Asperger Syndrome

Asperger  syndrome  (AS)  is  the  term  applied  to the mildest and highest functioning end of the autistic (or pervasive developmental disorder [PDD]) spectrum, which ranges from AS to classic autism. People with AS typically display impairments in three areas: social difficulties (i.e., reading social cues, social awkwardness, and poor social skills), subtle communication problems (i.e., pedantic tone of voice and rate of speech, lack of fluidity in speech, difficulty understanding linguistic humor such as sarcasm and irony), and repetitive, rigid, or restricted behaviors (i.e., extreme interest in a topic or activity, insistence on particular behavioral routines). Compared with children with other autistic spectrum disorders, children with AS are characterized as having higher cognitive abilities and relatively normal language functioning.

Although Hans Asperger originally described children with this clinical picture in the 1940s, AS was not officially recognized until 1994 in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Within a year of one another,  Leo  Kanner  and Asperger  each  published papers describing children displaying symptoms in each of the three areas of developmental impairment. Lorna Wing’s (1981) paper was the major work to stimulate further review of Asperger’s description and its relationship Kanner’s. Wing estimated that Kanner’s definition of autism applied to only 10% of children with autism, and she called attention to the need for new diagnoses or a broader definition of the disorder. Wing also changed the disorder’s name from autistic psychopathy to Asperger’s syndrome.

Research  suggests  that AS  is  considerably  more common than autism. Whereas autism occurs in about 4 of every 10,000 children, estimates of AS have ranged as high as 20 to 25 per 10,000. Probably about 3 or 4 of every 1,000 children develop the full clinical picture of AS before about 10 years of age. Like autism, AS is much more common in boys than girls. In fact, studies suggest that males are about 5 times more likely to have AS than females are. Because females with AS sometimes exhibit different patterns of symptoms, prevalence figures may underestimate the proportion of females with AS in the general population.

AS is commonly associated with other disorders, including obsessive-compulsive disorder (OCD), attention deficit hyperactive disorder (ADHD), central auditory processing disorder (CAPD), Tourette’s syndrome, hyperlexia (ability to read very quickly, but deficient understanding of verbal language), depression, and anxiety. Although these difficulties commonly appear alongside AS, the syndrome can exist by itself or in combination with other disorders as well.

AS is usually congenital or arises following brain damage sustained during birth or the first few years of life. It is uncommon for AS to appear as a consequence of brain damage suffered later in life. In some cases, there is a clear genetic component (i.e., one parent has AS). Research suggests that the genes involved do not cause AS but instead cause a variety of language and social differences and personality styles, of which the autistic spectrum disorders are the extreme form. The strengths of people with AS can run in families, too. Parents and siblings often have similar talents and interests as those of people with autism spectrum disorders. For example, strong visual-spatial, mechanical, and memory skills are often found in the families of people with autism spectrum disorders. Thus, AS is just one of several possible outcomes of having certain genes.

In addition to a genetic component, a number of other causes for AS and other disorders along the PDD continuum have been suggested, including infection during pregnancy or in the first years of life (e.g., herpes simplex virus); inherited immune system deficiency (e.g., diabetes); and various pregnancy, labor, and delivery complications. Although research supports many of these potential causes, there is absolutely no evidence to support the claim that the measles-mumps-rubella (MMR) vaccine plays a role in AS.

During the first 2 years, there might be nonspecific indications that development may not be quite normal; however, it is not possible at this early stage to determine the future course or the diagnosis. Some of the nonspecific symptoms (meaning that plenty of children who do not go on to develop AS also show these) include sleeping difficulties, poor attention, overactivity or extreme passivity, and poor body adaptability. Before age 2, some children with AS may also display classic autism symptoms such as heightened sensitivity to certain sensory stimuli; stereotypical, self-stimulatory behavior such as rocking; echolalia (excessive repeating of stock phrases previously heard); or difficulty with initiating or maintaining eye contact with others.

The DSM-IV requires basically normal early language development for a diagnosis of AS; however, most children with AS have some delays in the development and understanding of spoken language. For instance, when other people try to communicate with these children, they may stare vacantly or over fixate on people or objects during communication. About one in three children with AS is quite delayed in speech development but begins using complicated phrases only a few months after starting to talk. Also, many children diagnosed with AS are awkward with their motor behavior in that they may be clumsy, have difficulty with balance or with judging distances, have poor fine motor coordination, and have an unusual gait or posture.

Between the ages of 3 and 5, the problems that children with AS have with social interaction and language become more evident. Preschool boys with AS tend to be more interested in toys and objects than their peers. In fact, they tend to withdraw from the group to engage in their own special interests. When they do interact with others, their actions are often awkward or rough (e.g., pushing or taking toys). Unlike boys, girls with AS seem to be have more social interests. The girls may fixate on others and may even smell, taste, or bite the people and objects around them. Interestingly, despite the inability of many late preschool-age children with AS to maintain normal social interactions and conversation, many are already good readers by this time.

Although some symptoms are present at earlier ages, AS  is  rarely  diagnosed  until  the  elementary school years. At about age 10, nearly all the characteristic symptoms are present. They tend to naïvely trust others, talk excessively, have difficulty forming friendships, and behave in emotionally inappropriate ways. They are often perceived as “being in their own world” and are limited by extremely narrow interest patterns. Children with AS can have a few interests at once and can change interests over time. The content is not so much the problem as is the way they become absorbed in their interest, leaving little time for anything else.

Another characteristic of AS is an obsession with rituals and routines that can be handicapping in early and middle childhood and very disruptive for the family. The routines are often linked to the child’s special interests, but they can also interfere with daily activities such as eating, dressing, and brushing teeth. Although the DSM-IV does not include communication problems in the diagnosis of AS, most researchers believe that both speech and language are affected.

Children with AS may have an excellent vocabulary but have difficulty understanding language in context and  difficulty  carrying  on  effective  conversations. In addition, articulation problems are also possible. These communication problems may also affect nonverbal skills, resulting in inappropriate body language, poor facial mimicry, and a fixated gaze. Motor control problems continue to affect children with AS throughout adolescence.

Although people with AS face major difficulties, they also have tremendous strengths. They tend to have good general IQ, excellent rote memory, perseverance, and perfectionism. Thus, it is typically important to have appropriate education and treatment to ensure the best possible development for children with AS. Individuals with AS who have serious problems in the area of psychosocial adaptation may need a competent diagnostic workup. Most children with AS are able to function well in “normal,” yet highly structured and predictable classrooms. To ensure the best outcomes, there should be a great deal of collaboration between parents, teachers, and other school officials (e.g., school psychologists) to determine the specific educational needs of each child. With training, other students can help teach children with AS socialization and communication skills. Social skills training can help people with AS and can also help facilitate communication with others. Individual talks with a psychologist or doctor may also have a positive effect, especially in times of depression or social isolation. Group sessions may also benefit older children and adults with AS.

As for medication, research has not indicated one pharmacological treatment that can effectively treat the basic impairments of AS. However, medications can often help treat some of the problems associated with AS. Serotonin reuptake inhibitors (SRIs) such as  citalopram,  sertraline,  fluoxetine,  fluvoxamine, and paroxetine can effectively treat mild to moderate depression, social phobia, and extreme rigidity and obsessive-compulsive symptoms for some AS children; others find antidepressants (e.g., imipramine and amitriptyline) and antianxiety medications to be more effective in treating these kinds of symptoms. Mild to severe ADHD symptoms can often be alleviated by central nervous system stimulants.

References:

1. Asperger, H. (1944/1991). “Autistic psychopathy” in childhood. In Frith (Ed. & Trans.), Autism and Asperger syndrome (pp. 37–92). Cambridge, UK: Cambridge University Press. (Original work published 1944).
2. Autism Society  of  America,  http://www.autismsociety.org/site/PageServer?pagename=Aspergers
3. Gillberg, C. (2002). A guide to Asperger syndrome. Cambridge, UK: Cambridge University
4. Kanner, (1943). Autistic disturbances of affective content.Nervous Child, 2, 217–250.
5. MAAP Services, (n.d.). The source: Autism, Asperger’s Syndrome, pervasive  developmental  disorders. Available from http://maapservices.org
6. Mesibov,  G.   ,   Shea,   V.,   &   Adams,   L.W.   (2001).Understanding Asperger syndrome and high functioning autism. New York: Kluwer Academic/Plenum.
7. National Alliance for  the  Mentally  Ill,  http://www.nami.org/ Content/ContentGroups/Helpline1/Asperhtm Ozonoff, S., Dawson, G., & McPartland, J. (2002). A parent’s guide to Asperger syndrome and high-functioning autism: How to meet the challenges and help your child thrive.New York: Guilford.
8. Wing, (1981). Asperger’s syndrome: A clinical account.Psychological Medicine, 11, 115–129.
9. Yale Child Study Center, Developmental Disabilities Clinic, http://info.med.yale.edu/chldstdy/autism/asperhtml