolar disorder are beginning to appear in the literature (44).

Although pharmacological studies of lithium are few among developmentally disabled individuals, case reports indicate that lithium can be quite helpful in the treatment of bipolar symptoms in kids with pervasive developmental disorders (28, 31, 46). In addition, DeLong and Dwyer (33) reported that four out of seven kids with Aspergers and comorbid bipolar disorder and a family history of bipolar disorder had a good response to lithium treatment (33).

Kids with Aspergers generally require ongoing multimodal intervention to achieve optimal functioning; psychotherapy, social skills training, speech and language intervention at times, occupational and physical therapy, vocational training, and psychopharmacologic intervention can treat the severely impairing symptoms of comorbid psychiatric disorders (1, 6). Coordination of services and communication between various providers is essential. Our patient, Michael, was ultimately placed in a special school for individuals with Aspergers that provided psychotherapy, social pragmatics, group therapy, and some vocational training.

CONCLUSION—

Michael’s story illustrates a number of important points regarding the comorbidity of bipolar and Aspergerss. From an early age, Michael clearly had characteristics that are seen in kids with Aspergers. Furthermore, the hallmarks of Aspergers remained with Michael, even after his comorbid bipolar disorder was appropriately treated. Although Michael was impaired by his developmental disorder, it is quite clear that the symptoms of Michael’s bipolar disorder led to severe disruption of functioning. Michael had symptoms of an affective illness beginning at an early age. For him, delayed diagnosis and treatment led to 5.5 years of progressive dysfunction and a worsening of symptoms. His affective disorder exacerbated the underlying symptoms of Aspergers. For example, when he was manic, Michael became more intrusive and engaged in more socially inappropriate behaviors; his pedantic speech became more pressured, he engaged in lengthy monologues, and his obsessionality became intense. Once comorbid bipolar disorder was diagnosed and appropriate treatment occurred, Michael gradually began to recover and his self-injury, aggression, and intense pressured obsessiveness disappeared. Michael’s father has a history of depression, which is consistent with the findings of a higher rate of affective illness in the first-degree relatives of kids with Aspergers.

Michael has a history of treatment with a typical antipsychotics, during which he developed oral dyskinesia. Some literature has suggested that kids with autistic spectrum disorders may have a slightly higher incidence of dyskinesias or withdrawal dyskinesias (41). Of note, Michael’s tongue movements disappeared when he was switched to risperidone. In addition, Michael responded well to the combination of lithium and risperidone. Both medications (lithium and risperidone) have been described in the literature as being helpful and well tolerated in individuals with autistic spectrum disorders (31, 32, 43).

Educating pediatricians, pediatric neurologists, child psychiatrists, and other mental health professionals about the high prevalence of comorbid psychiatric conditions in individuals with autistic spectrum disorders is crucial so that these kids receive appropriate treatment. Appropriate treatment can greatly enhance a youngster’s ability to optimize his or her developmental trajectory (6, 7), as shown in this case conference.

Finally, since kids with autistic spectrum disorders and other developmental disorders have historically been excluded from treatment trials, the existing psychopharmacological literature is sparse. More rigorous research is needed on the use of psychopharmacological agents in this population to assess more fully the risks and benefits of treatment for comorbid affective disorders and other psychiatric conditions.


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Aspergers Children and Discipline Problems

Question

Our son has Asperger's Syndrome but it would appear to be a mild condition as he has developed very well and does not exhibit extreme symptoms of the syndrome. However my wife and I have become exasperated of late in trying to teach our child about inappropriate or naughty behaviour. He does not respond to sanctions or punishments and even when he does and the reason for a sanction is explained he does not seem to learn from the sanction so that the behaviour is often repeated again and again and the threat of the same or similar sanction has no effect. Can you make any suggestions? Sanctions include being sent to his room, removal of favourite toys or treats and although he responds/accepts the actual punishment he will not learn the lesson which we are trying to teach him. Thanks in anticipation.


Answer

Disciplining kids displaying behavior consistent with Aspergers (high-functioning autism) will often require an approach which is somewhat unique compared to that of other kids. Finding the balance between understanding the needs of a youngster with Aspergers and discipline which is age appropriate and situationally necessary is achievable when applying some simple but effective strategies. These strategies can be implemented both at home and in more public settings.

General Behavior Problems

Traditional discipline may fail to produce the desired results for kids with Aspergers, primarily because they are unable to appreciate the consequences of their actions. Consequently, punitive measures are apt to exacerbate the type of behavior the punishment is intended to reduce, whilst at the same time giving rise to distress in both the youngster and parent.

At all times the emotional and physical well-being of your youngster should take priority. Often this will necessitate removing your youngster from a potentially distressing situation as soon as possible. Consider maintaining a diary of your youngster's behavior with a view to ascertaining patterns or triggers. Recurring behavior may be indicative of a youngster taking some satisfaction in receiving a desired response from peers, parents or teachers.

For example, a youngster with Aspergers may come to understand that hurting another youngster in class will result in his being removed from class, notwithstanding the associated consequence to his peer. The solution may not be most effectively rooted in punishing the youngster for the behavior, or even attempting to explain the situation from the perspective of their injured peer, but by treating the root cause behind the motivation for the misbehavior...for example, can the youngster be made more comfortable in class so that they will not want to leave it?

One of the means to achieve this may be to focus on the positive. Praise for good behavior, and reinforcement by way of something like a Reward Book, can assist. The use of encouraging verbal cues delivered in a calm tone are likely to elicit more beneficial responses than the harsher verbal warnings which might be effective on kids who are not displaying some sort of Asperger characteristic. If necessary, when giving directions to cease a type of misbehavior, these should also be couched as positives rather than negatives. For example, rather than telling a youngster to stop hitting his brother with the ruler, the youngster should be directed to put the ruler down.

Obsessive or Fixated Behavior

Almost all kids go through periods of development where they become engrossed in one subject matter or another, but kids with Aspergers often display obsessive and repetitive characteristics, which can have significant implications for behavior.

For example, if an Aspergers youngster becomes fixated upon reading a particular story each night, they may become distressed if this regime is not adhered to, or if the story is interrupted. Again, the use of a behavior diary can assist in identifying fixations for your youngster. Once a fixation is identified, it is important to set appropriate boundaries for your youngster. Providing a structure within which your youngster can explore the obsession can assist in then keeping the obsession within reasonable limits, without the associated angst which might otherwise arise through such limitations. For example, tell your youngster that they may watch their favorite cartoon for half an hour after dinner, and make clear time for that in their routine.

It is appropriate to utilize the obsession to motivate and reward your youngster for good behavior. Always ensure any reward associated with positive behavior is granted immediately to assist the youngster recognizing the nexus between the two.

A particularly useful technique to try to develop social reciprocity is to have your youngster talk for five minutes about a particularly favored topic after they have listened to you talk about an unrelated topic. This serves to help your youngster understand that not everyone shares their enthusiasm for their subject matter.

Bridging the Gap between Aspergers and Discipline and Other Siblings

For siblings without Aspergers, the differential and what at times no doubt appears to be preferential treatment received by an Aspergers sibling can give rise to feelings of confusion and frustration. Often they will fail to understand why their brother or sister apparently seems free to behave as they please without the normal constraints placed upon them.

It is important to explain to siblings or peers of Aspergers kids and encourage open discussion about the disorder itself. Encouragement should extend to the things siblings can do to assist the Aspergers youngster, and this should be positively reinforced through acknowledgement when it occurs.

Sleep Difficulties

Aspergers kids are renowned for experiencing sleep problems. Kids with Aspergers may have lesser sleep requirements, and as such are more likely to become anxious about sleeping, or may find they become anxious when waking during the night or early in the morning.

Combat your youngster's anxiety by making their bedrooms a place of safety and comfort. Remove or store items which might be prone to injure your youngster if they decide to wander at night. Include in the behavioral diary a record of your youngster's sleep patterns. It may assist your youngster if you keep a list of their routine, including dinner, bath time, story and bed, in order to provide structure. Include an image or symbol of them waking in the morning to provide assurance as to what will happen. Social stories have proven to be a particularly successful tactic in decreasing a youngster's anxiety by providing clear instructions on how part of their day is likely to play out.

At School

Another Asperger characteristic is that kids will often experience difficulty during parts of the school day which lack structure. If left to their own devices their difficulties with social interaction and self management can result in anxiety. The use of a buddy system can assist in providing direction, as can the creation of a timetable for recess and lunch times. These should be raised with class teachers and implemented with their assistance.

Explain the concept of free time to your youngster, or consider providing a separate purpose or goal for your youngster during such time, such as reading a book, or helping to set up paint and brushes for the afternoon tasks.

In Public

Kids with Aspergers can become overwhelmed to the point of distress by even a short sourjourn in public. The result is that many parents with Aspergers simply seek to avoid as much as possible situations where their youngster is exposed to the public. Whilst expedient, it may not offer the best long term solution to your youngster, and there are strategies to assist with outings.

Consider providing your youngster with an ipod, or have the radio on in the car to block out other sounds and stimuli. Prepare a social story or list explaining to the youngster a trip to the shops, or doctor. Be sure to include on the list your return home. Consider giving your youngster a task to complete during the trip, or having them assist you. At all times, maintaining consistency when dealing with Aspergers and discipline is key. It pays to ensure that others involved in your youngster's care are familiar with your strategies and techniques, such as those outlined above, and are able to apply them.

Most importantly, don't hesitate to seek support networks for parents with Aspergers, and take advantage of the wealth of knowledge those who have dealt with the disorder before you have developed. The assistance you can gain from these and other resources can assist you in developing important strategies to deal with problems with Aspergers in a manner most beneficial to your youngster.

Additional Points to Consider

An Asperger youngster may throw tantrum or behave aggressively when he is disappointed or frustrated as other kids do. But he is not doing it intentionally, because as an Asperger youngster, he is unable to understand that other people have thoughts and feelings. He doesn't know that other people hurt when he hit them. He may learn this as he gets older, but it may take sometimes. So how do parents of Aspergers kids tell them to not hit other people? How can they handle their misbehavior?

Discipline is about teaching your youngster good and appropriate behavior. Discipline is about helping them to become an independent and responsible people. Regardless, your youngster is special need or not, you still need to discipline him with the consideration of his special needs. In particular, you need to keep in mind of his unusual perception of pain. Therefore, hitting them or any physical punishment is big no-no. The hitting will not teach that their behavior is unacceptable. In contrast, it may encourage them that hitting others is an acceptable behavior. It may even encourage self injurious behavior. In fact many experts strongly agree to not use physical punishment on autistic kids and advised them to find alternative methods of discipline method.

The best method is through positive discipline, where you focus on his acceptable behavior and provide rewards so that your youngster would be encouraged to repeat the behavior. To do that, first you need to establish ground rules. The ground rules must states specifically of what is consider as an acceptable behavior and what is not. You must catch and reward them when they are well-behaved and following the rules. A reward need not necessarily be a physical or expensive reward. It can be a genuine praise or word of encouragement. Most importantly, the reward must be clear and specific. The youngster should be able to know exactly the behavior that earned the reward. Rather than saying "Good job," say "Thank you for cleaning up your room."

Some Asperger youngsters are not able to generalize information. They are usually not able to apply what they learn in one learning context to another learning context. For example, he may learn that hitting his friend at school is not acceptable, but he may not necessarily understand that he cannot hit his sister at home. That is, once the situation change, it will be a totally a new learning experience for him. Be consistent and provide many repetitions in disciplining them. If there is punishment, make sure that the punishment is always the same for the bad behavior. Consistent environment and many repetitions will help your Asperger youngster to learn and remember the differences between right and wrong.

Disciplining an Asperger youngster is not easy, but with your loving care and understanding of him will make the task much easier to fulfill. I feel by accommodating his special needs and the loved he feel, he takes discipline a lot better. Be persistent and enjoy every small success. He may not be the captain of a football team, but he is taking small steps to become an independent and responsible person.



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

How to Deal with Your Asperger Child's Temper Tantrums

Some youngsters throw tantrums and some never do. Youngsters throw tantrums as a way of expressing anger and frustration. If the behavior is dealt with incorrectly, the youngster may learn to use tantrums to manipulate people and to gain attention. In dealing with tantrums, the ultimate goal is to teach the youngster acceptable ways of expressing anger.

Surviving the tantrum—

The most important things to remember when your youngster is in the throes of a tantrum are:
  • Don't let the disapproval of other people affect your response to the tantrum.
  • Don't punish the youngster.
  • Don't reward the youngster.
  • Isolate the youngster if possible.
  • Keep the youngster safe.
  • Stay calm and ignore the behavior to the extent possible.

When your youngster throws a tantrum, she is essentially out of control. You must make sure that you stay firmly in control. Punishing the youngster for throwing a tantrum, by yelling or spanking for example, makes the tantrum worse in the short term and prolongs the behavior in the long term. Trying to stop the tantrum by giving in to the youngster's demands is even worse. This is the way to teach a youngster to use tantrums for manipulation, and will cause the behavior to continue indefinitely, even into adulthood.

At Home—

When the youngster throws a tantrum at home, calmly carry her to a place where she can be left safely by herself, such as a crib or a playpen. Then leave the room, shut the door, and don't go back until she calms down. When the youngster is calm, have a talk with her about her behavior. If you don't feel safe leaving the youngster alone, stay with her, but don't respond to the tantrum in any way. Don't even make eye contact.

In Public—

If the youngster throws a tantrum in public, carry him out of the public area if possible, and take him to a place where you can have some privacy. The best place to take him is to the car, where he can be buckled into his car seat. Then you stand near the car or sit in the car and wait it out without reacting to the tantrum. When the tantrum subsides, talk to the youngster about his behavior, and then return to your activities.

Sometimes it won't be possible for you to escape from the public place easily. For example, if you are in a commercial jet and the youngster throws a tantrum while you are coming in for a landing (as my daughter once did), you are basically stuck where you are. Likewise, you may find it hard to escape if you are standing in a long check-out line at the grocery store with a cart full of groceries. Under such circumstances, all you can do is grit your teeth and hang on. Ignore the screaming youngster. Ignore the glares and snide remarks of the people around you. Keep your cool. (Anyway, a screaming youngster in a check-out line speeds it up, so your youngster is actually doing everyone a favor.) Once you are able to make your escape, talk to the youngster about his behavior.

Teaching the youngster alternatives to tantrums—

Once your youngster has settled down, you and she need to have a talk right away while the memories of the episode are still fresh in her mind. She threw the tantrum because she was angry or frustrated. Don't get into the issue of why she was angry or frustrated. Concentrate on the tantrum itself, explaining to the youngster that the behavior isn't appropriate. Then teach her what she should do instead when she feels angry. This works with youngsters of any age, even toddlers. Your toddler will understand you. Toddlers understand far more than they are able to express.

First describe the behavior: "You felt angry and you threw a tantrum. You were screaming, throwing things, and kicking the walls." You say this so the youngster will understand exactly what you are talking about.

Then you explain that tantrums are not proper behavior. Make sure that you are clear that the tantrum is bad, not the youngster. "Tantrums are not appropriate behavior. In our family, we don't scream and throw things and kick. That behavior is not acceptable." This has an impact on the youngster, because your youngster wants to do the right thing. You help her by explaining that tantrums are the wrong thing. And don't worry about using big words such as "appropriate." If you use big words with a youngster, the youngster will learn big words. If you use only little words, your youngster will learn only little words.

Then give the youngster some alternatives: "I know you felt angry. When you are angry, what you do is say, 'I'm angry!' Can you say that?" Have the youngster repeat the phrase after you.

Next review what you have said. "What are you going to say next time you're angry?" Get her to repeat the phrase, "I'm angry!" Then say, "Next time you're angry, are you going to scream?" The youngster will probably say or indicate "no." "Next time you're angry, are you going to throw things?" "Next time you're angry, are you going to kick?" End up with, "Tell me again what you're going to do next time you're angry."

You will have to repeat this discussion many, many times. It takes a long time for a youngster to learn how to control a temper tantrum.

Preventing tantrums—

You may notice after awhile that certain settings and circumstances seem to precipitate your youngster's tantrums. My daughter, for example, always threw tantrums when we went to a restaurant.

You can prevent tantrums by talking to the youngster beforehand. Explain to the youngster what you are about to do. ("We're going to go have lunch at Taco Bell.") Then tell the youngster what kind of behavior you expect, putting your expectations in positive terms. ("At Taco Bell, we're going to behave well. That means we will be polite, speak quietly, and use our words to ask for things and to say how we feel.") After you have told the youngster what you want, tell him what you don't want. ("We will not scream, throw things or kick. We don't do those things in public. It bothers people.") This tells the youngster not only what behaviors to avoid, but why to avoid them. Then get the youngster to agree to this. Say, "Now, tell me how you're going to behave when we go out. Are you going to speak quietly?" The youngster should indicate "yes." "Are you going to use your words?" "Yes." "Are you going to scream or throw things or kick?" "No." Then say, "That's great! We'll have a good time!" My daughter never once threw a tantrum if she agreed ahead of time not to. Run through this litany every time you plan to go out, because if you forget, the youngster will revert to tantrums in that environment!

If your youngster tends to throw tantrums in stores after you refuse the youngster's demand for treats, you can often avert the tantrum by making a game out of the youngster's demand, as follows:

Youngster: "I want candy!
You: "I want a rocket ship to Mars."

Youngster: "Give me candy!"
You: "Give me a rocket ship to Mars."

Youngster: "Give me candy!"
You: "I'll give you candy if you give me a rocket ship to Mars."

Youngster: "Here." (Pretending to hand you something.)
You: "Here." (Pretending to hand the youngster something.)

Youngster: "But this isn't real."
You: "What you gave me wasn't real, either."

Youngster: "But I don't have a real rocket ship!"
You: "Well, I guess you're out of luck, then!"

This may not work with every youngster, but it worked with my daughter. It's good for a youngster to learn that it's okay to want things, but it doesn't follow that a person always gets what he wants.

Another way of dealing with the grocery store tantrum is to discuss treats with the youngster beforehand. Tell the youngster where you are going, and what kind of treats, if any, the youngster can expect to get at the store. You might say, "When we go to the store, you can select one lollipop, any flavor you like, as a treat." Make it clear that one lollipop is all the youngster will get. If you don't want the youngster to get a treat that day, you should tell this to the youngster ahead of time. A youngster will often accept not getting a treat if told beforehand. But make sure that whatever you tell the youngster before the trip to the store, you stick to it!

My Aspergers Child: How to Prevent Tantrums in Aspergers Children

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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to read the full article...

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