Best Treatment Options for Aspergers and HFA

"What are some of the better treatment options for children on the autism spectrum?"

While there is no cure for Aspergers or High Functioning Autism (HFA), treating it early with proper school-based programs and medical care can (a) greatly reduce symptoms and (b) increase your youngster's ability to grow and learn new skills.

Early Intervention—

Research has shown that intensive behavioral therapy during the toddler or preschool years can significantly improve cognitive and language skills in young kids with Aspergers and HFA. There is no single best treatment for all kids, but the American Academy of Pediatrics recently noted common features of effective early intervention programs. These include:
  1. Encouraging activities that include typically developing kids, as long as such activities help meet a specific learning goal
  2. Guiding the youngster in adapting learned skills to new situations and settings and maintaining learned skills
  3. Having small classes to allow each youngster to have one-on-one time with the therapist or teacher and small group learning activities
  4. Having special training for moms and dads and family
  5. Measuring and recording each youngster's progress and adjusting the intervention program as needed
  6. Providing a high degree of structure, routine, and visual cues, such as posted activity schedules and clearly defined boundaries, to reduce distractions
  7. Providing focused and challenging learning activities at the proper developmental level for the youngster for at least 25 hours per week and 12 months per year
  8. Starting as soon as a youngster has been diagnosed with Aspergers
  9. Using a curriculum that focuses on:
  • Cognitive skills, such as pretend play or seeing someone else's point of view- Language and communication
  • Research-based methods to reduce challenging behaviors, such as aggression and tantrums
  • Self-help and daily living skills, such as dressing and grooming
  • Social skills, such as joint attention (looking at other people to draw attention to something interesting and share in experiencing it)
  • Typical school-readiness skills, such as letter recognition and counting

One type of a widely accepted treatment is Applied Behavior Analysis (ABA). The goals of ABA are to shape and reinforce new behaviors, such as learning to speak and play, and reduce undesirable ones. ABA, which can involve intensive, one-on-one child-teacher interaction for up to 40 hours a week, has inspired the development of similar interventions that aim to help children with Aspergers and HFA reach their full potential. ABA-based interventions include:
  • Pivotal Response Training: Aims at identifying pivotal skills, such as initiation and self-management that affect a broad range of behavioral responses. This intervention incorporates parent and family education aimed at providing skills that enable the youngster to function in inclusive settings.
  • Verbal Behavior: Focuses on teaching language using a sequenced curriculum that guides kids from simple verbal behaviors (echoing) to more functional communication skills through techniques such as errorless teaching and prompting.

Other types of early interventions include:
  • TEACCH (Treatment and Education of Autistic and related Communication handicapped Kids): Emphasizes adapting the youngster's physical environment and using visual cues (e.g., having classroom materials clearly marked and located so that students can access them independently). Using individualized plans for each student, TEACCH builds on the youngster's strengths and emerging skills.
  • Interpersonal Synchrony: Targets social development and imitation skills, and focuses on teaching kids how to establish and maintain engagement with others.
  • Developmental, Individual Difference, Relationship-based (DIR) / Floortime Model: Aims to build healthy and meaningful relationships and abilities by following the natural emotions and interests of the youngster. One particular example is the Early Start Denver Model, which fosters improvements in communication, thinking, language, and other social skills and seeks to reduce atypical behaviors. Using developmental and relationship-based approaches, this therapy can be delivered in natural settings such as the home or pre-school.

For kids younger than age 3, these interventions usually take place at home or in a childcare center. Because moms and dads are a youngster's earliest educators, more programs are beginning to train moms and dads to continue the therapy at home.

Children on the autism spectrum may benefit from some type of social skills training program. While these programs need more research, they generally seek to increase and improve skills necessary for creating positive social interactions and avoiding negative responses. For example, Children’s Friendship Training focuses on improving kid's conversation and interaction skills and teaches them how to make friends, be a good sport, and respond appropriately to teasing.


Working With Schools—

Start by speaking with your youngster's teacher, school counselor, or the school's student support team to begin an evaluation. Each state has a Parent Training and Information Center and a Protection and Advocacy Agency that can help you get an evaluation. A team of professionals conducts the evaluation using a variety of tools and measures. The evaluation will look at all areas related to your youngster's abilities and needs.

Once your youngster has been evaluated, he has several options, depending on the specific needs. If your youngster needs special education services and is eligible under the Individuals with Disabilities Education Act (IDEA), the school district (or the government agency administering the program) must develop an individualized education plan, or IEP specifically for your youngster within 30 days.

IDEA provides free screenings and early intervention services to kids from birth to age 3. IDEA also provides special education and related services from ages 3 to 21. Information is available from the U.S. Department of Education.

If your youngster is not eligible for special education services (not all kids on the spectrum are eligible) he can still get free public education suited to his or her needs, which is available to all public-school kids with disabilities under Section 504 of the Rehabilitation Act of 1973, regardless of the type or severity of the disability.

The U.S. Department of Education's Office for Civil Rights enforces Section 504 in programs and activities that receive Federal education funds. More information on Section 504 is available on the Department of Education website.

During middle and high school years, your youngster's educators will begin to discuss practical issues such as work, living away from a parent or caregiver's home, and hobbies. These lessons should include gaining work experience, using public transportation, and learning skills that will be important in community living.

Medications—

Some medications can help reduce symptoms that cause problems for your youngster in school or at home. Many other medications may be prescribed off-label, meaning they have not been approved by the U.S. Food and Drug Administration (FDA) for a certain use or for certain people. Physicians may prescribe medications off-label if they have been approved to treat other disorders that have similar symptoms to Aspergers, or if they have been effective in treating adults or older kids with Aspergers and HFA. Physicians prescribe medications off-label to try to help the youngest patients, but more research is needed to be sure that these medicines are safe and effective for kids and teens with the disorder.

At this time, the only medications approved by the FDA to treat aspects of ASDs are the antipsychotics risperidone (Risperdal) and aripripazole (Abilify). These medications can help reduce irritability—meaning aggression, self-harming acts, or temper tantrums—in kids ages 5 to 16 who have the disorder.

Some medications that may be prescribed off-label for kids on the spectrum include the following:
  • Stimulant medications, such as methylphenidate (Ritalin), are safe and effective in treating people with attention deficit hyperactivity disorder (ADHD). Methylphenidate has been shown to effectively treat hyperactivity in kids with Aspergers and HFA as well. But not as many kids with the disorder respond to treatment, and those who do have shown more side effects than kids with ADHD and not ASDs.
  • Antipsychotic medications are more commonly used to treat serious mental illnesses such as schizophrenia. These medicines may help reduce aggression and other serious behavioral problems in kids, including kids with Aspergers and HFA. They may also help reduce repetitive behaviors, hyperactivity, and attention problems.
  • Antidepressant medications, such as fluoxetine (Prozac) or sertraline (Zoloft), are usually prescribed to treat depression and anxiety but are sometimes prescribed to reduce repetitive behaviors. Some antidepressants may also help control aggression and anxiety in kids on the autism spectrum. However, researchers still are not sure if these medications are useful; a recent study suggested that the antidepressant citalopram (Celexa) was no more effective than a placebo (sugar pill) at reducing repetitive behaviors in these young people.

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

==> Highly Effective Research-Based Parenting Strategies for Children with Asperger's and High-Functioning Autism

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How Aspergers is Diagnosed

"We have a son who we believe may have asperger syndrome and we were wondering how this disorder is diagnosed."

An Aspergers diagnosis is often a two-stage process. The first stage involves general developmental screening during the child’s checkups with a doctor or an early childhood health care provider. Kids who show some developmental problems are referred for additional evaluation. The second stage involves a thorough evaluation by a team of doctors and other health professionals with a wide range of specialties. At this stage, a youngster may be diagnosed as having some form of autism. Kids with an autism spectrum disorder can usually be reliably diagnosed by age 2, though research suggests that some screening tests can be helpful at 18 months or even younger.

Many individuals (e.g., family doctors, teachers, and moms/dads) may minimize signs of Aspergers at first, believing that kids will "catch up" with their friends. While you may be concerned about labeling your young youngster with Aspergers, the earlier the disorder is diagnosed, the sooner specific interventions may begin. Early intervention can reduce or prevent the more severe problems associated with Aspergers. Early intervention may also improve your youngster's IQ, language, and everyday functional skills (also called adaptive behavior).


Screening—

Your child’s checkup should include a developmental screening test, with specific Autism Spectrum Disorder (ASD) screening at 18 and 24 months. Screening for ASD is not the same as diagnosing ASD. Screening instruments are used as a first step to tell the doctor whether a youngster needs more testing. If your youngster's doctor does not routinely screen your youngster for ASD, ask that it be done.

For moms and dads, your own experiences and concerns about your youngster's development will be very important in the screening process. Keep your own notes about your youngster's development and look through family videos, photos, and baby albums to help you remember when you first noticed each behavior and when he/she reached certain developmental milestones.

Types of ASD Screening Instruments—

Sometimes the doctor will ask moms/dads questions about their youngster's symptoms to screen for Aspergers or some other form of Autism. Other screening instruments combine information from parents with the doctor's own observations of the youngster. Examples of screening instruments for toddlers and preschoolers include:

• Checklist of Autism in Toddlers (CHAT)
• Communication and Symbolic Behavior Scales (CSBS).
• Modified Checklist for Autism in Toddlers (M-CHAT)
• Screening Tool for Autism in Two-Year-Olds (STAT)
• Social Communication Questionnaire (SCQ)

To screen for mild Autism in older kids, the doctor may rely on different screening instruments, such as:

• Australian Scale for Asperger's Syndrome (ASAS)
• Autism Spectrum Screening Questionnaire (ASSQ)
• Childhood Asperger Syndrome Test (CAST)

Comprehensive Diagnostic Evaluation—

The second stage of diagnosis must be thorough in order to find whether other conditions may be causing your youngster's symptoms. A team that includes a psychologist, a neurologist, a psychiatrist, a speech therapist, or other professionals experienced in diagnosing Aspergers may do this evaluation. The evaluation may assess the youngster's cognitive level (i.e., thinking skills), language level, and adaptive behavior (i.e., age-appropriate skills needed to complete daily activities independently, for example eating, dressing, and toileting).

Because Aspergers is a complex disorder that sometimes occurs along with other illnesses or learning disorders, the comprehensive evaluation may include brain imaging and gene tests, along with in-depth memory, problem-solving, and language testing. Kids with any delayed development should also get a hearing test and be screened for lead poisoning as part of the comprehensive evaluation.

Any kid can lose his/her hearing (for various reasons), but common Aspergers symptoms (e.g., not turning to face a person calling their name) can make it seem that the youngster can’t hear – when in fact he/she can. If a youngster is not responding to speech, especially to his/her name, it's important for the doctor to test whether a youngster has hearing loss.

The evaluation process is a good time for moms and dads to ask questions and get advice from the whole evaluation team. The outcome of the evaluation will help plan for treatment and interventions to help your youngster. Be sure to ask who you can contact with follow-up questions.

Finding the Right Job: Help for Young Adults with Aspergers

If you’re an older teen or young adult with Aspergers or High Functioning Autism, be sure to find a job that makes use of your strengths.

"Aspies" tend to 1) have poor short-term memory, 2) have good long-term memory, and 3) be visual thinkers (although some are non-visual thinkers). Thus, in some (if not most) cases, a job that takes these three factors into consideration may be a good fit for Aspergers employees.

The “visual thinking” jobs listed below (a) put very little demand on fast processing of information in short-term memory and (b) utilize the visual thinking and long-term memory of the Aspie.

The “non-visual thinking” jobs listed below are for those who are good with numbers, facts and music. These jobs also put low demands on short-term memory and utilize an excellent long-term memory.

Good jobs for Aspies who are visual thinkers:
  • Animal trainer or veterinary technician
  • Automobile mechanic
  • Building maintenance
  • Building trades
  • Commercial art
  • Computer animation
  • Computer programming
  • Computer-troubleshooter and repair
  • Drafting
  • Equipment designing
  • Factory maintenance
  • Handcrafts of many different types such as wood carving, jewelry making, ceramics, etc.
  • Laboratory technician
  • Photography
  • Small appliance and lawnmower repair
  • Video game designer
  • Web page design

Good jobs for Aspies who are non-visual thinkers:
  • Accounting
  • Bank Teller
  • Clerk and filing jobs
  • Computer programming
  • Copy editor
  • Engineering
  • Inventory control
  • Journalist
  • Laboratory technician
  • Library science
  • Physicist or mathematician
  • Statistician
  • Taxi driver
  • Telemarketing
  • Tuning pianos and other musical instruments


Job Tips for Young Adults with Aspergers:

1. Aspies who are still in high school should be encouraged to take courses at a local college in drafting, computer programming or commercial art. This will help keep them motivated and serve as a refuge from bullying.

2. If you can’t afford a computer for your older teen to learn programming or computer aided drafting, used computers can often be obtained for free or at a very low cost when a business or an engineering company upgrades their equipment. Many people don’t realize that there are many usable older computers sitting in storerooms at schools, banks, factories and other businesses. It will not be the latest new thing, but it is more than adequate for a student to learn on.

3. Jobs should have a well-defined goal or endpoint.

4. Make a portfolio of your work.

5. Pick a college major in an area where you can get jobs. Computer science is a good choice because it is very likely that many of the best programmers have either Aspergers or some of its traits. Other good majors are accounting, engineering, library science, and art with an emphasis on commercial art and drafting.

6. Sell your work, not your personality.

7. The employer must recognize your social limitations.

8. You need to learn a few social survival skills, but you will make friends at work by sharing your shared interest with the other people who work in your specialty.

9. Young adults with Aspergers have to compensate for poor social skills by making themselves so good in a specialized field that people will be willing to "buy" their skill even though social skills are poor.

10. Be patient with yourself as you navigate the give-and-take of the social environment in the workplace.

Autism Spectrum Disorders: How Parents Can Help Their Children

Moms and dads are usually the first to notice unusual behaviors in their youngster. In some cases, the baby seemed “different” from birth, unresponsive to others or focusing intently on one item for long periods of time. The first signs of an Autism Spectrum Disorder (ASD) can also appear in kids who seem to have been developing normally. When an engaging, babbling toddler suddenly becomes silent, withdrawn, self-abusive, or indifferent to social overtures, something is wrong. Research has shown that moms and dads are usually correct about noticing developmental problems, although they may not realize the specific nature or degree of the problem.

Autism spectrum disorders can often be reliably detected by the age of 3 years, and in some cases as early as 18 months.2 Studies suggest that many kids eventually may be accurately identified by the age of 1 year or even younger. The appearance of any of the warning signs of Autism Spectrum Disorders is reason to have a youngster evaluated by a professional specializing in these disorders.

The autism spectrum disorders range from a severe form, called autistic disorder, to a milder form, high-functioning autism or Aspergers. If a youngster has symptoms of either of these disorders, but does not meet the specific criteria for either, the diagnosis is called pervasive developmental disorder not otherwise specified (PDD-NOS). Other rare, very severe disorders that are included in the autism spectrum disorders are Rett syndrome and childhood disintegrative disorder.

The autism spectrum disorders are more common in the pediatric population than are some better known disorders such as diabetes, spinal bifida, or Down syndrome.2 A recent study of a U.S. metropolitan area estimated that 3.4 of every 1,000 kids 3-10 years old had autism.3 The earlier the disorder is diagnosed, the sooner the youngster can be helped through treatment interventions. Doctors, family physicians, daycare providers, educators, and moms and dads may initially dismiss signs of Autism Spectrum Disorders, optimistically thinking the youngster is just a little slow and will “catch up.”

All kids with Autism Spectrum Disorders demonstrate deficits as follows:
  • repetitive behaviors or interests
  • social interaction
  • unusual responses to sensory experiences (e.g., certain sounds or the way objects look)
  • verbal and nonverbal communication

Each of these symptoms runs the gamut from mild to severe. They will present in each individual youngster differently. For instance, a youngster may have little trouble learning to read but exhibit extremely poor social interaction. Each youngster will display communication, social, and behavioral patterns that are individual but fit into the overall diagnosis of Autism Spectrum Disorders.

Kids with Autism Spectrum Disorders do not follow the typical patterns of child development. In some kids, hints of future problems may be apparent from birth. In most cases, the problems in communication and social skills become more noticeable as the youngster lags further behind other kids the same age. Some other kids start off well enough. Oftentimes between 12 and 36 months old, the differences in the way they react to parents and other unusual behaviors become apparent. Some moms and dads report the change as being sudden, and that their kids start to reject others, act strangely, and lose language and social skills they had previously acquired. In other cases, there is a plateau, or leveling, of progress so that the difference between the youngster with autism and other kids the same age becomes more noticeable.

Possible Indicators of Autism Spectrum Disorders—
  • Does not babble, point, or make meaningful gestures by 1 year of age
  • Does not combine two words by 2 years
  • Does not respond to name
  • Does not speak one word by 16 months
  • Loses language or social skills

Other Indicators—
  • At times seems to be hearing impaired
  • Doesn't seem to know how to play with toys
  • Doesn't smile
  • Excessively lines up toys or other objects
  • Is attached to one particular toy or object
  • Poor eye contact

Social Symptoms—

From the start, typically developing infants are social beings. Early in life, they gaze at others, turn toward voices, grasp a finger, and even smile. In contrast, most kids with Autism Spectrum Disorders seem to have tremendous difficulty learning to engage in the give-and-take of everyday human interaction. Even in the first few months of life, many do not interact - and they avoid eye contact. They seem indifferent to others, and often seem to prefer being alone. They may resist attention or passively accept hugs and cuddling. Later, they seldom seek comfort or respond to moms and dads' displays of anger or affection in a typical way. Research has suggested that although kids with Autism Spectrum Disorders are attached to their moms and dads, their expression of this attachment is unusual and difficult to “read.” To moms and dads, it may seem as if their youngster is not attached at all. Parents who looked forward to the joys of cuddling, teaching, and playing with their youngster may feel crushed by this lack of the expected and typical attachment behavior.

Kids with Autism Spectrum Disorders also are slower in learning to interpret what others are thinking and feeling. Subtle social cues—whether a smile, a wink, or a grimace—may have little meaning. To a youngster who misses these cues, a statement like “come here” always means the same thing, whether the speaker is smiling and extending her arms for a hug, or frowning and planting her fists on her hips. Without the ability to interpret gestures and facial expressions, the social world may seem bewildering. To compound the problem, children with Autism Spectrum Disorders have difficulty seeing things from another person's perspective. Most 3-year-olds understand that others have different information, feelings, and goals than they have. A child with an Autism Spectrum Disorder may lack such understanding. This inability leaves them unable to predict or understand other's actions.

Although not universal, it is common for children with Autism Spectrum Disorders also to have difficulty regulating their emotions. This can take the form of “immature” behavior such as crying in class or verbal outbursts that seem inappropriate to those around them. The child with an Autism Spectrum Disorder might also be disruptive and physically aggressive at times, making social relationships still more difficult. They have a tendency to “lose control,” particularly when they're in a strange or overwhelming environment, or when angry and frustrated. They may at times break things, attack others, or hurt themselves. In their frustration, some bang their heads, pull their hair, or bite their arms.

Communication Difficulties—

By age 3, most kids have passed predictable milestones on the path to learning language (one of the earliest is babbling). By the first birthday, a typical toddler says words, turns when he hears his name, points when he wants a toy, and when offered something distasteful, makes it clear that the answer is “no.”

Some kids diagnosed with Autism Spectrum Disorders remain mute throughout their lives. Some infants who later show signs of Autism Spectrum Disorders coo and babble during the first few months of life, but they soon stop. Others may be delayed, developing language as late as age 5 to 9. Some kids may learn to use communication systems such as pictures or sign language.

Those who do speak often use language in unusual ways. They seem unable to combine words into meaningful sentences. Some speak only single words, while others repeat the same phrase over and over. Some kids with Autism Spectrum Disorders parrot what they hear, a condition called echolalia. Although many kids with no Autism Spectrum Disorders go through a stage where they repeat what they hear, it normally passes by the time they are 3.

Some kids that are only mildly affected may exhibit slight delays in language, or even seem to have precocious language and unusually large vocabularies, but have great difficulty in sustaining a conversation. The “give and take” of normal conversation is hard for them, although they often carry on a monologue on a favorite subject, giving no one else an opportunity to comment. Another difficulty is often the inability to understand body language, tone of voice, or “phrases of speech.” They might interpret a sarcastic expression such as “Oh, that's just great” as meaning it really IS great.

While it can be hard to understand what kids with Autism Spectrum Disorders are saying, their body language is also difficult to understand. Facial expressions, movements, and gestures rarely match what they are saying. Also, their tone of voice fails to reflect their feelings. A high-pitched, sing-song, or flat, robot-like voice is common. Some kids with relatively good language skills speak like little grown-ups, failing to pick up on the “kid-speak” that is common in their peer-group.

Without meaningful gestures or the language to ask for things, children with Autism Spectrum Disorders are at a loss to let others know what they need. As a result, they may simply scream or grab what they want. Until they are taught better ways to express their needs, kids with Autism Spectrum Disorders do whatever they can to get through to others. As these children grow up, they can become increasingly aware of their difficulties in understanding others and in being understood. As a result they may become anxious or depressed.

Repetitive Behaviors—

Although kids with Autism Spectrum Disorders usually appear physically normal and have good muscle control, odd repetitive motions may set them off from other kids. These behaviors might be extreme and highly apparent or more subtle. Some spend a lot of time repeatedly flapping their arms or walking on their toes. Some suddenly freeze in position.

As kids, they might spend hours lining up their cars and trains in a certain way, rather than using them for pretend play. If someone accidentally moves one of the toys, the youngster may be tremendously upset. Kids with Autism Spectrum Disorders need - and demand - absolute consistency in their environment. A slight change in any routine (e.g., in mealtimes, dressing, taking a bath, going to school at a certain time and by the same route, etc.) can be extremely disturbing. Perhaps order and sameness lend some stability in a world of confusion.

Repetitive behavior sometimes takes the form of a persistent, intense preoccupation. For example, the youngster might be obsessed with learning all about vacuum cleaners, train schedules, or lighthouses. Often there is great interest in numbers, symbols, or science topics.

Sensory Problems—

When kid’s perceptions are accurate, they can learn from what they see, feel, or hear. On the other hand, if sensory information is faulty, the youngster's experiences of the world can be confusing. Many kids with Autism Spectrum Disorders are highly attuned - or even painfully sensitive - to certain sounds, textures, tastes, and smells. Some kids find the feel of clothes touching their skin almost unbearable. Some sounds (e.g., vacuum cleaner, ringing telephone, sudden storm, sound of waves lapping the shoreline, etc.) may cause these kids to cover their ears and scream. In Autism Spectrum Disorders, the brain seems unable to balance the senses appropriately. Some kids with Autism Spectrum Disorders are oblivious to extreme cold or pain. The youngster may fall and break an arm, yet never cry. Another may bash his head against a wall and not wince, but a light touch may make the youngster scream with alarm.

The Diagnosis of Autism Spectrum Disorders—

Although there are many concerns about labeling a youngster with an Autism Spectrum Disorder, the earlier the diagnosis is made, the earlier needed interventions can begin. Evidence over the last 15 years indicates that intensive early intervention in optimal educational settings for at least 2 years during the preschool years results in improved outcomes in most young kids with Autism Spectrum Disorders.2

In evaluating a youngster, clinicians rely on behavioral characteristics to make a diagnosis. Some of the characteristic behaviors of Autism Spectrum Disorders may be apparent in the first few months of a youngster's life, or they may appear at any time during the early years. For the diagnosis, problems in at least one of the areas of communication, socialization, or restricted behavior must be present before the age of 3. The diagnosis requires a two-stage process. The first stage involves developmental screening during check-ups; the second stage entails a comprehensive evaluation by a multidisciplinary team.9

Screening—

A check-up should include a developmental screening test. If your youngster's doctor does not routinely check your youngster with such a test, ask that it be done. Your own observations and concerns about your youngster's development will be essential in helping to screen him or her.9 Reviewing family videotapes, photos, and baby albums can help moms and dads remember when each behavior was first noticed and when the youngster reached certain developmental milestones.

Several screening instruments have been developed to quickly gather information about a youngster's social and communicative development within medical settings. Among them are:
  • Social Communication Questionnaire (SCQ) (for kids 4 years of age and older)
  • Screening Tool for Autism in Two-Year-Olds (STAT)
  • Modified Checklist for Autism in Toddlers (M-CHAT)
  • Checklist of Autism in Toddlers (CHAT)

Some screening instruments rely solely on parent responses to a questionnaire, and some rely on a combination of parent report and observation. Key items on these instruments that appear to differentiate kids with autism from other groups before the age of 2 include pointing and pretend play. Screening instruments do not provide individual diagnosis, but serve to assess the need for referral for possible diagnosis of Autism Spectrum Disorders. These screening methods may not identify kids with mild Autism Spectrum Disorders, such as those with high-functioning autism or Aspergers.

During the last few years, screening instruments have been devised to screen for Aspergers and higher functioning autism. The Autism Spectrum Screening Questionnaire (ASSQ),14 the Australian Scale for Asperger's Syndrome,15 and the most recent, the Childhood Aspergers Test (CAST),16 are some of the instruments that are reliable for identification of school-age kids with Aspergers or higher functioning autism. These tools concentrate on social and behavioral impairments in kids without significant language delay.

If, following the screening process or during a routine check-up, your youngster's doctor sees any of the possible indicators of Autism Spectrum Disorders, further evaluation is indicated.

Comprehensive Diagnostic Evaluation—

The second stage of diagnosis must be comprehensive in order to accurately rule in or rule out an Autism Spectrum Disorder or other developmental problem. This evaluation may be done by a multidisciplinary team that includes a psychologist, a neurologist, a psychiatrist, a speech therapist, or other professionals who diagnose kids with Autism Spectrum Disorders.

Because Autism Spectrum Disorders are complex disorders and may involve other neurological or genetic problems, a comprehensive evaluation should entail neurologic and genetic assessment, along with in-depth cognitive and language testing.9 In addition, measures developed specifically for diagnosing autism are often used. These include the Autism Diagnosis Interview-Revised (ADI-R)17 and the Autism Diagnostic Observation Schedule (ADOS-G).18The ADI-R is a structured interview that contains over 100 items and is conducted with a caregiver. It consists of four main factors—the youngster's communication, social interaction, repetitive behaviors, and age-of-onset symptoms. The ADOS-G is an observational measure used to “press” for socio-communicative behaviors that are often delayed, abnormal, or absent in kids with Autism Spectrum Disorders.

Still another instrument often used by professionals is the Childhood Autism Rating Scale (CARS).19 It aids in evaluating the youngster's body movements, adaptation to change, listening response, verbal communication, and relationship to individuals. It is suitable for use with kids over 2 years of age. The examiner observes the youngster and also obtains relevant information from the moms and dads. The youngster's behavior is rated on a scale based on deviation from the typical behavior of kids of the same age.

Two other tests that should be used to assess any youngster with a developmental delay are a formal audiologic hearing evaluation and a lead screening. Although some hearing loss can co-occur with Autism Spectrum Disorders, some kids with Autism Spectrum Disorders may be incorrectly thought to have such a loss. In addition, if the youngster has suffered from an ear infection, transient hearing loss can occur. Lead screening is essential for kids who remain for a long period of time in the oral-motor stage in which they put any and everything into their mouths. Kids with an autistic disorder usually have elevated blood lead levels.9

Customarily, an expert diagnostic team has the responsibility of thoroughly evaluating the youngster, assessing the youngster's unique strengths and weaknesses, and determining a formal diagnosis. The team will then meet with the moms and dads to explain the results of the evaluation.

Although moms and dads may have been aware that something was not “quite right” with their youngster, when the diagnosis is given, it can be a devastating blow to some. At such a time, it is hard to stay focused on asking questions. But while members of the evaluation team are together is the best opportunity, moms and dads will have to ask questions and get recommendations on what further steps they should take for their youngster. Learning as much as possible at this meeting is very important, but it is helpful to leave this meeting with the name or names of professionals who can be contacted if moms and dads have further questions.

Available Aids—

When your youngster has been evaluated and diagnosed with an autism spectrum disorder, you may feel inadequate to help your youngster develop to the fullest extent of his or her ability. As you begin to look at treatment options and at the types of aid available, you will find out that there is help for you. It is going to be difficult to learn and remember everything you need to know about the resources that will be most helpful. Write down everything. If you keep a notebook, you will have a foolproof method of recalling information. Keep a record of the doctors' reports and the evaluation your youngster has been given so that his or her eligibility for special programs will be documented. Learn everything you can about special programs for your youngster; the more you know, the more effectively you can advocate.

For every youngster eligible for special programs, each state guarantees special education and related services. The Individuals with Disabilities Education Act (IDEA) is a Federally mandated program that assures a free and appropriate public education for kids with diagnosed learning deficits. Usually kids are placed in public schools and the school district pays for all necessary services. These will include, as needed, services by a speech therapist, occupational therapist, school psychologist, social worker, school nurse, or aide.

By law, the public schools must prepare and carry out a set of instruction goals, or specific skills, for every youngster in a special education program. The list of skills is known as the youngster's Individualized Education Program (IEP). The IEP is an agreement between the school and the family on the youngster's goals. When your youngster's IEP is developed, you will be asked to attend the meeting. There will be several individuals at this meeting, including a special education teacher, a representative of the public schools who is knowledgeable about the program, other individuals invited by the school or by you (you may want to bring a relative, a youngster care provider, or a supportive close friend who knows your youngster well). Moms and dads play an important part in creating the program, as they know their youngster and his or her needs best. Once your youngster's IEP is developed, a meeting is scheduled once a year to review your youngster's progress and to make any alterations to reflect his or her changing needs.

If your youngster is under 3 years of age and has special needs, he or she should be eligible for an early intervention program. This program is available in every U.S. state. Each state decides which agency will be the lead agency in the early intervention program. The early intervention services are provided by workers qualified to care for toddlers with disabilities and are usually in the youngster's home or a place familiar to the youngster. The services provided are written into an Individualized Family Service Plan (IFSP) that is reviewed at least once every 6 months. The plan will describe services that will be provided to the youngster, but will also describe services for moms and dads to help them in daily activities with their youngster and for siblings to help them adjust to having a brother or sister with Autism Spectrum Disorders.

Treatment Options—

There is no single best treatment package for all kids with Autism Spectrum Disorders. One point that most professionals agree on is that early intervention is important; another is that most children with Autism Spectrum Disorders respond well to highly structured, specialized programs.

Before you make decisions on your youngster's treatment, you will want to gather information about the various options available. Learn as much as you can, look at all the options, and make your decision on your youngster's treatment based on your youngster's needs. You may want to visit public schools in your area to see the type of program they offer to special needs kids.

Guidelines used by the Autism Society of America include the following questions moms and dads can ask about potential treatments:
  • Are there assessment procedures specified?
  • Are there predictable daily schedules and routines?
  • Do staff members have training and experience in working with kids and teens with autism?
  • Has the treatment been validated scientifically?
  • How are activities planned and organized?
  • How is progress measured? Will my youngster's behavior be closely observed and recorded?
  • How many kids have gone on to placement in a regular school and how have they performed?
  • How much individual attention will my youngster receive?
  • How successful has the program been for other kids?
  • How will failure of the treatment affect my youngster and family?
  • How will the treatment be integrated into my youngster's current program? Do not become so infatuated with a given treatment that functional curriculum, vocational life, and social skills are ignored.
  • Is the environment designed to minimize distractions?
  • What is the cost, time commitment, and location of the program?
  • Will my youngster be given tasks and rewards that are personally motivating?
  • Will the program prepare me to continue the therapy at home?
  • Will the treatment result in harm to my youngster?


Among the many methods available for treatment and education of children with autism, applied behavior analysis (ABA) has become widely accepted as an effective treatment. Thirty years of research demonstrated the efficacy of applied behavioral methods in reducing inappropriate behavior and in increasing communication, learning, and appropriate social behavior.20 The basic research done by Ivar Lovaas and his colleagues at the University of California, Los Angeles, calling for an intensive, one-on-one youngster-teacher interaction for 40 hours a week, laid a foundation for other educators and researchers in the search for further effective early interventions to help those with Autism Spectrum Disorders attain their potential. The goal of behavioral management is to reinforce desirable behaviors and reduce undesirable ones.21, 22

An effective treatment program will:
  • actively engage the youngster's attention in highly structured activities
  • build on the youngster's interests
  • offer a predictable schedule
  • provide regular reinforcement of behavior
  • teach tasks as a series of simple steps

Parental involvement has emerged as a major factor in treatment success. Moms and dads work with educators and therapists to identify the behaviors to be changed and the skills to be taught. Recognizing that parents are the youngster's earliest educators, more programs are beginning to train moms and dads to continue the therapy at home.

As soon as a youngster's disorder has been identified, instruction should begin. Effective programs will teach early communication and social interaction skills. In kids younger than 3 years, appropriate interventions usually take place in the home or a child care center. These interventions target specific deficits in:

• attention
• compliance
• imitation
• initiative of interaction
• language
• learning
• motivation

Included are behavioral methods, communication, occupational and physical therapy along with social play interventions. Often the day will begin with a physical activity to help develop coordination and body awareness. The kids string beads, piece puzzles together, paint, and participate in other motor skills activities. At snack time the teacher encourages social interaction and models how to use language to ask for more juice. The kids learn by doing. Working with the kids are students, behavioral therapists, and moms and dads who have received extensive training. In teaching the kids, positive reinforcement is used.23

Kids older than 3 years usually have school-based, individualized, special education. The youngster may be in a segregated class with other autistic kids or in an integrated class with kids without disabilities for at least part of the day. Different localities may use differing methods but all should provide a structure that will help the kids learn social skills and functional communication. In these programs, educators often involve the moms and dads, giving useful advice in how to help their youngster use the skills or behaviors learned at school when they are at home.24

In elementary school, the youngster should receive help in any skill area that is delayed and, at the same time, be encouraged to grow in his or her areas of strength. Ideally, the curriculum should be adapted to the youngster's needs. Many schools today have an inclusion program in which the youngster is in a regular classroom for most of the day, with special instruction for a part of the day. This instruction should include such skills as learning how to act in social situations and in making friends. Although higher-functioning kids may be able to handle academic work, they too need help to organize tasks and avoid distractions.

During middle and high school years, instruction will begin to address such practical matters as work, community living, and recreational activities. This should include work experience, using public transportation, and learning skills that will be important in community living.25

All through your youngster's school years, you will want to be an active participant in his or her education program. Collaboration between moms and dads and educators is essential in evaluating your youngster's progress.

The Teen Years—

Adolescence is a time of stress and confusion – and it is no less so for teenagers with some form of autism. Like all kids, they need help in dealing with their budding sexuality. While some behaviors improve during the teenage years, some get worse. Increased autistic or aggressive behavior may be one way some teens express their newfound tension and confusion.

The teenage years are also a time when teenagers become more socially sensitive. At the age that most teens are concerned with acne, popularity, grades, and dates, teens with some form of autism may become painfully aware that they are different from their friends. They may notice that they lack friends. And unlike their schoolmates, they aren't dating or planning for a career. For some, the sadness that comes with such realization motivates them to learn new behaviors and acquire better social skills.

Interventions—

In an effort to do everything possible to help their kids, many moms and dads continually seek new treatments. Some treatments are developed by reputable therapists or by moms and dads of a youngster with an Autism Spectrum Disorder. Although an unproven treatment may help one youngster, it may not prove beneficial to another. To be accepted as a proven treatment, the treatment should undergo clinical trials, preferably randomized, double-blind trials that would allow for a comparison between treatment and no treatment.

Dietary interventions are based on the idea that 1) food allergies cause symptoms of autism, and 2) an insufficiency of a specific vitamin or mineral may cause some autistic symptoms. If moms and dads decide to try for a given period of time a special diet, they should be sure that the youngster's nutritional status is measured carefully.

A diet that some moms and dads have found was helpful to their autistic youngster is a gluten-free, casein-free diet. Gluten is a casein-like substance that is found in the seeds of various cereal plants—wheat, oat, rye, and barley. Casein is the principal protein in milk. Since gluten and milk are found in many of the foods we eat, following a gluten-free, casein-free diet is difficult.

A supplement that some moms and dads feel is beneficial for an autistic youngster is Vitamin B6, taken with magnesium (which makes the vitamin effective). The result of research studies is mixed; some kids respond positively, some negatively, some not at all or very little.5

In the search for treatment for autism, there has been discussion in the last few years about the use of secretin, a substance approved by the Food and Drug Administration (FDA) for a single dose normally given to aid in diagnosis of a gastrointestinal problem. Anecdotal reports have shown improvement in autism symptoms, including sleep patterns, eye contact, language skills, and alertness. Several clinical trials conducted in the last few years have found no significant improvements in symptoms between patients who received secretin and those who received a placebo.26

Medications are often used to treat behavioral problems, such as aggression, self-injurious behavior, and severe tantrums that keep the child with an Autism Spectrum Disorder from functioning more effectively at home or school. The medications used are those that have been developed to treat similar symptoms in other disorders. Many of these medications are prescribed “off-label.” This means they have not been officially approved by the FDA for use in kids, but the doctor prescribes the medications if he or she feels they are appropriate for your youngster. Further research needs to be done to ensure not only the efficacy but the safety of psychotropic agents used in the treatment of kids and teens.

On October 6, 2006 the U.S. Food and Drug Administration (FDA) approved risperidone (generic name) or Risperdal (brand name) for the symptomatic treatment of irritability in autistic kids and teens ages 5 to 16. The approval is the first for the use of a drug to treat behaviors associated with autism in kids. These behaviors are included under the general heading of irritability, and include aggression, deliberate self-injury and temper tantrums.

Olanzapine (Zyprexa) and other antipsychotic medications are used "off-label" for the treatment of aggression and other serious behavioral disturbances in kids, including kids with autism. Off-label means a doctor will prescribe a medication to treat a disorder or in an age group that is not included among those approved by the FDA. Other medications are used to address symptoms or other disorders in kids with autism. Fluoxetine (Prozac) and sertraline (Zoloft) are approved by the FDA for kids age 7 and older with obsessive-compulsive disorder. Fluoxetine is also approved for kids age 8 and older for the treatment of depression.

Fluoxetine and sertraline are antidepressants known as selective serotonin reuptake inhibitors (SSRIs). Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested that they may have unintentional effects on some individuals, especially teens and young grown-ups. In 2004, after a thorough review of data, the Food and Drug Administration (FDA) adopted a "black box" warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in kids and teens taking antidepressants. In 2007, the agency extended the warning to include young grown-ups up to age 25. A "black box" warning is the most serious type of warning on prescription drug labeling. The warning emphasizes that patients of all ages should be closely monitored, especially during the initial weeks of treatment, for any worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations.

A youngster with an Autism Spectrum Disorder may not respond in the same way to medications as typically developing kids. It is important that moms and dads work with a doctor who has experience with kids with autism. A youngster should be monitored closely while taking a medication. The doctor will prescribe the lowest dose possible to be effective. Ask the doctor about any side effects the medication may have and keep a record of how your youngster responds to the medication. It will be helpful to read the “patient insert” that comes with your youngster's medication. Some individuals keep the patient inserts in a small notebook to be used as a reference. This is most useful when several medications are prescribed.

• Seizures. Seizures are found in one in four persons with Autism Spectrum Disorders, most often in those who have low IQ or are mute. They are treated with one or more of the anticonvulsants. These include such medications as carbamazepine (Tegretol®), lamotrigine (Lamictal®), topiramate (Topamax®), and valproic acid (Depakote®). The level of the medication in the blood should be monitored carefully and adjusted so that the least amount possible is used to be effective. Although medication usually reduces the number of seizures, it cannot always eliminate them.

• Inattention and hyperactivity. Stimulant medications such as methylphenidate (Ritalin®), used safely and effectively in persons with attention deficit hyperactivity disorder, have also been prescribed for kids with autism. These medications may decrease impulsivity and hyperactivity in some kids, especially those higher functioning kids.

• Behavioral problems. Antipsychotic medications have been used to treat severe behavioral problems. These medications work by reducing the activity in the brain of the neurotransmitter dopamine. Among the older, typical antipsychotics, such as haloperidol (Haldol®), thioridazine, fluphenazine, and chlorpromazine, haloperidol was found in more than one study to be more effective than a placebo in treating serious behavioral problems.27 However, haloperidol, while helpful for reducing symptoms of aggression, can also have adverse side effects, such as sedation, muscle stiffness, and abnormal movements. Placebo-controlled studies of the newer “atypica” antipsychotics are being conducted on kids with autism. The first such study, conducted by the NIMH-supported Research Units on Pediatric Psychopharmacology (RUPP) Autism Network, was on risperidone (Risperdal®).28 Results of the 8-week study were reported in 2002 and showed that risperidone was effective and well tolerated for the treatment of severe behavioral problems in kids with autism. The most common side effects were increased appetite, weight gain and sedation. Further long-term studies are needed to determine any long-term side effects. Other atypical antipsychotics that have been studied recently with encouraging results are olanzapine (Zyprexa®) and ziprasidone (Geodon®). Ziprasidone has not been associated with significant weight gain.

• Anxiety and depression. The selective serotonin reuptake inhibitors (SSRI's) are the medications most often prescribed for symptoms of anxiety, depression, and/or obsessive-compulsive disorder (OCD). Only one of the SSRI's, fluoxetine, (Prozac®) has been approved by the FDA for both OCD and depression in kids age 7 and older. Three that have been approved for OCD are fluvoxamine (Luvox®), age 8 and older; sertraline (Zoloft®), age 6 and older; and clomipramine (Anafranil®), age 10 and older.4 Treatment with these medications can be associated with decreased frequency of repetitive, ritualistic behavior and improvements in eye contact and social contacts. The FDA is studying and analyzing data to better understand how to use the SSRI's safely, effectively, and at the lowest dose possible.

Several other medications have been used to treat Autism Spectrum Disorders symptoms; among them are other antidepressants, naltrexone, lithium, and some of the benzodiazepines such as diazepam (Valium®) and lorazepam (Ativan®). The safety and efficacy of these medications in kids with autism has not been proven. Since individuals may respond differently to different medications, your youngster's unique history and behavior will help your doctor decide which medication might be most beneficial.

Adults with an Autism Spectrum Disorder—

Some grown-ups with Autism Spectrum Disorders, especially those with high-functioning autism or with Aspergers, are able to work successfully in mainstream jobs. Nevertheless, communication and social problems often cause difficulties in many areas of life. They will continue to need encouragement and moral support in their struggle for an independent life.

Many others with Autism Spectrum Disorders are capable of employment in sheltered workshops under the supervision of managers trained in working with persons with disabilities. A nurturing environment at home, at school, and later in job training and at work, helps persons with Autism Spectrum Disorders continue to learn and to develop throughout their lives.

The public schools’ responsibility for providing services ends when the person with Autism Spectrum Disorders reaches the age of 22. The family is then faced with the challenge of finding living arrangements and employment to match the particular needs of their adult youngster, as well as the programs and facilities that can provide support services to achieve these goals. Long before your youngster finishes school, you will want to search for the best programs and facilities for your young adult. If you know other moms and dads of Autism Spectrum Disorders grown-ups, ask them about the services available in your community. If your community has little to offer, serve as an advocate for your youngster and work toward the goal of improved employment services. Research the resources listed in the back of this brochure to learn as much as possible about the help your youngster is eligible to receive as an adult.

Living Arrangements for the Adult with an Autism Spectrum Disorder—

• Foster homes and skill-development homes. Some families open their homes to provide long-term care to unrelated grown-ups with disabilities. If the home teaches self-care and housekeeping skills and arranges leisure activities, it is called a “skill-development” home.

• Independent living. Some grown-ups with Autism Spectrum Disorders are able to live entirely on their own. Others can live semi-independently in their own home or apartment if they have assistance with solving major problems, such as personal finances or dealing with the government agencies that provide services to persons with disabilities. This assistance can be provided by family, a professional agency, or another type of provider.

• Living at home. Government funds are available for families that choose to have their adult youngster with Autism Spectrum Disorders live at home. These programs include Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), Medicaid waivers, and others. Information about these programs is available from the Social Security Administration (SSA). An appointment with a local SSA office is a good first step to take in understanding the programs for which the young adult is eligible.

• Long-term care facilities. This alternative is available for those with Autism Spectrum Disorders who need intensive, constant supervision.

• Supervised group living. Persons with disabilities frequently live in group homes or apartments staffed by professionals who help the individuals with basic needs. These often include meal preparation, housekeeping, and personal care needs. Higher functioning persons may be able to live in a home or apartment where staff only visit a few times a week. These persons generally prepare their own meals, go to work, and conduct other daily activities on their own.

Vaccinations—

The Institute of Medicine (IOM) conducted a thorough review on the issue of a link between thimerosal (a mercury based preservative that is no longer used in vaccinations) and autism. The final report from IOM, Immunization Safety Review: Vaccines and Autism, released in May 2004, stated that the committee did not find a link.

Until 1999, vaccines given to infants to protect them against diphtheria, tetanus, pertussis, Haemophilus influenzae type b (Hib), and Hepatitis B contained thimerosal as a preservative. Today, with the exception of some flu vaccines, none of the vaccines used in the U.S. to protect preschool aged kids against 12 infectious diseases contain thimerosal as a preservative. The MMR vaccine does not and never did contain thimerosal. Varicella (chickenpox), inactivated polio (IPV), and pneumococcal conjugate vaccines have also never contained thimerosal.

A U.S. study looking at environmental factors including exposure to mercury, lead and other heavy metals is ongoing.

Biologic Basis of Autism Spectrum Disorders—

Because of its relative inaccessibility, scientists have only recently been able to study the brain systematically. But with the emergence of new brain imaging tools—computerized tomography (CT), positron emission tomography (PET), single photon emission computed tomography (SPECT), and magnetic resonance imaging (MRI), study of the structure and the functioning of the brain can be done. With the aid of modern technology and the new availability of both normal and autism tissue samples to do postmortem studies, researchers will be able to learn much through comparative studies.

Postmortem and MRI studies have shown that many major brain structures are implicated in autism. This includes the cerebellum, cerebral cortex, limbic system, corpus callosum, basal ganglia, and brain stem.29 Other research is focusing on the role of neurotransmitters such as serotonin, dopamine, and epinephrine.

Research into the causes of autism spectrum disorders is being fueled by other recent developments. Evidence points to genetic factors playing a prominent role in the causes for Autism Spectrum Disorders. Twin and family studies have suggested an underlying genetic vulnerability to Autism Spectrum Disorders.30To further research in this field, the Autism Genetic Resource Exchange, a project initiated by the Cure Autism Now Foundation, and aided by an NIMH grant, is recruiting genetic samples from several hundred families. Each family with more than one member diagnosed with Autism Spectrum Disorders is given a 2-hour, in-home screening. With a large number of DNA samples, it is hoped that the most important genes will be found. This will enable scientists to learn what the culprit genes do and how they can go wrong.

Another exciting development is the Autism Tissue Program (http://www.brainbank.org), supported by the Autism Society of America Foundation, the Medical Investigation of Neurodevelopmental Disorders (M.I.N.D.) Institute at the University of California, Davis, and the National Alliance for Autism Research. The program is aided by a grant to the Harvard Brain and Tissue Resource Center (http://www.brainbank.mclean.org), funded by the National Institute of Mental Health (NIMH) and the National Institute of Neurological Disorders and Stroke (NINDS). Studies of the postmortem brain with imaging methods will help us learn why some brains are large, how the limbic system develops, and how the brain changes as it ages. Tissue samples can be stained and will show which neurotransmitters are being made in the cells and how they are transported and released to other cells. By focusing on specific brain regions and neurotransmitters, it will become easier to identify susceptibility genes.

Recent neuroimaging studies have shown that a contributing cause for autism may be abnormal brain development beginning in the infant’s first months. This “growth dysregulation hypothesis” holds that the anatomical abnormalities seen in autism are caused by genetic defects in brain growth factors. It is possible that sudden, rapid head growth in an infant may be an early warning signal that will lead to early diagnosis and effective biological intervention or possible prevention of autism.



References—

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Teaching Children and Teens with Asperger Syndrome and High-Functioning Autism

In this post, we will look at (a) the major challenges that Aspergers (high functioning autistic) students face in an educational setting, and (b) the appropriate classroom accommodations that teachers can utilize:


Poor Motor Coordination— 
Students with Aspergers are physically clumsy and awkward; have stiff, awkward gaits; are unsuccessful in games involving motor skills; and experience fine-motor deficits that can cause penmanship problems, slow clerical speed and affect their ability to draw.

Classroom Accommodations—
1. Students with Aspergers may require a highly individualized cursive program that entails tracing and copying on paper, coupled with motor patterning on the blackboard. The educator guides the student's hand repeatedly through the formation of letters and letter connections and also uses a verbal script. Once the student commits the script to memory, he can talk himself or herself through letter formations independently.

2. Do not push the student to participate in competitive sports, as his poor motor coordination may only invite frustration and the teasing of team members. The student with Aspergers lacks the social understanding of coordinating one's own actions with those of others on a team.

3. Individuals with Aspergers may need more than their peers to complete exams (taking exams in the resource room not only offer more time but would also provide the added structure and educator redirection these students need to focus on the task at hand).

4. Involve the student with Aspergers in a health/fitness curriculum in physical education, rather than in a competitive sports program.

5. Refer the student with Aspergers for adaptive physical education program if gross motor problems are severe.

6. When assigning timed units of work, make sure the student's slower writing speed is taken into account.

7. Younger students with Aspergers benefit from guidelines drawn on paper that help them control the size and uniformity of the letters they write. This also forces them to take the time to write carefully.


Academic Difficulties— 
Students with Aspergers usually have average to above-average intelligence (especially in the verbal sphere) but lack high level thinking and comprehension skills. They tend to be very literal: Their images are concrete, and abstraction is poor. Their pedantic speaking style and impressive vocabularies give the false impression that they understand what they are talking about, when in reality they are merely parroting what they have heard or read. The student with Aspergers frequently has an excellent rote memory, but it is mechanical in nature; that is, the student may respond like a video that plays in set sequence. Problem-solving skills are poor.

Classroom Accommodations—
1. Academic work may be of poor quality because the student with Aspergers is not motivated to exert effort in areas in which he is not interested. Very firm expectations must be set for the quality of work produced. Work executed within timed periods must be not only complete but done carefully. The student with Aspergers should be expected to correct poorly executed class work during recess or during the time he usually pursues his own interests.

2. Capitalize on these students' exceptional memory: Retaining factual information is frequently their forte.

3. Students with Aspergers often have excellent reading recognition skills, but language comprehension is weak. Do not assume they understand what they so fluently read.

4. Do not assume that students with Aspergers understand something just because they parrot back what they have heard.

5. Emotional nuances, multiple levels of meaning, and relationship issues as presented in novels will often not be understood.

6. Offer added explanation and try to simplify when lesson concepts are abstract.

7. Provide a highly individualized academic program engineered to offer consistent successes. The student with Aspergers needs great motivation to not follow his own impulses. Learning must be rewarding and not anxiety-provoking.

8. The writing assignments of children with Aspergers are often repetitious, flit from one subject to the next, and contain incorrect word connotations. These students frequently do not know the difference between general knowledge and personal ideas and therefore assume the educator will understand their sometimes abstruse expressions.


Emotional Vulnerability—
Students with Aspergers have the intelligence to compete in regular education but they often do not have the emotional resources to cope with the demands of the classroom. These students are easily stressed due to their inflexibility. Self-esteem is low, and they are often very self-critical and unable to tolerate making mistakes. Individuals with Aspergers, especially teens, may be prone to depression (a high percentage of depression in adults with Aspergers has been documented). Rage reactions/temper outbursts are common in response to stress/frustration. Students with Aspergers rarely seem relaxed and are easily overwhelmed when things are not as their rigid views dictate they should be. Interacting with people and coping with the ordinary demands of everyday life take continual Herculean effort.


Classroom Accommodations—
1. Affect as reflected in the educator's voice should be kept to a minimum. Be calm, predictable, and matter-of-fact in interactions with the student with Aspergers, while clearly indicating compassion and patience. Hans Asperger, the psychiatrist for whom this syndrome is named, remarked that “the educator who does not understand that it is necessary to teach students [with Aspergers] seemingly obvious things will feel impatient and irritated.”

2. Be aware that teens with Aspergers are especially prone to depression. Social skills are highly valued in adolescence and the child with Aspergers realizes he is different and has difficulty forming normal relationships. Academic work often becomes more abstract, and the teen with Aspergers finds assignments more difficult and complex. In one case, educators noted that a teen with Aspergers was no longer crying over math assignments and therefore believed that he was coping much better. In reality, his subsequent decreased organization and productivity in math was believed to be function of his escaping further into his inner world to avoid the math, and thus he was not coping well at all.

3. Do not expect the student with Aspergers to acknowledge that he is sad/ depressed. In the same way that they cannot perceive the feelings of others, these students can also be unaware of their own feelings. They often cover up their depression and deny its symptoms.

4. Educators must be alert to changes in behavior that may indicate depression, such as even greater levels of disorganization, inattentiveness, and isolation; decreased stress threshold; chronic fatigue; crying; suicidal remarks; and so on. Do not accept the student's assessment in these cases that he is "OK".

5. It is critical that teens with Aspergers who are mainstreamed have an identified support staff member with whom they can check in at least once daily. This person can assess how well he is coping by meeting with him daily and gathering observations from other educators.

6. Prevent outbursts by offering a high level of consistency. Prepare these students for changes in daily routine, to lower stress (see "Resistance to Change" section). Students with Aspergers frequently become fearful, angry, and upset in the face of forced or unexpected changes.

7. Report symptoms to the student's therapist or make a mental health referral so that the student can be evaluated for depression and receive treatment if this is needed. Because these students are often unable to assess their own emotions and cannot seek comfort from others, it is critical that depression be diagnosed quickly.

8. Students with Aspergers must receive academic assistance as soon as difficulties in a particular area are noted. These students are quickly overwhelmed and react much more severely to failure than do other students.

9. Students with Aspergers who are very fragile emotionally may need placement in a highly structured special education classroom that can offer individualized academic program. These students require a learning environment in which they see themselves as competent and productive. Accordingly, keeping them in the mainstream, where they cannot grasp concepts or complete assignments, serves only to lower their self-concept, increase their withdrawal, and set the stage for a depressive disorder. (In some situations, a personal aide can be assigned to the student with Aspergers rather than special education placement. The aide offers affective support, structure and consistent feedback.)

10. Teach the students how to cope when stress overwhelms him, to prevent outbursts. Help the student write a list of very concrete steps that can be followed when he becomes upset (e.g., 1-Breathe deeply three times; 2-Count the fingers on your right hand slowly three times; 3-Ask to see the special education educator, etc.). Include a ritualized behavior that the student finds comforting on the list. Write these steps on a card that is placed in the student's pocket so that they are always readily available.


Impairment in Social Interaction— 
Students with Aspergers show an inability to understand complex rules of social interaction; are naive; are extremely egocentric; may not like physical contact; talk at people instead of to them; do not understand jokes, irony or metaphors; use monotone or stilted, unnatural tone of voice; use inappropriate gaze and body language; are insensitive and lack tact; misinterpret social cues; cannot judge "social distance;" exhibit poor ability to initiate and sustain conversation; have well-developed speech but poor communication; are sometimes labeled "little professor" because speaking style is so adult-like and pedantic; are easily taken advantage of (do not perceive that others sometimes lie or trick them); and usually have a desire to be part of the social world.

Classroom Accommodations—
1. Although they lack personal understanding of the emotions of others, students with Aspergers can learn the correct way to respond. When they have been unintentionally insulting, tactless or insensitive, it must be explained to them why the response was inappropriate and what response would have been correct. Individuals with Aspergers must learn social skills intellectually: They lack social instinct and intuition.

2. Students with Aspergers tend to be reclusive; thus the educator must foster involvement with others. Encourage active socialization and limit time spent in isolated pursuit of interests. For instance, a educator's aide seated at the lunch table could actively encourage the student with Aspergers to participate in the conversation of his peers not only by soliciting his opinions and asking him questions, but also by subtly reinforcing other students who do the same.

3. Emphasize the proficient academic skills of the student with Aspergers by creating cooperative learning situations in which his reading skills, vocabulary, memory and so forth will be viewed as an asset by peers, thereby engendering acceptance.

4. In the higher age groups, attempt to educate peers about the student with Aspergers when social ineptness is severe by describing his social problems as a true disability. Praise classmates when they treat him with compassion. This task may prevent scapegoating, while promoting empathy and tolerance in the other students.

5. Most students with Aspergers want friends but simply do not know how to interact. They should be taught how to react to social cues and be given repertoires of responses to use in various social situations. Teach the students what to say and how to say it. Model two-way interactions and let them role-play. The student's social judgment improves only after they have been taught rules that others pick up intuitively. One adult with Aspergers noted that he had learned to "ape human behavior." A college professor with Aspergers remarked that her quest to understand human interactions made her "feel like an anthropologist from Mars".

6. Older children with Aspergers might benefit from a "buddy system." The educator can educate a sensitive nondisabled classmate about the situation of the student with Aspergers and seat them next to each other. The classmate could look out for the student with Aspergers on the bus, during recess, in the hallways and so forth, and attempt to include him in school activities.

7. Protect the student from bullying and teasing.


Restricted Range of Interests— 
Students with Aspergers have eccentric preoccupations or odd, intense fixations (sometimes obsessively collecting unusual things). They tend to relentlessly "lecture" on areas of interest; ask repetitive questions about interests; have trouble letting go of ideas; follow own inclinations regardless of external demands; and sometimes refuse to learn about anything outside their limited field of interest.

Classroom Accommodations—
1. Do not allow the student with Aspergers to perseveratively discuss or ask questions about isolated interests. Limit this behavior by designating a specific time during the day when the student can talk about this. For example: A student with Aspergers who was fixated on animals and had innumerable questions about a class pet turtle knew that he was allowed to ask these questions only during recesses. This was part of his daily routine and he quickly learned to stop himself when he began asking these kinds of questions at other times of the day.

2. For particularly recalcitrant students, it may be necessary to initially individualize all assignments around their interest area (e.g., if the interest is dinosaurs, then offer grammar sentences, math word problems and reading and spelling tasks about dinosaurs). Gradually introduce other topics into assignments.

3. Some students with Aspergers will not want to do assignments outside their area of interest. Firm expectations must be set for completion of class work. It must be made very clear to the student with Aspergers that he is not in control and that he must follow specific rules. At the same time, however, meet the students halfway by giving them opportunities to pursue their own interests.

4. Children can be given assignments that link their interest to the subject being studied. For example, during a social studies unit about a specific country, a student obsessed with trains might be assigned to research the modes of transportation used by people in that country.

5. Use of positive reinforcement selectively directed to shape a desired behavior is the critical strategy for helping the student with Aspergers. These students respond to compliments (e.g., in the case of a relentless question-asker, the educator might consistently praise him as soon as he pauses and congratulate him for allowing others to speak). These students should also be praised for simple, expected social behavior that is taken for granted in other students.

6. Use the student's fixation as a way to broaden his repertoire of interests. For instance, during a unit on rain forests, the child with Aspergers who was obsessed with animals was led to not only study rain forest animals but to also study the forest itself, as this was the animals' home. He was then motivated to learn about the local people who were forced to chop down the animals' forest habitat in order to survive.


Insistence on Sameness— 
Students with Aspergers are easily overwhelmed by minimal change, are highly sensitive to environmental stressors, and sometimes engage in rituals. They are anxious and tend to worry obsessively when they do not know what to expect; stress, fatigue and sensory overload easily throw them off balance.

Classroom Accommodations—
1. Allay fears of the unknown by exposing the student to the new activity, educator, class, school, camp and so forth beforehand, and as soon as possible after he is informed of the change, to prevent obsessive worrying. (For instance, when the student with Aspergers must change schools, he should meet the new educator, tour the new school and be apprised of his routine in advance of actual attendance. School assignments from the old school might be provided the first few days so that the routine is familiar to the student in the new environment. The receiving educator might find out the student's special areas of interest and have related books or activities available on the student's first day.)

2. Avoid surprises: Prepare the student thoroughly and in advance for special activities, altered schedules, or any other change in routine, regardless of how minimal.

3. Minimize transitions.

4. Offer consistent daily routine: The student with Aspergers must understand each day's routine and know what to expect in order to be able to concentrate on the task at hand.

5. Provide a predictable and safe environment.


Poor Concentration—
Students with Aspergers are often off task, distracted by internal stimuli; are very disorganized; have difficulty sustaining focus on classroom activities (often it is not that the attention is poor but, rather, that the focus is "odd" ; the individual with Aspergers cannot figure out what is relevant, so attention is focused on irrelevant stimuli); tend to withdrawal into complex inner worlds in a manner much more intense than is typical of daydreaming and have difficulty learning in a group situation.

Classroom Accommodations—
1. A tremendous amount of regimented external structure must be provided if the student with Aspergers is to be productive in the classroom. Assignments should be broken down into small units, and frequent educator feedback and redirection should be offered.

2. Students with severe concentration problems benefit from timed work sessions. This helps them organize themselves. Class work that is not completed within the time limit (or that is done carelessly) within the time limit must be made up during the student's own time (i.e., during recess or during the time used for pursuit of special interests). Students with Aspergers can sometimes be stubborn; they need firm expectations and a structured program that teaches them that compliance with rules leads to positive reinforcement (this kind of program motivates the student with Aspergers to be productive, thus enhancing self-esteem and lowering stress levels, because the student sees himself as competent).

3. If a buddy system is used, sit the student's buddy next to him so the buddy can remind the student with Aspergers to return to task or listen to the lesson.

4. In the case of mainstreamed children with Aspergers, poor concentration, slow clerical speed and severe disorganization may make it necessary to lessen his homework/class work load and/or provide time in a resource room where a special education educator can provide the additional structure the student needs to complete class work and homework (some students with Aspergers are so unable to concentrate that it places undue stress on moms and dads to expect that they spend hours each night trying to get through homework with their student).

5. Seat the student with Aspergers at the front of the class and direct frequent questions to him to help him attend to the lesson.

6. The educator must actively encourage the student with Aspergers to leave his inner thoughts/ fantasies behind and refocus on the real world. This is a constant battle, as the comfort of that inner world is believed to be much more attractive than anything in real life. For young students, even free play needs to be structured, because they can become so immersed in solitary, ritualized fantasy play that they lose touch with reality. Encouraging a student with Aspergers to play a board game with one or two others under close supervision not only structures play but offers an opportunity to practice social skills.

7. Work out a nonverbal signal with the student (e.g., a gentle pat on the shoulder) for times when he is not attending.


==> The Complete Guide to Teaching Students with Aspergers and High-Functioning Autism

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