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Evaluating Clients for Aspergers: Advice for Therapists

Question

I am a family therapist for the Anderson Center of Saint John’s. A client of mine recently reported a childhood history of difficulty learning social rules, learning problems, and rocking behaviors, which he learned to stop. He also reports social difficulties as a young adult. What is the easiest method to evaluate him to rule out Aspergers?

Answer

Aspergers (AS) can be quite difficult to diagnose. Individuals with this condition can function relatively well in daily life; however, they are generally socially immature and may be perceived as strange or eccentric.

While the more overt symptoms of Aspergers are typically more apparent in early childhood, symptoms may only become apparent with the increasing functional and social demands of adolescence. In the teenager with Aspergers, the stress of unrecognized disability, limited achievement, and a sense of failure are often revealed by increasing contrast with siblings and peers. Family and peers may become exasperated by the individual's self-centered insensitivity, obsessiveness, and rigid inflexibility, further distorting personal relationships. Each one of these variables can add secondary disability and lead to dependency that is disproportionate to the individual's mental ability.

Grown-ups with Aspergers present with subtle and specific difficulties, particularly in communication, social interactions, and interests. However, not all individuals are affected as extremely as noted below:

• Social relationships: Relationships are one-sided, distant, or absent. An unempathic objectivity leads to difficulties ranging from understanding friendship (how friends differ from acquaintances) to developing sexual relationships (grasping rules that distinguish seduction from date rape). People with Aspergers misunderstand relationships and are either too intense or too detached.

• Interests: At the most extreme, an individual with Aspergers has an eccentric life with rigid routines and a systematic, narrow focus on activities such as stamp collecting, baseball statistics, or railway timetables. Interests remain circumscribed and, rather than being an avenue for social interaction, they are enjoyed in solitude.

• Communication: Conversation is often one-sided, long-winded, circumstantial, lecture-like, and delivered in a robotic fashion. Less obvious abnormalities include unrecognized, underlying discrepancies between verbal and nonverbal language and between comprehension and expression. Individuals may lack eye contact, have few facial expressions and awkward body movements, and they may eventually develop social anxiety and nervous tics.

Grown-ups with Aspergers may also have problems with future planning and organization. Some compensate for this by being extremely meticulous in their planning and keeping extensive written or mental checklists. Other possible symptoms include hypersensitivity to sensory stimuli, violent outbursts, self-injurious behavior, rituals, odd posturing, and hand flapping.

When evaluating an individual for possible Aspergers, therapists can adhere to these guidelines…

Setting:

• Waiting causes increased stress levels. Whenever possible, schedule clients for Aspergers assessment as the first or last appointment of the day. If this is not possible, allow them to wait in a small side room or in their car, or allow them to go home and come back at a later agreed time.

• Prevent other sensory overload by minimizing loud noises and high-pitched sounds.

• Be aware that hand flapping, rocking, or ear covering may be their calming mechanism, so do not stop the behavior unless absolutely necessary.

• Avoid bright lighting. Some individuals with Aspergers are very light sensitive and can even detect the flashing of fluorescent lights.

Interview:

• Allow the individual extra time to process what you say to them.

• Ask for the information that you need, because an individual with Aspergers may not volunteer vital information without being asked directly, and because they may expect you to know what they are thinking.

• Avoid using facial expressions, body language, or gestures without verbal instructions, as these may be misunderstood.

• Explain what you are going to do before you do it, and use pictures when possible.

• Individuals with Aspergers do not understand personal space. Thus, they require more personal space than the average individual, or they may invade your space.

• Individuals with Aspergers take everything literally, so be concrete and avoid the use of idioms, irony, metaphors, and words with double meanings.

• Realize that the individual may not make eye contact during the interview, and do not assume that a nonverbal individual does not understand what you are saying.

• Use clear, simple language and speak in short sentences.

Physical Assessment:

• If performing something intrusive, such as phlebotomy, realize that individuals with Aspergers may have high or low pain tolerance or an unusual response to pain, such as laughter, humming, singing, or clothing removal. Use local anesthetics whenever possible.

• Give direct requests. Say, "Open your mouth." Don't say, "Can you open your mouth?" With the latter question, they may not understand that you are actually asking them to do something.

• Exams may prove very stressful, so warn the individual before touching him/her.

Therapists may choose to utilize an assessment tool to identify Aspergers. One that is easily available is the Adult Asperger Assessment (AAA), developed at the Aspergers Research Center (ARC), situated within the School of Clinical Medicine in the Department of Psychiatry, Section of Developmental Psychiatry, at the University of Cambridge, United Kingdom. Other diagnostic rating scales can be found at Online Asperger Syndrome Information & Support (OASIS).

Because individuals with Aspergers may misperceive their situation, it really is helpful to complete the assessment with data from others, such as spouses, buddies, teachers, and employers. Additionally it is advisable to give the individual with Aspergers an itemized report of the assessment to avoid misunderstandings that may arise from spoken communication.

Differential Diagnoses:

The the signs of Aspergers imitate other disorders; therefore, therapists must become familiar with the most probable differential diagnoses:

• ADHD is characterized by impaired functioning in multiple settings, including home and school, and in relationships with peers. Symptoms include impulsiveness, hyperactivity, and inattention.

• Antisocial PD is characterized by a pattern of disregard for other individual's rights, often crossing the line and violating those rights.

• Catatonic schizophrenia is characterized by prominent psychomotor disturbances that may alternate between extremes such as hyperkinesis and stupor.

• Generalized anxiety disorder is characterized by constant, exaggerated worrisome thoughts and tension about everyday routine life events and activities for a period of at least 6 months.

• Obsessive-compulsive PD is characterized by a preoccupation with orderliness, perfectionism, and control at the expense of flexibility, openness, and efficiency.

• Panic disorder is characterized by repeated episodes of intense fear that strike often and without warning. Physical symptoms include chest pain, heart palpitations, shortness of breath, dizziness, abdominal distress, feelings of unreality, and fear of dying.

• Paranoid schizophrenia is characterized by relatively stable and often paranoid delusions, usually accompanied by auditory hallucinations.

• Personality disorders (PD): Avoidant PD is characterized by a persistent and complex pattern of feelings of inadequacy, extreme sensitivity to what other individuals think about them, and social inhibition.

• Schizoid PD is characterized by a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings.

• Selective mutism is characterized by the persistent lack of speech in at least 1 social situation, despite the ability to speak in other situations.

• Simple schizophrenia (especially treatment-resistant) is characterized by an insidious but progressive development of oddities of conduct, inability to meet the demands of society, and a decline in total performance.

• Social phobia is characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations.

Aspergers is tough to diagnose, and the diagnosis ought to be confirmed by a mental health professional well versed in the diagnosis and treatment of Aspergers. However, a definitive diagnosis can be quite a relief because it allows individuals to learn about their condition, understand where and why they have difficulties, and obtain suitable support.

The Aspergers Comprehensive Handbook

Helping Teachers To Understand Your Aspergers Child

Question

My son has been diagnosed with Asperger's and we are now working with the middle school for their evaluation processes to approve special education help. They are specifically stating that they do not believe the diagnosis based on observations of my son interacting with other children at school and being the 'life of the party' basically for the group.

I have tried to explain that this behavior is his way of coping with the lunchroom situation as a learned behavior and that he is not actually experiencing the situation the same way they are based on his comments to me at home each day about his interactions with the other students. How do I get these educated people to listen to lowly me, mom, and get him the help he needs that they seem to want to deny?


Answer

I’m assuming you have already started the IEP process (if not, type “IEP” in the search box above for more information).

I would get a note from the doctor who diagnosed your child with Aspergers so the teachers can verify (this will help establish some credibility). Then you should provide teachers with an information sheet to help educate them about Aspergers. Below is a sample information sheet that you can tailor to your individual needs. It should help teachers understand and deal with some of the everyday questions that come up regarding Aspergers:

_______________________________________


Dear _______,

I am _____'s mother. My son has been diagnosed with Aspergers, which is a neurobiological disorder on the autistic spectrum. Kids with ASPERGERS may have difficulty using and understanding nonverbal behaviors and developing appropriate peer relationships, in part, because their interactions often lack spontaneous exchange. While they often have keen interests and skills in certain subjects, they also may have a great deal of difficulty with organization. ASPERGERS kids may appear to lack in empathy, have difficulty with sensory issues and very often strongly rely on routine.


Our son has many positive characteristics. However, listed below are some issues that may become apparent to you as you work with him. Many of the behaviors you will see are NOT under his control and they are not a result of malice or willful misbehavior. At times our son simply does not innately know how to appropriately respond.

No doubt, you will learn other strategies which will be helpful and we would appreciate your sharing with us. Please call us at any time if you have questions about our son or Aspergers. We can be reached at: __________

General Behaviors—

• At times, our son may experience "meltdowns" when nothing may help behavior. At times like this, please allow a "safe and quiet spot" where our son will be allowed to "cool off" Try to take note of what occurred before the meltdown (was it an unexpected change in routine, for example) and it's best to talk "after" the situation has calmed down.
• Foster a classroom atmosphere that supports the acceptance of differences and diversity.
• Generally speaking, an adult speaking in a calm voice will reap many benefits
• It is important to remember that, just because the youngster learns something in one situation, this doesn't automatically mean that he remembers or is able to generalize the learning to new situations.
• Note strengths often and visually. This will give our son the courage to keep on plugging.
• Our son may have vocal outbursts or shriek. Be prepared for them, especially when having a difficult time. Also, please let the other kids know that this is a way of dealing with stress or fear.
• Our son may need help with problem-solving situations. Please be willing to take the time to help with this.
• Our son reacts well to positive and patient styles of teaching.
• Aspergers is characterized by a sort of "Swiss cheese" type of development: that is, some things are learned age-appropriately, while other things may lag behind or be absent. Furthermore, kids may have skills years ahead of normal development (for example, a youngster may understand complex mathematics principles, yet not be able to remember to bring their homework home).
• When dividing up assignments, please assign teams rather than have the other kids "choose members", because this increases the chances that our son will be left out or teased.
• When it reaches a point that things in the classroom are going well, it means that we've gotten it right. It doesn't mean that our son is "cured", "never had a problem" or that "it's time to remove support". Increase demands gradually.
• When you see anger or other outbursts, our son is not being deliberately difficult. Instead, this is in a "fight/fright/flight" reaction. Think of this as an "electrical circuit overload" Prevention can sometimes head off situations if you see the warning signs coming.

Perseverations—

• Allowing our son to write down the question or thought and providing a response in writing may break the stresses/cycle.
• It is more helpful if you avoid being pulled into this by answering the same thing over and over or raising your voice or pointing out that the question is being repeated. Instead, try to redirect our son's attention or find an alternative way so he can save face.
• Our son may repeat the same thing over and over again, and you may find that this increases as stress increases.

Transitions—

• Giving one or two warnings before a change of activity or schedule may be helpful
• Our son may have a great deal of difficulty with transitions. Having a picture or word schedule may be helpful.
• Please try to give as much advance notice as possible if there is going to be a change or disruption in the schedule.

Sensory Motor Skills/Auditory Processing—

• Breaking directions down into simple steps is quite helpful
• Directions are more easily understood if they are repeated clearly, simply and in a variety of ways.
• Our son has difficulty understanding a string of directions or too many words at one time
• Our son may act in a very clumsy way; he may also react very strongly to certain tastes, textures, smells and sounds.
• Speaking slower and in smaller phrases can help.
• Using picture cures or directions may also help

Stimuli—

• Allow him to "move about" as sitting still for long periods of time can be very difficult (even a 5 minute walk around, with a peer can help a lot).
• He may get over-stimulated by loud noises, lights, strong tastes or textures, because of the heightened sensitivity to these things.
• Unstructured times (such as lunch, break and PE) may prove to be the most difficult for him. Please try to help provide some guidance during these more difficult times.
• With lots of other kids, chaos and noise, please try to help him find a quiet spot to which he can go for some "solace".

Visual Cues—

• Hand signals may be helpful, especially to reinforce certain messages, such as "wait your turn", "stop talking" (out of turn), or "speak more slowly or softly".
• Some ASPERGERS kids learn best with visual aids, such as picture schedules, written directions or drawings (other kids may do better with verbal instruction)

Interruptions—

• When someone tries to help by finishing his sentences or interrupting, he often has to go back and start over to get the train of thought back.
• At times, it may take more than few seconds for my son to respond to questions. He needs to stop what he's thinking, put that somewhere, formulate an answer and then respond. Please wait patiently for the answer and encourage others to do the same. Otherwise, he will have to start over again.

Eye Contact—

• Unlike most of us, sometimes forcing eye contact breaks his concentration
• He may actually hear and understand you better if not forced to look directly at your eyes.
• At times, it looks as if my son is not listening to you when he really is. Don't assume that because he is not looking at you that he is not hearing you.

Social Skills and Friendships—

• Talking with the other members of the class may help, if done in a positive way and with the permission of the family. For example, talking about the fact that many or most of us have challenges and that the ASPERGERS youngster’s challenge is that he cannot read social situations well, just as others may need glasses or hearing aids.
• Identifying 1 or 2 empathetic children who can serve as "buddies" will help the youngster feel as though the world is a friendlier place
• Herein lays one of the biggest challenges for ASPERGERS kids. They may want to make friends very badly, yet not have a clue as to how to go about it.
• Children with Aspergers may be at greater risk for becoming "victims" of bullying behavior by other children. This is caused by a couple of factors:

1. Asperger kids want to be included and/or liked so badly that they are reluctant to "tell" on the bully, fearing rejection from the perpetrator or other children.
2. There is a great likelihood that the response or "rise" that the "bully" gets from the Asperger youngster reinforces this kind of behavior

Routine—

• Let him know, if possible, when there will be a substitute teacher or a field trip occurring during regular school hours.
• Please let our son know of any anticipated changes as soon as you know them, especially with picture or word schedules.
• This is very important to most ASPERGERS kids, but can be very difficult to attain on a regular basis in our world.

Language—

• Sarcasm and some forums of humor are often not understood by my son. Even explanations of what is meant may not clarify, because the perspectives of ASPERGERS youngster can be unique and, at times, immovable.
• Although his vocabulary and use of language may seem high, ASPERGERS kids may not know the meaning of what they are saying even though the words sound correct.

Organizational Skills—

• If necessary allow him to copy the notes of other kids or provide him with a copy. Many ASPERGERS kids are also dysgraphic and they are unable to listen to you talk, read the board and take notes at the same time.
• It may be helpful to develop schedules (picture or written) for him.
• Our son lacks the ability of remember a lot of information or how to retrieve that information for its use.
• Please post schedules and homework assignments on the board and make a copy for him. Please make sure that these assignments get put into his backpack because he can't always be counted on to get everything home without some help.

In conclusion, please know that at times, some of my son's behaviors may be aggravating and annoying to you and to members of his class. Please know that this is normal and expected. Try not to let the difficult days color the fact that YOU are a wonderful teacher with a challenging situation and that nothing works all of the time (and some things don't even work most of the time). You will also be treated to a new and very unique view of the world that will entertain and fascinate you at times. Please feel free to share with us whatever you would like. We have heard it before. It will not shock us or make us think poorly of you. Communication is the key and by working together as a team we can provide the best for our son.

Thank you,

Parent’s Name: __________

__________________________________________


Here is a real example, based on the template above, of an information sheet that one parent hand-delivered to her child’s teacher.


Dear Mrs. Shroud,

My child, Michael _____, has Aspergers. This means his patterns of thought and behavior will be a little different than you may be used to. Here are some issues that may come up, along with some suggestions:

My Aspergers child may have additional difficulty with:

• Balance
• Multiple step directions
• Multi-tasking
• Organization
• Tics and odd mannerisms (humming, repetitive motions, rocking, etc.)
• Transitions
• Unstructured time

Lists and visual aids are a great way to help with some of these challenges. Break down complex tasks into simpler steps, if possible, and please understand that multi-tasking (e.g., reading, answering questions, and filling out worksheet at the same time) simply may not be possible. Aspergers children thrive on routine and predictability.

Fine motor skills will affect:

• Button and shoe lacing skills
• Handwriting skills
• Scissor skills
• The ability to color within the lines

Please understand that handwriting is especially difficult and even painful for my Aspergers child. He is not slacking or messy on purpose, but working slowly to improve a difficult skill.

Meltdowns may occur because:

• Bad surprises can overwhelm and panic my child
• My child is easily frustrated and upset
• Time pressure and/or stress can cause panic
• Too much noise and activity can over-stimulate him

Please stay calm. If it looks like my child is getting worked up, don’t ignore him – he never pretends and it will only get worse. He is not falling apart on purpose, and has no idea what he looks like. This is not a bid for attention, but a very real feeling of frustration and panic. Please help him find a solution – even if it seems obvious – to the problem at hand.

My Aspergers child’s literal thinking makes it difficult for him to understand:

• Nuance and sarcasm
• Sayings/proverbs and sometimes jokes
• Shades of grey
• When rules do not apply

Aspergers children can be bossy and even offensive in reminding everyone of the rules. Their inflexibility is not a mask or pretense, but an inability to understand shades of grey.

Please be consistent with any rules, and clearly state when they do not apply. Remind my child that the rules apply the same to everyone. Help guide him when any situation presents shades of grey or nuance, to avoid confusion, misunderstandings, and/or meltdowns.

Social Skills Challenges will mean:

• Difficulty recognizing facial expression, tone of voice, and body language
• He does not automatically glance at others to check which task/page/worksheet needs to be done at the moment
• He may not stay with the group or do what the group is doing
• Inability to automatically understand how others are thinking or feeling
• Little to no eye contact
• Unintentional inappropriate behavior
• Volume control and/or monotone voice

This means that teamwork and cooperating in groups will be challenging for my Aspergers child. He will not always recognize when someone’s behavior is offensive (including his own), and will not understand when others become upset or even cruel.

Please be patient and help facilitate understanding on all sides. Speak clearly and avoid body language; use speech to get any points across, and don’t assume he understands what is happening socially. Watch out for bullying/teasing, misunderstandings, wandering, and ostracism.

Some common positives for Aspergers:

• Honesty and directness
• Intelligence
• Intense interest in facts and details
• Keen visual memory
• Love of learning (especially when the subject appeals)
• Think-outside-the-box mentality

Thank you!

Sincerely,

Virginia _______




COMMENTS:

•    Anonymous said... My son is also HFA and is currently in an all-inclusion community classroom. This is working very well for him because the class and teachers are geared to work with and educate our children along with neurotypical children. All the children are hand-picked to be in this class and the parents want their kids there too. It's an excellent program.
•    Anonymous said... I've talked to every teacher my son has ever had till I was blue in the face...all requests for visual learning were ignored. I homeschool him now and he is so much happier learning the way he can understand it best...visually.
•    Anonymous said... In my area, there is a programme called Earlybird Plus which is a 12 week course attended by the parent and the teacher so you can both learn about Autism together. I was referred into it by my local CAMHS
•    Anonymous said... All good except if teacher is old school really doesn't bel children have learning delays thinking they can teach anyone and it's the parenting. Also old school teaching has the idea of my way or the highway. Not realising auditory learning may not be as effective for a visual learner.

Please post your comment below…

Aspergers Children and Anger Problems

Question

My Aspergers son has anger problems. How can I help him understand what his real emotions are?

Answer

For kids with Aspergers (high functioning autism), anger can be a major challenge. Many people do not realize the strong connection between Aspergers and behavioral issues like anger, anxiety, and depression. The very characteristics of Aspergers lead to these behavioral issues. Some of these characteristics are:
  • Gross and fine motor problems
  • Inflexible thinking
  • Lack of language skills, especially social language, gestures and cues
  • Narrow interests
  • Sensory issues
  • Social skills weaknesses

Understanding anger in Aspergers children is quite simple. Nearly all of your son’s anger stems from frustration. The characteristics of Aspergers listed above (plus others) create a confusing and uncomfortable social environment. The natural reaction is frustration, and the natural escalation of frustration is anxiety, then anger. Helping an Aspergers child understand his anger and other emotions, however, can be quite difficult. You must help your son understand the cause of his emotions, and then develop a plan to avoid the negative emotions that stem from frustration. There are several options available for the mother/father searching for anger-management for their Aspergers children. Here are a couple of those options:

1. Home Solutions— Not everyone with Aspergers anger issues choose private therapy. For some people, these therapies are not covered by insurance or are simply not available. Others choose to handle therapy and learning situations at home, in their own way. This is perfectly acceptable, and in all honesty, quite helpful for the child even if you do choose private therapy. Support at home will increase progress. Some examples of home solutions are:
  • Five point scale assessments teach a youngster how to recognize his anger or anxiety and prepare to control their emotional responses.
  • Parenting discipline programs teach parents how to use proper discipline techniques, which in turn, may diffuse some of the youngster’s anxiety and anger.
  • Play therapy/activities make learning emotional control fun.
  • Social stories can be written for specific behavioral problems and situations. These stories can put your youngster’s feelings into words and offer him simple solutions.

2. Cognitive-Behavioral Therapy— Many people with Aspergers anger choose to try cognitive-behavioral therapy. This therapy is highly recommended for kids with Aspergers. Cognitive-behavioral therapy is individual therapy designed around the idea that a child’s emotions and thought processes are what control that child’s outward feelings and behaviors. Most people tend to blame the situation or other people. This therapy places the focus on a child’s internal thoughts. In other words, if we think a certain way, even though the situation makes us feel the opposite, we can begin to feel better about that situation.

For your Aspergers child, anger can get in the way of learning, playing, and life. Perhaps you can use some of the above suggestions to help him handle his anger and better understand his emotions.

I cover a lot of ground on anger issues for children with Aspergers in my eBook entitled My Aspergers Child: Preventing Tantrums and Meltdowns.

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.

Click here to read the full article…

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.

Click here for the full article...

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.

Click here to read the full article…

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."

Click here to read the full article…

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.

Click here for the full article...