Hyperactivity—
There has recently been considerable interest and research into the possible connection between autism spectrum disorders and Attention Deficit Hyperactivity Disorder (ADHD). This interest includes both the similarities in symptoms as well as genetics. Hyperactivity, inattentiveness and impulsivity can be present in a number of childhood onset disorders, including ADHD as well as autism spectrum disorders. Kids with Attention Deficit Disorder (ADD) are often considered as having some characteristics indicative of Aspergers. Although they are two distinct disorders, they are not mutually exclusive and a youngster could have both conditions.
One nine year old boy with Aspergers, Jake, displayed severe symptoms of hyperactivity. He could barely contain himself when in his therapist's office, preferring to remove all the books from her bookshelf and trying to race down the hallways.
Another possibility is that of misdiagnosis. Some kids originally diagnosed with ADHD have later been re-diagnosed with a diagnosis on the autistic spectrum.
Perhaps the central feature of Aspergers is the unusual profile of social and emotional behavior... with ADHD, the kids tend to know how to play and want to play, but do so badly... kids with ADD have a diverse range of linguistic skills and interests, while there is a distinct language and interests profile for those with Aspergers. Their interests tend to be idiosyncratic and solitary, in contrast to those kids with ADD whose interests are more likely to be conventional for kids of that age. Kids with both conditions prefer and respond well to routines and predictability, can experience sensory sensitivity and have problems with motor coordination... Both conditions can be associated with impulsivity but this feature tends to be less of an issue with Aspergers... The youngster with ADD has a propensity to have problems with organization skills... With Aspergers, the profile includes unusual aspects of organizational skills such as unconventional means of solving problems and inflexibility.
Obsessive-Compulsive Traits—
Inflexibility regarding routines and rituals is a very common characteristic of people with autism and Aspergers. In Leo Kanner's writings about autism in 1943, he referred to the youngster with autism as having an "obsessive insistence on sameness".
While many people with autism spectrum disorder display inflexibility and rigidity, sometimes the symptoms are extreme and may warrant an additional diagnosis of Obsessive-compulsive disorder (OCD). It is conceivable that some higher-functioning autistic people's quasi-obsessive behaviors reflect true symptoms of a co-existing OCD. There was a woman with Aspergers who needed to check her doors and stove many times a day. Also, there was a man with Aspergers who needed to wash his hands very frequently because he feared contamination by germs. In these two examples, the extreme nature of the symptomatology and the fact that the people involved were troubled by their rituals support the diagnosis of OCD.
A commonly asked question is how to make a distinction between obsessive-compulsive symptoms and the unusual preoccupations of many people with Aspergers. In general, people with OCD realize their behavior is odd and are upset by their inability to control their symptoms. The special interests of people with Aspergers are different from a compulsive disorder in that the individual really enjoys their interest and does not try to resist it. As Janice, an adult with Aspergers said, "It's fun!"
There is considerable controversy in the field about whether people with autism or Aspergers who have milder ADHD or OCD symptoms should be diagnosed with multiple disorders. In other words, does the individual have Aspergers with hyperactive traits or is it preferable to diagnose him with Aspergers as well as ADHD? Does he have Aspergers with obsessive-compulsive characteristics or Aspergers plus OCD? Some clinicians feel that autism spectrum disorder, including Aspergers, is a broad category encompassing a wide variety of symptoms, with some people displaying more of some symptoms than others. On the other hand, other clinicians worry that many symptoms which respond well to psychopharmacological treatment may go untreated if not specifically diagnosed.
Anxiety—
Anxiety appears to be extremely common among people with autism and Aspergers. As one might expect, there are certain situations that typically lead to anxiety in this population. These situations include such things as changes in routine, interference with rituals, things not happening in the expected way, failing at tasks, and sensory overload.
Interestingly, for some people on the spectrum, it is the "little" things which seem to cause the most distress, while more major changes may be experienced with less disruption. Brandon, the boy who became overwhelmed with a change in television programming, looked forward with eager anticipation as his family prepared to move to a new house and, in fact, did quite well before, during and after the move.
If anxiety builds up to a critical level in any child, a temper tantrum may be the end result. Unfortunately, for a youngster on the spectrum, a temper tantrum may be an overwhelming and prolonged event. Furthermore, the techniques often used with typically developing kids may not work and may even prolong the difficulty. Trying to talk the youngster through the experience or reasoning with him is usually not effective. In addition, after the temper tantrum has subsided, trying to process with the youngster what happened and why may even contribute to the return of anxiety as well as the temper tantrum. Brenda Smith-Myles has referred to this phenomenon as "recycling".
Clearly, it is preferable to be proactive in preventing temper tantrums whenever possible, rather than trying to stop them once they have begun. In a proactive approach, thought is given beforehand to the kinds of things likely to provoke a temper tantrum in any particular child and either trying to avoid them or preparing for them. For example, for an individual greatly upset by change, one approach is to try to keep things as consistent and predictable as possible. When changes are unavoidable, if they are known in advance, it is often helpful to prepare the child for this fact. Another approach is to teach the child in a gradual, but systematic way, techniques for dealing with the changes and disruptions in life.
In addition to trying to prevent temper tantrums whenever possible, it is useful to have a plan in place to deal with them should they occur. This approach has more likelihood of success if utilized early in the temper tantrum; circumventing a temper tantrum is usually much easier than trying to stop one in full swing. The plan needs to be tailor made to the child; what works for one individual may be quite different from what works for another. It is often useful for teachers to speak to parents about what approaches are helpful in dealing with their kids. Undoubtedly, they have had many opportunities to try out different techniques! For some kids, removing them from the scene and providing them with "settling" activities may be useful. For example, Fred was often helped by being led to a quiet place where he could look at his calendars and yearbooks. For some kids, touch, especially firm pressure, can be a useful technique. On the other hand, for kids who are sensory defensive, touch can be too overwhelming. The following example illustrates one approach to containing a temper tantrum.
Mike had been eagerly looking forward to going on the Swan Boats in Boston. One day, his parent planned an outing in which they rode the subway into town, an experience Mike loved, and then went on to the boats. Unfortunately, just as they were about to board, the skies opened up in a downpour and the attendant announced the Swan Boats were closing. Mike began a full-fledged temper tantrum, complete with screaming, name-calling and flailing. His parent somehow managed to usher him into the subway station and onto the train, where, naturally, everyone else was also congregating because of the weather! Although the train was extremely crowded, the other passengers gave Mike and his parent a wide berth. She sat him down on a seat and knelt before him, placing her face very close to his and cupping his face in her hands. In a soothing voice, she told him repeatedly to look at her and reassured him that he was okay. His sobbing and flailing soon ceased.
Depression—
Like anxiety, depression is quite common in people with Aspergers. Many people develop problems with low self-esteem and depression during adolescence. It is at this time that many become acutely aware of their differences from their peers. Unfortunately, this is also the time in life when fitting in becomes so critical.
Some people with Aspergers develop affective disorders, which include true clinical depression and bipolar disorder. There is some data to suggest the incidence of these disorders in Aspergers is higher than in the general population. When these disorders do occur, there may be changes in the individual’s predominant mood or in his view of himself and the world. Vegetative symptoms, e.g., changes in sleep, eating, and activity level, may also occur. Of critical importance is the fact that some people with Aspergers and autism display an increase in “autistic” behaviors, for example, stereotyped motor mannerisms, self-injurious behaviors, or aggressiveness, when they become depressed. This fact seems to contribute to the problem of mental illness not being accurately diagnosed in this population, because clinicians sometimes attribute the increased “autistic” symptoms to the autism or Aspergers, rather than to the affective illness. Affective disorders are also more difficult to diagnose in this population because many people with autism spectrum disorders have difficulty communicating their feelings, both in words and in facial expressions. As a general rule of thumb, a significant change from the individual’s baseline level of functioning should raise questions about the possibility of an additional diagnosis.
In "Emotional Disturbance and Mental Retardation: Diagnostic Overshadowing", Steven Reiss, Grant W. Levitan and Joseph Szyszko of the University of Illinois conducted an important study outlining difficulties similar to those described above. They conducted two experiments showing that people with mental retardation were less likely than controls to be diagnosed with emotional disturbances. They coined the term diagnostic overshadowing, meaning that the emotional problems seemed less significant, or were overshadowed in importance, by the presence of mental retardation. Although this study did not include people with autism or Aspergers, it seems highly likely that similar results would occur. The following example illustrates this point.
Tony, an 8 year old with high functioning autism, was a gentle, rather easy-going youngster and was included in a Montessori classroom. During the fall of 3rd grade, he seemed to become more and more depressed, with increasingly frequent episodes of weeping with no apparent precipitant. His condition continued to deteriorate throughout the fall and by Christmas he required psychiatric hospitalization. By this time, he was weeping almost constantly, had become assaultive, and was trying to escape from his family’s home, which was situated near a major highway. In addition, he kept repeating bizarre demands, such as insisting the names of the days of the week be changed to those of the names of the kids in his class. After discharge from the hospital, he went to a residential school, where the psychiatrist viewed his symptoms as indicative of his autism. It was not until sometime later that another psychiatrist correctly concluded that Tony carried the additional diagnosis of bipolar illness.