Asperger s Syndrome. The diagnosis

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1 Asperger s Syndrome The diagnosis

2 Dr. Gerard J. Nijhof Orthopedagogue / health care psychologist Ph.D., Free University Amsterdam Current occupation at Amsta, Amsterdam department for people with intellectual disabilities Correspondence: g.nijhof@amsta.nl

3 History of the Asperger s Syndrome (1) Autism is described by Kanner (1943) and Asperger (1938, 1944). Asperger lived in Vienna, Kanner in Baltimore (USA). Asperger published in German, Kanner in English. The work of Asperger was a long time relatively unknown because it was only published in German. 1980: Asperger died.

4 History of the Asperger s Syndrome (2) 1981: Lorna Wing publication with 34 cases with resemblance to the description of Asperger. 1989: first diagnostic criteria and 1991: description of diagnostic criteria by Gillberg (Sweden).

5 DSM-V In the upcoming DSM-V one finds only the classification Autistic Spectrum Disorder the separate classification of Asperger s Syndrome has been put aside. So today we have a lecture that would be obsolete in a couple of months however I am convinced that we shall use the term AS for many years to come!

6 What to expect in this lecture (1) Characteristics of Asperger s Syndrome (AS) in general for children. Gillberg s diagnostic criteria. Compensatory and adjustment strategies. Scales to determine the occurrence of Asperger s Syndrome. Is AS different from HFA (High Functioning Autism)? Is it clinically relevant to make this distinction?.

7 What to expect in this lecture (2) Special focus on two specific themes: Solitude Girls: diagnostic assessment

8 Children with Asperger s syndrome: characteristics in general (1) Delayed social maturity. Immature forms of empathy. Difficulty in making friends, they re often bullied by other children. Difficulty with communication. Lack of control of emotions.

9 Characteristics (2) Unusual language: Advanced: vocabulary and syntax. Delayed: conversation skills. Unusual prosody (sound and rhythm). Tendency to be pedantic.

10 Characteristics (3) Fascination for something in an obsessive way, unusual in intensity or focus. Difficulty in maintaining attention ( classroom). Unusual profile of learning abilities. Need for assistance to get oneself organized. Clumsiness in terms of gait/walking pattern and coordination of actions. Sensitivity for specific sounds, aromas, textures (clothes) or touch.

11 Gillberg: diagnostic criteria Categories: 1. Social impairment, extreme egocentricity. 2. Narrow interest. 3. Compulsive need for introducing routines and interests. 4. Speech and language peculiarities. 5. Non verbal communication problems. 6. Motor clumsiness.

12 sub-1: Social impairment Difficulties interacting with peers. Indifference to peer contacts (being alone). Difficulties interpreting social cues. Socially and emotionally inappropriate behaviour (behaviour beyond the social context).

13 sub-2: Narrow interests Exclusion of other activities, only being interested in own activities. Preferring repetitive behaviour, continuous repeating activities and actions. Learning by head in stead of grasping the sense of things.

14 sub-3: Compulsive routines and interests Compulsive routines which have an effect on every aspect of daily life. Compulsive routines, having an effect on others (family and friends).

15 sub-4: Speech and language peculiarities Delayed speech development. Superficially perfect language expression. Formal pedantic language. Odd prosody, peculiar voice characteristics (rhythm may be strange, may be a little bit staccato). Impairment of comprehension, misinterpretations, taking things literally, own meanings of words.

16 sub-5: Non verbal communication problems Limited use of gestures. Clumsy body language, lacking social grace, sensitivity or acuteness. Limited facial expression. Inappropriate facial expression. Facial expression does not correspond to the situation in which it is manifested. Peculiar stiff gaze, sometimes staring behaviour.

17 sub-6: Motor clumsiness Poor performance in motor area, in neurodevelopmental tests, but in daily life too.

18 Compensatory or adjustment strategies Self-blame. Escape in imagination. Imaginary friends are predictable. Denial. Arrogance. Imitation of other children or characters (e.g. film stars).

19 Scales to determine the occurence of Asperger s Syndrome (1) ASQ or AQ (Simon Baron Cohen) adults: This scale produces an Autism Spectrum Quotient, but is also useful for AS. EQ: This scale produces an Empathy Quotiënt. SQ: This scale produces an Systemizing Quotient.

20 The Autism Spectrum Quotient (AQ) Test copy; MRC-SBC/SJW February Published: Journal of Autism and Developmental Disorders, 31, 5-17 (2001). 50 items

21 The Empathy Quotient (EQ) Intended to measure how easily you pick up on other people's feelings and how strongly you are affected by other people's feelings (60 items).

22 The Systemizing Quotient (SQ) The drive to analyse and explore a system, to extract underlying rules that govern the behaviour of a system; and the drive to construct systems (60 items).

23 Scales to determine the occurence of Asperger s Syndrome (2) The interpretation of the three scales and the DSM-IV criteria can play a significant role in obtaining a diagnosis for AS. Australian scale for Asperger s Syndrome (children) by Attwood.

24 The Australian Scale for Asperger s Syndrome Tony Attwood: Asperger s syndrome: A Guide For Parents and Professionals Dimensions: A. Social & emotional abilities B. Communication skills C. Cognitive skills D. Specific interests E. Movement skills F. Other characteristics (M.S. Garnett and A.J. Attwood)

25 Aspergers s Syndrome Scale: example Designed to identify behaviours and abilities indicative of Asperger's Syndrome in children during their primary school years. A. SOCIAL AND EMOTIONAL ABILITIES Rarely Frequently 1. Does the child lack an understanding of how to play with other children? For example, unaware of the unwritten rules of social play? When free to play with other children, such as school lunchtime, does the child avoid social contact with them? For example, finds a secluded place or goes to the library as the ordinary level expected of a child of that age. (M.S. Garnett and A.J. Attwood)

26 Is AS different from HFA: distinction clinically relevant? It seems likely that some of the persons being described as having Asperger s Syndrome could easily have been diagnosed as HFA (High Functioning Autism) by another expert and vice versa. This would often make it impossible to differentiate between the two.

27 Arguments for separate diagnoses (Mesibov) Persons with AS show less atypical language and communication than persons with HFA. Persons with AS have more social interests and less unusual social behaviours than persons with HFA. Persons with AS generally have markedly higher verbal IQ-scores than performance IQ-scores, while the opposite is true for persons with HFA. Persons with AS are more likely to show higher degrees of motor clumsiness and delayed development of motor skills than persons with HFA.

28 Arguments against separate diagnoses (Mesibov) Autism varies in severity and is associated with varying levels of intelligence. What is called AS is in fact mild autism with average to above average intelligence, associated with less impairment in all areas of functioning. The differences seen between groups in research studies are obscured by methodological limitations, including inconsistent or evolving diagnostic criteria. The pattern of verbal vs. performance IQ is not specific for either group. Research data indicate significant levels of motor coordination difficulties in both groups.

29 AS or HFA: Tony Attwood Attwood: There are no convincing arguments or data that confirm that AS and HFA are separate or distinct disorders. For young children the distinction may be useful, but later on there are so many influencing factors that a distinction is difficult to make. For clinicians the difference is irrelevant (except for young children) when the profiles of social and behavioural abilities are similar and the treatment is in fact the same.

30 Specific theme: Solitude Being alone is one of the symptoms one encounters in dealing with persons with autism or Asperger s Syndrome. But: is it so bad to be alone for people with Asperger's Syndrome?

31 Solitude (1) Attwood example: when parents leave their child alone in the bedroom there is not a qualitative impairment in social interaction there are no speech and language peculiarities heard the child can pay attention to his special interests as long as (s)he likes, without anyone judging the activity as abnormal in intensity or focus

32 Solitude (2) Solitude can in fact facilitate learning. Learning in a classroom setting requires considerable social and linguistic skills. In solitude many times successful self-teaching was attained by using books, computer, television. In solitude the autistic symptoms may rapidly dissolve

33 Solitude (3) Being alone has its advantages problems only occur when another person is around. No interaction = no problems People with AS may function reasonably well in oneto-one interactions. Two is a company, three is a crowd In group interactions the occurrence of social errors and misinterpretations are more often than not the case.

34 Solitude (4) More people = more interaction = more problems. Being alone can be experienced as a comfortable condition. In the assessment it is possible that while it is a oneto-one situation the diagnostician doesn t notice a symptom. During the diagnostic process one needs to get an impression of the person functioning within a complex social context.

35 Specific theme: Girls - diagnostic assessment We will pay short attention to the specific problems we encounter in the assessment of girls/females. It is important to know something about the differences for the understanding of AS.

36 Girls: diagnostic assessment (1) Attwood: 1000 diagnostic assessments over 12 years, ratio males to females 4 to 1. With girls it is more difficult to recognize AS, due to coping and camouflage mechanisms. Girls are more likely to develop a reciprocal conversation, including appropriate signs of affect and gestures, but. they easily adopt a social role or script (imitation), often based on the characteristics of a girl they know and who is considered by them as socially skilled.

37 Girls: diagnostic assessment (2) Girls use their intellectual abilities rather than their intuition to determine what to say and what to do. In playing they can hide their confusion by refusing invitations to engage until they are sure of what they should do. The general strategy is to wait while carefully observing the setting they re in. Participation only occurs when they are sure of what to do, imitating the previous actions of other children. Problems arise when the rules or nature of the game suddenly change.

38 Girls: diagnostic assessment (3) Girls can develop the ability to disappear in a large group, being on the periphery of social interaction, on the outside looking in. They can be well behaved and polite, thereby avoiding interaction. If one is very polite, then interpersonal distance can easily be obtained. Main trend: passively avoiding cooperation and social inclusion. Girls may be able to develop a close friendship, they are not bitchy, they are safe for other girls.

39 Girls: diagnostic assessment (4) For girls with AS the failure to develop peer relationships is not the same as it is for boys. Girls differ qualitatively on this dimension. Misunderstanding of social phenomena arises when their major friend ( mentor ) is no longer available (e.g. moves): it is the loss of their communication model and translator. Their special interests are less idiosyncratic ( peculiar ) or eccentric. Their main problem lies in the intensity and dominance of their (essentially normal) interest in daily life. Their motor coordination problems are less conspicuous, also it is less likely they have conduct problems.

40 Girls: diagnostic assessment (5) The qualities of girls for masking the signs of AS make it difficult for parents and teachers to recognize these signs. However, with increasing maturity women are more prepared to seek help for long-term and unresolved problems in the area of emotions, employment and relationships. In adulthood it is not unlikely that the AS male to female ratio is much higher. Attwood guesses it may be 2 to 1, based on his practice experiences.

41 AS boys and girls in perspective Boys with AS can be like little professors, they don t stop talking, even if their communication partner clearly is being bored. Girls with AS are more like little philosophers, they think more thoroughly about social situations, analyzing social interactions.

42 Handbook Tony Attwood: The complete Guide to Asperger s syndrome

43 Thank you for your kind attention This lecture is based on my own experience and on the research and practical work of many colleagues. We are beginning to gain insight in the complex world of Asperger s Syndrome, but a lot still needs to be clarified.

44

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