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ASPERGER'S SYNDROME

Asperger's Syndrome is a milder variant of Autistic Disorder. Both Asperger's Disorder and Autistic Disorder are in fact subgroups of a larger diagnostic category called either Autistic Spectrum Disorders (ASD) or Pervasive Developmental Disorders (PDD). It manifests in highly individual ways and can have both positive and negative effects on a person. It is typically characterized by issues with social and communication skills

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Individuals affected by Asperger's Disorder, are characterized by social isolation and odd behavior in childhood. There are impairments in two-sided social interaction and non-verbal communication. Though grammatical, their speech is peculiar due to abnormalities of inflection and a repetitive pattern. Clumsiness is prominent both in their articulation and gross motor behavior. They usually have a circumscribed area of interest which usually leaves no space for more age appropriate, common interests. Some examples are cars, trains, history, scientific facts, door knobs, hinges, meteorology, astronomy or even murder mysteries.

Asperger's Syndrome is characterized by:

  • Clumsy and ill-coordinated movements and odd posture
  • Dull and monotonic speech
  • Peculiarities in speech and language
  • Poor nonverbal communication
  • Repetitive behaviors or rituals. Gets upset if personal space is disturbed
  • Narrow interests or preoccupation
  • Extensive logical/technical patterns of thought
  • Socially and emotionally inappropriate behavior and interpersonal interaction
  • Lack of empathy
  • Naive, inappropriate, one-sided social interaction, little ability to form friendships and consequent social isolation
  • Intense absorption in circumscribed topics such as the weather, facts about TV stations, railway tables or maps, which are learned in rote fashion and reflect poor understanding, conveying the impression of eccentricity

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The actual diagnosis (labeling) should be the final step in the evaluation. The assignment of a label should be done in a thoughtful way, so as to minimize stigmatization and avoid unwarranted assumptions. Every child is different and therefore, it is absolutely crucial that intervention programs derived from comprehensive evaluations are individualized to insure that they address the unique profile of needs and strengths exhibited by the given child. The psychiatric label should never be assumed to convey a precise preconceived set of behaviors and needs. Its main function is to convey an overall sense of the pattern of difficulties present. Professionals should never start a discussion of the child's needs by evoking the label. Rather, they should provide a detailed description of evaluation findings that resulted in the diagnosis of Asperger's Syndrome. A discussion of any inconsistency with the diagnosis, as well as of the clinician's level of confidence in assigning that diagnosis, should also be provided.

A thorough assessment of the child's assets and deficits in the context of an interdisciplinary evaluation includes assessments of behavioral (or psychiatric) history and current status, neuropsychological functioning, communication patterns (particularly the use of language for the purpose of social interaction, or pragmatics), and adaptive functioning (the individual's ability to translate potential into competence in meeting the demands of everyday life).

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Assessments are usually conducted by

Psychiatrists: Assessment includes observations of the child during more and less structured periods: for example, while interacting with parents and while engaged in assessment by other members of the evaluation team. Specific areas for observation and inquiry include the patient's patterns of special interest and leisure time, social and affective presentation, quality of attachment to family members, development of peer relationships and friendships, capacities for self-awareness, perspective-taking and level of insight into social and behavioral problems, typical reactions in novel situations, and ability to intuit other person's feelings and infer other person's intentions and beliefs. Problem behaviors that are likely to interfere with remedial programming should be noted (e.g., marked aggression). Other areas of observation involve the presence of obsessions or compulsions, depression, anxiety and panic attacks, and coherence of thought.

Clinical Psychologists: Assessment includes establishing the overall level of intellectual functioning, profiles of strengths and weaknesses, and style of learning. The specific areas examined and measured include neuropsychological functioning (e.g., motor and psychomotor skills, memory, executive functions, problem-solving, concept formation, visual-perceptual skills), adaptive functioning (degree of self-sufficiency in real-life situations), academic achievement (performance in school-like subjects), and personality assessment (e.g., common preoccupations, compensatory strategies of adaptation, mood presentation).

Speech-Language Pathologists: Assessment aims to obtain both quantitative and qualitative information regarding the various aspects of the child's communication skills. It goes beyond testing the formal speech and language development (e.g., articulation, vocabulary, sentence construction and comprehension), which are often areas of strength. The assessment should examine nonverbal forms of communication (e.g., gaze, gestures), non-literal language (e.g., metaphor, irony, absurdities, and humor), prosody of speech (melody, volume, stress and pitch), pragmatics (e.g., turn-taking, sensitivity to cues provided by the interlocutor, adherence to typical rules of conversation), and content, coherence, and contingency of conversation; these areas are typically one of the major difficulties for individuals with AS. Particular attention should be given to perseveration on restricted topics and social reciprocity.

A quick guide that helps differentiate between Asperger's and High Functioning Autism-

  • onset is usually later
  • outcome is usually more positive
  • social and communication deficits are less severe
  • circumscribed interests are more prominent
  • verbal IQ is usually higher than performance IQ (in autism, the case is usually the reverse)
  • clumsiness is more frequently seen
  • family history is more frequently positive
  • neurological disorders are less common

DIAGNOSTIC CRITERIA FOR ASPERGER'S DISORDER

DSM-IV (the most recent Diagnostic and Statistical Manual of the American Psychiatric Association, 1994) provides the following guidelines for definging Asperger's Syndrome

A. Qualitative impairment in social interaction, as manifested by at least two of the following:

(1)Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze,     facial expression, body postures, and gestures to regulate social interaction
(2)Failure to develop peer relationships appropriate to developmental level
(3)A lack of spontaneous seeking to share enjoyment, interests, or achievements with other     people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other     people)
(4)Lack of social or emotional reciprocity

B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

(1)Encompassing preoccupation with one or more stereotyped and restricted patterns of     interest that is abnormal either in intensity or focus
(2)Apparently inflexible adherence to specific, nonfunctional routines or rituals
(3)Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting,     or complex whole-body movements)
(4)Persistent preoccupation with parts of objects

C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.

D. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years).

E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.

F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.

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As in autism, intervention of Asperger's Syndrome is essentially supportive and symptomatic. Special educational services are sometimes helpful but there is no evidence on the effectiveness of specific interventions. Acquisition of basic skills in social interaction as well as in other areas of adaptive functioning should be encouraged. Supportive psychotherapy focused on problems of empathy, social difficulties, and depressive symptoms may be helpful, although it is usually very difficult for individuals with Asperger's Syndrome to engage in more intensive, insight-oriented psychotherapy.

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It has been observed that in the past, many individuals with Asperger's Syndrome are initially diagnosed as learning disabled with eccentric features, a non-psychiatric diagnostic label which alters the course of intervention programmes that maybe provided to these children. Many professionals and teachers are usually unaware of the extent and significance of the disabilities in Asperger's Syndrome. Proficient verbal skills, overall IQ usually within the normal range, and a solitary lifestyle often mask outstanding deficiencies observed primarily in novel or otherwise socially demanding situations, thus decreasing the perception of the very salient needs for supportive intervention. Thus, most often the actual problems faced by many of these children are left unidentified which in turn leads to increased social and emotional issues in adolescents and adulthood. It is very crucial to identify individuals with Asperger's Syndrome early to be able to provide them with unique and optimal services that will highlight their strengths and enhance social-emotional adjustments in later life.

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Any child should be provided services in an inter-disciplinary setting which has a team comprising people with varied expertise. A key feature of "interdisciplinary model" is where members discuss among themselves and the family and work towards the overall development of the child.

Professionals involved in planning an effective intervention programme includes

•  Psychiatrists
•  Speech and Language pathologists
•  Occupational therapists
•  Special Educators
•  Psychologists
•  Counselors

The above mentioned professionals work on one or more of the following areas -

 

Educational guidelines should be derived from the individual's neuropsychological profile of assets and deficits; specific intervention techniques should be similar to those usually employed for many subtypes of learning disabilities. Skills, concepts, cognitive strategies, and so on, may be more effectively taught in an explicit and rote fashion using a parts-to-whole verbal instruction approach, where the verbal steps are in the correct sequence for the behavior to be effective.

If significant motor and visual-motor deficits are corroborated during the evaluation, the individual should receive physical and occupational therapy. Therapists should not only focus on traditional techniques designed to remediate motor deficits, but should also reflect an effort to integrate these activities with learning of visual-spatial concepts, visual-spatial orientation, and body awareness.

Individuals with Asperger's Syndrome tend to rely on rigid rules and routines. This can be used as an advantage to foster positive habits and enhance the person's quality of life and that of family members. The teaching approach should be practiced routinely in naturally occurring situations and across different settings in order to maximize generalization of acquired skills.

It is very essential that these skills are taught by a communication specialist with a special interest in the pragmatics in speech. Social training groups are very effective for the practicing specific social skills. The programme may include working on recognizing and practicing appropriate nonverbal behavior (e.g., the use of gaze for social interaction, monitoring and patterning of inflection of voice) and enhancing social awareness, perspective-taking skills, and correct interpretation of ambiguous communications (e.g., non-literal language). Generalization of learned strategies and social concepts should be instructed, from the therapeutic setting to everyday life e.g. to examine some aspects of a person's physical characteristics as well as to retain full names in order to enhance knowledge of that person and facilitate interaction in the future.

The programmes described above may not cure but will help those diagnosed with Asperger's Syndrome better function in society.

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The following should be seen as suggestions to be considered when discussing optimal approaches to be adopted while working with your child.

  1. Social awareness should be cultivated, by providing opportunities and interact with people and focusing on the relevant aspects of given situations, and pointing out the irrelevancies contained therein.
  2. To enhance the individual's ability to compensate for typical difficulties processing visual sequences, particularly when these involve social themes, by making use of equally typical verbal strengths.
  3. Self-evaluation should be encouraged. Learning to analyze one's own behaviour and talk about it in a positive manner is very essential. Self-evaluation should also be used to strengthen self-esteem and maximize situations in which success can be achieved.
  4. Awareness should be gained into which situations are easily managed and which are potentially troublesome.
  5. Rule sequences for e.g., shopping, using transportation, etc., should be taught verbally and repeatedly rehearsed.
  6. Verbal instructions, rote planning and consistency are essential.
  7. The individual should be instructed on how to identify a novel situation and to resort to a pre-planned, well rehearsed list of steps to be taken. This list should involve a description of the situation, retrieval of relevant knowledge and step-by-step decision making.
  8. The link between specific frustrating or anxiety-provoking experiences and negative feelings should be taught to the child in a concrete, cause-effect fashion, so that he/she is able to gradually gain some measure of insight into his/her feelings. Also, the awareness of the impact of his/her actions on other people's feelings should be fostered in the same fashion.

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