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Asperger Syndrome


 

Asperger Syndrome

by Vera Bernard-Opitz, Kenneth Lyen, Lam Chee Meng

Definition

Asperger syndrome is defined as a condition resembling autism in which there are speech and language abnormalities, problems with nonverbal communication, severe impairment in social interaction, a fixation on a narrow field of interest, rigidity in following unchangeable routines and motor clumsiness.

Historical

In 1944, Hans Asperger described a distinctive pattern of behavior that resembled autism and is now referred to as Asperger syndrome. A year earlier, Kanner had published his observations on autism. Unlike Asperger syndrome in which the intelligence is normal or high, Kanner’s autistic subjects were quite severely intellectually disabled.

Epidemiology

In Sweden, the prevalence of Asperger syndrome is around two per 1,000 school children, and boys outnumber girls by quite a large margin. Asperger syndrome is more common and less severe than Kanner autism.

Inheritance

A number of families have a mix of members with Asperger syndrome and Kanner autism. This suggests that there is an overlap in these two conditions, and it may eventually turn out that they actually represent different degrees of severity of the same condition.

Clinical Features

Persons with Asperger syndrome may have a history of school difficulties. They display abnormalities in speech, nonverbal communication, social interaction skills, and motor coordination. They may engage in repetitive activities and are resistant to changes in routine. Other family members may have similar disturbances. Asperger syndrome is more commonly associated with normal or high intelligence.

Speech

The development of speech may be delayed. The words expressed may be sing-song in intonation, or they may be flat, with inappropriately exaggerated inflections. There may be pronoun substitution, so that "you" is used instead of "I". The Asperger subject may invent new words (neologisms) or use long and obscure words instead of simpler ones. Speech content can be pedantic and repetitive. Simple humor may be appreciated, but complex jokes may elude them.

Nonverbal Communication

There may be a paucity of facial expressions. Eccentric gestures, like holding the arms in the air and other odd posturings are sometimes manifest. They may frequently misread the body language, intentions or facial expressions of other people. Eye contact is said to be poor, but in Asians, this can be difficult to assess, because it is not the usual practice to look someone in the eye when communicating with that person.

Social Interactions

They have difficulties in initiating and sustaining relationships with others. Social rejection may result from a failure to grasp the rules of etiquette or social conduct, including rules which govern speech, hand gestures, body posture, choice of clothing and proximity to others. They may have a preference for machines or fantasies rather than human interactions. Even hygiene can be at the same time obsessionally clean and filthy. The Asperger subject may shower several times a day, but never brush the teeth. There may be extreme lack of common sense.

Resistance to Change

Once they develop a daily pattern, they resist any change in their routines. In a similar vein, they may form intense attachments to certain belongings, and may become very unhappy when away from home.

Motor Coordination

Their movements are awkward and clumsy, their posture appears peculiar, and they may have a tremor which can affect their writing and drawing.

Skills and Interests

Persons with Asperger syndrome may have an exaggerated interest or skill in one or two areas of expertise, and they may absorb every detail in these subjects. This is similar to those individuals with Kanner autism who sometimes display quite brilliant talent in a certain skill (autistic savants).

School Experiences

Children with Asperger syndrome tend to behave quite oddly and, because of their poor social defenses, may be bullied at school. They tend to do badly in their studies because they may prefer to pursue their own interests rather than complete their homework.

Differential Diagnosis

There is controversy over whether Asperger syndrome is part of the autism continuum or a separate entity. Asperger syndrome individuals tend to have higher intelligence than those with Kanner autism, but there is some overlap.

Currently there are no valid tests that can reliably differentiate Asperger syndrome from infantile autism. The observation that people with Kanner autism may transform into Asperger syndrome after intensive treatment further supports the notion that Asperger syndrome is part of the autism spectrum.

The unusual behavior, anxieties and fixed habits of those suffering from Asperger syndrome superficially resemble a number of psychiatric conditions, such as schizophrenia, the manic phase of manic-depression, generalized anxiety disorder, and obsessive-compulsive disorder.

Therapy

There is no specific medical treatment for Asperger syndrome. Therapy is largely educational and behavior modification.

- Teach the Asperger syndrome individual how to interpret facial expressions and physical gestures.

- Teach him how to analyze social situations.

- Encourage him to do some voluntary work.

- Find out what motivates that particular individual with Asperger syndrome, e.g., he may be willing to work for money to buy more computer equipment, and use it as positive reinforcement.

- Be sensitive to the person’s emotions, e.g., do not laugh at a joke that was not intended.

- If the person with Asperger syndrome uses "faultless logic leading to nonsensical conclusions", then he needs to be aware of the absurdity of his conclusions.

- Some individuals can even gain insight into their own condition by reading about Asperger syndrome.

- It may be helpful to introduce people with this condition to each other.

Drug Treatment

Individuals with Kanner autism sometimes respond to high doses of vitamin B6 or pyridoxine. As this is a relatively safe drug with preventable side effects, it can be given an empirical trial. If a person with Asperger syndrome has a coexisting problem, such as an anxiety disorder, then treatment for this should be given. If there are fits, anticonvulsants should be administered.

It is important to emphasize that the medical treatment of Asperger syndrome is only a small part of the total therapy. Adequate comprehensive treatment requires education, analysis of the environment with appropriate behavioral adjustments and psychotherapy if indicated. In addition, there should be meticulous evaluation and treatment of other concomitant medical problems. Thus, a team approach to treatment is essential. Medication cannot be used as a substitute for these other components of therapy.

Prognosis

The outcome of Asperger syndrome is very unpredictable, and may range from poor to excellent.

Case Studies

John is a 14-year-old in a special school. He had a normal delivery at birth but did not talk until he was six years old. Now, he is able to express himself in short sentences and has a reading age of a nine-year-old boy. However, his understanding of what he reads is below that. He has no friends. When he is not engaged in any activity, he sings to himself, bites himself and puts his fingers in his mouth and nose. John was diagnosed as having autism with developmental delay.

Ahmad is a 13-year-old boy who comes from a low income family. Despite not having any tuition and coming from a family background that does not speak English at home, Ahmad did well academically and was in the top academic stream. As a child he had delayed speech. Over the years, his speech improved, and he liked to talk, but had difficulty communicating his thoughts. He has a high-pitched voice with a flat tone. Up till today, he has no friends because he is unable to relate to others. He has a strong interest in television programs and knows a lot about them. In fact, he has learned a lot of "communication skills" like reflective listening, summarizing, and interpreting body language, from watching TV interviews. He has a very strong logical memory. He is diagnosed with Asperger syndrome.

Both John and Ahmad lie within the spectrum of autism.

Learning Styles

People with autism spectrum disorder learn in a different way from others. They tend to learn much better when information is presented to them in a visual way. While the phrase "a picture is worth a thousand words" applies to the average person, "a picture is worth ten thousand words" applies to most people with autism spectrum disorder. They also tend to have a strong memory for details, but have difficulties piecing the bits of information together to form a whole. In other words, they see the trees but not the wood. Gary Mesibov illustrates the way they see the world like a laser pointer, while non-autistic people see the world like a regular torchlight. A laser pointer is a highly-focused beam of light and causes an intense concentration in energy on one aspect of the environment. Organizing, sequencing, and time concepts are generally areas of difficulty for people with autism spectrum disorder and Asperger syndrome.

Savant

About 10 per cent of people with autism spectrum disorder have talent or are "gifted" in some specific area. Some are gifted in writing poetry, while others are talented in music, drawing, designing, computers, and calculating the day when given a date. The movies Rain Man and Mercury Rising are examples of individuals with autism spectrum disorder who have special talents.

What is the Most Effective Intervention Program?

The most common and effective form of intervention for individuals with Asperger syndrome is structured teaching, communication training, applied behavioral analysis, and social skills training. The best intervention programs come from having a deep understanding of how they see the world. These intervention programs can then be crafted to help them to see the world meaningfully. Individuals with Asperger syndrome need help in understanding the social environment and learn best when information is communicated to them in a visual way.

To meet their learning needs, TEACCH , a division of the University of North Carolina, USA, developed a structure teaching approach that focuses on the use of visual information to prepare the individual with autism spectrum disorder to learn. There are three main components to this approach: physical structure, visual schedule, and work system.

There is no one clear approach or program that works for all people with autism spectrum disorder. An effective intervention program should have the following components:

- Clear assessment of needs.

- Development of learning goals in his immediate environment with a long term aim of creating independence.

- A variety of learning opportunities for the child. This should include direct teaching, group teaching (for older children), independent practice, incidental teaching, generalization to other people and situations, and repeated practices.

- All teaching activities should be meaningful.

What are the Long-Term Goals of Intervention?

In terms of priority for goal setting, personal skills are the most important and form the foundation for skills building. Both parents and professionals place independence as the long-term goal for individuals with autism spectrum disorder. This is followed by intellectual skills and interpersonal skills.

Conclusions

We believe Asperger syndrome to be part of the autism spectrum disorder. The diagnosis is often missed by parents and teachers because children with this condition have normal to high intelligence. Nevertheless they have difficulties socializing, and may have some learning difficulties. Using visual cues to assist in their learning, giving them social skills training, can be most helpful to them.

This article first appeared in Rainbow Dreams (2002).