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Aspergers: Answer to Diagnostic Mysteries?

As a young child, Jayne was consumed by Pokemon, the collectible card game of animated creatures originated in Japan. It was no mere pastime, but an all-encompassing interest that engaged her considerable vocabulary to the exclusion of all other age-appropriate attachments or interests. And it was accompanied by other troubling signs: an inability to make eye contact with others, to engage with peers in a reciprocal fashion, and to make friends.

As Jayne matured, her social isolation deepened, as did the uncommon and all-consuming nature of her interests. As a teen, she developed an exhaustive knowledge about everything related to a fast-food chain in the state where she resides. At an age when conformity to the norm is at a premium and castigation of those who deviate is most severe, Jayne inhabits an island of her own inaccessible idiosyncrasy.

As little as 14 years ago, she also may have had difficulty getting a psychiatric diagnosis that fit. Too verbal and intellectually adept for autism, she was liable to get a diagnosis of obsessive-compulsive disorder (OCD), a personality disorder, or even schizophrenia.

Today, Jayne's primary condition is recognized as Aspergers, a close relative of autism distinguished by severe and sustained impairment in social interaction, but without the clinically significant delay in language acquisition characteristic of autism; also distinctive is the presence of restrictive, highly idiosyncratic interests.

First introduced in DSM-IV in 1994, Aspergers is still prone to being overlooked or labeled as something else. As in the case of Jayne, OCD is often diagnosed – she exhibits some of those features and receives medication for them. But overlooked before she was diagnosed with Aspergers was the severe and sustained impairment in social interaction, dating back to her earliest years.

Even a decade ago people had a good understanding about autism, but these “Aspergers-like” children fell between the cracks. They didn't fall neatly into any psychiatric diagnosis, and they didn't look like they had autism because their language was so well developed. People knew they were odd, but no one knew what to do with them. As a clinician in child mental health, it has been a great relief to have this diagnosis as something you can hang your hat on. These children have tremendous needs that must be met by schools and the medical community.

They Talk Before They Walk—

These are children who talk before they walk. Words are their lifeline, and from a research perspective, that's a critical observation that captures the difference from autism.

The Aspergers description went “underground” for several decades, but during an international field trial of autism conducted by Volkmar and others in the 1980s, a number of clients consistently surfaced, across cultures and languages, who matched the definition. From this emerged a consensus definition for inclusion of Aspergers in DSM-IV in 1994.

Now the criteria are in need of refinement and will likely be updated in the next edition of DSM. Chief among the difficulties with the current criteria is dependence upon the absence of criteria normally present in autism—namely, the lack of delay in acquisition of language at age 2 or 3—and the stipulation that if autism cannot be ruled out, it should be the diagnosis of choice.

While Aspergers individuals do not lack vocabulary or speech production and are often precocious in this area, they have trouble fitting language into context and lack other skills requiring intuition of social context. They may have a variety of language weaknesses as toddlers including delayed onset of speech, rattling on in tangential ways, and speech articulation problems. But they are of a different quality than those found in high-functioning autism, such as mutism or very severe deficits in vocabulary.

Clinicians say a client's history of language acquisition is difficult enough to ascertain when a patient first presents at the age of 10 or 12, let alone as an adult. When you see these children in the clinic, it feels somewhat artificial to make a distinction just because they had an early language delay.

If they had a language delay at age 3 or 4, I am forced by DSM to call it autism, and if they didn't and have a normal IQ, to call it Aspergers. That's not a problem because those who have the language delay often continue to have signs of autism. And often, the more severe cases end up being called autism and the less severe cases are Aspergers. But not always, and it can seem arbitrary eight or nine years down the road. If the family is overwhelmed, the least of their concerns is remembering exactly when the child first uttered single words and phrases.

Confusion over diagnosis, combined with a relative paucity of research, has resulted in extremely wide-ranging estimates of prevalence of Asperger's—between 3 and 48 per 10,000. Nonetheless, there are real differences between Aspergers and autism, and they need to be better spelled out.

So what should clinicians look for?

In making the diagnosis, clinicians should look for three bell-ringer traits. These are impaired social interactions, especially difficulty with social reciprocity; idiosyncratic interests or activities; and odd, mechanical, or socially inappropriate speech patterns.

As with Jayne, treatment may involve medication of secondary symptoms such as obsessive-compulsive tendencies or attention-deficit problems; antidepressants, anxiolytics, or atypical antipsychotic medications may be useful.

Social-skills training targeted at teaching specific, often rudimentary social rules and protocols is the other component of treatment. Social algorithms—how to respond to different social situations and verbal cues—allow patients with Aspergers to learn conversation and other social skills cognitively so they can approximate an intuitive sense of how to behave.

In contrast to autism, you want to use the verbal capacities of Aspergers clients as a pathway to treatment.

The long-term prognosis is not necessarily bleak; the intensity of interest and volume of knowledge that clients may bring to idiosyncratic subjects can make them highly valued workers as adults. Along a continuum the symptoms of Aspergers can at some point “fade to normal,” and there are those in the community of people with autism-spectrum disorders who resist being labeled as disordered. For young people, especially teenagers, the “different-ness” they experience can be traumatic.

Even when these children don't meet criteria for depression, they are very much at risk for demoralization. In middle school especially they can experience self-hatred and anger as they try to make friends and find more and more that people aren't interested in their favorite topics and aren't patient with their social awkwardness.

So there is a place in treatment for supportive therapy and psycho-education. Sometimes I will give them things to read about Aspergers, and they are incredibly relieved to know there is a disorder, and that other people have it – and have found a way to lead happy lives.

My Aspergers Child: Preventing Meltdowns and Tantrums in Aspergers Children

Aspergers: Diagnosis and Clinical Features

The diagnosis of Aspergers requires the demonstration of qualitative impairments in social interaction and restricted patterns of interest, criteria which are identical to autism. In contrast to autism, there are no criteria in the cluster of language and communication symptoms, and onset criteria differ in that there should be no clinically significant delay in language acquisition, cognitive and self-help skills. Those symptoms result in significant impairment in social and occupational functioning. In some contrast to the social presentation in autism, children with Aspergers find themselves socially isolated, but are not usually withdrawn in the presence of others.

Typically, they approach others but in an inappropriate or eccentric fashion. For example, they may engage the interlocutor, usually an adult, in one-sided conversation characterized by long-winded, pedantic speech, about a favorite and often unusual and narrow topic. They may express interest in friendships and in meeting people, but their wishes are invariably thwarted by their awkward approaches and insensitivity to the other person's feelings, intentions, and non-literal and implied communications (e.g., signs of boredom, haste to leave, and need for privacy).

Chronically frustrated by their repeated failures to engage others and form friendships, some children with Aspergers develop symptoms of an anxiety or mood disorder that may require treatment, including medication.

They also may react inappropriately to, or fail to interpret the valence of the context of the affective interaction, often conveying a sense of insensitivity, formality, or disregard to the other person's emotional expressions.

They may be able to describe correctly, in a cognitive and often formalistic fashion, other people's emotions, expected intentions and social conventions; yet, they are unable to act upon this knowledge in an intuitive and spontaneous fashion, thus losing the tempo of the interaction.

Their poor intuition and lack of spontaneous adaptation are accompanied by marked reliance on formalistic rules of behavior and rigid social conventions. This presentation is largely responsible for the impression of social naiveté and behavioral rigidity that is so forcefully conveyed by those with Aspergers.

Although significant abnormalities of speech are not typical of children with Aspergers, there are at least three aspects of communication patterns that are of clinical interest:

1. The communication style of children with Aspergers is often characterized by marked verbosity. The youngster may talk incessantly, usually about a favorite subject, often in complete disregard to whether the listener might be interested, engaged, or attempting to interject a comment, or change the subject of conversation. Despite such long-winded monologues, the child may never come to a point or conclusion. Attempts by the interlocutor to elaborate on issues of content or logic, or to shift the interchange to related topics, are often unsuccessful.

2. Speech may often be tangential and circumstantial, conveying a sense of looseness of associations and incoherence. Even though in a very small number of cases this symptom may be an indicator of a possible thought disorder, the lack of contingency in speech is a result of the one-sided, egocentric conversational style (e.g., unrelenting monologues about the names, codes, and attributes of innumerable TV stations in the country), failure to provide the background for comments and to clearly demarcate changes in topic, and failure to suppress the vocal output accompanying internal thoughts.

3. Speech may be marked by poor prosody, although inflection and intonation may not be as rigid and monotonic as in autism. They often exhibit a constricted range of intonation patterns that is used with little regard to the communicative functioning of the utterance (e.g., assertions of fact, humorous remarks). Rate of speech may be unusual (e.g., too fast) or may lack in fluency (e.g., jerky speech), and there is often poor modulation of volume (e.g., voice is too loud despite physical proximity to the conversational partner). The latter feature may be particularly noticeable in the context of a lack of adjustment to the given social setting (e.g., in a library, in a noisy crowd).

Young people with Aspergers typically amass a large amount of factual information about a topic in a very intense fashion. The actual topic may change from time to time, but often dominates the content of social interchange. Frequently the entire family may be immersed in the subject for long periods of time. This behavior is peculiar in the sense that oftentimes extraordinary amounts of factual information are learned about very circumscribed topics (e.g., snakes, names of stars, TV guides, deep fat fryers, weather information, personal information on members of congress) without a genuine understanding of the broader phenomena involved. This symptom may not always be easily recognized in childhood since strong interests in certain topics, such as dinosaurs or fashionable fictional characters, are so ubiquitous. However, in both younger and older kids typically the special interests become more unusual and narrowly focused.

Children with Aspergers may have a history of delayed acquisition of motor skills such as pedaling a bike, catching a ball, opening jars, and climbing outdoor play equipment. They are often visibly awkward and poorly coordinated and may exhibited stilted or bouncy gait patterns and odd posture. Neuropsychologically, there is often a pattern of relative strengths in auditory and verbal skills and rote learning, and significant deficits in visual-motor and visual-perceptual skills and conceptual learning. Many people exhibit high levels of activity in early childhood, and, as noted, may develop anxiety and depression in adolescence and young adulthood.

My Aspergers Child: Preventing Meltdowns

Asperger Syndrome: Epidemiology

Given the lack of consensual definitions of diagnosis until recently, it is not surprising that the prevalence of Aspergers is unknown, although a rate of 2 to 4 in 10,000 has been reported.

There is little doubt that the condition is more prevalent in boys than girls, with a reported ratio of 9 to 1.

In the past few years, there have been a proliferation of parent support groups organized around the concept of Aspergers, and there are indications that this diagnosis is being given by clinicians much more frequently than even just a few years ago; there are also indications that Aspergers is currently functioning as a residual diagnosis given to normal-intelligence young people with a degree of social disabilities who do not fulfill criteria for autism, overlapping in this way, with the DSM-IV term PDD-NOS.

Possibly the most common usage of the term Aspergers is as synonymous or a replacement to autism in children with normative or superior IQs. This pattern has diluted the concept and reduced its clinical utility. Empirical validation of specific diagnostic criteria is badly needed, although this will have to await reports of rigorous studies employing standard diagnostic procedures, and “validators” truly independent of the diagnostic definition such as neuropsychological, neurobiological and genetic data.

The History Behind "Aspergers"

Aspergers  is characterized by impairments in social interaction and restricted interests and behaviors as seen in autism, but its early developmental course is marked by a lack of any clinically significant delay in spoken or receptive language, cognitive development, self-help skills, and curiosity about the environment. All-absorbing and intense circumscribed interests and one-sided verbosity as well motor clumsiness are typical of the condition, but are not required for diagnosis.

In 1944, Hans Asperger, an Austrian pediatrician with interest in special education, described four kids who had difficulty integrating socially into groups. Unaware of Kanner's description of early infantile autism published just the year before, Asperger called the condition he described "autistic psychopathy", indicating a stable personality disorder marked by social isolation.

Despite preserved intellectual skills, the kids showed marked paucity of nonverbal communication involving both gestures and affective tone of voice, poor empathy and a tendency to intellectualize emotions, an inclination to engage in long winded, one-sided, and sometimes incoherent speech, rather formalistic speech (he called them "little professors"), all-absorbing interests involving unusual topics which dominated their conversation, and motoric clumsiness. Unlike Kanner's patients, these kids were not as withdrawn or aloof; they also developed, sometimes precociously, highly grammatical speech, and could not in fact be diagnosed in the first years of life.

Discarding the possibility of a psychogenic origin, Asperger highlighted the familial nature of the condition, and even hypothesized that the personality traits were primarily male transmitted. Aspergers work, originally published in German, became widely known to the English speaking world only in 1981, when Lorna Wing published a series of cases showing similar symptoms. Her codification of the syndrome, however, blurred somewhat the differences between Kanner's and Aspergers descriptions, as she included a small number of girls and mildly mentally retarded kids, as well as some kids who had presented with some language delays in their first years of life. Since then, several studies have attempted to validate AS as distinct from autism without mental retardation, although comparability of findings has been difficult due to the lack of consensual diagnostic criteria for the condition.3

Aspergers was not accorded official recognition before the publication of ICD-10 and DSM-IV, although it was first reported in the German literature in 1944. Aspergers work was known primarily in German speaking countries, and it was only in the 1970's that the first comparisons with Kanner's work were made, primarily by Dutch researchers such as Van Krevelen, who were familiar with both English and German literatures. The initial attempts at comparing the two conditions were difficult because of major differences in the patients described – Kanner's patients were both younger and more cognitively impaired. Also, Aspergers conceptualization was influenced by accounts of schizophrenia and personality disorders, whereas Kanner had been influenced by the work of Arnold Gesell and his developmental approach.

Attempts at codifying Aspergers prose into a categorical definition for the condition were made by several influential researchers in Europe and North America, but no consensual definition emerged until the advent of ICD-10. And given the reduced empirical validation of the ICD-10 and DSM-IV criteria, the definition of the condition is likely to change as new and more rigorous studies emerge in the near future.

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

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

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How to Prevent Meltdowns in Children on the Spectrum

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

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Parenting Defiant Teens on the Spectrum

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

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

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

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Parenting Children and Teens with High-Functioning Autism

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

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

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

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