Question
I am a family therapist for the Anderson Center of Saint John’s. A client of mine recently reported a childhood history of difficulty learning social rules, learning problems, and rocking behaviors, which he learned to stop. He also reports social difficulties as a young adult. What is the easiest method to evaluate him to rule out Aspergers?
Answer
Aspergers (AS) can be quite difficult to diagnose. Individuals with this condition can function relatively well in daily life; however, they are generally socially immature and may be perceived as strange or eccentric.
While the more overt symptoms of Aspergers are typically more apparent in early childhood, symptoms may only become apparent with the increasing functional and social demands of adolescence. In the teenager with Aspergers, the stress of unrecognized disability, limited achievement, and a sense of failure are often revealed by increasing contrast with siblings and peers. Family and peers may become exasperated by the individual's self-centered insensitivity, obsessiveness, and rigid inflexibility, further distorting personal relationships. Each one of these variables can add secondary disability and lead to dependency that is disproportionate to the individual's mental ability.
Grown-ups with Aspergers present with subtle and specific difficulties, particularly in communication, social interactions, and interests. However, not all individuals are affected as extremely as noted below:
• Social relationships: Relationships are one-sided, distant, or absent. An unempathic objectivity leads to difficulties ranging from understanding friendship (how friends differ from acquaintances) to developing sexual relationships (grasping rules that distinguish seduction from date rape). People with Aspergers misunderstand relationships and are either too intense or too detached.
• Interests: At the most extreme, an individual with Aspergers has an eccentric life with rigid routines and a systematic, narrow focus on activities such as stamp collecting, baseball statistics, or railway timetables. Interests remain circumscribed and, rather than being an avenue for social interaction, they are enjoyed in solitude.
• Communication: Conversation is often one-sided, long-winded, circumstantial, lecture-like, and delivered in a robotic fashion. Less obvious abnormalities include unrecognized, underlying discrepancies between verbal and nonverbal language and between comprehension and expression. Individuals may lack eye contact, have few facial expressions and awkward body movements, and they may eventually develop social anxiety and nervous tics.
Grown-ups with Aspergers may also have problems with future planning and organization. Some compensate for this by being extremely meticulous in their planning and keeping extensive written or mental checklists. Other possible symptoms include hypersensitivity to sensory stimuli, violent outbursts, self-injurious behavior, rituals, odd posturing, and hand flapping.
When evaluating an individual for possible Aspergers, therapists can adhere to these guidelines…
Setting:
• Waiting causes increased stress levels. Whenever possible, schedule clients for Aspergers assessment as the first or last appointment of the day. If this is not possible, allow them to wait in a small side room or in their car, or allow them to go home and come back at a later agreed time.
• Prevent other sensory overload by minimizing loud noises and high-pitched sounds.
• Be aware that hand flapping, rocking, or ear covering may be their calming mechanism, so do not stop the behavior unless absolutely necessary.
• Avoid bright lighting. Some individuals with Aspergers are very light sensitive and can even detect the flashing of fluorescent lights.
Interview:
• Allow the individual extra time to process what you say to them.
• Ask for the information that you need, because an individual with Aspergers may not volunteer vital information without being asked directly, and because they may expect you to know what they are thinking.
• Avoid using facial expressions, body language, or gestures without verbal instructions, as these may be misunderstood.
• Explain what you are going to do before you do it, and use pictures when possible.
• Individuals with Aspergers do not understand personal space. Thus, they require more personal space than the average individual, or they may invade your space.
• Individuals with Aspergers take everything literally, so be concrete and avoid the use of idioms, irony, metaphors, and words with double meanings.
• Realize that the individual may not make eye contact during the interview, and do not assume that a nonverbal individual does not understand what you are saying.
• Use clear, simple language and speak in short sentences.
Physical Assessment:
• If performing something intrusive, such as phlebotomy, realize that individuals with Aspergers may have high or low pain tolerance or an unusual response to pain, such as laughter, humming, singing, or clothing removal. Use local anesthetics whenever possible.
• Give direct requests. Say, "Open your mouth." Don't say, "Can you open your mouth?" With the latter question, they may not understand that you are actually asking them to do something.
• Exams may prove very stressful, so warn the individual before touching him/her.
Therapists may choose to utilize an assessment tool to identify Aspergers. One that is easily available is the Adult Asperger Assessment (AAA), developed at the Aspergers Research Center (ARC), situated within the School of Clinical Medicine in the Department of Psychiatry, Section of Developmental Psychiatry, at the University of Cambridge, United Kingdom. Other diagnostic rating scales can be found at Online Asperger Syndrome Information & Support (OASIS).
Because individuals with Aspergers may misperceive their situation, it really is helpful to complete the assessment with data from others, such as spouses, buddies, teachers, and employers. Additionally it is advisable to give the individual with Aspergers an itemized report of the assessment to avoid misunderstandings that may arise from spoken communication.
Differential Diagnoses:
The the signs of Aspergers imitate other disorders; therefore, therapists must become familiar with the most probable differential diagnoses:
• ADHD is characterized by impaired functioning in multiple settings, including home and school, and in relationships with peers. Symptoms include impulsiveness, hyperactivity, and inattention.
• Antisocial PD is characterized by a pattern of disregard for other individual's rights, often crossing the line and violating those rights.
• Catatonic schizophrenia is characterized by prominent psychomotor disturbances that may alternate between extremes such as hyperkinesis and stupor.
• Generalized anxiety disorder is characterized by constant, exaggerated worrisome thoughts and tension about everyday routine life events and activities for a period of at least 6 months.
• Obsessive-compulsive PD is characterized by a preoccupation with orderliness, perfectionism, and control at the expense of flexibility, openness, and efficiency.
• Panic disorder is characterized by repeated episodes of intense fear that strike often and without warning. Physical symptoms include chest pain, heart palpitations, shortness of breath, dizziness, abdominal distress, feelings of unreality, and fear of dying.
• Paranoid schizophrenia is characterized by relatively stable and often paranoid delusions, usually accompanied by auditory hallucinations.
• Personality disorders (PD): Avoidant PD is characterized by a persistent and complex pattern of feelings of inadequacy, extreme sensitivity to what other individuals think about them, and social inhibition.
• Schizoid PD is characterized by a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings.
• Selective mutism is characterized by the persistent lack of speech in at least 1 social situation, despite the ability to speak in other situations.
• Simple schizophrenia (especially treatment-resistant) is characterized by an insidious but progressive development of oddities of conduct, inability to meet the demands of society, and a decline in total performance.
• Social phobia is characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations.
Aspergers is tough to diagnose, and the diagnosis ought to be confirmed by a mental health professional well versed in the diagnosis and treatment of Aspergers. However, a definitive diagnosis can be quite a relief because it allows individuals to learn about their condition, understand where and why they have difficulties, and obtain suitable support.
The Aspergers Comprehensive Handbook