1. Asperger Syndrome: Identification and Treatment Catherine Jones-Hazledine,Ph.D. Munroe-Meyer Institute University of Nebraska Medical Center

2. What is Asperger Syndrome? A Neurodevelopmental disorder characterized by social deficits, unusual and intensely restricted interests, and relative preservation of language skills and cognitive functioning. First described by Austrian physician Asperger in 1944.

3. Diagnostic Criteria (DSM-IV) 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 4. Lack of social or emotional reciprocity

4. 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. Diagnostic Criteria (DSM-IV)

5. 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 1. Single words used by age 2 2. Communicative phrases used by age 3 Diagnostic Criteria (DSM-IV)

6. E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than social interaction), and curiosity about the environment in childhood. F. Criteria is not met for another specific Pervasive Developmental Disorder or Schizophrenia Diagnostic Criteria (DSM-IV)

7. Other Diagnostic Issues Tends to be diagnosed after age 3 – Diagnosis more certain in older children (past preschool) More common in males Some controversy about independence from autism Motor delays or motor clumsiness often noted (though not required for diagnosis) Increased frequency of Asperger’s, as well as “unusual traits” in family members

8. Clinical Presentation Preoccupations with unusual interests that may become central focus of life – E.g. postal delivery routes, train schedules, personal information about Supreme Court Judges Difficulty dealing with feelings (their own or others) – Poor empathy – Tendency to intellectualize emotion Impaired Social Interaction – Inappropriate Conversations – Non-reciprocal interactions – Difficulty making or keeping friends Motor awkwardness, odd posture – Odd posture, gait – Poor handwriting

9. Other Diagnostic Concepts Which Share Similarities Semantic-Pragmatic Disorder – Characterized by adequate speech, but reduced communication value Right Hemisphere Learning Disability – Problems processing social/emotional information Nonverbal Learning Disability – Neuropsychological profiles of strengths and weaknesses – Problems with Social and Communication Skills – Asperger’s associated with NLD, but not the reverse Study of Neuropsych profiles – 18 of 21 consistent with NLD Schizoid Disorder – Social Isolation, emotional detachment, unusual communication, rigid thought and behavior – Social Disability tends to be more severe in Asperger’s

10. Comparison with Autism Similarities – Lack of adequate social relationships – Problems with emotion – Restricted Interests – Poor social language skills Differences – Later age of onset – Language absent or delayed in autism – More social interest in Asperger Syndrome – Motor deficits more common in Asperger Syndrome – Opposite neuropsychological profiles

11. Language and Communication in Asperger Disorder Abnormal inflection and voice quality Abnormal rate and volume (e.g. talking too fast or too loud) Tangential speech Trouble with turn-taking in conversation Difficulty self-censoring Verbosity Non-verbal deficits – Facial expression, posture, eye contact

12. Neuropsychological Testing Results Deficits – Fine and gross motor skills – Visual-motor integration – Visual-spatial perception – Non-verbal concept formation – Visual memory Strengths – Articulation – Verbal Output – Auditory perception – Vocabulary – Verbal Memory

13. School Related Problems Organizational deficits Problems completing tasks Graphomotor problems Specific Academic Deficits Behavioral problems – Rudeness – Noncompliance

14. Performance By Setting Worst – Unstructured social situations – Novel situations – Situations requiring “off the cuff” problem solving Best – Highly structured – Routine – Academically driven

15. Treatment Mostly supportive and focuses on addressing problematic symptoms Special Education Services can be helpful Physical Therapy and Occupational Therapy may be needed Vocational Training Psychological services may address comorbidity issues (depression, obsessions, thought disorder) Encouragement to access social contact Medication sometimes used, but not routine – Little evidence of efficacy – Side effects can be problematic

16. Problems More research about, and resources for, Autism – May not be helpful for Asperger’s children due to different profiles Children with Asperger Syndrome sometimes denied services – Higher IQ – More verbal skills – Sometimes not overt behavioral problems

17. Treatment Guidelines (Klin and Volkmer, 2000) Small setting or use of trained paraprofessional Communication Specialist with social skills training expertise – Blended throughout school day Frequent social opportunities – Structured and supervised Focus on daily life skills as well as academics Adaptability of curriculum Availability of mental health assistance – Monitoring – Resource to staff – Liaison with parents

18. Treatment General Teaching Strategies – Compensatory strategies (usually verbal) – Use of explicit methods and rote memorization – Move toward Generalization Social Skills Protocols – e.g. “Social Stories” (Carol Gray)

19. What to Teach? (Klin & Volkmer, 2000) Problem solving skills Behavioral routines – “First I do this, then I do/say this” – Verbal instruction – rehearsal Specific strategies for frequent problems Preplanning for “new” situations – What is the situation? – What do I know about this? – Step by step decision – Use of resources (who to call for assistance)

20. What to Teach? Social Awareness – Differences in perception highlighted Self-evaluation Link between certain situations and negative feelings Adaptive Skills – Adaptive Behavior Assessment System – II (ABAS II) Address specific strengths/weaknesses – Motor, visual-motor, problem-solving, auditory attention, reasoning

21. What to Teach? Social and communication skills training – Basic skills in social interaction – Appropriate nonverbal behavior – Verbal decoding of nonverbal behavior – Social awareness and perspective taking – Increasing vocabulary of emotion Generalization

22. References American Psychiatric Association (APA). (1994). Diagnostic and statistical manual of mental disorders (4 th ed.). Washington, DC: Author. Klin, A., Volkmer,F., & Sparrow, S. (Eds). (2000). Asperger Syndrome. New York, New York: Guildford Press. Klin, A., Sparrow, S., Volkmar, F., Cicchetti, D., and Rourke, B. (1995). Asperger Syndrome. In B. P. Rourke (Ed.), Syndrome of nonverbal learning disabilities: Neurodevelopmental manifestations (pp. 93 – 118). Reese, P., & Challenner, N. (2001). Autism and PDD: Adolescent Social Skills Lessons. East Moline, IL: Linguisystems.

23. Internet Addresses (From Klin, Volkmar,& Sparrow, 2000) Asperger Syndrome Coalition of the United States, Inc. (ASC-U.S.) (http://www.asperger.org)http://www.asperger.org ASPEN (Asperger Syndrome Education Network, Inc) (http://www.aspennj.org)http://www.aspennj.org Autism Society of America (http://www.autism-society.org)http://www.autism-society.org Division TEACCH (Treatment and Education of Autism and related Communication handicapped Children, University of North Carolina at Chapel Hill) (http://www.unc.edu/depts/teacch)http://www.unc.edu/depts/teacch OASIS (Online Asperger Syndrome Information and Support) (http://www.udel.edu/bkirby/asperger)http://www.udel.edu/bkirby/asperger Yale Child Study Center (http://www.autism.fm) (http://www.autism.fm)http://www.autism.fm