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In 1994, Asperger's
Disorder (AS) was recognized as a distinct clinical
entity in the DSM-IV with its own diagnostic
criteria. Because AS is a pervasive developmental disorder (PDD), it shares certain features with other pervasive disorders. At times, distinguishing AS from High-Functioning Autism (HFA) or Nonverbal Learning Disability (NLD) may be very difficult. Recent neuroimaging studies attempting to identify discrete patterns associated with AS and HFA have produced interesting data, but at the present time, there is no clinical scale or brain imaging study that can conclusively help with differential diagnosis.
Whereas the features
of autism are generally severe and noticeable
within the first years of life, children with
AS have a more typical development. In
general, a child with AS does not
have the language delays often seen in autism (although
they may have some atypical speech), and the
Asperger's child's IQ is generally higher than those diagnosed with autism (although some autistic children do have IQs in the average range). Many children with
AS have normal
intelligence.
While children with
autism may have no interaction with peers, children
with Asperger's do interact with peers, but may
experience significant difficulty in social
relationships. Children with AS often seem to be
loners and their intense
focus on their narrow area interest may lead to
isolation and/or peer rejection. Children with Asperger's are focused on detail and may amass a lot of information on their area of interest, often sounding like a "little professor" when they speak about it. Unfortunately, they do not seem to notice whether or not their peers are interested, bored, or growing frustrated with them. The "give and take" of everyday social conversations is a minefield for the child or adult with AS.
Although children with AS have normal language development in the early years, they may not always understanding the meaning of the words and may use them incorrectly. They also think and react to the literal meaning of
others' communications. Using slang or sarcasm with them -- such as saying "Hop to it!" may result in a literal interpretation instead of the child understanding that you mean, "Hurry up." Although some language skills are intact, comprehension of language and directions is often impaired. This impairment impacts academic tasks requiring following directions and drawing inferences, and also affects their social relationships.
One of the cardinal deficits associated with AS is difficulty "reading" others' intentions or needs. One component skill that
appears to be impaired relates to face gaze, and a
number of studies have noted abnormal patterns
(see, for example, Trepagnier et al., 2002, and the October 2008 NIMH science update on eye gaze). Individuals with AS do not seem to derive the same
information from facial features (such as eyes) as
their non-AS peers, and generally do not spend as
much time watching others' eyes during
conversations. Interestingly, some research
suggests that those who watch lips are more
socially competent than those who don't. Perhaps
the AS individual who is unable to "read" eyes
compensates by watching the lips and mouth. Inability to derive information from eye gaze is not the whole problem, however. Inability to read body language and other aspects of language impairment also result in social disability.
Little (2002) surveyed parents of children with AS and NLD on peer relations. She found an overall yearly prevalence
rate of victimization by peers or siblings or peer
shunning of 94%. A reported 10% of the children had
been attacked by a gang in the past year and 15%
were reported to have been victims of nonsexual
assaults to the genitals. A third of the children
had not been invited to a single birthday party in
the past year, and many were eating alone at lunch
or were picked last for teams. Peer shunning was
significantly correlated with peer bullying and
assault.
Because the data were
parental reports based on an Internet survey, it is
possible that the reported rates are an
overestimate of the true population values for
children with Asperger's, but it is interesting to
note that these rates are significantly higher than
those reported by parents of children and
adolescents with Tourette's Syndrome in another
Internet-based survey. In the latter study (Packer,
2005), peer teasing and some rejection
were reported, but more children had been invited
to birthday parties and there was only one report
of a child being physically assaulted because of
their tics. Thus, even allowing for design
limitations, Little's data are consistent with
clinical reports suggesting significant social
impairment associated with AS.
By adolescence, many youth with AS have significant social anxiety and avoidant behaviors (cf, Kuusikko et al., 2008).
Swedish physician
Christopher Gillberg categorizes the features of
Asperger's into six main domains of
impairment:
-- Social
impairment with extreme egocentricity, which may
include:
- Inability to
interact with peers
- Lack of desire
to interact with peers
- Poor
appreciation of social cues
- Socially and
emotionally inappropriate
responses
-- Limited
interests and preoccupations,
including:
- More rote than
meaning
- Relatively
exclusive of other interests
- Repetitive
adherence
-- Repetitive
routines or rituals, that may be:
- Imposed on
self, or
- Imposed on
others
-- Speech and
language peculiarities, such as:
- Superficially
perfect expressive language
- Odd prosody,
peculiar voice
characteristics
-- Impaired
comprehension including misinterpretation of
literal and implied meanings.
-- Nonverbal
communication problems, such as:
- Limited use of
gesture
- Clumsy body
language
- Limited or
inappropriate facial expression
- Peculiar
"stiff" gaze
- Difficulty
adjusting physical
proximity
-- Motor
clumsiness -- may not be present in all
cases.
As suggested by the
above, individuals with AS are more likely to
experience problems that are not confined to just
one factor or deficit. In addition to impairment in
deriving accurate inferences from facial cues and
auditory cues, individuals with AS are also more
likely to experience difficulty in taking chunks of
information and integrating them into a coherent
whole, regardless of whether the elements are visual pieces of a puzzle or sentences. Because they cannot integrate information, their ability to draw inferences is impaired (Jolliffe
& Baron-Cohen, 2000; 2001). Thus, even on a
content level and despite normal IQ, individuals with AS may not be able
to derive the same information as a non-AS peer,
leading to incorrect inferences about others'
views or about a situation in an academic task or work situation.
Motor clumsiness has also been linked to AS. Many of these children and adults would meet diagnostic criteria for Developmental Coordination Disorder but are not diagnosed with it because the diagnosis is not supposed to be used if the diagnosis of a pervasive developmental disorder has already been made.
On a day-to-day
level, then, children and adolescents with
Asperger's may experience significant problems and
their parents may need extensive support, which
might include parent education and training in
effective environmental supports and interventions
for dealing with problematic behaviors. Sofronoff and Farbotko (2002)
provide some data suggesting that parenting
workshops may be of benefit to parents of children
with AS.
While children with
Asperger's will often have special education needs,
many of them will do well academically and go on to
attend college. Many will also be able to develop
meaningful relationships with family and friends,
although the quality of the relationships may be
different than what most people experience. Many
adults with AS will experience significant
impairment socially, however. Adults with AS
are more likely to have anxious personalities, more
likely to experience coping difficulties in social
interaction, and less likely to be self-directed.
As one adult with AS
commented to me sadly one time, "My wife shouldn't
have to hold up a sign that says 'Hug me now' when
she's upset, but even when she tells me that she's
upset, I never seem to know what to say or do."
Social skills training for adults with AS and
counseling that involves spouses and family members
may be of benefit to adults with AS, and over the
past few years, more and more resources have
appeared.
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