The connection between Semantic Pragmatic Disorder and Aspergers Syndrome

Has anyone found any direct combination of Aspergers Syndrome and Specific Learning Disability? Have a small girl of 5 yrs who displays these traits.

Aspergers may be associated with learning difficulties and attention deficit disorder. Indeed, many kids and teens with Aspergers have previously been diagnosed with AD/HD instead of Aspergers. Children with AD/HD may have difficulty with social interaction, but the primary difficulties are inattention, hyperactivity and impulsivity. In children with Aspergers, the social awkwardness is a greater concern. As kids with Aspergers enter adolescence, they become acutely aware of their differences. This may lead to depression and anxiety. The depression, if not treated, may persist into adulthood.

Also, what is the connection between Semantic Pragmatic Disorder and Aspergers Syndrome??

==> First, we'll look at SPG...

Semantic Pragmatic Disorder—

HISTORY—

Semantic-Pragmatic Disorder was originally defined in the literature on Language Disorder in 1983, by Rapin and Allen, although at that time it was classified as a syndrome. They referred to a group of kids who presented with mild Autistic features and specific semantic pragmatic language problems.

In babyhood, moms & dads often described them as model babies or by contrast babies who seemed to cry too much. Many of these kids babbled little or very late and went on using 'jargon' speech much longer than other kids of the same age. Their first words were late and learning language was a hard slog. Some had other speech disorders too. Problems were usually first identified between 18 months and 2 years when the youngster had few if any real words.

Many moms & dads wondered if their kids were deaf at first because they did not appear to respond to speech. Assessment found that most kids had good hearing, although some did have otitis media and had grommets fitted to ensure maximum hearing.

The problem usually proved to be one of listening and processing the meaning of language instead. Many of the kids ignored their names early on but would hear the telephone or the door bell and even respond to the rustle of a sweet paper. Early on in their lives, Semantic-Pragmatic Disordered kids were found to have comprehension problems finding it difficult to follow instructions which were not part of the normal routine. Comprehension problems usually improved or responded well to speech therapy so that by the age of four years, many of the kids appeared to be functioning superficially, very well.

By the time these kids reached school, staff and moms & dads were aware that there was something "different" about them, but they couldn't quite put their finger on it. Sometimes the kids would appear to follow very little conversation, while at other times they could give a detailed explanation of an event. Later on in school they were often good at math, science, and computers but had great difficulty in writing a coherent sentence or playing with other kids. They were also unable to share and take turns. They could appear aggressive, selfish, bossy, over confident, shy or withdrawn. Many, therefore, were singled out as behavior problems and subjected to behavioral regimes which did not always work and left the youngster confused about what he was supposed to be doing. As one 6 year old Semantic-Pragmatic Disordered youngster said to his mother, "I don't want to be naughty".

Current Thinking—

Today we have a better understanding of the Disorder. We know that Semantic-Pragmatic Disordered kids have many more problems than just speaking and understanding words, so we call it a communication disorder rather than a language disorder. We think that the difficulty for kids with SEMANTIC PRAGMATIC DISORDER may be in the way they process information. Kids with SEMANTIC PRAGMATIC DISORDER find it more difficult to extract the central meaning or the saliency of an event. They tend to focus on detail instead; for example the sort of youngster who finds the duck hidden in the picture but fails to grasp the situation or story in the picture or the youngster who points out the spot on your face before saying 'hello'.

Extracting information from around us is something we do all the time. We are always looking for similarities and differences so that we can understand and anticipate. Kids who find it difficult to extract any kind of meaning will find it even more difficult to generalize and grasp the meaning of new situations. They will therefore cling on to keeping events the same and predictable. Maintaining sameness, by following routines slavishly, insisting on eating certain foods or wearing particular articles of clothing or developing obsessional interests are all characteristics of kids with SEMANTIC PRAGMATIC DISORDER Because these kids have difficulty extracting meaning both aurally and visually, the more stimulating the environment becomes the more difficult they find extracting information. Because people have minds which allow them to behave independently they are much less predictable and more difficult to understand than objects or machines. Kids with SEMANTIC PRAGMATIC DISORDER are often more sociable with friends at home or in a formal 1:1 assessment situation than in a busy classroom. Carers may be puzzled by the apparent discrepancy.

Listening and Understanding Language—

Because kids with SEMANTIC PRAGMATIC DISORDER find it difficult to focus their listening, they are easily distracted by noises outside the classroom or someone talking on the other side of the room. They may butt in on conversations which have nothing to do with them. They are often described by staff as inattentive or impulsive. They may find loud noise in the classroom distressing and may comment on this. Sometimes when kids with SEMANTIC PRAGMATIC DISORDER are trying very hard to concentrate they may not hear speech at all and ignore general instructions in the classroom while they are trying to work. Many class teachers say they sometimes have to stand in front of their kids with SEMANTIC PRAGMATIC DISORDER or touch them before they respond.

Although many kids with SEMANTIC PRAGMATIC DISORDER do very well; sometimes way above their age level on formal language assessments, this does not mean that they do not have comprehension difficulties. What it does mean is that our methods of testing are not tapping the right areas, or the ones we are using are not standardized yet.

Their difficulties in understanding language are usually fairly subtle by the time they are 5. Kids with SEMANTIC PRAGMATIC DISORDER can often respond to long instructions like, "put the blue pen under the big book", because the objects are there, because it is here and now in time, and because bright kids with SEMANTIC PRAGMATIC DISORDER usually have very little difficulty in understanding visible concepts like size, shape and color and can be well ahead of their peers. The other very important point is this kind of language does not require knowledge about the person giving the instruction.

Kids with SEMANTIC PRAGMATIC DISORDER would find comments and questions like "Where did you come from then?,.. What are you doing later?" "That was very clever of you!", much more difficult. This language requires more than listening and understanding words. You need to understand what the speaker was thinking and intending. You need to understand non literal expressions and time concepts too.

SEMANTIC PRAGMATIC DISORDER kid’s understanding usually breaks down in a busy classroom when the teacher starts to chat, tell jokes, or makes a few sarcastic remarks. Kids with SEMANTIC PRAGMATIC DISORDER often feel very uncomfortable at this point because they take everything literally. If other kids become aware of this, they can learn to tease and take advantage.

Because kids with SEMANTIC PRAGMATIC DISORDER have difficulty in understanding what other people are thinking when they are talking, they cannot understand when people are lying or deceiving them. Many moms & dads of kids with SEMANTIC PRAGMATIC DISORDER have reported to us that their kids have had their lunches taken off them or parted with pocket money and returned home unable to give a clear account of what happened.

Talking—

As well as subtle comprehension problems kids with SEMANTIC PRAGMATIC DISORDER have difficulties with talking too. These are not always picked up by moms & dads or staff because so often they chat fluently. It is the particular way in which they use language which identifies them as a group. That is, they have specific Pragmatic Difficulties.

Kids with SEMANTIC PRAGMATIC DISORDER have a different style of learning language; they seem to learn more by memorizing than knowing what the individual words really mean; so they cannot use language with the same range and flexibility as other kids. Kids with SEMANTIC PRAGMATIC DISORDER remember whole chunks of adult phrases and because they are not sure which bits are more important than others they learn everything accurately including the intonation and the accent of the speaker! Sometimes you can hear yourself talking. All in all they seem to say a lot more than they really understand. Some kids with SEMANTIC PRAGMATIC DISORDER use a flat or 'sing-songy' voice when they are echoing other people's language.

Kids with SEMANTIC PRAGMATIC DISORDER often remember to use this echoed language appropriately so they can sound very grown up which contrasts dramatically with their social immaturity. However, when you ask them to give you an account of an event or discuss a picture story which they have not rehearsed, you find them groping for original words and the whole account is very disjointed. One mum described how her son of 5 would tell everyone off in his class including the teacher using her words but could never explain what he had done at school or ask the teacher for help.

When you analyze the content of a SEMANTIC PRAGMATIC DISORDER youngster's speech, you find a disappropriate amount of echoed social phrases and very little about how people feel or think. SEMANTIC PRAGMATIC DISORDER kid’s delayed social development means that they do not make distinctions between people. Adults, kids, teachers and moms & dads are treated the same so when Adam said "don't talk to me like that" to a visitor, he was understandably thought to be very rude, when in fact he was simply repeating what had been said to him. SEMANTIC PRAGMATIC DISORDER kid’s inappropriate or immature use of language can be very embarrassing. They say things like, "why has that lady got such a big nose", or they give the family secret away to the very person you had intended it to be kept from. It is easy to see why adults find kids with SEMANTIC PRAGMATIC DISORDER so exasperating at times.

Problems with talking really show up at a conversational level for kids with SEMANTIC PRAGMATIC DISORDER First of all their delayed social development means that like younger kids, they are much more interested in themselves than other people so they tend to choose topics about themselves, their family or their special interests. Because they have insufficient understanding of their conversational partner, they tend not to understand that she might not be interested in their latest obsession and because the SEMANTIC PRAGMATIC DISORDER youngster has no idea what is pertinent in his story and what is not, when he is able to describe past events, he tends to give an over detailed account and fails to read the signals of boredom in his listener. He may, on the other hand believe that his listening partner shares his thoughts exactly. He thus assumes common knowledge and fails to put his partner sufficiently in the picture and requests for information may bring one word answers only.

On top of these problems so far described, the SEMANTIC PRAGMATIC DISORDER youngster may misunderstand what his conversation partner intended so he may give rather bizarre answers or he may, if he is skilful enough, change the topic and gear it back to what he understands and keep talking just to shut his partner out. Conversation can take on very strange meanings, if you are not aware of the SEMANTIC PRAGMATIC DISORDER youngster's difficulty.

Understanding how others think—

Some S.P.D kids become skilled at talking about pictures or sequences of pictures but you find them only able to give you the bare facts. Their inability to describe people's thoughts and intentions within the picture mean they cannot be creative or abstract in their account or they cannot infer or make sensible predictions. They cling to the observable features of the picture without dealing with the implied underlying meaning.

The SEMANTIC PRAGMATIC DISORDER youngster's difficulty in seeing the world through other people's eyes or understanding that other people think differently from himself, is often described as a youngster who does not have a 'theory of mind'.

There has been a lot of research recently into when kids develop a 'theory of mind'. Researchers have used false belief stories and deception tasks (which tests the youngster's ability to understand that people who do not share the same knowledge will behave differently) to determine when kids develop this skill. Researchers think that four year olds have quite good understanding of minds but that kids on the Autistic Continuum * find this more difficult.

Most 'core' Autistic kids never acquire a complex theory of mind where as SEMANTIC PRAGMATIC DISORDER do seem to but later than other skills at the same developmental stage. This lack of social 'nous' above all else makes life difficult for the SEMANTIC PRAGMATIC DISORDER youngster. They find it difficult to make friends with kids of their own age and tend to gravitate towards younger or much older kids unless of course there are other kids with SEMANTIC PRAGMATIC DISORDER in the class - when they seem to be attracted to each other like magnets. We think that kids with SEMANTIC PRAGMATIC DISORDER need to spend time together so they can feel on a par with each other and not constantly at the mercy of more sophisticated peers.

We think teachers should explain to other kids, in simple terms, why it is the SEMANTIC PRAGMATIC DISORDER youngster cannot conform and to keep an eye on his vulnerability both inside and outside of the classroom.

Creative Play—

Researchers have also suggested that the difficulty kids with SEMANTIC PRAGMATIC DISORDER have in playing creatively and in mentalizing has a common cognitive origin. The ability to separate one’s own thinking from that of another person may start at birth and develop through simple turn taking and shared attention games. Even breast feeding, humpty dumpty or peek-a-boo requires turn taking and mentalizing.

At about 18 months, kids take a leap forward in their mentalizing, they are able to think even more abstractly and they can switch from abstract to concrete thinking very easily. For example, they can pretend a toy cup is a telephone, but they also understand that the toy cup is a cup.

Toddlers' teddies take on extra meanings when they become people who are taken to bed, fed and even used to fight kid’s battles for them. Three year olds know how to switch from pretend to reality and develop story lines with their friends when they say, "Let’s pretend you are .....".

Kids with SEMANTIC PRAGMATIC DISORDER, on the other hand, find this kind of abstract thinking much more difficult. This makes their play less creative so that a tower of bricks is always a tower of bricks until someone else tells him otherwise. Kids with SEMANTIC PRAGMATIC DISORDER tend to flit from toy to toy or play repetitively. They show more interest in real activities like water, motor play, operating machines, tidying up and stacking toys. Many kids with SEMANTIC PRAGMATIC DISORDER understand representation i.e. that a toy cup stands for a real cup and they will often perform the appropriate action on the toy. They are not however pretending. The youngster who is really pretending is taking on the role of someone else and using their persona to develop a story line.

Many bright kids with SEMANTIC PRAGMATIC DISORDER try to solve the mystery of pretence by copying other peoples' pretence or copying moms & dads actions in the same detailed way they copy their speech. Some kids with SEMANTIC PRAGMATIC DISORDER copy exerts from TV programs exactly, and some people actually think kids with SEMANTIC PRAGMATIC DISORDER are being creative when in fact they are simply copying in detail. We call this kind of play functional play. This inability to separate pretence from reality can pose problems for some kids watching t.v. Although most kids with SEMANTIC PRAGMATIC DISORDER prefer cartoon programs, many, as they mature, enjoy films too. We would suggest that as far as possible you limit access to programs which contain violence and that you explain what is real and what is not.

This inability to be creative is usually extended to drawing skills too. Many kids with SEMANTIC PRAGMATIC DISORDER are late acquiring representational drawing skills. Many have to be taught how to draw a face and they can only repeat it in a particular way. Some kids with SEMANTIC PRAGMATIC DISORDER will only copy draw and some will only draw objects related to their obsessional interests. One youngster we knew would only draw pyramids, another drew horses. Very few, except the most able, can draw a picture story which is not the same each time.

Motor Difficulties—

Some kids with SEMANTIC PRAGMATIC DISORDER have fine motor difficulties. They find handwriting very difficult. They often need specialized help in making the correct letter shapes.

Some kids with SEMANTIC PRAGMATIC DISORDER have mild gross motor difficulties too, not always noticed early on except they are sometimes described as walking with an 'odd gait'. They are late riding bikes, find gym work difficult and take little interest in rule based games like football. Perceptual difficulties too can interfere with performance on practical skills, e.g. the sort of youngster who tells you how to prepare a 3 course meal but cannot put the beans on the toast.

Memory Skills—

Many bright kids with SEMANTIC PRAGMATIC DISORDER have exceptional memory skills which compensate for their communication problems. Many have a detailed memory for past events which other members of the family have long forgotten. Most have a detailed memory for social phrases as mentioned. Many have a memory for routes and can direct moms & dads long distances by car! Some have an excellent memory for reading, others remember tunes.

Academic Performance—

In the classroom, academic performance tends to be patchy. First of all, the SEMANTIC PRAGMATIC DISORDER youngster's egocentricity means that he can only understand topic work from his own perspective. Refusing to do work may signal the work has no meaning for him and may suggest to the teacher and moms & dads that they need to supplement class work with more concrete shared experience. Kids with SEMANTIC PRAGMATIC DISORDER often have excellent number concepts and teachers and moms & dads are puzzled by the youngster's slowness in grasping how to do 'sums'. It seems they find the abstract symbols of adding + and subtracting - rather meaningless unless they are allowed to make their own. Later on, they often fail to understand the value of money or tell analogue time - unless of course either one happens to be an obsessional interest.

We think these difficulties can be remediated if addressed early on. Kids with SEMANTIC PRAGMATIC DISORDER usually manage fairly well during infant classes and it is often not until junior level, when help has not been available that obstacles seem to be met. At junior level, the major problems are handwriting and creative writing.

We would suggest that if handwriting is still unintelligible at nine years, there is little point in persisting with further handwriting practice and that it may be more sensible to encourage development of written skills through the use of word processors.

Creative writing, rather like pretend play, is something which may remain inflexible. Many kids with SEMANTIC PRAGMATIC DISORDER find it easier to regurgitate their own experiences or retell stories. One youngster we know is so accomplished at memorizing stories and interweaving them into new ones that he has actually won prizes for creative writing!

Some kids with SEMANTIC PRAGMATIC DISORDER learn to read very early but not necessarily with understanding. We call this hyperlexia. Other kids find reading and writing a hard slog and we call this dyslexia. As yet we cannot predict which kids will fall into which group.

SEMANTIC PRAGMATIC DISORDER is therefore a complex disorder not yet fully understood. Except we now know that most of the problems experienced by these kids have something to do with abstract thinking and mentalizing; but just like any group of kids, they are all different. They have their individual personality and their individual abilities, which mean they have individual needs.

School Placements—

Some kids have moderate learning difficulties on top of their SEMANTIC PRAGMATIC DISORDER problems and do best in special schools, but many kids are brighter than average and can do very well in mainstream education; particularly if they have the support of a helper or spend time in a language unit or a language school. We think that as our understanding of the disorder improves then we shall be able to provide an educational environment which best meets their needs.

For bright kids with SEMANTIC PRAGMATIC DISORDER, we think that the most important question is, "What is it that makes the SEMANTIC PRAGMATIC DISORDER youngster unique?" He has a different style of learning which is equally valid but it does necessitate a special understanding and a different approach. If we are to maintain his self esteem and reduce his anxiety to levels that allow him to learn, then we should perhaps start from the premise of what can this youngster do, rather than what can't he do.

With a clear understanding of his skills and his needs, our expectations should become more realistic and our interventions less punitive. The SEMANTIC PRAGMATIC DISORDER youngster may not show embarrassment when he has violated a class social rule but he will feel a failure if he is saturated with labels of 'naughty', 'silly' and 'no common sense'. He simply needs to know what is acceptable and what is unacceptable.

Bright kids with SEMANTIC PRAGMATIC DISORDER are usually very quick at picking up rules if they are spelt out and will stick to them much more slavishly than the rest of the class. The secret of good teaching is perhaps to anticipate when these rules may need revision. Kids with SEMANTIC PRAGMATIC DISORDER often perform best in small, orderly 'old fashioned' styled classrooms.

Growing Up—

We haven't followed any of language unit kids with SEMANTIC PRAGMATIC DISORDER into adulthood yet, but we do know that the kids whose problems have been identified early and whose behavior and communication problems have been recognized as part of the learning disorder tend to integrate best at least up to senior level. Some kids have managed the transition to senior school well and one we expect to go to university. Other kids however bright would simply be too vulnerable to cope socially at comprehensive school even though much of the academic work would be within their scope. We hope that in time some specialist facility may be offered locally at senior school for those who need it.

What we are sure of at this stage, is that kids with SEMANTIC PRAGMATIC DISORDER do have problems recognizing what is sociably acceptable and unacceptable and that they should not be educated with kids whose primary diagnosis is E.D.B (Emotional Disturbed Behavior). We believe that SEMANTIC PRAGMATIC DISORDER kid’s behavior problems escalate in the presence of conduct disorders.

We have also found that some kids with SEMANTIC PRAGMATIC DISORDER who find it difficult to cope in a busy mainstream class are out performed by similar kids in special school, particularly if there is high Speech Therapy input and if the school has a genuine interest in developing a service for kids with Semantic Pragmatic Difficulties.

Echoed speech, comprehension problems and refusal to co-operate are all behaviors minimized in the appropriate setting.

Kids with SEMANTIC PRAGMATIC DISORDER will probably benefit most from an adapted curriculum where teachers and speech therapists work alongside each other to provide an integrated academic and communication program.

Kids with SEMANTIC PRAGMATIC DISORDER often do well if they spend time with kids who are equally or less socially sophisticated than themselves. They need social peers as well as intellectual ones. Kids who will encourage or insist on interaction rather than kids who ignore.

Kids with SEMANTIC PRAGMATIC DISORDER need extra talking practice, not less. With help, kids with SEMANTIC PRAGMATIC DISORDER will overcome most of their language comprehension problems but if their conversation is to be timely and appropriate they need to 'know' who their conversational partner is.

Autistic Continuum—

This phrase refers to all kids who share the same specific cognitive deficit resulting in problems with sociability, language and pretence. At the severe end of the continuum, we have kids labeled as Autistic, Core Autistic or Classically Autistic.

At the other end of the continuum, we have kids with milder problems who may have diagnostic labels of Semantic-Pragmatic Disorder or Autistic Spectrum Disorders.

Autistic Spectrum Disorders—

This recently adopted phrase refers to kids who fall some way between normality and Autism but outside Core Autism. Labels like Atypical Autism, Aspergers Syndrome, or Semantic-Pragmatic disorder are often used and they all describe similar communication difficulties to a greater or lesser degree. All kids on the Autistic Continuum including those with Core Autism have Semantic-Pragmatic difficulties with language and they should all be viewed in the context of Autism. That is they share the same triad of difficulties, with sociability, pretence and language.

Kids with SEMANTIC PRAGMATIC DISORDER are the group who are sociably the most able but who have much more difficulty early on at least learning basic language skills. But whose difficulties we suspect in adulthood will blur into the realms of mild eccentricity.

Kids with Aspergers Syndrome tend to have more problems with socializing than kids with Semantic Pragmatic Disorder but are generally earlier fluent speakers. There seems to be a pay off between early comprehension skills and sociability. As kids mature, it is often difficult to specify what label best fits. Many kids improve dramatically and diagnostic labels can change.

Labeling or not—

There is an argument, at least in the early years, particularly for more able kids, to use less specific diagnostic labels like Autism and simply to describe kids who may well improve dramatically in the pre-school years as falling within the 'Autistic Continuum' or as having an Autistic Spectrum Disorder.

Specific labels, however, can be useful, at the school stage of development both for research and for planning resources. There is clearly an enormous difference between a youngster with severe learning difficulties and Autism and a youngster of superior intelligence with a Semantic-Pragmatic Disorder. When we are describing kids on the Autistic Continuum, we must also be clear in our own minds about whether we are simply describing levels of sociability or whether we are also describing more generalized learning difficulty. The two do not necessarily go hand in hand.

As a rule of thumb, however, kids with Semantic Pragmatic Disorders as a group have less generalized learning difficulties than Autistic Kids.

Origins of Semantic-Pragmatic Difficulty—

We now think there is a family link between these Autistic Spectrum Disorders. We have sometimes found that having identified one youngster on the Autistic Continuum, another youngster in the family has been found to have milder communication problems too, particularly if they are male.

Moms & dads ask why? Well as you have probably deduced, the evidence is now pointing to a disorder which is genetic in origin. Autistic Spectrum Disorders are sometimes associated with other genetic disorders like Fragile X Syndrome, Retts Syndrome and Tuberousclerosis.

We think the problem is much more complex than one parent passing on a problem. Just like two hearing moms & dads can produce a profoundly deaf youngster, we think that two healthy moms & dads can produce a youngster with a communication disorder.

Some moms & dads of kids with SEMANTIC PRAGMATIC DISORDER describe eccentric relatives or others with psychiatric illness, but this is by no means always the case. We still have much to learn about genes and inheritance. What we can say is, boys are much more likely to have communication problems than girls: something in the ratio of 6:1.

Some moms & dads describe difficult birth histories and wonder if brain damage at birth could have been responsible. Well it is possible, but unlikely that a brain injury could be so specific. We think that in the majority of cases, the genetic makeup of the youngster makes him more vulnerable at birth.

If the same partners are contemplating extending their families after discovering they have a youngster with Autism and Semantic-Pragmatic Difficulties, we would recommend they sought Genetic counseling first.

Prognosis—

Semantic-Pragmatic Disorder is not an illness like Diabetes. It is a developmental disorder which improves with age. Rates of progress are probably dependent on overall intelligence and the support of carers. At centers like Heathlands, carers hope to maximize on such improvement by providing support and guidance throughout childhood.

Until about 10 years ago, we were only able to recognize the most handicapped kids with Autism. Kids were either Autistic or they were not Autistic. This meant that many able kids on the continuum with very mild and specific learning difficulties were excluded from a diagnosis and subsequent help. Many were dismissed as eccentric or language disordered or as having behavior problems, leaving moms & dads with much unresolved guilt.

Today we have extended the boundaries to include those kids with only mild social difficulties, some of whom may be able to extend their special interest and abilities to outperform their peers in mainstream.

The gloomy picture of Autism and Mental Handicap once painted is not something that necessarily follows. If you are a parent and you have been given this article to read, you should feel reasonably optimistic.

TELL TALE SIGNS—

(These are the features we have observed in many of our kids but not all in one youngster!)

Early Developmental 0-2 years:

1. "Golden" baby
2. A loner.
3. Didn't always look at you properly or enough when talking to you.
4. Didn't babble much.
5. Didn't take teddy to bed.
6. Difficult toddler with no sense of danger.
7. Fussy eater
8. Inappropriate response to sensory stimuli (e.g. touching, pain, noise)
9. Late pointing to share knowledge.
10. Late recognizing himself in a mirror or in a photograph.
11. Late talking
12. No boundaries.
13. Not interested in baby games.
14. Over clingy or wandered off too easily.
15. Thought he was deaf.

Nursery age development 2-4 years:

1. Appears to have a receptive language disorder.
2. Better conversation at home than at school.
3. Cannot play or negotiate with other kids
4. Cannot share.
5. Can't initiate pretend games with other kids.
6. Difficulty cutting out.
7. Doesn't build much with lego or tends to build the same.
8. Echoes people’s conversations, stories and t.v. programs.
9. Good at jigsaws, colors, numbers, shapes.
10. Has to be prompted to use social greetings like 'hello' and 'goodbye'.
11. Late drawing representationally. Prefers scribble if left.
12. Loves music and has a good memory for tunes
13. Never asks for help - too independent.
14. Obsessional interests like cars, dinosaurs and Michael Jackson!
15. Only interacts at a rough and tumble or chase level.
16. Only watches cartoon t.v. or animal programs
17. Prefers 'helping' with real activities like operating machinery or washing up.
18. Prefers to 'read' his own story (usually Thomas the Tank Engine).
19. Pretend is only action on object and doesn't have a storyline.
20. Rarely dresses up.
21. Tantrums persisting.
22. Very active - doesn't settle to play for long.
23. Wouldn't settle at playgroup and had to be removed.

School Age development:

1. Appears rude or can say things that embarrass you.
2. Approaches people inappropriately by kissing them or wrapping his arm around them or standing too close.
3. Cannot cope in crowds like assembly or parties.
4. Can't follow topic work in the classroom.
5. Can't get his ideas on paper.
6. Can't tell you what he did at school without shared knowledge.
7. Difficulty coping with school dinners (e.g. food fads, slow eater, surrounding noise, conversational expectations).
8. Distractible in the classroom.
9. Does not see himself as a member of a group.
10. Doesn't ask the teacher for help.
11. Doesn't exchange eye contact or facial expression appropriately.
12. Doesn't like football or complex rule based games.
13. Doesn't really follow the storyline of a book.
14. Doesn't take turns in conversation.
15. Doesn't understand abstract concepts like: tomorrow, next week, guess, wish.
16. Doesn't use much gesture like shrugging shoulders.
17. Excellent number concepts but difficulty with + or - or telling the time or value of money.
18. Fluent speaker but only wants to talk about things important to him.
19. Follows his own interests rather than the class.
20. Follows rules slavishly, and expects everyone else too.
21. Good memory for places and events.
22. Has no special friend but dominates some kids or plays on his own.
23. Has to be told how to behave.
24. Late reader or 'super' reader.
25. Literal understanding doesn't know when you are being sarcastic or joking.
26. Naive and unable to see deception in others.
27. Obsessional questioning. Answers don't satisfy him.
28. Poor handwriting
29. Seems much more childish for his age than his intelligence would suggest.
30. Sounds like a grown up sometimes.
31. Under performing at school.

Summarizing Difficulties—

Social/Emotional Delay and Disorder:

• Approaches kids and adults inappropriately.
• Childish.
• Demands a lot of adult attention.
• Difficulty making friends of his own age.
• Does not understand status.
• Doesn't recognize the difference between good and bad behavior unless told.
• Doesn't understand other people’s intentions.
• Egocentric.
• Feels bad about himself if he makes a mistake but doesn't feel embarrassment.
• Little empathy
• Naive

Language Disorder:

• Confuses he/she
• Conversation can sound too grown up or rude.
• Difficulty establishing shared attention and joint reference.
• Disproportional early vocabulary of nouns to verbs.
• Doesn't initiate conversation appropriately.
• Doesn't use language sociably and tends not to bother about social greetings.
• Early listening and comprehension problems.
• Easily distracted.
• Late talking and late pointing reverentially.
• Later on few words to describe thoughts, feelings and intentions of others.
• May have other language problems like fluency or speech disorder.
• Not interested in or able to follow topics outside his own experience.
• Over uses social phrases or non-specific pronouns e.g. 'over there'.
• Poor Auditory discrimination so he may misuse words e.g. 'cartoon' for 'carton'.
• Quiet baby.
• Single track attention in a busy room.
• Sometimes appears deaf.
• Talks nonstop about his own interests.
• Uses a flatter or exaggerated intonation pattern.
• Uses time labels incorrectly. Words like 'yesterday' can mean any period back in time.

Play skills:

• Can't share easily.
• Can't share pretence or develop story lines.
• Difficulty in following rules of games like tag, hide and seek or football.
• Finds it difficult to develop to and fro games with adults e.g. throwing and catching a ball. Hide and Seek.
• Good at lego and jigsaws.
• Likes playing on his own repetitively.
• Only plays chase or rough and tumble with other kids.
• Prefers real activities to pretend.
• Prefers self chosen activity and resists adult direction.
• Some anxiety about playing in the playground, particularly if there is no apparatus or objects to play with.

Academic Skills:

• Difficulties in playground. May result in anxious behavior just before break times with reappearance in classroom at playtimes.
• Difficulties with: handwriting, creative stories, reading comprehension, spelling and mathematical representation.
• Follows his own interests.
• Good at number, science and computers.
• Interprets topics from his own perspective.
• Only works when he wants to and appears to have no motivation for some work.
• Refuses to conform.

Motor Skills:

• Fine Motor Difficulties make practical skills like scissors, drawing, handicraft difficult.
• Gross Motor Difficulties makes riding bikes, swimming, dressing and rule based games like football difficult.

Sensory Difficulties:

• Many have a heightened awareness of smell or taste and may refuse certain foods. Others have a diminished awareness of hunger and may only eat if told.
• Some are late acquiring an interest in sensory exploration and continue to need this kind of play activity more than other kids of the same age and ability.
• Some avoid touching certain materials particularly sticky or wet substances.
• Some kids have a heightened awareness of loud noise. Others ignore loud noise and focus on peripheral sound.
• Some kids seem to have a diminished awareness of pain 'bravely' picking themselves up after serious accidents and only displaying signs of distress after observing the visible signs of hurt e.g. blood

Sameness:

This is not usually a major problem for kids with SEMANTIC PRAGMATIC DISORDER Overplaying with toys or over drawing are usually a sign of anxiety and that something in the environment needs changing - like a Speech and Language Therapist talking too much!

Over activity:

This is a feature shared by other kids with learning difficulties and may serve to confuse the diagnosis.

Initially, however, kids with Semantic-Pragmatic difficulties have very good concentration (sometimes too much) for self chosen activities like watching cartoon videos or playing with sand and water but become 'hyperactive' with more adult directed activity. Activity levels usually increase with complexity of tasks, complexity of environment, and expectations of failure. Over activity levels usually decrease with age and confidence but are hardly ever reduced by increased physical activity. Some moms & dads have found an association between food additives and levels of activity and while restricted diets do help, the problem is rarely solved this way.

Helping Kids with SEMANTIC PRAGMATIC DISORDER—

Social Development:

a. Provide a certain amount of predictability to reduce anxiety

b. Give a simple explanation to the other kids in the class (in mainstream).

c. Allow him to work in small groups or in a small class.

d. Facilitate his interactions with other kids. Do not allow him to opt out by holding your hand in the playground or dominating one youngster.

e. Give clear rules of how to behave without negative judgments. It is not healthy to be constantly told you are 'silly' or 'naughty'. When you do not know what it is you are doing wrong.

f. If he can't cope outside, give him special tidying or sorting jobs e.g. library.

g. If he hits out when thwarted, you may need to monitor him for a few days, if you want to stop this. While he may not be intentionally aggressive, he will not have sufficient empathy to know how hard to hit. His behavior could be a danger to other kids.

h. Encourage sharing, first by identifying his needs, secondly, by reflecting the other youngster's needs and thirdly by insisting he shares.

i. Make dinner time a pleasant experience. He may need an adult to sit with him.


Language:

a. Provide him with suitable conversation partners.

b. Give the youngster time to reply.

c. Acknowledge the youngsters communication even if it is inappropriately done and even if he cannot have his way.

d. Aim to teach him more appropriate strategies

e. Keep the class as orderly as possible with 'noise' to a minimum.

f. Make sure he knows what to do and what to do next.

g. If you want him to follow a general classroom instruction make sure you say his name.

h. Invite moms & dads into school on a weekly basis.

i. Talk slowly in simple sentences and do not bombard him with questions. When he asks a question make sure you are responding to his intentions rather than just the words otherwise you may be on the road to developing repetitive questioning in him.

j. If you want him to take a message home (however simple) write it down for him.

k. Use gesture or visual props when introducing new topics. Always work from shared practical experience first. This is a crucial element of teaching if knowledge is to be generalized and cannot be over emphasized.

l. Inform moms & dads which topics are being covered so they can supplement with extra hands on experience too.

m. Home school diary to help conversation and writing skills.

n. If his language doesn't make sense don't respond to what he says. Think of what he means to tell you. (his intentions)

o. Reflect what you think the youngster means when he echoes adult language, e.g. "I think it is getting awfully late", might mean "Adam is worried,. Adam doesn't understand". Hopefully this kind of comment if it matches the youngster's thinking will help him use the right words next time and reduce questioning.

p. If the youngster is involved in confrontation with another youngster, it is often helpful to reflect what the other youngster is thinking too, e.g. "Adam wants the pen". "David says it's mine".

q. Because kids with SEMANTIC PRAGMATIC DISORDER are so inflexible in thought, we suggest you tune into their thinking first. If you say what they are thinking first then the SEMANTIC PRAGMATIC DISORDER youngster is much more likely to listen. Then you can switch to what you want to say. Avoid dealing with situations by opening with a question:- e.g. "What's happening Peter?" is expressing your feelings and doesn't match what it is the youngster is thinking. Matching your words to the youngster's thoughts is called mapping. We think that mapping allows the youngster to build up a vocabulary of useful words which should have maximum meaning. If words have meaning then they should be used much more flexibly.

r. Over use specific vocabulary which youngster finds difficult. Pay particular attention to teaching opposites - e.g. he/she put/take upstairs/downstairs

s. Choose 2 or 3 words each week and ask moms & dads to do the same. Choose vocabulary from programs like living language particularly words of space, quantity, personal feelings and time.

t. Avoid sarcasm. Explain if you do.

u. Take care when you say "X is not good for you" (he may never eat it again!)

v. If you are doing 'news' work, encourage him to bring in visual props like pictures to help him talk about the 'there and then'.


Play skills:

a. Encourage sensory exploration and 'Wendy House' play

b. Help him vary his play, beyond set routines

c. Help youngster interact in playground.

d. Facilitate role play based on real life experience with props. e.g. reenact his birthday party or a trip to McDonalds using the empty cartons etc..

e. Help creative drawing and building - again based on real life visits and photos and video recordings.

f. Start group activities like story time or action rhymes with an activity he can do to hold his interest immediately.

g. Facilitate turn taking and anticipatory games through youngster centered play.

h. Encourage simple rule based games like hide and seek.


Academic Help:

a. Do not be deceived by his memory skills, make sure he 'understands'.

b. Use his visual skills and sense of order to develop understanding.

c. Extra help with correct letter formation.

d. Help him write sentences based on what the youngster has just done - with props e.g. written sequence of a practical activity.

e. If he has any obsessive or special interests, rather than ignoring them, it may be possible for him to develop them so he incorporates some useful knowledge.

f. Spelling rules - taught systematically.

g. Reading - help comprehension by reading the story to youngster first, and then discussing the text and asking him questions which require him to infer or predict but be prepared to give him the answers. Finally, ask the youngster to read the story to you.

h. Allow him to read some books above his comprehension level if he is hyperlexic so he feels as good as the other kids in the class.

i. If he is finding reading difficult, make him his own reading book with photographs based on himself and his family.

j. Exemption from topic work which may be too complex e.g. Religious or Historical projects. It may not be sensible for example to work on topics like the Romans if he does not understand what 'last week' means.


Math:

a. Help him translate mathematical problems like "If I have two sweets and you give me two more" into higher levels of representation e.g. 2+2 (make sure he understands the link).

b. Explain symbols + If these are difficult for him let him make his own and change them gradually.

c. Systematic help with 'time' based on school routine. Make sure you have a clock with numbers (one hand at a time).

d. Value of money (real money). Allow him pocket money as soon as he is old enough.

e. Make sure he understands the difference between words like:
• a few / a lot
• more / more than
• each / all / both
• how many / count
• 15 /50

f. If he is having problems with 'base 10' concepts. He may need to have special help with understanding concepts like eleven (one T. one) or twenty-three (two T. three) etc.

g. He may need extra help with estimating and measuring.


Self Esteem:

Find something he can do better than the rest of the group. If he can become the class artist or computer expert then he will gain the respect of his peers.


==> Next, we will look at Aspergers...

Aspergers Syndrome—

For years, psychiatrists have debated how to classify and subdivide the category of Pervasive Developmental Disorder (PDD). Pervasive Developmental Disorder is a category that contains several specific diagnoses. People with PDD have problems with the social interaction and often show delays in several other areas. These other areas may include language, coordination, imaginative activities, and intellectual functioning. The degree of severity can vary tremendously in the various forms of PDD. Autism is one of the more severe forms of PDD. An child with Autism has marked difficulty relating to other human beings. He or she frequently has delayed or absent speech and may be mentally retarded. Aspergers is on the milder end of PDD. People with Aspergers generally have normal intelligence and normal early language acquisition. However, they show difficulties with social interactions and non-verbal communications. They may also show perseverative or repetitive behaviors.

The Young Child: A preschool aged youngster might show difficulty understanding the basics of social interaction. He or she may have difficulty picking up social cues. He may want friends but be unable to make or keep any friends.

Elementary School Aged Child: One often hears the phrase, “poor pragmatic language skills.” This means that the child cannot use the right tone and volume of speech. He may stand too close or make poor eye contact. He may have trouble understanding age-appropriate humor and slang expressions. Many are clumsy and have visual-perceptual difficulties. Learning difficulties, subtle or severe, are common. The youngster may become fixated on a particular topic and bore others with frequent or repetitive talk even when the other Kids have given clear signals that they are no longer interested in the topic. Some have difficulties tolerating changes in their daily routine. Change must be introduced gradually.

The Adolescent: This may be the most difficult time for an child with Aspergers. Those with milder forms of the disorder may first come to treatment when they are in middle school. In adolescence, social demands become more complex. Subtle social nuances become important. Some may show an increase in oppositional or aggressive behavior. People with Aspergers have difficulty understanding which of their peers might want to be a friend. A socially marginal boy might try to date the most popular girl in his class. He will probably experience rejection. He is unaware that some other girl might accept his invitation. Because of his social naiveté, he may not realize when someone is trying to take advantage of him. He can be especially vulnerable to manipulation and peer pressure.

Adulthood: There is less information on Aspergers in adulthood. Some people with mild Aspergers are able to learn to compensate. They become indistinguishable from everyone else. They marry, hold a job and have Kids. Other people live an isolated existence with continuing severe difficulties in social and occupational functioning. People with Aspergers often do well in jobs that require technical skill but little social finesse. Some do well with predictable repetitive work. Others relish the challenge of intricate technical problem solving. I knew a man, now deceased, who had many of the characteristics of Aspergers. He lived with his mother and had few social contacts. When he visited relatives, he did not seem to understand how to integrate himself into their household routine. When the relatives would explain the situation to him, he was able to accept it. However, he was unable to generalize this to similar situations. Although he was a psychologist, his work involved technical advisory work, not face-to-face clinical sessions.

Associated Difficulties: Aspergers may be associated with learning difficulties and attention deficit disorder. Indeed, many Kids and teenagers with Aspergers have previously been diagnosed with AD/HD instead of Aspergers. People with AD/HD may have difficulty with social interaction, but the primary difficulties are inattention, hyperactivity and impulsivity. In people with Aspergers, the social awkwardness is a greater concern. As people with Aspergers enter adolescence, they become acutely aware of their differences. This may lead to depression and anxiety. The depression, if not treated, may persist into adulthood.

Treatment for Aspergers—

Medications: There is no one specific medication for Aspergers. Some are on no medication. In other cases, we treat specific target symptoms. One might use a stimulant for inattention and hyperactivity. An SSRI such as Paxil, Prozac or Zoloft might help with obsessions or perseveration. The SSRIs can also help associated depression and anxiety. In people with stereotyped movements, agitation and idiosyncratic thinking, we may use a low dose antipsychotic such as risperidone.

Social Skills Training: This is one of the most important facets of treatment for all age groups. I often tell moms & dads and teachers that the person needs to learn body language as an adult learns a foreign language. The person with Aspergersmust learn concrete rules for eye contact, social distance and the use of slang. Global empathy is difficult, but they can learn to look for specific signs that indicate another person’s emotional state. Social skills are often best practiced in a small group setting. Such groups serve more than one function. They give people a chance to learn and practice concrete rules of interpersonal engagement. They may also be a way for the participant to meet others like himself. People with Aspergers do best in groups with similar people. If the group consists of street-wise, antisocial peers, the Aspergers child may retreat into himself or be dominated by the other members.

Educational Interventions: Because Aspergers covers a wide range of ability levels the school must individualize programming for each student with Aspergers. Teachers need to be aware that the student may mumble or refuse to look him in the eye. Teachers should notify the student in advance about changers in the school routine. The student may need to have a safe place where he can retreat if he becomes over stimulated. It may be difficult to program for a very bright student with greater deficits. In one case, a student attended gifted classes but also had an aide to help her with interpersonal issues. That student is now in college. Kids with Aspergers are often socially naive. They may not do well in an Emotionally Disturbed class if most of the other students are aggressive, street-wise and manipulative. I have seen some do well when placed with other students with pervasive developmental disorders. Some do well in a regular classroom with extra support. This extra help might include an instructional assistant, resource room or extra training for the primary teacher.

Psychotherapy: People with Aspergers may have trouble with a therapist who insists that they make an early intense emotional contact. The therapist may need to proceed slowly and avoid more emotional intensity than the patient can handle. Concrete, behavioral techniques often work best. Play can be helpful in a limited way if the therapist uses it to teach way of interaction of the therapist uses play as a break from an emotionally tense if it is used to lower emotional tension. Adults and Kids may also do well in group therapy. Support groups can also be helpful.

Moms & dads play an important role in helping their youngster or teenager. This youngster or teenager will require time and extra nurturance. It is important to distinguish between willful disobedience and misunderstanding of social cues. It is also important to sense when the youngster is entering emotional overload so that one can reduce tension. They may need to prepare the youngster for changes in the daily routine. One must choose babysitters carefully. Moms & dads may have to take an active role in arranging appropriate play dates for the younger youngster. Some moms & dads seek out families with similar Kids. Kids with Aspergers often get along with similar playmates. Moms & dads should help teachers understand the world from the youngster’s unique point of view. Parenting an teenager with Aspergers can be a great challenge. The socially naive teenager may not be ready for the same degree of freedom as his peers. Often moms & dads can find a slightly older teenager who can be a mentor. This person can help the teenager understand how to dress, and how to use the current slang. If the mentor attends the same school, he can often give clues about the cliques in that particular setting.

Adults may benefit from group therapy or individual behavioral therapy. Some speech therapists have experience working with adults on pragmatic language skills. Behavioral coaching, a relatively new type of intervention, can help the adult with Aspergers organize and prioritize his daily activities. Adults may need medication for associated problems such as depression or anxiety. It is important to understand the needs and desires of that particular adult. Some adults do not need treatment. They may find jobs that fit their areas of strength. They may have smaller social circles, and some idiosyncratic behaviors, but they may still be productive and fulfilled.


References—

1. Aarons and Gittons 1992 Autism - A guide for parents and professionals.
2. Aarons and Gittons Dec. 91 Autism as a context. Bulleting No. 476.
3. Bishop and Rosenbloom 87 Childhood Language Disorders : Classification and overview in language development and disorder.
4. Bishop D. 89 Autism, Aspergers Syndrome and Semantic Pragmatic Disorder. Where are the boundaries? British Journal of Disorders of Communication 24
5. Child language teaching and therapy Vol 1 No. 1
6. Ed. Yule and Rutter. Pub. Mac Keith Press
7. Frith 89 Autism : Explaining the Enigma. Blackwell
8. Frith 91 Autism and Asperger Syndrome. Cambridge
9. Granberg 85 Some problems in the Early stages of teaching numbers to language handicapped children.
10. Hughes Martin 86 Children and number difficulties in learning mathematics. Blackwell.
11. Leinonesse and Smith BR 92 Clinical Pragmatics.
12. Neuropsychology of language, reading and spelling New York : Academic Press
13. Rapin L & Allen D. 83 Development Language Disorders Nostologic consideration. JN U. Kirk Ed.
14. Wilson A. 92 Do Semantic Pragmatic Disordered children have a Theory of mind? (MSC research project in press)
15. Wing C. 1992 Autistic Continuum Disorders.

Asperger Syndrome: Comprehensive Overview

Asperger syndrome (AS) is characterized by impairments in social interaction and restricted interests and behaviors as seen in autism, but its early developmental course is marked by a lack of any clinically significant delay in spoken or receptive language, cognitive development, self-help skills, and curiosity about the environment. All-absorbing and intense circumscribed interests and one-sided verbosity as well motor clumsiness are typical of the condition, but are not required for diagnosis.

1. History and nosology—

In 1944, Hans Asperger, an Austrian pediatrician with interest in special education, described four kids who had difficulty integrating socially into groups.19 Unaware of Kanner's description of early infantile autism published just the year before, Asperger called the condition he described "autistic psychopathy", indicating a stable personality disorder marked by social isolation. Despite preserved intellectual skills, the kids showed marked paucity of nonverbal communication involving both gestures and affective tone of voice, poor empathy and a tendency to intellectualize emotions, an inclination to engage in long winded, one-sided, and sometimes incoherent speech, rather formalistic speech (he called them "little professors"), all-absorbing interests involving unusual topics which dominated their conversation, and motoric clumsiness. Unlike Kanner's patients, these kids were not as withdrawn or aloof; they also developed, sometimes precociously, highly grammatical speech, and could not in fact be diagnosed in the first years of life. Discarding the possibility of a psychogenic origin, Asperger highlighted the familial nature of the condition, and even hypothesized that the personality traits were primarily male transmitted. Aspergers work, originally published in German, became widely known to the English speaking world only in 1981, when Lorna Wing published a series of cases showing similar symptoms.20 Her codification of the syndrome, however, blurred somewhat the differences between Kanner's and Aspergers descriptions, as she included a small number of girls and mildly mentally retarded kids, as well as some kids who had presented with some language delays in their first years of life. Since then, several studies have attempted to validate ASPERGERS as distinct from autism without mental retardation, although comparability of findings has been difficult due to the lack of consensual diagnostic criteria for the condition.3

ASPERGERS was not accorded official recognition before the publication of ICD-10 and DSM-IV, although it was first reported in the German literature in 1944. Aspergers work was known primarily in German speaking countries, and it was only in the 1970's that the first comparisons with Kanner's work were made, primarily by Dutch researchers such as Van Krevelen, who were familiar with both English and German literatures. The initial attempts at comparing the two conditions were difficult because of major differences in the patients described - Kanner's patients were both younger and more cognitively impaired. Also, Aspergers conceptualization was influenced by accounts of schizophrenia and personality disorders, whereas Kanner had been influenced by the work of Arnold Gesell and his developmental approach. Attempts at codifying Aspergers prose into a categorical definition for the condition were made by several influential researchers in Europe and North America, but no consensual definition emerged until the advent of ICD-10. And given the reduced empirical validation of the ICD-10 and DSM-IV criteria, the definition of the condition is likely to change as new and more rigorous studies emerge in the near future.21

2. Epidemiology—

Given the lack of consensual definitions of diagnosis until recently, it is not surprising that the prevalence of the condition is unknown, although a rate of 2 to 4 in 10,000 has been reported.22 There is little doubt that the condition is more prevalent in males than females, with a reported ratio of 9 to 1. In the past few years, there have been a proliferation of parent support organizations organized around the concept of ASPERGERS, and there are indications that this diagnosis is being given by clinicians much more frequently than even just a few years ago; there are also indications that ASPERGERS is currently functioning as a residual diagnosis given to normal-intelligence kids with a degree of social disabilities who do not fulfill criteria for autism, overlapping in this way, with the DSM-IV term PDD-NOS. Possibly the most common usage of the term ASPERGERS is as synonymous or a replacement to autism in children with normative or superior IQs. This pattern has diluted the concept and reduced its clinical utility. Empirical validation of specific diagnostic criteria is badly needed, although this will have to await reports of rigorous studies employing standard diagnostic procedures, and validators truly independent of the diagnostic definition such as neuropsychological, neurobiological and genetic data.3

3. Diagnosis and clinical features—

The diagnosis of ASPERGERS requires the demonstration of qualitative impairments in social interaction and restricted patterns of interest, criteria which are identical to autism. In contrast to autism, there are no criteria in the cluster of language and communication symptoms, and onset criteria differ in that there should be no clinically significant delay in language acquisition, cognitive and self-help skills. Those symptoms result in significant impairment in social and occupational functioning.9

In some contrast to the social presentation in autism, children with ASPERGERS find themselves socially isolated but are not usually withdrawn in the presence of others. Typically, they approach others but in an inappropriate or eccentric fashion. For example, they may engage the interlocutor, usually an adult, in one-sided conversation characterized by long-winded, pedantic speech, about a favorite and often unusual and narrow topic. They may express interest in friendships and in meeting people, but their wishes are invariably thwarted by their awkward approaches and insensitivity to the other person's feelings, intentions, and non-literal and implied communications (e.g., signs of boredom, haste to leave, and need for privacy). Chronically frustrated by their repeated failures to engage others and form friendships, some children with ASPERGERS develop symptoms of an anxiety or mood disorder that may require treatment, including medication. They also may react inappropriately to, or fail to interpret the valence of the context of the affective interaction, often conveying a sense of insensitivity, formality, or disregard to the other person's emotional expressions. They may be able to describe correctly, in a cognitive and often formalistic fashion, other people's emotions, expected intentions and social conventions; yet, they are unable to act upon this knowledge in an intuitive and spontaneous fashion, thus losing the tempo of the interaction. Their poor intuition and lack of spontaneous adaptation are accompanied by marked reliance on formalistic rules of behavior and rigid social conventions. This presentation is largely responsible for the impression of social naiveté and behavioral rigidity that is so forcefully conveyed by these children.

Although significant abnormalities of speech are not typical of children with ASPERGERS, there are at least three aspects of these children' communication patterns that are of clinical interest.21 First, speech may be marked by poor prosody, although inflection and intonation may not be as rigid and monotonic as in autism. They often exhibit a constricted range of intonation patterns that is used with little regard to the communicative functioning of the utterance (e.g., assertions of fact, humorous remarks). Rate of speech may be unusual (e.g., too fast) or may lack in fluency (e.g., jerky speech), and there is often poor modulation of volume (e.g., voice is too loud despite physical proximity to the conversational partner). The latter feature may be particularly noticeable in the context of a lack of adjustment to the given social setting (e.g., in a library, in a noisy crowd). Second, speech may often be tangential and circumstantial, conveying a sense of looseness of associations and incoherence. Even though in a very small number of cases this symptom may be an indicator of a possible thought disorder, the lack of contingency in speech is a result of the one-sided, egocentric conversational style (e.g., unrelenting monologues about the names, codes, and attributes of innumerable TV stations in the country), failure to provide the background for comments and to clearly demarcate changes in topic, and failure to suppress the vocal output accompanying internal thoughts. Third, the communication style of children with ASPERGERS is often characterized by marked verbosity. The youngster or adult may talk incessantly, usually about a favorite subject, often in complete disregard to whether the listener might be interested, engaged, or attempting to interject a comment, or change the subject of conversation. Despite such long-winded monologues, the individual may never come to a point or conclusion. Attempts by the interlocutor to elaborate on issues of content or logic, or to shift the interchange to related topics, are often unsuccessful.

Children with ASPERGERS typically amass a large amount of factual information about a topic in a very intense fashion. The actual topic may change from time to time, but often dominates the content of social interchange. Frequently the entire family may be immersed in the subject for long periods of time. This behavior is peculiar in the sense that oftentimes extraordinary amounts of factual information are learned about very circumscribed topics (e.g., snakes, names of stars, TV guides, deep fat fryers, weather information, personal information on members of congress) without a genuine understanding of the broader phenomena involved. This symptom may not always be easily recognized in childhood since strong interests in certain topics, such as dinosaurs or fashionable fictional characters, are so ubiquitous. However, in both younger and older kids typically the special interests become more unusual and narrowly focused.

Children with ASPERGERS may have a history of delayed acquisition of motor skills such as pedaling a bike, catching a ball, opening jars, and climbing outdoor play equipment. They are often visibly awkward and poorly coordinated and may exhibited stilted or bouncy gait patterns and odd posture. Neuropsychologically, there is often a pattern of relative strengths in auditory and verbal skills and rote learning, and significant deficits in visual-motor and visual-perceptual skills and conceptual learning. Many kids exhibit high levels of activity in early childhood, and, as noted, may develop anxiety and depression in adolescence and young adulthood.

4. Course and prognosis—

There are no systematic long-term follow-up studies of kids with ASPERGERS as yet, partially because of nosologic issues. Many kids are able to attend regular education classes with additional support services, although these kids are especially vulnerable to being seen as eccentric and of being teased or victimized; others require special education services, usually not because of academic deficits but because of their social and behavioral difficulties. Aspergers initial description predicted a positive outcome for many of his patients, who were often able to utilize their special talents for the purpose of obtaining employment and leading self-supporting lives. His observation of similar traits in family members, i.e., fathers, may also have made him more optimistic about ultimate outcome. Although his account was tempered somewhat by the time he had seen 200 patients with the syndrome (25 years after his original paper), Asperger continued to believe that a more positive outcome was a central criterion differentiating children with his syndrome from those with Kanner's autism. Although some clinicians have informally concurred with this statement, particularly in regards to gainful employment, independence, and establishment of a family, no studies specially addressing the long-term outcome of children with ASPERGERS is currently available. The social impairment (particularly the eccentricities and social insensitivity), is thought to be lifelong.

Summary—

Autism and Asperger syndrome are syndromes resulting from early-emerging and fundamental disruptions in the socialization process leading to a cascade of developmental impacts on social engagement and adaptation, communication and imagination, among other disabilities. Many areas of cognitive functioning are often preserved, and sometimes children with these conditions exhibit surprising if not prodigious skills. The early onset, symptom profile, and chronicity of these conditions implicate core biological mechanisms.23 Advancements in genetics, neurobiology and neuroimaging (described elsewhere in this supplement), are concurrently furthering our understanding of the nature of these conditions and of the formation of the social brain in typical children.24 Together with the new wave of prospective studies of autism,25 where siblings at risk for developing the condition are followed up from birth, a new social neuroscience perspective on the pathogenesis and pathobiology of factors is emerging. This effort is likely to elucidate the mysteries of the etiology and the pathogenesis of these conditions. Translational research into more efficacious treatment, if not prevention, will then hopefully follow.

Aspergers: Behavioral Interventions

The diagnostic criteria for Aspergers as outlined in DSM IV TR [1] includes in criterion a description of some of the qualitative impairments in social interaction. The list of characteristics includes:

•Failure to develop peer relationships appropriate to developmental level
•Lack of social or emotional reciprocity
•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

Clinical experience and autobiographies confirm that such individuals have considerable difficulty with the understanding and expression of nonverbal behaviors and social reciprocity. Regarding peer relationships, when we observe and assess the social play and friendship skills of kids with Aspergers, we recognize a delay in the conceptualization of friendship. The youngster may have an overall intellectual ability within the normal range, but their understanding of friendship skills resembles a much younger child. It is not simply a matter of developmental delay, however. There are aspects that are conspicuously unusual for any of the developmental stages [2].

At present, we can only speculate what the consequences may be for a youngster who fails to develop peer relationships that are appropriate for their developmental level, but inevitably there will be lasting effects in several aspects of cognitive, social, and emotional development. When playing in a group, kids learn the value of alternative perspectives and solutions in problem solving. They acquire increasingly sophisticated and successful strategies to resolve conflict and the interpersonal and team skills valued by employers. Many of the characteristics valued in a close friend become the attributes associated with lasting personal relationships.

Clinical experience also suggests that the social isolation of kids with Aspergers in the school playground can increase the youngster's vulnerability to being teased and bullied and a lack of close friends also can be a contributory factor in the development of childhood depression. A delay in social knowledge also can lead to anxiety in social situations that may develop into social phobia, school refusal, and agoraphobia. Thus, we achieve cognitive and affective growth within our circle of friends. It is inevitable that impaired peer relationship skills can result in significant psychopathology.

The DSM IV description of Aspergers includes reference to an association between Aspergers and several secondary mental disorders, including depressive and anxiety disorders. The presence of a secondary mood disorder unavoidably adds to the already considerable difficulty coping with everyday life for people with Aspergers. We are, however, only just beginning to develop effective remedial programs to improve peer relationships, emotional reciprocity, nonverbal communication, and mood [3]. This article examines two frameworks for behavioral interventions, namely the developmental stages in friendship skills, with remedial strategies for each stage, and modifications to Cognitive Behavior Therapy, to accommodate the unusual profile of cognitive skills of people with Aspergers.

The developmental stages in the concept of friendship—

Before considering programs to improve the general understanding of the concept of friendship and specific friendship skills, it is important to determine the youngster's stage of friendship development [4], [5]. Unfortunately, there are no standardized tests to measure friendship skills as there are for language skills, motor development, and cognitive abilities. Assessments can be made by analysis of the person's answers to specific questions, however, and observation of their interactions with peers. The questions can include:

• How do you make friends?
• What do friends do?
• What makes a good friend?
• What makes you a good friend?
• Who are your friends at school?
• Why do we have friends?
• Why is (name) your friend?

Before the age of 3 years, kids interact with members of their family, but their concept of peers is often one of rivalry for possessions rather than friendship. If another youngster comes to their house, they may hide their favorite toys or become agitated if they have to take turns and share. There may be some parallel play, imitation, and intellectual curiosity in observing and copying what other kids are doing, as it may be fun and may impress a parent, but the youngster does not have the interpersonal insights and skills we associate with the reciprocal elements of being a friend. The first indicators of friendship occur at approximately the age of 3 years.

Stage 1: 3–6 years—

From the ages of 3 to 6 years there is a functional and egocentric conceptualization of friendship. When asked why a particular youngster is their friend, a youngster's reply usually is based on proximity (lives next door, sits at same table) or possessions (they have toys that the youngster admires or wants to use). Toys and play activities are the focus of friendship and the youngster gradually moves from engaging primarily in parallel play to recognizing that some games and activities cannot happen unless there is an element of sharing and turn taking. Cooperation skills are limited, however; the main characteristic of this age group is one-way and egocentric (he helps me or she likes me). Conflict is typified by demands, ultimatums, and physical force.

If a youngster from 3–4 years is asked what they did today, they tend to describe what they played with, whereas after the age of approximately 4 years they start to include who they played with. Social play gradually becomes more than just the construction and completion of the activity. Friendships are transitory, however, and the youngster has their own agenda of what to do and how to do it.

Remedial programs for stage 1—

If one uses behavioral or learning theory terms, kids with Aspergers need to identify the relevant stimuli or cues and appropriate responses [6]. For example, in stage one, kids learn the cues to join a group of kids without causing disruption or annoyance. An activity can be to brainstorm with the youngster the entry cues, such as someone giving a welcoming gesture or facial expression, a pause in the activity or conversation, or an appropriate act such as returning the ball. These ‘acts’ of the social ‘play’ can be ‘rehearsed’ by identifying a few kids who are keen to help the friendship skills of the youngster with Aspergers. They can be informed that he or she is learning the cues and rules for joining in their play.

The youngster with Aspergers will be trying to join in (under the guidance of an adult) and to recognize the relevant cue. When this occurs they can help the youngster with Aspergers identify the cue and intellectually process the response by momentarily freezing their actions, thereby isolating the cue. This gives the youngster time to identify the cue (which can be pointed out by the adult) and to decide what to say or do in response, perhaps with a prompt and encouragement from the adult. Their response and the entry are then successfully completed. The procedure of identifying the cues in contrived settings and practicing appropriate responses (rehearsal) can be used for many friendship skills. The adult acts as a mentor or stage director, giving guidance and encouragement. It is important that the attitude from adults is one of discovery and guidance so that the youngster with Aspergers does not perceive the activity as being critical of their ability and a public recognition of their social errors.

Young kids with Aspergers may demonstrate more mature interaction skills with adults than with their peers. It is important that adults, especially moms & dads, observe the natural play of the youngster's peers, noting the games, equipment, rules, and language. They can then practice the same play with the youngster but with an adult ‘acting’ as their peer. This includes using what the author describes as ‘child speak,’ namely the speech of kids rather than adults. It is important that the adult role-plays examples of being a good friend, and also situations that illustrate unfriendly acts, such as disagreements and teasing. Appropriate and inappropriate responses can be enacted to provide the youngster with a range of responses.

Moms & dads can borrow or buy duplicate equipment that is used at school or is popular with their peers. Once the youngster has rehearsed with an adult who can easily modify the pace of play and amount of instruction, they can have a ‘dress rehearsal’ with another youngster, perhaps an older sibling or mature youngster in their class who can act as a friend to provide further practice before the skills are used openly with their peer group. Another strategy to learn the relevant cues, thoughts, and behavioral script is to write Social Stories that can be used by the youngster to improve their social understanding and abilities [7].

Stage 2: 6–9 years—

At this stage the youngster starts to recognize that they need a friend to play certain games and that that friend must like those games. They become more aware of the thoughts and feelings of their peers and how their actions and comments can hurt, physically and emotionally. The youngster is prepared to sometimes inhibit their intentions and to accept and incorporate the influences, preferences, and goals of their friends in their play. There is less of a dominant/submissive quality, and helping, especially mutual help, is one of the indices of friendship at this stage. A friend may be chosen because of similar interests, and aspects of their friend's character are recognized (he's fun to be with); yet when asked who is their friend, they may nominate someone who is known to be popular rather than a mutually recognized friendship.

The concept of reciprocity (she comes to my party and I go to hers) and the genuine sharing of resources and being fair become increasingly important. When managing conflict, the youngster's view is that the offender must retract the action and a satisfactory resolution is perhaps described as “an eye for an eye.” The concept of responsibility and justice is based on who started the conflict, not what was subsequently done or how it ended. At approximately 8 years of age, the youngster develops the concept of a best friend as not only their first choice for social play, but also as someone who helps in practical terms (he knows how to fix the computer) and in times of emotional stress (she cheers me up when I'm feeling sad).

Remedial programs for stage 2—

In stage 2, kids develop greater cooperation skills when playing with their peers and develop more constructive means of dealing with conflict. It is important that the youngster with Aspergers experiences more cooperative than competitive games. In competitive games there are winners and losers and strict rules. The youngster with Aspergers can require considerable tuition using Social Stories to understand the concepts of being fair and gracious in defeat. Clearly the youngster's recognition of the relevant cues and responses for cooperative play are acknowledged and encouraged.

Specific aspects of cooperative play that need to be recognized, however, are identifying and contributing to the common goal, accepting suggestions rather than being autocratic or indifferent, and giving guidance and encouragement. The youngster acknowledges that when functioning as a cooperative and cohesive group, some activities and goals are easier and quicker to achieve. Role play games can be used to illustrate appropriate and inappropriate actions with some time taken to explain why, in a logical and empathic sense, certain actions are considered friendly or not friendly. The unfriendly actions that are particularly relevant for kids with Aspergers are interruptions, failure to recognize personal body space, inappropriate touch, and coping with mistakes.

During stage 2, there is an increase in social cognition that enables the youngster to benefit from published training programs designed to improve Theory of Mind skills [8]. Programs on Theory of Mind skills also can help the youngster distinguish between accidental and intentional acts. The youngster may consider only the act from their perspective and not consider the cues that would indicate it was not deliberate. Educational programs on emotions also can help the youngster identify the cues that indicate the emotional state of their friend and themselves. The intention is to develop their empathy skills so that they can be recognized as a caring friend.

Finally in stage 2, the author has noted that there can be different coping mechanisms used by girls with Aspergers in comparison with boys. Girls with Aspergers are more likely to be interested observers of the social play of other girls and to imitate their play at home using dolls, imaginary friends, and by adopting the persona of a socially able girl. This solitary practice of the social play of their peers can be a valuable opportunity to analyze and rehearse friendship skills. Some girls with Aspergers can develop a special interest in reading fiction that may be age-appropriate or classic literature. This also provides an insight into thoughts, emotions, and social relationships. It is also noticeable that other girls can be more maternal than boys and can facilitate the inclusion of a girl with Aspergers within an established group of friends. Their social difficulties can be accommodated and guided by peers who value the role of mother or educator. The girl with Aspergers also may be popular because she is honest and consistent and less likely to be spiteful.

Stage 3: 9–13 years—

In the third stage, a friend is not simply someone who helps; they are chosen because of special attributes in their abilities and personalities. A friend is someone who genuinely cares and has complimentary attitudes, ideas, and values. There is a strong need to be liked by their peers and a mutual sharing of experiences and thoughts. With such self-disclosure, there is the recognition of being trustworthy and seeking advice not only for practical problems but also for interpersonal issues. There is a need for companionship and greater selectivity and durability in the friendship alliances. At this stage, there is a distinct gender split and peer pressure becomes increasingly important. Peer group acceptance and values become more important than the opinion of moms & dads. Friends also support each other in terms of managing emotions. If the youngster is sad, close friends will cheer them up, or if angry, calm them down to prevent the person from getting into trouble.

When conflicts occur, friends will use more effective repair mechanisms. They can be less “heated,” with reduced confrontation and more disengagement, admitting making a mistake and recognizing it is not simply a matter of winner and loser. A satisfactory resolution can actually strengthen the relationship. The friend is forgiven and the conflict is put in perspective. These qualities of interpersonal skills that are played out in friendships are the foundation of interpersonal skills for adult relationships.

Remedial programs for stage 3—

In stage 3, there is usually a clear gender preference in the choice of friends. The activities and interests of boys, who may be playing team games or sports, may be considered of little value to the boy with Aspergers. They also are likely to be less able than their peers in team games and ball skills that may lead to teasing and bullying by boys who can be notoriously intolerant of someone who is different. When the boy with Aspergers approaches girls, they can be more readily included in their activities, and girls can be more patient, maternal, and supportive. One of the consequences of being more welcomed by girls than by boys and spending more time playing with girls than boys is that the boy with Aspergers can imitate the prosody and body language of their female friends. This can result in further isolation and torment from male peers. The youngster needs a balance of same and opposite gender friends, and some social engineering could be necessary to ensure acceptance by both groups.

During stage 3 there is a strong desire for companionship rather than functional play, and the youngster with Aspergers can feel lonely and sad if their attempts at friendship are unsuccessful [9], [10]. They need tuition and guidance, but this may be achieved by discussion with supportive peers and adults. Individual kids who have a natural rapport with a youngster with Aspergers can be guided and encouraged to be a mentor in the classroom, playground, and in social situations. Their advice may be accepted as having greater value than that of moms & dads or a teacher. It is also important to encourage their friends or peers to help them regulate their mood, stepping in and helping the person calm down if they are becoming agitated or tormented. Friends may need to provide reassurance if the person is anxious and to cheer them up when sad. The youngster with Aspergers also needs advice and encouragement to be reciprocal with regard to emotional support, and must be taught how to recognize the signs of distress or agitation in their friend and how to respond.

At this stage, the existing remedial programs use strategies to develop teamwork rather than friendship skills. To be attending a program on teamwork skills for sports or employment may be considered more acceptable to the young teenager with Aspergers, who may be sensitive to any suggestion that they need remedial programs to have friends. Another strategy to help the teenager who is sensitive to being publicly identified as having few friends is to adapt speech and drama classes.

Liane Holliday-Wiley, in her book Pretending To Be Normal, describes how she improved her social skills by observation, imitation, and acting [11]. This is an appropriate and effective strategy, especially in stage 3. The person with Aspergers can learn and practice conversational scripts, self-disclosure, body language, facial expression, and tone of voice for particular situations, and role-play people they know who are socially successful. The teenager or adult with Aspergers sometimes uses this strategy naturally; however, it is important to ensure that they choose good role models to portray.

Stage 4: 13 years to adult—

In the previous stage there can be a small core of close friends, but in stage 4 the breadth and depth of friendship increases. There can be different friends for different needs, such as comfort, humor, or practical advice. A friend is defined as someone who “accepts me for who I am” or “we think the same way about things.” A friend provides a sense of personal identity and is compatible with one's own personality. An important aspect of the quality of friendship is the ability to accept the self before being able to relate to others at an adult level; otherwise friendships can be manipulated as a means of resolving personal issues. There are less concrete and more abstract definitions of friendship with what may be described as autonomous interdependence. The friendships are less possessive and exclusive and conflict resolved with self-reflection, compromise, and negotiation.

Remedial programs for stage 4—

Because of the developmental delay in the conceptualization of friendship, when the person with Aspergers reaches stage 4, they have usually left high school and seek friends through work and recreational pursuits. Attempts to change a relationship from colleague or work mate to friend can present some challenges to the young adult with Aspergers. A mentor at work who understands their unusual profile of friendship skills can provide guidance and act as a confidante and advocate. The mentor also can help determine the degree of genuine interest in friendships from the colleague. Sometimes people with Aspergers assume that a friendly act, smile, or gesture has greater implications than was intended. There can be a tendency to develop an intense interest or infatuation with a particular person. This topic may dominate their time and conversation and can lead to behavior such as stalking.

Conversely, the person with Aspergers can be desperate to have a friend and may become the recipient of financial, physical, or sexual abuse, through failing to recognize that the other person's intentions are not honorable. The two-way misinterpretation of signals and intentions can lead to mutual confusion. Relationship counseling can be suggested, but at present counselors often have limited knowledge and experience regarding Aspergers [12]. An interesting development in recent years is older and more mature adults with Aspergers providing guidance and counseling through group counseling sessions organized by adult support groups. These groups are often formed by concerned moms & dads and individuals with Aspergers who want to meet like-minded individuals. They meet on a regular basis to discuss topics that range from employment issues to personal relationships.

The Internet has become the modern equivalent of the dance hall in terms of an opportunity for young people to meet. The great advantage of this form of communication to the person with Aspergers is that they often have a greater eloquence to disclose and express their inner self and feelings through typing rather than conversation. In social gatherings, the person is expected to be able to listen to and process the other person's speech (often against a background of other conversations), to immediately reply, and simultaneously analyze nonverbal cues, such as gestures, facial expression, and tone of voice.

When using the computer, the person can concentrate on social exchange using a visual rather than auditory medium. As in any other situation, the person with Aspergers may be vulnerable to others taking advantage of their social naivety and desire to have a friend. The person with Aspergers needs to be taught caution and to not provide personal information until they have discussed the Internet friendship with someone they trust. Genuine and long-lasting friendships can develop over the Internet based on shared experiences, interests, and mutual support. It is an opportunity to meet like-minded individuals who accept the person because of their knowledge rather than their social persona. The person with Aspergers is somewhat egocentric and eccentric but can prove an honest, loyal, and knowledgeable friend.

Mood disorders—

When one considers the diagnostic criteria for Aspergers and the effects of the disorder on the person's adaptive functioning in a social context, one would expect such individuals to be vulnerable to the development of secondary mood disorders. The current research indicates that approximately 65% of teenager patients with Aspergers have an affective disorder that includes anxiety disorders [13], [14], [15], [16], [17], [18] and depression [16]. There is also evidence to suggest an association with delusional disorders [19], paranoia [20], and conduct disorders [21]. We know that comorbid affective disorders in teenagers with Aspergers are the rule rather than the exception, but why should this population be more prone to affective disorders?

Research has been conducted on the family histories of kids with autism and Aspergers and has identified a higher than expected incidence of mood disorders [22], [23], [24], [25]. Individuals with Aspergers could be vulnerable to a genetic predisposition to mood disorders. When one also considers their difficulties with regard to social reasoning, empathy, verbal communication, profile of cognitive skills, and sensory perception, however, they are clearly prone to considerable stress as a result of their attempts at social inclusion. Chronic levels of stress can precipitate a mood disorder. Thus, there may be constitutional and circumstantial factors that explain the higher incidence of affective disorders.

The theoretic models of autism developed within cognitive psychology and research in neuropsychology also provide some explanation as to why such individuals are prone to secondary mood disorders. The extensive research on Theory of Mind skills confirms that individuals with Aspergers have considerable difficulty identifying and conceptualizing the thoughts and feelings of other people and themselves [26], [27], [28], [29], [30]. The interpersonal and inner world of emotions seems to be uncharted territory for people with Aspergers.

Research on executive function in subjects with Aspergers suggests characteristics of being disinhibited and impulsive, with a relative lack of insight that affects general functioning [31], [32], [33], [34]. Impaired executive function also can affect the cognitive control of emotions. Clinical experience indicates there is a tendency to react to emotional cues without cognitive reflection. Research with subjects with autism using new neuroimaging technology also has identified structural and functional abnormalities of the amygdala [35], [36], [37], [38], which is known to regulate a range of emotions, including anger, fear, and sadness. Thus, we also have neuroanatomic evidence that suggests there will be problems with the perception and regulation of the emotions.

Managing anxiety, depression, and anger –

When clinicians diagnose a secondary mood disorder, they need to know how to modify standard psychologic treatments to accommodate the unusual cognitive profile of people with Aspergers. As the primary psychologic treatment for mood disorders is cognitive behavior therapy (CBT), this article now examines such modifications based on our knowledge of the disorder and preliminary clinical experience.

CBT has been designed and refined over several decades and has proven to be effective in changing the way a person thinks about and responds to feelings such as anxiety, sadness, and anger [39], [40]. CBT focuses on aspects of cognitive deficiency in terms of the maturity, complexity, and efficacy of thinking, and cognitive distortion in terms of dysfunctional thinking and incorrect assumptions. Thus, it has direct applicability to patients with Aspergers who are known to have deficits and distortions in thinking.

The therapy has several components, the first being an assessment of the nature and degree of mood disorder using self-report scales and a clinical interview. The subsequent stage is affective education with discussion and exercises on the connection between cognition, affect, and behavior, and the way in which individuals conceptualize emotions and construe various situations. Subsequent stages are cognitive restructuring, stress management, self-reflection, and a schedule of activities to practice new cognitive skills. Cognitive restructuring corrects distorted conceptualizations and dysfunctional beliefs. The person is encouraged to establish and examine the evidence for or against their thoughts and build a new perception of specific events. Stress management and cue controlled relaxation programs are used to promote responses incompatible with anxiety or anger. Self-reflection activities help the person recognize their internal state, monitor and reflect on their thoughts, and construct a new self-image. A graded schedule of activities is also developed to allow the person to practice new abilities that are monitored by the therapist.

Assessment—

There are several self-rating scales that have been designed for kids and adults with specific mood disorders that can be administered to patients with Aspergers. There are specific modifications that can be used with this clinical group, however, as they may be more able to accurately quantify their response using a numeric or pictorial representation of the gradation in experience and expression of mood. Examples include an emotion “thermometer,” bar graphs, or a “volume” scale. These analogue measures are used to establish a baseline assessment and are incorporated in the affective education component. To minimize word retrieval problems, multiple-choice questions can be used in preference to open-ended, sentence-completion tasks. A pictorial dictionary of feelings also can be used as additional cues for a diary or logbook completed during the therapy by the patient.

The assessment includes the construction of a list of behavioral indicators of mood changes. The indicators can include changes in the characteristics associated with Aspergers, such as an increase in time spent engaged in solitude or their special interest, rigidity, or incoherence in their thought processes, or behavior intended to impose control in their daily lives and over others. This is in addition to conventional indicators such as a panic attack, comments indicating low self worth, and episodes of anger. It is essential to collect information from a wide variety of sources, as kids and adults with Aspergers can display quite different characteristics according to their circumstances. For example, there may be little evidence of a mood disorder at school but clear evidence at home. Moms & dads and teachers also can complete a daily mood diary to determine whether there is any cyclical nature to, or specific triggers for, mood changes.

The clinician also needs to assess the coping mechanisms and vocabulary of emotional expression of the person with Aspergers. Although there are no standardized tests to measure such abilities, some characteristics have been identified by clinical experience. For example, discussion with moms & dads can indicate that the youngster displays affection, but the depth and range of expression is usually limited and immature for their chronologic age. Their reaction to pleasure and pain can be atypical, with idiosyncratic mannerisms that express feeling excited, such as hand flapping, or a stoic response to pain and punishments. Examples of characteristics that moms & dads may be concerned about are a lack of apparent gratitude or remorse and paradoxic and atypical responses to particular situations. For example, the youngster may giggle when expected to show remorse [41] and be remarkably quick in resolving grief. They also may misinterpret gestures of affection, such as a hug, with the comment that the squeeze was perceived as uncomfortable and not comforting. Their emotional reactions also can be delayed, perhaps with an expression of anger some days or weeks after the event.

Their coping or emotional recovery mechanisms need to be assessed and can include characteristics such as retreating into solitude, increasing time spent engaged in a special interest, reading fantasy literature, and playing computer games. Some individuals internalize their reaction with self-blame and low self-esteem, whereas others externalize their reaction, becoming critical of others and developing an arrogant and intolerant personality. The former may show signs of depression and anxiety, whereas the latter are often referred for problems with anger management. Different emotions can prevail at particular times of the day, however, for example, being anxious before school and angry when returning home. It is also valuable to assess not only how the youngster repairs their own feelings but also how they repair the feelings of others. Research suggests that people with Aspergers use fewer of the available cues in facial expression and body language to infer emotional states [42].

The clinician needs to assess the client's ability to identify the cues of emotional states in others and to know when specific words and actions are anticipated, for example, providing gestures and words of affection when a family member or friend is sad or reassurance when they are anxious. Questions can be asked, such as “How would you know when your mother is feeling sad?” and “What would you do if she were crying?” Another area of assessment is their awareness of the impact of their own mood state and associated behavior on the thoughts and feelings of others, namely an assessment of empathy. Unfortunately we do not have any standardized tests to measure empathy; accordingly, most information is obtained from discussion with the person with Aspergers and their family for examples of a relative lack of empathic response.

Affective education—

Affective education is the next stage in a course of CBT and an essential component for those with Aspergers. The main goal is to learn why we have emotions, their use and misuse, and the identification of different levels of expression. A basic principle is to explore one emotion at a time as a theme for a project. The choice of which emotion to start with is decided by the therapist, but a useful starting point is happiness or pleasure. A scrapbook can be created that illustrates the emotion. For young kids, this can include pictures of people expressing the different degrees of happiness or pleasure, but can be extended to pictures of objects and situations that have a personal association with the feeling, for example, a photograph of a rare lizard for a person with a special interest in reptiles.

For adults, the book can illustrate the pleasures in their life, with a list based on the song My Favorite Things. The content also can include the sensations that may elicit the feeling, such as aromas, tastes, and textures. The scrapbook can be used as a diary to include compliments, and records of achievement, such as certificates and memorabilia. At a later stage in therapy, the scrapbook can be used to change a particular mood but it also can be used to illustrate different perceptions of a situation. If the therapy is conducted in a group, the books can be compared and contrasted. Talking about trains may be an enjoyable experience for one participant but perceived as remarkably boring or dominating for another. Part of the education is to explain that although this topic may create a feeling of well being in the one participant, their attempt to cheer up another person by talking about trains may not be a successful strategy, perhaps producing a response that they did not expect. One of the interesting aspects that the author has noticed is that clients with Aspergers tend to achieve enjoyment primarily from knowledge, interests, and solitary pursuits, and less from social experiences, in comparison with other client groups. They are often at their happiest when alone.

The affective education stage includes the therapist describing and the client discovering the salient cues that indicate a particular level of emotional expression in facial expression, tone of voice, body language, and context. The face is described as an information center for emotions. The typical errors include not identifying which cues are relevant or redundant, and misinterpreting cues. The therapist uses a range of games and resources to “spot the message” and explain the multiple meanings; for example, a furrowed brow can mean anger or bewilderment, or may be a sign of aging skin. A loud voice does not automatically mean that a person is angry.

Once the key elements that indicate a particular emotion have been identified, it is important to use an “instrument” to measure the degree of intensity. The therapist can construct a model “thermometer,” “gauge,” or volume control, and can use a range of activities to define the level of expression. For example, they can use a selection of pictures of happy faces and place each picture at the appropriate point on the instrument. During the therapy it is important to ensure the client shares the same definition or interpretation of words and gestures and to clarify any semantic confusion. Clinical experience has indicated that some clients with Aspergers can use extreme statements such as “I am going to kill myself” to express a level of emotion that would be more moderately expressed by another client. During a program of affective education, the therapist often has to increase the client's vocabulary of emotional expression to ensure precision and accuracy.

The education program includes activities to detect specific degrees of emotion in others but also in oneself, using internal physiologic cues, cognitive cues, and behavior. Technology can be used to identify internal cues in the form of biofeedback instruments such as auditory EMG and GSR machines. The client and those who know them well can create a list of their physiologic, cognitive, and behavioral cues that indicate their increase in emotional arousal. The degree of expression can be measured using one of the special instruments used in the program, such as the emotion thermometer. One of the aspects of the therapy is to help the client perceive their “early warning signals” that indicate emotional arousal that may need cognitive control; perhaps, using a metaphor, they can be the warning lights and instruments on a car dashboard.

When a particular emotion and the levels of expression are understood, the next component of affective education is to use the same procedures for a contrasting emotion. After exploring happiness, the next topic explored would be sadness; feeling relaxed would be explored before a project on feeling anxious. The client is encouraged to understand that certain thoughts or emotions are “antidotes” to other feelings, for example, some strategies or activities associated with feeling happy may be used to counteract feeling sad.

Some individuals with Aspergers can have considerable difficulty translating their feelings into conversational words. There can be a greater eloquence, insight, and accuracy using other forms of expression. The therapist can use prose in the form of a “conversation” by typing questions and answers on a computer screen or techniques such as comic strip conversations that use figures with speech and thought bubbles [7]. When designing activities to consolidate the new knowledge on emotions, one can use a diary, e-mail, art, or music as a means of emotional expression that provides a greater degree of insight for client and therapist.

Other activities to be considered in affective education are the creation of a photograph album that includes pictures of the client and family members expressing particular emotions, or video recordings of the client expressing their feelings in real-life situations. This can be particularly valuable to demonstrate their behavior when expressing anger. Another activity entitled “Guess the message” can include the presentation of specific cues, such as a cough as a warning sign or a raised eyebrow to indicate doubt. It is also important to incorporate the person's special interest in the program. For example, the author has worked with individuals whose special interest has been the weather and has suggested that their emotions are expressed as a weather report. There are several kids's reading books that have a particular emotion as a theme and self-help books for teenagers with specific mood disorders that can be used as a form of bibliotherapy. We also now have books and computer programs that provide a social and emotional curriculum that includes activities for affective education for kids with Aspergers [43], [44].

Cognitive restructuring—

Cognitive restructuring enables the client to correct distorted conceptualizations and dysfunctional beliefs. The process involves challenging their current thinking with logical evidence and ensuring the rationalization and cognitive control of their emotions. The first stage is to establish the evidence for a particular belief. People with Aspergers can make false assumptions of their circumstances and the intentions of others. They have a tendency to make a literal interpretation, and a casual comment may be taken out of context or may be taken to the extreme. For example, a young teenage boy with Aspergers was once told his voice was breaking. He became extremely anxious that his voice was becoming faulty and decided to consciously alter the pitch of his voice to repair it. The result was an artificial falsetto voice that was incongruous in a young man.

A teenage girl with Aspergers overheard a conversation at school that implied that a girl must be slim to be popular. She then achieved a dramatic weight loss in an attempt to be accepted by her peers. We are all vulnerable to distorted conceptualizations, but people with Aspergers are less able to put things in perspective, seek clarification, and consider alternative explanations or responses. The therapist encourages the client to be more flexible in their thinking and to seek clarification, using questions or comments such as “Are you joking?” or “I'm confused about what you just said.” Such comments also can be used when misinterpreting someone's intentions such as, “Did you do that deliberately?” and to rescue the situation after the patient has made an inappropriate response with a comment such as, “I'm sorry I offended you,” or “Oh dear, what should I have done?”

To explain a new perspective or to correct errors or assumptions, comic strip conversations can help the client determine the thoughts, beliefs, knowledge, and intentions of the participants in a given situation [7]. This technique involves drawing an event or sequence of events in storyboard form with stick figures to represent each participant, and speech and thought bubbles to represent their words and thoughts. The client and therapist use an assortment of fibro-tipped colored pens, with each color representing an emotion. As they write in the speech or thought bubbles, the person's choice of color indicates their perception of the emotion conveyed or intended. This can clarify the client's interpretation of events and the rationale for their thoughts and response. This technique can help the client identify and correct any misperception and determine how alternative responses might affect the participants' thoughts and feelings.

One common effect of misinterpretation is the development of paranoia. Our knowledge of impaired Theory of Mind skills in the cognitive profile of kids with Aspergers suggests a simple explanation. The youngster can have difficulty distinguishing between accidental or deliberate intent. Other kids will know from the context, body language, and character of the person involved that the intent was not to cause distress or injury. Individuals with Aspergers, however, can focus primarily on the act and the consequences: “He hit me and it hurt, so it was deliberate,” whereas other kids would consider the circumstances: “He was running, tripped, and accidentally knocked my arm.” There may need to be training in checking the evidence before responding and developing more accurate “mind reading” skills.

Cognitive restructuring also includes a process known as “attribution retraining.” The person may blame others exclusively and not consider their own contribution, or they can excessively blame themselves for events [2]. One aspect of Aspergers is a tendency for some clients to adopt an attitude of arrogance or omnipotence where the perceived focus of control is external. Specific individuals are held responsible and become the target for retribution or punishment. These people have considerable difficulty accepting that they themselves have contributed to the event. The opposite can occur, however, when the client has extremely low self-esteem and feels personally responsible, which results in feelings of anxiety and guilt. There also can be a strong sense of what is right and wrong and conspicuous reaction if others violate the social “laws” [2]. The youngster may be notorious as the class “policeman,” dispensing justice but not realizing what is within their authority. Attribution retraining involves establishing the reality of the situation, the various participants' contributions to an incident, and determining how the person can change their perception and response.

Cognitive restructuring also includes activities that are designed to improve the person's range of emotional repair mechanisms. The author has extended the use of metaphor to design programs that include the concept of an emotional toolbox to “fix the feeling.” Patients know that a toolbox usually includes a variety of tools to repair a machine, and discussion and activities are used to identify different types of “tools” for specific problems associated with emotions.

One type of emotional repair tool can be represented by a hammer, which signifies physical “tools” such as going for a walk or run, bouncing on a trampoline, or crushing empty cans for recycling. The intention is to repair emotions constructively by a safe physical act that increases the heart rate. One client explained how a game of tennis “takes the fight out of me.” A paintbrush can be used to represent relaxation tools that lower the heart rate, such as drawing, reading, or listening to calming music. A two-handle saw can be used to represent social activities or individuals who can help repair feelings. This can include communication with someone who is known to be empathic and able to dispel negative feelings. This can be by spoken conversation or typed communication, enabling the client to gain a new perspective on the problem and providing some practical advice.

A picture of a manual can be used to represent thinking tools that are designed to improve cognitive processes. This includes phrases that encourage reflection before reaction. Evan, a young man with Aspergers, developed his “antidote to poisonous thoughts.” The procedure is to provide a comment that counteracts negative thoughts, for example, “I can't cope” (negative or poisonous thought) “but I can do this with help” (positive thought or antidote). The person also is taught that becoming emotional can inhibit their intellectual abilities in a particular situation that requires good problem-solving skills. When frustrated, one needs to become “cool” and less rigid in one's thinking to solve the problem, especially if the solution requires social cognition.

There is a discussion of inappropriate tools (with the comment that one would not use a hammer to fix a computer) to explain how some actions, such as violence and thoughts such as suicide, are not appropriate emotional repair mechanisms. For example, one client would slap himself to stop negative thoughts and feelings. Another tool that could become inappropriate is to retreat into a fantasy world (perhaps imagining they are a superhero), or to plan retaliation. The use of escape into fantasy literature and games can be a typical tool for ordinary teenagers but is of concern when this becomes the exclusive coping mechanism; the border between fantasy and reality may be unclear and the thinking becomes delusional.

Cognitive restructuring can be used to return to concrete thinking. Also of concern is when daydreams of retaliation to teasing and bullying are expressed in drawings, writing, and threats. Although this is a conventional means of emotional expression, there is a concern that the expression is misinterpreted as an intention to carry out the fantasy or indeed may be a precursor to retaliation using weapons. Unusual tools also are discussed. For example, during a group CBT session on sadness, a teenage girl explained that, “Crying doesn't work for me, so I get angry.” Clinical experience suggests that tears may be rare as a response to feeling sad, with a more common response to sadness being anger. The program includes the development of a range of conventional means of emotional expression and repair mechanisms and an explanation as to why some of their reactions are misinterpreted by others.

Clinical experience also has indicated that humor and imagination can be used as thinking tools. Those with Aspergers are not immune to the benefits of laughter, can enjoy jokes typical of their developmental level, and can be remarkably creative with puns and jokes [45]. One tool or mechanism that seems to be unusual is that of being quick at resolving grief and serious tragedies. This characteristic can be of concern to the person's family, who expect the classic signs of prolonged and intense grieving; they consider the person as uncaring, yet the rapid recovery is simply a feature of Aspergers.

Other interesting characteristics are the inclusion of talking to pets as a social tool, sometimes in preference to talking to friends, and the positive effects on mood from helping someone. This strategy can be effective for clients with Aspergers who also need to be needed and can improve their mood by being of practical assistance. Finally, the concept of a toolbox can be extremely helpful in enabling the person with Aspergers not only to repair their own feelings but also to repair the feelings of others. They often benefit from tuition in learning what tools to use to help friends and family and which tools others use, so that they may borrow tools to add to their own emotional repair kit.

Stress management—

Individuals with Aspergers are prone to greater stress in their daily lives than their peers. Social interaction, especially with more than one person, in which they have to identify, translate, and respond to social and emotional cues and cope with unexpected noise levels, inevitably increases stress to a point where the person's coping mechanisms may collapse. A stress assessment based on our knowledge of Aspergers will help the clinician determine what are the natural and idiosyncratic stressors for the client [46]. Subsequently, an effective stress management program can be designed as an essential component of CBT.

Traditional relaxation procedures using activities to encourage muscle relaxation and breathing exercises can be taught to clients with Aspergers as a counter conditioning procedure, but one must also consider the circumstances in which they are particularly prone to stress. Environmental modification can significantly reduce stress. This can include reducing noise levels, minimizing distractions, and having a safe area for periods of solitude to relax or concentrate on schoolwork. If the clinician recognizes that a particular event is a major cause of stress, then it would be wise to consider whether the source of stress could be avoided, for example, recommending the temporary suspension of homework. At school, one option for the youngster who becomes stressed in the playground is to be able to withdraw to the school library, or for the worker who is anxious about socializing during the lunch break, to complete a crossword puzzle or go for a walk. Another source of stress for kids and adults is unexpected changes in work demands or circumstances. They may need advance preparation and time to adjust their work schedule.

Cue-controlled relaxation is also a useful component of a stress management plan. One strategy is for the client to have an object in their pocket that symbolizes or has been classically conditioned to elicit feelings of relaxation. For example, a teenage girl with Aspergers was an avid reader of fiction, her favorite book being The Secret Garden. She kept a key in her pocket to metaphorically open the door to the secret garden, an imaginary place where she felt relaxed and happy. A few moments touching or looking at the key helped her to contemplate a scene described in the book and to relax and achieve a more positive state of mind. Adults can have a special picture in their wallet such as a photograph of a woodland scene, which reminds the person of the solitude and tranquility of such a place

Self-reflection—

In conventional CBT programs, the client is encouraged to self-reflect to improve insight into their thoughts and feelings, promoting a realistic and positive self-image and enhancing the ability to self-talk for greater self-control. The concept of self-consciousness may be different for individuals with Aspergers, however. There may be a qualitative impairment in the ability to engage in introspection. Research evidence, autobiographies, and clinical experience have confirmed that some clients with Aspergers and high functioning autism can lack an “inner voice” and think in pictures rather than words [47], [48]. They also have difficulty translating their visual thoughts into words. As a teenager with Aspergers explained in relation to how visualization improves his learning (a picture is worth a thousand words), “I have the picture in my mind but not the thousand words to describe it.” Some have an “inner voice” but have difficulty disengaging mind and mouth, and vocalize their thoughts to the confusion or annoyance of those near them. Obviously, the therapy needs to accommodate such unusual characteristics.

The modifications include a greater use of visual material and resources using drawings, role-play, and metaphor, and less reliance on spoken responses. It is interesting that many clients have a greater ability to develop and explain their thoughts and emotions using other expressive media, such as typed communication in the form of e-mail or a diary, music, art, or a pictorial dictionary of feelings [3].

When talking about themselves, young adults with autism and Aspergers do not anchor their self-attributes in social activities and relationships or use as wide a range of emotions in their descriptions as their peers [49]. They are less likely to describe themselves in the context of their relationships and interactions with other people. The self-reflection component of CBT may have to be modified to accommodate a concept of self primarily in terms of physical, intellectual, and psychologic attributes.

The therapy includes programs to adjust the client's self image to be an accurate reflection of their abilities and the neurologic origins of their disorder. Some time needs to be allocated to explaining the nature of Aspergers and how the characteristics account for their differences. The author recommends that as soon as the youngster or adult has the diagnosis of Aspergers, the clinician needs to carefully and authoritatively explain the nature of the disorder to their family, but the youngster also must receive a personal explanation. This is to reduce the likelihood of inappropriate compensatory mechanisms to their recognition of being different and concern as to why they have to see psychologists and psychiatrists.

They also may be concerned as to why they have to take medication and receive tuition at school that is not given to their peers. Over the last few years, there have been several publications and programs developed specifically to introduce the youngster or teenager to their diagnosis. The choice of which book or program to use is determined by the clinician, but it is important that the explanations are accurate and positive. The client will perceive the diagnosis as it is presented. If the approach is pessimistic, the reaction can be to trigger a depression or to reject the diagnosis and treatment. The clinician also can recommend the client read some of the autobiographies written by kids [50], [51] and adults [52], [53]. The subsequent discussion is whether and how to tell other people of the diagnosis, especially extended family, neighbors, friends, and colleagues.

When an accurate perception of self has been achieved, it is possible to explore cognitive mechanisms to accommodate their unusual profile of abilities, which the author describes as their talents and vulnerabilities, and to consider the directions for change in self-image. One approach is using the metaphor of a road map with alternative directions and destinations [54], and a Personal Construct Assessment [55].

Practice—

Once the client has improved their cognitive strategies to understand and manage their moods at an intellectual level, it is necessary to start practicing the strategies in a graduated sequence of assignments. The first stage is for the therapist to model the appropriate thinking and actions in role-play with the client, who then practices with the therapist or other group members, vocalizing thinking to monitor their cognitive processes. A form of graduated practice is used, starting with situations associated with a mild level of distress or agitation. A list of situations or triggers is created from the assessment conducted at the start of the therapy, with each situation written on a yellow Post-It note. The client uses the thermometer or measuring instrument originally used in the affective education activities to determine the hierarchy or rank order of situations.

The most distressing are placed at the upper level of the instrument. As the therapy progresses, the client and therapist work through the hierarchy using fading or systematic desensitization using a schedule of graduated exposure to encourage the client to be less emotionally reactive [56]. After practice during the therapy session, the client has a project to apply their new knowledge and abilities in real-life situations. The therapist obviously needs to communicate and coordinate with those who are supporting the client in real-life circumstances. After each practical experience, therapist and client consider the degree of success, using activities such as comic strip conversations to debrief, reinforcement for achievements, and a “boasting book” or certificate of achievement. It also helps to have a training manual for the client that includes suggestions and explanations. The manual becomes a resource for the client during the therapy but is easily accessible information when the therapy program is complete. One of the issues during the practice will be generalization.

People with Aspergers tend to be rigid in terms of recognizing when the new strategies are applicable in a situation that does not obviously resemble the practice sessions with the psychologist. It is necessary to ensure that strategies are used in a wide range of circumstances and no assumption made that once an appropriate emotion management strategy has proved successful, it will continue to be used in all settings.

The duration of the practice stage depends on the degree of success and list of situations. Gradually the therapist provides less direct guidance and support to encourage confidence in independently using the new strategies. The goal is to provide a template for current and future problem, but it will probably be necessary to maintain contact with the client for some time to prevent relapse.

Aspects of CBT can be incorporated into conventional family therapy [57] and social skills groups [58], and can be conducted as the primary psychologic treatment. Other specialists may be consulted during the program, especially if the client has signs of attention deficit disorder, Tourette syndrome, and specific learning problems. Predictors of a successful outcome may include the complexity and degree of expression of the mood disorder and diagnostic characteristics, the intellectual capacity of the client, and their circumstances and support. Two positive predictors that have been recognized by the author from clinical experience are a sense of humor and imagination.

Finally our scientific knowledge in the area of psychologic therapies and Aspergers is remarkably limited. We have case studies [59], but at present, no systematic and rigorous independent research studies that examine whether CBT is an effective treatment with this clinical population. This is despite the known high incidence of mood disorders, especially among teenagers with Aspergers. As a matter of expediency, a clinician may decide to conduct a course of CBT based on the known effectiveness of this form of psychologic treatment in the general population. We have yet to establish whether it is universally appropriate, however, and to confirm the modifications to accommodate the unusual characteristics and profile of abilities associated with Aspergers.


References—

[1]. [1] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edition, text revision. Washington, DC; 2000
[2]. [2] Church C, Alisanski S, Amanullah S. The social, behavioural and academic experiences of children with Asperger disorder. Focus on Autism and Other Developmental Disabilities. 2000;15(1):12–20.
[3]. [3] Attwood T. Asperger's syndrome: a guide for parents and professionals. London: Jessica Kingsley Publishers; 1998;.
[4]. [4] Roffey S, Taurant T, Majors K. Young friends: schools and friendship. London: Cassell; 1994;.
[5]. [5] Rubin KH. The friendship factor. New York: Viking; 2002;.
[6]. [6] Klin A. Attributing social meaning to ambiguous visual stimuli in higher-functioning autism and Asperger syndrome: the social attribution task. J Child Psychiatry. 2000;41:831–846.
[7]. [7] Schopler E, Mesibov GB, Kunce LJ. In: Asperger syndrome and high-functioning autism?. New York: Plenum Press; 1998;p. 167–198.
[8]. [8] Howlin P, Baron-Cohen S, Hadwin J. Teaching children with autism to mind-read: a practical guide. Chichester: Wiley; 1999;.
[9]. [9] Bauminger N, Kasari C. Loneliness and friendship in high functioning children with autism. Child Dev. 2000;71:447–456. MEDLINE
[10]. [10] Carrington S, Graham L. Perceptions of school by two teenage boys with Asperger syndrome and their mothers: a qualitative study. Autism. 2001;5:37–48. MEDLINE | CrossRef
[11]. [11] Holliday-Willey L. Pretending to be normal. London: Jessica Kingsley Publishers; 1999;.
[12]. [12] Aston MC. The other half of Asperger's syndrome: a guide to living in an intimate relationship with a partner who has Asperger syndrome. London: The National Autistic Society; 2001;.
[13]. [13] Kim JA, Szatmari P, Bryson SE, Streiner DL, Wilson F. The prevalence of anxiety and mood problems among children with autism and Asperger disorder. Autism. 2000;4:117–132. CrossRef
[14]. [14] Ghazuddin M, Wieder-Mikhail W, Ghaziuddin N. Comorbidity of Asperger syndrome: a preliminary report. J Intellect Disabil Res. 1998;42:279–283.
[15]. [15] Gillot A, Furniss F, Walter A. Anxiety in high-functioning children with autism. Autism. 2001;5(3):277–286. MEDLINE | CrossRef
[16]. [16] Green J, Gilchrist A, Burton D, Cox A. Social and psychiatric functioning in adolescents with Asperger disorder compared with conduct disorder. J Autism Dev Disord. 2000;30(4):279–293. MEDLINE | CrossRef
[17]. [17] Tantam D. Psychological disorder in adolescents and adults with Asperger disorder. Autism. 2000;4:47–62. CrossRef
[18]. [18] Tonge B, Brereton A, Gray K, Einfeld S. Behavioural and emotional disturbance in high-functioning autism and Asperger disorder. Autism. 1999;3:117–130. CrossRef
[19]. [19] Kurita H. Delusional disorder in a male adolescent with high-functioning PDD-NOS [brief report]. J Autism Dev Disord. 1999;29(5):419–423. MEDLINE | CrossRef
[20]. [20] Blackshaw AJ, Kinderman P, Hare DJ, Hatton C. Theory of mind, causal attribution and paranoia in Asperger disorder. Autism. 2001;5(2):147–163. MEDLINE | CrossRef
[21]. [21] Tantam D. Psychological disorder in adolescents and adults with Asperger disorder. Autism. 2000;4:47–62. CrossRef
[22]. [22] De Long GR, Dwyer JT. Correlation of family history with specific autistic subgroups: Asperger's disorder and bipolar affective disease. J Autism Dev Disord. 1988;18:593–600. MEDLINE | CrossRef
[23]. [23] Bolton P, Pickles A, Murphy M, Rutter M. Autism affective and other psychiatric disorders: patterns of familial aggregation. Psych Med. 1998;28:385–395.
[24]. [24] Ghaziuddin M, Greden J. Depression in children with autism/pervasive developmental disorders: a case-control family history study. J Autism Devel Disord. 1998;28:111–115.
[25]. [25] Piven J, Palmar R. Psychological disorder and the broad autism phenotype: evidence from a family study of multiple-incidence autism families. Am J Psychiatry. 1999;156:557–563.
[26]. [26] Baron-Cohen S, Jolliffe T. Another advanced test of theory of mind: evidence from very high functioning adults with autism or Asperger disorder. J Child Psychol Psychiatry. 1997;38:813–822. MEDLINE | CrossRef
[27]. [27] Baron-Cohen S, O'Riordan M, Stone V, Jones R, Plaisted K. Recognition of faux pas by normally developing children and children with Asperger disorder or high functioning autism. J Autism Devel Disord. 1999;29:407–418.
[28]. [28] Heavey L, Phillips W, Baron-Cohen S, Rutter M. The awkward moments test: a naturalistic measure of social understanding in autism. J Autism Dev Disord. 2000;30:225–236. MEDLINE | CrossRef
[29]. [29] Kleinman J, Marciano P, Ault R. Advanced theory of mind in high-functioning adults with autism. J Autism Dev Disord. 2001;31:29–36. MEDLINE | CrossRef
[30]. [30] Muris P, Steerneman P, Meesters C, Merckelbach H, Horselenberg R, Van Den Hogan T, et al. The TOM test: a new instrument for assessing theory of mind in normal children and children with pervasive developmental disorders. J Autism Dev Disord. 2001;29:67–80. MEDLINE | CrossRef
[31]. [31] Eisenmajer R, Prior M, Leekman S, Wing L, Gould J, Welham M, et al. Comparison of clinical symptoms in autism and Asperger's disorder. J Am Acad Child Adolescent Psychiatry. 1996;35:1523–1531.
[32]. [32] Pennington BF, Ozonoff S. Executive functions and developmental psychopathology. J Child Psychol Psychiatry Ann Res Rev. 1996;37:51–87.
[33]. [33] Ozonoff S, South M, Miller J. DSM-IV defined Asperger disorder: cognitive, behavioural and early history differentiation from high-functioning autism. Autism. 2000;4:29–46. CrossRef
[34]. [34] Nyden A, Gillberg C, Hjelmquist E, Heiman M. Executive function/attention deficits in boys with Asperger disorder, attention disorder and reading/writing disorder. Autism. 1999;3:213–228. CrossRef
[35]. [35] Adolphs R, Sears L, Piven J. Abnormal processing of social information from faces in autism. J Cognitive Neurosci. 2001;13:232–240.
[36]. [36] Baron-Cohen S, Ring HA, Wheelwright S, Bullmore ET, Brammer MJ, Simmons A, et al. Social intelligence in the normal autistic brain: an FMRI Study. Eur J Neurosci. 1999;11:1891–1898. CrossRef
[37]. [37] Fine C, Lumsden J, Blair RJR. Dissociation between theory of mind and executive functions in a patient with early left amygdala damage. Brain J Neurol. 2001;124:287–298.
[38]. [38] Critchley HD, Daly EM, Bullmore ET, Williams SCR, Van Amelsvoort T, Robertson DM, et al. The functional neuroanatomy of social behaviour. Brain. 2000;123:2203–2212. CrossRef
[39]. [39] Graham P. Cognitive behaviour therapy for children and families. Cambridge: Cambridge University Press; 1998;.
[40]. [40] Kendall PC. Child and adolescent therapy cognitive behavioural therapy procedures. New York: The Guildford Press; 2000;.
[41]. [41] Berthier ML. Hypomania following bereavement in Asperger's disorder: a case study. Neuropsychiatr Neuropsychol Behav Neurol. 1995;8:222–228.
[42]. [42] Koning C, Magill-Evans J. Social and language skills in adolescent boys with Asperger's disorder. Autism. 2001;5(1):23–36. MEDLINE | CrossRef
[43]. [43] McAfee J. Navigating the social world. A curriculum for individuals with Asperger's syndrome, high-functioning autism and related disorders. London: Jessica Kingsley Publishers; 2001;.
[44]. [44] Moyes R. Incorporating social goals in the classroom. A guide for teachers and parents of children with high-functioning autism and Asperger syndrome. London: Jessica Kingsley Publishers; 2001;.
[45]. [45] Werth A, Perkins M, Boucher J. Here's the weavery looming up. Autism. 2001;5(2):111–125. MEDLINE | CrossRef
[46]. [46] Groden J, Diller A, Bausman M, Velicer W, Norman G, Cautella J. The development of a stress survey schedule for persons with autism and other developmental disabilities. J Autism Dev Disord. 2001;31(2):207–217. MEDLINE | CrossRef
[47]. [47] Grandin T. Thinking in pictures. New York: Doubleday; 1995;.
[48]. [48] Hurlburt RT, Happe F, Frith U. Sampling the form of inner experience in three adults with Asperger's disorder. Psychol Med. 1994;24:385–395. MEDLINE | CrossRef
[49]. [49] Lee A, Hobson RP. On developing self-concepts: a controlled study of children and adolescents with autism. J Child Psychol Psychiatry. 1998;39:1131–1144. MEDLINE | CrossRef
[50]. [50] Hall K. Asperger syndrome, the universe and everything. London: Jessica Kingsley Publishers; 2001;.
[51]. [51] Jackson L. Freaks, geeks and Asperger syndrome: a user guide to adolescence. London: Jessica Kingsley Publishers; 2002;.
[52]. [52] Lawson W. Life beyond glass. A personal account of autism spectrum disorder. London: Jessica Kingsley Publishers; 1998;.
[53]. [53] Holliday-Willey L. Pretending to be normal. London: Jessica Kingsley Publishers; 1999;.
[54]. [54] Ronen T. Cognitive developmental therapy with children. Sussex: Wiley and Sons; 1997;.
[55]. [55] Hare DJ, Jones JPR, Paine C. Approaching reality: the use of personal construct assessment in working with people with Asperger syndrome. Autism. 1999;3:165–176. CrossRef
[56]. [56] Luiselli JK. Case demonstration of fading procedure to promote school attendance of a child with Asperger's disorder. J Pos Behav Inter. 2000;2(1):47–53.
[57]. [57] Stoddart K. Adolescents with Asperger disorder: three case studies of individual and family therapy. Autism. 1999;3:255–271. CrossRef
[58]. [58] Howlin P, Yates P. The potential effectiveness of social skills groups for adults with autism. Autism. 1999;3:299–307. CrossRef
[59]. [59] Hare DJ, Paine C. Developing cognitive behavioural treatments for people with Asperger's syndrome. Clin Psychol Forum. 1997;110:5–8.