Asperger's syndrome

In the disorder discovered by Hans Asperger in the 1940's, the classical autistic symptoms — low capacity for communication and social interaction, restricted and repetitious stereotyped behavior — take a different and less disabling form than the symptoms found in infantile autism, and may require not only different treatments but a different social attitude. Asperger's disorder (or syndrome) was added to the American Psychiatric Association's official diagnostic manual in 1994 and is believed to affect about one in 300 children (and adults), nearly 90% of them male.

Despite normal and sometimes superior intelligence, people with Asperger's have difficulty understanding social conventions and reading social cues. As a result, they often seem tactless or rude, and making friends can be hard for them. Complicated feelings tend to confuse them. They may be unable to take hints, keep secrets, or under--stand metaphor, irony, and humor. The meaning of gestures, tone of voice, and facial expressions are a mystery to them, and their own body language and expressions may be inappropriate or hard to interpret. They stand too close, talk too loudly, and don't make eye contact. They have one-track minds that focus narrowly but intensely, some-times producing long-winded lecturing on subjects of interest only to themselves.

They are often clumsy, with poor handwriting and sometimes repetitive movements like rocking, or routines that resemble obsessive-compulsive behavior. They are easily upset when their expectations are not met or their routines disturbed; for example, they may want to wear the same clothes and follow the same rigid schedule every day. Sometimes they are unusually sensitive to sounds, smells, and touch.

Asperger's syndrome is part of what is called the autistic spectrum. On one side, it is distinguished from the more severe forms of autism, which often involve mental retardation, no language or extremely limited language, and almost complete social isolation. Asperger's is sometimes distinguished from a special category of "high-functioning" autism, chiefly on the grounds that it implies better verbal than nonverbal intelligence. But many experts doubt that this distinction reflects a real difference. At the opposite end of the autistic continuum from infantile autism, some say, is a personality style characterized by social awkwardness, pedantry, eccentricity, or emotional remoteness. The line between this personality type and Asperger's disorder is not always clear.

Definition of Asperger's disorder

In a child or adult with no deficiencies in overall intellectual development, self-help skills, or language,

A. At least two of the following:

1. Difficulty using gaze, facial expressions, gestures, and body posture normally in social interactions.

2. Failure to develop appropriate relationships with others the same age.

3. Apparent lack of spontaneous desire to share interests, achievements, or pleasures with others.

4. Failure to reciprocate, socially or emotionally.

B. At least one of the following:

1. Abnormally intense preoccupation with any single interest, or preoccupation with an abnormally narrow interest.

2. Rigid insistence on certain seemingly pointless routines or rituals.

3. Stereotyped and repetitive movements.

4. Preoccupation with parts of objects.

Adapted from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000.

A hereditary basis

The autistic spectrum has strong genetic roots. The rate of matching for identical twins, if the whole range of autistic symptoms from mild to severe is included, runs to 90%. About a third of the parents of a child with Asperger's syndrome will have at least some related symptoms. Sometimes the condition is identified only in adulthood, when a father recognizes his own symptoms in his child or a wife recognizes them in her husband. Despite this hereditary basis, there is no evidence so far for a specific organic cause. Different combinations of genes may be involved in different families, and there may be more than one underlying brain malfunction or peculiarity.

One popular theory is that people with Asperger's syndrome and other autistic disorders lack a "theory of mind" — the intuitive understanding that others have their own thoughts and feelings. As a result, they cannot imagine their way into the minds of others to anticipate their responses. Instead, they have to infer other people's feelings, intentions, and interests laboriously, using explicit rules. That is supposed to explain why a person who can master complex technical operations does not know how to conduct an ordinary conversation. Brain scans show that in most of us the amygdala, a center of emotion, is activated when we judge facial expressions. In people with Asperger's syndrome, the area that lights up is the prefrontal cortex, a seat of judgment and planning. They are thinking out the meaning of the expression instead of responding to it immediately.

Resources

Asperger Syndrome Coalition of the United States www.asperger.org

Autism Society of America800-328-8476 (toll free)www.autism-society.org

Online Asperger Syndrome Information and Support (OASIS)www.udel.edu/bkirby/asperger

Diagnosis and treatment

Ideally, an experienced pediatric neurologist, child psychologist or psychiatrist, or developmental psychologist should diagnose Asperger's disorder. It cannot be identified by a single test, and an interview in an office can be misleading because these children often handle themselves well in a one-on-one situation with an adult. It's important to learn about the child's history and how he or she behaves with other children in school and at play. Screening questionnaires for teachers, parents, and children may help.

The line between a normal boy's fascination with the latest computer game and a symptom of Asperger's disorder can be difficult to draw. But the more unusual and intense a restricted interest is, and the earlier in life it appears, the more it suggests Asperger's. It is also a possible diagnosis if a child seems to look through rather than at other people, if his voice seems to lack normal emotional inflections, or if he is unusually sensitive to loud sounds or the feel of clothes.

Asperger's should not be confused with attention deficit disorder, even though the symptoms may include learning disabilities, impulsiveness, and apparent intolerance of frustration. Other children may dislike those with Asperger's disorder because of their social awkwardness, but that is not the same as the malice, aggression, and deceit of children with conduct disorders. Placing them with these children in special classes is a serious mistake, because their social ineptitude makes them easy victims for bullies.

Under federal law, children with developmental disorders, including Asperger's, are eligible for special education appropriate to their needs. They can receive an individual education plan that may provide teacher's aides, tutoring, a special curriculum, or in a few cases, special schools.

For learning, children with Asperger's disorder require consistency, clear instructions, system, and routine. They must be taught to maintain eye contact, read facial expressions, and conduct conversations. Above all, they need to know what is and is not socially acceptable — why they have to get in line for lunch at the school cafeteria, how to tell people when they want to be alone, when not to say exactly what is on their minds, how to judge whether someone likes them, why teachers and strangers cannot be approached in the same way as family members. Both schools and parents can use cognitive and behavioral methods to teach these skills.

People with Asperger's can also be helped by individual or group therapy, especially if they have other symptoms such as obsessive-compulsive routines or depression. They may need help in managing anger and anxiety arising from social rejection or bullying. Depression often becomes a problem for them in adolescence, when they may feel socially excluded and disdained by members of the opposite sex without quite understanding why. In marriage, they are usually reliable, faithful, and loyal, but may seem emotionally distant to their partners. Sometimes marital therapy may be useful.

Male mind?

Asperger's syndrome is one of those conditions that raises the question of where to draw the line between normal and abnormal and what to do about it. The symptoms of Asperger's are common among scientists and engineers, who spend much of their time engaged with physical nature and machines that have no moods, thoughts, or intentions to confuse them. It's also been said that Asperger's is an extreme variant of the "male mind," representing rule-based, systematic thinking. From an early age, experiments show that girls are better than boys at interpreting facial expressions and imagining the feelings of fictional characters, while boys are more likely to be interested in ordered lists and mechanical models.

Whether that distinction is valid or not, from their own perspective many people with Asperger's and Asperger-like symptoms are not disabled but different. They are capable of leading satisfying lives — and providing challenges and opportunities that fit their talents as well as their limitations is not necessarily the same as treating a disorder. Sometimes it is less important to change them than to change the attitudes of others toward them. Their condition can contribute to diversity and add value to human experience.

References

Attwood T. Asperger's Syndrome: A Guide for Parents and Professionals. Jessica Kingsley Publishers, 1998.

Khouzam HR, et al. "Asperger's Disorder: A Review of Its Diagnosis and Treatment," Comprehensive Psychiatry (May–June 2004): Vol. 45, No. 3, pp. 184–91.

Sacks O. "An Anthropologist on Mars," The New Yorker (Dec. 27, 1993): Vol. 49, No. 44, pp. 106–25.

Willemsen-Swinkels SH, et al. "The Autistic Spectrum: Subgroups, Boundaries, and Treatment," Psychiatric Clinics of North America (Dec. 2002): Vol. 25, No. 4, pp. 811–36.

Willey LH, et al. Pretending to Be Normal: My Life with Asperger's Syndrome. Jessica Kingsley Publishers, 1999.