The Diagnosis of Aspergers

Aspergers (AS) is one of the pervasive developmental disorders (PDD) which is a family of congenital conditions characterized by marked social impairment, communication difficulties, play and imagination deficits, and a range of repetitive behaviors or interests 1. The prototypical PDD is autism, which was first described by Leo Kanner at Johns Hopkins in 1943 2. Autism occurs in 1 out of every 1000 births 3, is a neurobiologic disorder with a strong genetic component (a 2%–5% recurrence rate in siblings, which is a 50 fold increase relative to the general population) 4, and some as yet tentative biologic markers involving brain structure (e.g., some people may have larger brains) and brain function (e.g., the typical brain specialization to recognize faces is not present) 5.

Approximately 70% of people with autism have a degree of mental retardation, and the typical cognitive profile includes great variability of skills (e.g., usually higher level nonverbal problem-solving skills and lower level language and conceptual skills) 6. Universally, there is a considerable discrepancy between a person's cognitive potential (i.e., IQ) and their ability to meet the demands of everyday life (or adaptive skills) 7. The diagnosis of autism is entirely behavioral and is made through clinical examination of a youngster's history and current presentation in the areas of social, communicative, and play/imagination behaviors 8. In the past decade, there has been progress in research of the biologic origins of autism, particularly in the areas of genetics and brain function, but there is no biologic test as yet (e.g., through blood analysis) to identify people with this condition 9.

In 1944, Hans Asperger, an Austrian pediatrician with an interest in special education, described four kids who had difficulty integrating socially into groups 10. 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 gestures and affective tone of voice, poor empathy and a tendency to intellectualize emotions, an inclination to engage in long-winded, one-sided, sometimes incoherent and rather formalistic speech (he called them “little professors”), all-absorbing interests involving unusual topics that dominated their conversation, and motoric clumsiness. Unlike Kanner's patients, these kids were not as withdrawn or aloof.

They also developed, sometimes precociously, highly grammatic speech, and in fact could not be diagnosed in the first years of life. Discarding the possibility of a psychogenetic origin, Asperger highlighted the familial nature of the condition, and even hypothesized that the personality traits were primarily male-transmitted. Asperger's 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 11. Her codification of the condition she called Aspergers blurred somewhat the differences between Kanner's and Asperger's descriptions, as she included a small number of girls and mildly mentally retarded kids, and 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 because of the lack of consensual diagnostic criteria for the condition 12. Although ASPERGERS was first granted official recognition in ICD-10 13, and appears as Asperger disorder in DSM-IV 1, its nosologic status is still uncertain.

Clinical features—

The diagnosis of ASPERGERS requires the demonstration of qualitative impairments in social interaction and restricted patterns of interest, criteria that 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 1.

In some contrast to the social presentation in autism, people with ASPERGERS find themselves socially isolated but are not usually withdrawn in the presence of other people, typically approaching 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 nonliteral 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 people with Aspergers develop symptoms of a 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 for 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; however, they are unable to act on 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 people 12.

Although significant abnormalities of speech are not typical of people with ASPERGERS, there are at least three aspects of these individuals' communication patterns that are of clinical interest 14. 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 function of the utterance (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 often there is 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 often may be tangential and circumstantial, conveying a sense of looseness of associations and incoherence.

Even though in a 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 people with ASPERGERS is often characterized by marked verbosity. The youngster or adult may talk incessantly, usually about a favorite subject, often in complete disregard as 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 person 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.

People with ASPERGERS typically amass a large amount of factual information about a topic in an intense fashion 12. The actual topic may change from time to time, but often dominates the content of social exchange. 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 because strong interests in certain topics, such as dinosaurs or fashionable fictional characters, are ubiquitous. In younger and older kids, however, typically the special interests interfere with learning in general because they absorb so much of the youngster's attention and motivation, and also interfere with the youngster's ability to engage in more reciprocal forms of conversation with others.

People 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 exhibit stilted or bouncy gait patterns and odd posture. Neuropsychologically there may be 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 15. Many kids exhibit high levels of activity in early childhood, and the commonest reported comorbid symptoms in adolescence and young adulthood are anxiety and particularly depression 16.

Clinical assessment—

ASPERGERS, like the other pervasive developmental disorders, involves delays and deviant patterns of behavior in multiple areas of functioning. To thoroughly evaluate all relevant domains, different areas of expertise, including overall developmental functioning, neuropsychologic features, and behavioral status are required. Hence the clinical assessment of people with this disorder is most effectively conducted by an experienced interdisciplinary team. In most cases, a comprehensive interdisciplinary assessment involves the following components: a thorough developmental and health history, psychological and communication assessments, and a diagnostic examination including differential diagnosis 17.

Further consultation regarding behavioral management, motor disabilities, possible neurologic concerns, psychopharmacology, and assessment related to advanced studies or vocational training also may be needed. Given the prevailing difficulties in the definition of ASPERGERS and the great heterogeneity of the condition, it is crucial that the aim of the clinical assessment be a comprehensive and detailed profile of the individual's assets, deficits, and challenges, rather than simply a diagnostic label. Effective educational and treatment programs can only be devised on the basis of such a profile, given the need to address specific deficits while capitalizing on the person's various resources and strengths.

The psychologic assessment aims at establishing the overall level of intellectual functioning, profiles of psychomotor functioning, verbal and nonverbal cognitive strengths and weaknesses, style of learning, and independent living skills. At a minimum, the psychologic assessment should include assessments of intelligence and adaptive functioning, although the assessment of more detailed neuropsychologic skills can be of great help to further delineate the youngster's profiles of strengths and deficits (e.g., organizational skills). A description of results should include not only quantified information but also a judgment as to how representative the youngster's performance was during the assessment procedure and a description of the conditions that are likely to foster optimal and diminished performance. For example, the youngster's responses to the amount of structure imposed by the adult, the optimal pace for presentation of tasks, successful strategies to facilitate learning from modeling and demonstrations, effective ways of containing off-task and maladaptive behaviors such as cognitive and behavioral rigidity (e.g., perseverations, perfectionism, ritualized behavior), distractibility (e.g., difficulty inhibiting irrelevant responses, tangentiality), and anxiety are all important observations that can be extremely useful for designing an appropriate intervention program.

Within the psychological assessment, particular attention should be placed on adaptive functioning, which refers to capacities for personal and social self-sufficiency in real-life situations. The importance of this component of the clinical assessment cannot be overemphasized. Its aim is to obtain a measure of the youngster's typical patterns of functioning in familiar and representative environments such as the home and school that may contrast markedly with the demonstrated level of performance and presentation in the clinic. It provides the clinician with an essential indicator of the extent to which the youngster is able to use his or her potential (as measured in the assessment) in the process of adaptation to environmental demands. A large discrepancy between intellectual level and adaptive level signifies that a priority should be made of instruction within the context of naturally occurring situations to foster and facilitate the use of skills to enhance quality of life.

The communication assessment should examine nonverbal forms of communication (e.g., gaze, gestures), nonliteral language (e.g., metaphor, irony, absurdities, and humor), suprasegmental aspects of speech (e.g., patterns of inflection, stress and volume modulation), pragmatics (e.g., turn-taking, sensitivity to cues provided by the interlocutor), and content, coherence, and contingency of conversation. Particular attention should be given to perseveration on circumscribed topics, metalinguistic skills (e.g., understanding of the language of mental states including intentions, emotions, and beliefs), reciprocity, and rules of conversation.

The diagnostic assessment should integrate information obtained in all components of the comprehensive evaluation, with a special emphasis on developmental history and current symptomatology. It should include observations of the youngster during more and less structured periods. This effort should take advantage of observations in all settings, including the clinic's reception area (e.g., contacts with other kids or with family members), the halls (e.g., how the youngster interacts initially with the examiners), and in the testing room during breaks, periods of silence, or otherwise unstructured situations.

Often the youngster's disability is much more apparent during such periods in which the youngster is not given any instruction and has no adult-imposed expectation as to how to behave. Specific areas for observation and inquiry include the patient's patterns of special interest and leisure time, social and affective presentation, quality of attachment to family members, development of peer relationships and friendships, capacities for self-awareness, perspective-taking and level of insight into social and behavioral problems, typical reactions in novel situations, and ability to intuit other person's feelings and infer other person's intentions and beliefs.

Problem behaviors that are likely to interfere with remedial programming should be noted (e.g., anxiety, temper tantrums). The kid’s ability to understand ambiguous nonliteral communications (particularly teasing and sarcasm) should be further examined, particularly in regard to the youngster's patterns of response (e.g., misunderstandings of such communications may elicit aggressive behaviors). Other areas of observation involve the presence of obsessions or compulsions, ritualized behaviors, depression and panic attacks, integrity of thought, and reality testing.

Treatment—

As in autism, treatment of ASPERGERS is essentially supportive and symptomatic, and to a great extent, overlaps with the treatment guidelines applicable to people with autism unaccompanied by mental retardation 18. One initial difficulty encountered by families is proving eligibility for special services. As people with ASPERGERS are often verbal and some of them do well academically (at least in some areas), educational authorities might judge that the deficits—primarily social and communicative—are not within the scope of educational intervention. In fact, these two aspects should be the core of any educational intervention and curriculum for people with this condition. With regard to learning strategies, skills, concepts, appropriate procedures, cognitive strategies, and behavioral norms may be more effectively taught in an explicit and rote fashion using a parts-to-whole verbal instruction approach, where the verbal steps are in the correct sequence for the behavior to be effective. Additional guidelines should be derived from the individual's neuropsychologic profile of assets and deficits. The acquisition of self-sufficiency skills in all areas of functioning should be a priority.

The tendency of people with ASPERGERS to rely on rigid rules and routines can be used to foster positive habits and enhance the person's quality of life and that of family members. Specific problem-solving strategies, usually following a verbal algorithm, may be taught for handling the requirements of frequently occurring, troublesome situations (e.g., involving novelty, intense social demands, or frustration). Training is usually necessary for recognizing situations as troublesome and for selecting the best available learned strategy to use in such situations. Social and communication skills are best taught by a communication specialist with an interest in pragmatics in speech in the context of individual and small group therapy. Communication therapy should include appropriate nonverbal behaviors (e.g., the use of gaze for social interaction, monitoring and patterning of inflection of voice), verbal decoding of nonverbal behaviors of others, social awareness, perspective-taking skills, and correct interpretation of ambiguous communications (e.g., nonliteral language).

Often, grown-ups with ASPERGERS fail to meet entry requirements for jobs in their area of training (e.g., college degree) or fail to maintain a job because of their poor interview skills, social disabilities, eccentricities, or anxiety attacks. It is important, therefore, that they are trained for and placed in jobs for which they are not neuropsychologically impaired, and in which they will enjoy a certain degree of support and shelter. It is also preferable that the job does not involve intensive social demands, time pressure, or the need to quickly improvise or generate solutions to novel situations. The little experience available with self-support groups suggests that people with ASPERGERS enjoy the opportunity to meet others with similar problems and may develop relationships around an activity or subject of shared interest. Special interests may be used as a way of creating social opportunities through hobby groups. Supportive psychotherapy and pharmacologic interventions may be helpful in dealing with feelings of despondency, frustration, and anxiety, although a more direct, problem-solving focus is believed to be more beneficial than an insight-oriented approach.

External validity—

Although ASPERGERS was first described more than 50 years ago 10, it was not until 1994 that is was included in DSM-IV 1 as one of the PDDs. Inclusion in the DSM-IV followed limited evidence that it could be differentiated from autism unaccompanied by mental retardation, or higher functioning autism (HFA) 19. As noted, however, its nosologic status remains unclear, in part because of the adoption of varying diagnostic schemes in the research literature 12. Although the advent of the DSM-IV definition was intended to create a consensual diagnostic starting point for research, it has been consistently criticized as overly narrow 20, 21, rendering the diagnostic assignment of ASPERGERS improbable or even “virtually impossible” 22, 23.

The introduction of ASPERGERS in DSM-IV and ICD-10 24 was prompted by the recognition that autism is a clinically heterogeneous disorder and that the characterization of subtypes of PDD might help behavioral and biologic research by allowing the identification of clinically more homogeneous groups 25, 26, 27. Although this effort has been successful for some PDD conditions (e.g., Rett syndrome) 28, it has not been the case in ASPERGERS. Published reports have modified DSM-IV or ICD-10 criteria 15, 29, treated ASPERGERS and HFA interchangeably 16, 17, 30, 31, or used unique investigator-defined criteria 32, making it difficult to compare studies. Only two studies 33, 34 have systematically compared different diagnostic schemes. These two studies generally revealed that different nosologic schemes result in the assignment of different diagnoses to the same patients, raising the important issue of how to compare studies using different definitions of ASPERGERS.

These studies, however, did not consider the question of the usefulness of a given diagnostic concept relative to important predictions that may have practical value to research (e.g., differences in neuropsychologic or neurobiologic findings between ASPERGERS and HFA), or clinical practice (e.g., differences in treatment efficacy, comorbid symptomatology, or outcome as a function of the given diagnostic assignment) 35. To summarize, the state of discussions on the nosologic status of ASPERGERS is, therefore, extremely problematic, given that studies cannot be necessarily compared because of the adoption of different diagnostic definitions, and there has been no comparison across different diagnostic schemes with regard to the relative usefulness of each of the schemes. And yet, the absence of a consensual or validated definition has not deterred the upsurge of research publications on the syndrome nor the apparently marked increased in the use of the diagnosis in clinical and educational settings 36.

It is apparent from this brief discussion of the external validity of ASPERGERS that studies comparing the usefulness of different diagnostic schemes is badly needed. This agenda for research is needed for several reasons.

First, there is a need to gauge the extent to which available research data obtained using different diagnostic systems are comparable.

Second, despite the upsurge in research and clinical interest in ASPERGERS, the absence of a validated definition prevents the development of standardized instrumentation that could enhance reliability of diagnostic assignment and make possible cross-site collaborations that are essential to behavioral and biological research.

Third, there are indications that the DSM-IV definition is being ignored in clinical practice 23, with the term being used as synonymous to higher functioning autism (HFA) (i.e., autism unaccompanied by mental retardation) or, maybe even more commonly, to PDD-NOS 12, creating a rift between DSM-IV and research and clinical practice, thus confusing and alienating investigators, clinicians, and parents alike.

And fourth, the scientifically interesting question as to whether or not there are qualitative discontinuities among the PDDs, or alternatively, whether the PDDs should be considered along a dimensional continuum (and what this dimension should be) is left unresolved without some resolution of the validity of the ASPERGERS diagnosis.

Several lines of research could serve the purpose of assessing the usefulness of different diagnostic schemes. First, learning profiles of assets and deficits are of great importance in educational treatment planning for people with PDDs 6, particularly in people with normative IQs 17. Neuropsychologic research of ASPERGERS is extremely equivocal to date. In 1995, the authors' group 15 documented considerable differences between people with HFA and ASPERGERS. Specifically, people with ASPERGERS showed a profile of assets and deficits consistent with a nonverbal learning disability (NLD) 37.

NLD is characterized by strengths in verbally mediated skills (e.g., vocabulary, rote knowledge, verbal memory, verbal output) and deficits in nonverbal skills (e.g., visual–spatial problem solving, visual–motor coordination). People with HFA exhibited the opposite profile. Such “double dissociation” has been shown to be one of the most powerful external validators of specific subtypes of syndromes 38. These findings have been supported by several studies focused on IQ profiles 39, 40, 41, although several other studies have failed to replicate them 42, 43. As noted, however, direct comparison across studies is not possible because different diagnostic schemes were used in them.

A second potential area of validation research in ASPERGERS could use patterns of comorbidity. Research on the psychiatric difficulties associated with the PDDs is of great importance for treatment planning, given that these symptoms may have the potential for being extremely debilitating (e.g., limiting the effectiveness of educational interventions and posing further limitations on the individual's ability to use his or her internal coping resources). Documentation of these difficulties can lead to psychopharmacologic approaches that can greatly alleviate such symptoms, thus making the student more available to other forms of intervention (e.g., educational see Towbin, this issue). ASPERGERS has been associated with a host of comorbid conditions, including schizophrenia 44, 45, Tourette syndrome 46, and attentional, affective, and obsessional disorders 47, 48. More recent research has emphasized anxiety, mood, and obsessional disorders to be particularly prevalent in this population 49, 50. As stated previously, however, there has been no attempt to study patterns of comorbidity that may be specific to HFA and AS, with most studies using the two diagnoses interchangeably.

A third potential line of research for external validation studies of ASPERGERS relates to the aggregation of social and other psychiatric disorders in family relatives. Research into patterns of genetic liability associated with the PDDs has been one of the most active areas of investigation in autism and related conditions 4. Studies have consistently shown higher rates of social disabilities or difficulties in family members of people with autism 51, 52, and of other psychiatric symptoms including anxiety, mood, and obsessional disorders 53, 54. None of these studies, however, has made the attempt to assess the usefulness of separating families of probands with HFA from those of probands with ASPERGERS.

The available data on the familiality of ASPERGERS are essentially limited to a handful of case reports and some preliminary studies 55, 56. Many case reports have been consistent with Asperger's original observation 10 of similar traits in family members, particularly fathers or male relatives 57, 58, 59. Whether or not variants of autism such as ASPERGERS might reflect greater or lower genetic liability could be of great significance in elucidating mechanisms involved in producing the marked heterogeneity among PDDs. Such studies, however, cannot be conducted without standardized diagnostic procedures, which, in turn, depend on some initial consensus as to the criteria for the definition of ASPERGERS.

To avoid insularity among research groups (i.e., each one adopting its own diagnostic scheme) and to advance the field from its current stalemate, one approach might be to simultaneously compare different diagnostic schemes and assess each one on the basis of independent factors of clinical or research significance. Such research is not yet available.

Future directions for research and clinical service—

The current state of affairs in nosologic research of ASPERGERS, with little available evidence to point to a distinction between this concept and HFA, PDD-NOS, and other similar diagnostic entities 12, has prompted many investigators to derive premature conclusions. For example, some have treated ASPERGERS as different from other conditions, whereas others have treated it as the same as other conditions. The more typical approach is to see ASPERGERS within the spectrum of PDDs, maybe indicating some half point between autism and normalcy. The authors' discussion suggests that either position is unwarranted at present.

Those who view ASPERGERS as different from other disorders have the onus to document in what ways ASPERGERS is unique among the social disabilities. This task requires comparison of extant diagnostic schemes. Those who view ASPERGERS as within the spectrum of social disabilities have the onus to define what this spectrum consists of. This task requires isolation of specific psychologic (e.g., IQ, language functions, metacognitive skills) or neurobiologic (e.g., genetic liabilities, neurostructure, or neurofunction findings) that can quantify the social disability spectrum and predict social outcome. Both of these programmatic research areas are still in their incipience.

It is nevertheless crucial to separate this research discussion from the areas of clinical practice and provision of services dedicated to people with ASPERGERS and their families. The unavoidable confusion conveyed to parents and advocates inherent in the fragility of the validity status of ASPERGERS is sufficiently harmful to justify a concerted effort on the part of clinicians and advocates to adhere to some unequivocal principles so that the needs of their clients are properly addressed.

First, whether or not there is controversy over the fine-grained distinctions between ASPERGERS and other conditions, and despite some literature and great media coverage over some famous people exhibiting or not exhibiting this condition, the vast majority of kids, adolescents, and grown-ups with ASPERGERS require a comprehensive package of treatments. Equivocating about these individuals' needs on the basis of the poor scientific status of the diagnostic concept is unjustified.

Second, adequate educational programs should not be based on a diagnostic label and generalizations associated with it, but on individualized profiles of assets and deficits that can be accomplished only through thorough evaluations involving psychologic, communication, and psychiatric assessments.

And third, the notion that ASPERGERS is simply a “milder” form of autism, regardless of whether or not this statement is scientifically justified, should be well contextualized in that, whereas “mild” is a term comparing people with this condition with those with prototypical autism and a degree of mental retardation, it is certainly not “mild” when considering these people' great difficulties in meeting the demands of everyday life. In other words, eligibility for services should be fiercely advocated.

Treatment should focus on those areas of greatest challenges, those that are known to deleteriously impact on these individuals' capacity for independent living, vocational satisfaction, and better social adjustment. These include socialization skills in general (e.g., social reciprocity and social communication), adaptive skills (e.g., “street smarts,” how to function in the community, how to fend for oneself in potentially inhospitable environments), organizational skills (e.g., how to perform complex tasks and anticipate problems), a cognitive–behavioral, and sometimes psychopharmacologic plan to alleviate anxiety and depression when these emerge, and sympathetic mental health and educational professionals who strive to build on these individuals' unique assets to compensate for their deficits and to create more positive social experiences.

The Aspergers Comprehensive Handbook

References—

[1]. [1] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edition. Text revision, DSM-IV-TR. Washington, DC: Author. 2000.

[2]. [2] Kanner L. Autistic disturbances of affective contact. Nervous Child. 1943;2:217–253.

[3]. [3] Fombonne E. The epidemiology of autism: a review. Psychol Med. 1999;29:769–786. MEDLINE | CrossRef

[4]. [4] Rutter M. Genetic studies of autism: from the 1970s into the millennium. J Child Psychol Psychiatry. 2000;28:3–14.

[5]. [5] Schultz RT, Romanski LM, Tsatsanis KD. Neurofunctional models of autistic disorder and Asperger syndrome: clues from neuroimaging. In: Klin A, Volkmar F, Sparrow S editor. Asperger syndrome. New York, NY: Guilford Press; 2000;p. 172–209.

[6]. [6] Klin A, Carter A, Volkmar FR, Cohen DJ, Marans WD, Sparrow SS. Assessment issues in children with autism. In: Cohen DJ, Volkmar FR editor. Handbook of autism and pervasive developmental disorders. 2nd edition. New York, NY: Wiley; 1997;p. 411–418.

[7]. [7] Gillham JE, Carter AS, Volkmar FR, Sparrow SS. Toward a developmental operational definition of autism. J Autism Dev Disord. 2000;30(4):269–278. MEDLINE | CrossRef

[8]. [8] Lord C. Diagnostic instruments in autism spectrum disorders. In: Cohen DJ, Volkmar FR editor. Handbook of autism and pervasive developmental disorders. 2nd edition. New York, NY: Wiley; 1997;p. 460–483.

[9]. [9] Bailey A, Phillips W, Rutter M. Autism: towards an integration of clinical, genetic, neuropsychological, and neurobiological perspectives. J Child Psychol Psychiatry. 1996;37(1):89–126. MEDLINE | CrossRef

[10]. [10] Asperger H. Die ‘Autistischen Psychopathen’ im Kindesalter. Arch Psychiatr Nervenkr. 1944;117:76–136. CrossRef

[11]. [11] Wing L. Asperger's syndrome: a clinical account. Psychol Med. 1981;11:115–129. MEDLINE | CrossRef

[12]. [12] Volkmar FR, Klin A. Diagnostic issues in Asperger syndrome. In: Klin A, Volkmar FR, Sparrow SS editor. Asperger syndrome. New York, NY: Guilford Press; 2000;p. 25–71.

[13]. [13] World Health Organization . The ICD-10 classification of mental and behavioral disorders. Geneva: Author; 1992;.

[14]. [14] Klin A, Volkmar FR. Asperger syndrome. In: Cohen DJ, Volkmar FR editor. Handbook of autism and pervasive developmental disorders. New York, NY: Wiley & Sons; 1997;p. 94–122.

[15]. [15] Klin A, Volkmar FR, Sparrow SS, Cicchetti DV, Rourke BP. Validity and neuropsychological characterization of Asperger syndrome. J Child Psychol Psychiatry. 1995;36:1127–1140. MEDLINE | CrossRef

[16]. [16] Martin A, Patzer DK, Volkmar FR. Psychopharmacological treatment of higher-functioning pervasive developmental disorders. In: Klin A, Volkmar FR, Sparrow SS editor. Asperger syndrome. New York, NY: Guilford Press; 2000;p. 210–230.

[17]. [17] Klin A, Sparrow SS, Marans WD, Carter A, Volkmar FR. Assessment issues in children and adolescents with Asperger syndrome. In: Klin A, Volkmar FR, Sparrow SS editor. Asperger syndrome. New York, NY: Guilford Press; 2000;p. 309–339.

[18]. [18] Klin A, Volkmar FR. Treatment and intervention guidelines for individuals with Asperger syndrome. In: Klin A, Volkmar FR, Sparrow SS editor. Asperger syndrome. New York, NY: Guilford Press; 2000;p. 340–366.

[19]. [19] Volkmar FR, Klin A, Siegel B, Szatmari P, Lord C, Campbell M, et al. DSM-IV Autism/Pervasive Developmental Disorder Field Trial. Am J Psychiatry. 1994;151:1361–1367.

[20]. [20] Eisenmajer R, Prior M, Leekam S, Wing L, Gould J, Welham M, et al. Comparison of clinical symptoms in autism and Asperger's disorder. J Am Acad Child Adolesc Psychiatry. 1996;35:1523–1531. Abstract | Full-Text PDF (786 KB) | CrossRef

[21]. [21] Szatmari P, Archer L, Fisman S, Streiner DL, Wilson F. Asperger's syndrome and autism: differences in behavior, cognition, and adaptive functioning. J Am Acad Child Adolesc Psychiatry. 1995;34:1662–1671. Abstract | Full-Text PDF (977 KB) | CrossRef

[22]. [22] Miller J, Ozonoff S. The external validity of Asperger disorder: lack of evidence from the domain of neuropsychology. J Abnorm Psychol. 2000;109:227–238. CrossRef

[23]. [23] Mayes SD, Calhoun SL, Crites DL. Does DSM-IV Asperger's disorder exist?. J Abnorm Child Psychol. 2001;29:263–271. MEDLINE | CrossRef

[24]. [24] World Health Organization . The ICD-10 classification of mental and behavioral disorders. Geneva: Author; 1992;.

[25]. [25] Rutter M. The Emanuel Miller Memorial Lecture 1998. Autism: two-way interplay between research and clinical work. J Child Psychol Psychiatry. 1999;40:169–188. MEDLINE | CrossRef

[26]. [26] Bailey A, Palferman S, Heavey L, Le Couteur A. Autism: the phenotype in relatives. J Autism Dev Disord. 1998;28:369–392. MEDLINE | CrossRef

[27]. [27] Volkmar FR, Klin A, Cohen DJ. Diagnosis and classification of autism and related conditions: consensus and issues. In: Cohen DJ, Volkmar FR editor. Handbook of autism and pervasive developmental disorders. New York, NY: Wiley; 1997;p. 5–40.

[28]. [28] Gura T. Gene defect linked to Rett syndrome. Science. 1999;286(5437):27. MEDLINE | CrossRef

[29]. [29] Ozonoff S, Rogers S, Pennington B. Asperger's syndrome: evidence of an empirical distinction. J Child Psychol Psychiatry. 1991;32:1107–1122. MEDLINE | CrossRef

[30]. [30] Gillberg C, Gillberg C, Rastam M, Wentz E. The Asperger Syndrome (and high-functioning autism) Diagnostic Interview (ASDI): a preliminary study of a new structured clinical interview. Autism. 2001;5:57–66. MEDLINE | CrossRef

[31]. [31] Howlin P. Outcome in adult life for more able individuals with autism or Asperger syndrome. Autism. 2000;4:63–83. CrossRef

[32]. [32] Gillberg C. Asperger syndrome and high-functioning autism. Br J Psychiatry. 1998;172:200–209. MEDLINE | CrossRef

[33]. [33] Ghaziuddin M, Tsai LY, Ghaziuddin N. A comparison of the diagnostic criteria for Asperger syndrome [brief report]. J Autism Dev Disord. 1992;22(4):643–649. MEDLINE | CrossRef

[34]. [34] Leekam S, Libby S, Wing L, Gould J, Gillberg C. Comparison of ICD-10 and Gillberg's criteria for Asperger syndrome. Autism. 2000;4:11–28. CrossRef

[35]. [35] Szatmary P. Perspectives on the classification of Asperger syndrome. In: Klin A, Volkmar FR, Sparrow SS editor. Asperger syndrome. New York, NY: Guilford Press; 2000;p. 403–417.

[36]. [36] In: Klin A, Volkmar FR, Sparrow SS editor. Asperger syndrome. New York, NY: Guilford Press; 2000;.

[37]. [37] Rourke B. Nonverbal learning disabilities: the syndrome and the model. New York, NY: Guilford Press; 1989;.

[38]. [38] Fletcher JM. External validation of learning disability typologies. In: Rourke PB editors. Neuropsychology of learning disabilities: essentials of subtype analysis. New York, NY: Guilford Press; 1985;p. 187–211.

[39]. [39] Ehlers S, Nyden A, Gillberg C, Dahlgren Sandberg A. Asperger syndrome, autism and attention disorders: a comparative study of the cognitive profiles of 120 children. J Child Psychol Psychiatry. 1997;38(2):207–217. MEDLINE | CrossRef

[40]. [40] Lincoln A, Courchesne E, Allen M, Hanson E, Ene M. Neurobiology of Asperger syndrome: seven case studies and quantitative magnetic resonance imaging findings. In: Schopler E, Mesibov G, Kunce LJ editor. Asperger syndrome or high-functioning autism?. New York, NY: Plenum; 1998;p. 145–166.

[41]. [41] Lincoln AJ, Allen M, Kilman A. The assessment and interpretation of intellectual abilities in people with autism. In: Schopler E, Mesibov G editor. Learning and cognition in autism. New York, NY: Plenum; 1995;p. 89–117.

[42]. [42] Szatmari P, Archer L, Fisman S, Streiner DL, Wilson F. Asperger's syndrome and autism: differences in behavior, cognition, and adaptive functioning. J Am Acad Child Adolesc Psychiatry. 1995;34:1662–1671. Abstract | Full-Text PDF (977 KB) | CrossRef

[43]. [43] Ozonoff S. Neuropsychological function and the external validity of Asperger syndrome. In: Klin A, Volkmar FR, Sparrow SS editor. Asperger syndrome. New York, NY: Guilford Press; 2000;p. 72–96.

[44]. [44] Clarke DJ, Little Johns CS, Corbett JA, Joseph S. Pervasive developmental disorders and psychoses in adult life. Br J Psychiatry. 1989;155:692–699. MEDLINE

[45]. [45] Tantam D. Asperger's syndrome [annotation]. J Child Psychol Psychiatry. 1988;29:245–255. MEDLINE | CrossRef

[46]. [46] Kerbeshian J, Burd L. Asperger's syndrome and Tourette syndrome: the case of the pinball wizard. Br J Psychiatry. 1986;148:731–736. MEDLINE | CrossRef

[47]. [47] Ghaziuddin M, Tsai L, Ghaziuddin N. Comorbidity of autistic disorder in children and adolescents. Eur Child Adolesc Psychiatry. 1992;1(4):209–213. CrossRef

[48]. [48] Thomsen PH. Obsessive-compulsive disorder in children and adolescents: a 6–22-year follow-up study: clinical descriptions of the course and continuity of obsessive-compulsive symptomatology. Eur Child Adolesc Psychiatry. 1994;3:82–96. CrossRef

[49]. [49] Kim J, Szatmari P, Bryson S, Streiner DL, Wilson FJ. The prevalence of anxiety and mood problems among children with autism and Asperger syndrome. Autism. 2000;4:117–132. CrossRef

[50]. [50] Green J, Gilchrist A, Burton D, Cox A. Social and psychiatric functioning in adolescents with Asperger syndrome compared with conduct disorder. J Autism Dev Disord. 2000;30:279–293. MEDLINE | CrossRef

[51]. [51] Piven J, Palmer P, Jacobi D, Childress D, Arndt S. The broader autism phenotype: evidence from a family study of multiple-incidence autism families. Am J Psychiatry. 1997;154:185–190.

[52]. [52] Murphy M, Bolton PF, Pickles A, Fombonne E, Piven J, Rutter M. Personality traits of the relatives of autistic probands. Psychol Med. 2000;30:1411–1424. MEDLINE | CrossRef

[53]. [53] Piven J, Palmer P. Psychiatric disorder and the broad autism phenotype: evidence from a family study of multiple-incidence autism families. Am J Psychiatry. 1999;156:557–563.

[54]. [54] Bolton PF, Pickles A, Murphy M, Rutter M. Autism, affective and other psychiatric disorders: patterns of familial aggregation. Psychol Med. 1998;28(2):385–395. MEDLINE | CrossRef

[55]. [55] Folstein SE, Santangelo SL. Does Asperger syndrome aggregate in families?. In: Klin A, Volkmar FR, Sparrow SS editor. Asperger syndrome. New York, NY: Guilford Press; 2000;p. 159–171.

[56]. [56] Volkmar FR, Klin A, Pauls D. Nosological and genetic aspects of Asperger syndrome. J Autism Dev Disord. 1998;28:457–463. MEDLINE | CrossRef

[57]. [57] Bowman EP. Asperger's syndrome and autism: the case for a connection. Br J Psychiatry. 1988;152:377–382. MEDLINE | CrossRef

[58]. [58] DeLong GR, Dwyer JT. Correlation of family history with specific autistic subgroups: Asperger's syndrome and bipolar affective disease. J Autism Dev Disord. 1988;18(4):593–600. MEDLINE | CrossRef

[59]. [59] Gillberg C, Gillberg IC, Steffenburg S. Siblings and parents of children with autism: a controlled population-based study. Dev Med Child Neurol. 1992;34:389–398. MEDLINE

Promoting Social Communication in Aspergers Children and Teens

Social and communicative dysfunctions are arguably the most handicapping conditions associated with Aspergers. Although the rubric social communication is used frequently to encompass these deficits, social communication is actually a redundant term. All communication, by its definition as an exchange of information between speaker and listener, is social in nature. The purpose of using the term social communication here, however, is to focus attention on the close relationship between the linguistic forms of communication used by high functioning people with autistic spectrum disorders (ASDs), and the function of these skills in the achievement of social interaction. In fact, in typical people over the age of 3 years, linguistic communication is the primary modality of social interchange.

Although linguistic communication skills are used for a variety of purposes—regulating others' behavior, referring to objects and events, narrating and predicting experiences, and learning academic content, for example—the present paper focuses on just one of these functions: achieving mutuality and engagement with others. Effectively establishing this engagement, even with access to advanced language skills, constitutes one of the core deficits of intelligent people with ASPERGERS. Social communicative abilities are crucial to achieving the community integration and peer acceptance that would seem to be within the grasp of these bright young individuals, yet so often eludes them. The high rates of depression reported in verbal teens with Autistic spectrum disorders are generally interpreted to be a reaction to this frustrating situation 1. Young individuals with ASPERGERS are frequently eloquent in their despondency at their isolation from the social world 2.

This review of programs for addressing social communication needs in individuals with ASPERGERS, then, highlights what is known about recruiting the language competencies possessed by high functioning people in the service of promoting cooperative play, social inclusion, and friendship. It examines programs that target interactive skills at a range of developmental levels from preschool through adolescence, and with a range of theoretic perspectives from highly teacher-directed discrete trial methods to more naturalistic and child-centered approaches. An effort is made to highlight programs that have reported carefully applied research designs, well defined groups of kids, and appropriate measures of change and generalization in peer-reviewed venues, which, unfortunately, constitute a minority of the programs advocated for this population.

Although the focus of this volume is on Aspergers, the needs of kids with this disorder do not differ greatly from those of high functioning kids with other kinds of Autistic spectrum disorders. Because most research on social communication training has focused on kids with autism or pervasive developmental disorders-not otherwise specified (PDD-NOS) and few published studies have looked at ASPERGERS exclusively, studies that include high functioning, verbal kids at all points along the autistic spectrum are included. At the conclusion of the review, this information is interpreted in light of the specific characteristics of ASPERGERS, and recommendations for selecting programs most appropriate for the ASPERGERS population are made.

Early social communicative interventions—

During the preschool period, between 3 and 5 years of age, typical kids develop a range of social interaction skills that are mediated in important ways by their language development. Garvey 3 showed that kids as young as age 3 years use language to negotiate play roles and activities (“I'll be the doctor and you can be the sick person”).

According to Patterson and Westby 4, by age 3 years, kids use language for a multitude of purposes in play, including to narrate action, to plan future events in the play context, to mark dialogue with metalinguistic markers such as “he said,” and to vary voices to distinguish characters. Kids with ASPERGERS, even though they do not show significant delays in the acquisition of the forms of language, are, as a result of their core deficits, less able to demonstrate these varied uses of language in the context of cooperative play, and often show great difficulty in entering socio-dramatic play situations without support 5. For these reasons, social communication programs in the preschool period typically use play as the primary context.

Wolfberg 6 reports that, without support, verbal kids with Autistic spectrum disorders tend toward repetitive enactments of solitary routines around their obsessive interests and avoid social play or approach peers with obscure, one-sided overtures that are unlikely to be reciprocated. Schuler and Wolfberg 5 discuss the challenges in helping kids with Autistic spectrum disorders participate more successfully in social play. One of the paradoxes of this endeavor is that play—by its nature—is symbolic, exclusively child-centered, open-ended, and defined by joint attention and action. Yet these very attributes tap the most profound areas of deficit in kids with Autistic spectrum disorders. Moreover, it is known that effective interventions for kids with AUTISM SPECTRUM DISORDER are highly structured, routine, predictable, and adult-organized 7. How, then, can adult-structured interventions help youngsters to participate in the child-directed, dynamic flow of interactive play?

Schuler and Wolfberg 5 argue that the way to resolve this conflict is to provide kids with Autistic spectrum disorders with opportunities for guided participation in social play. There are two primary means of supplying this guidance: through coaching by grown-ups and through mediation provided by trained peers. Brown and Conroy 8, Lord and McGee 9, and Rogers 10 provide reviews of published literature on preschool social communication intervention. These reviews reveal that kids with Autistic spectrum disorders do show increases in social play when appropriate supports are provided. For the present review, some examples of adult-mediated approaches are presented, and then those that make use of trained peers are discussed.

Adult-mediated interventions—

Early studies in this area focused on adult-mediated interactions, using applied behavior analysis procedures. Allen and colleagues 11 showed that restructuring educators' reinforcements to socially isolated kids, by ignoring their initiations to grown-ups and reinforcing attention to peers, was enough to increase child-to-child interactions. Odom et al 12 used teacher prompting without reinforcement to increase social interactions of young kids with AUTISM SPECTRUM DISORDER. Individual coaching using teacher prompts and praise in the context of peer play was also found to increase rates of social initiation by target kids, but these bids were only responded to 50% of the time by typical peers 13. Only when peer training was added did rates of successful interaction increase. Drasgow et al 14 suggested that these procedures need to be practiced in all the environments in which generalization is to occur for the interactive behaviors to be maintained.

Goldstein et al 15 used grown-ups to teach socio-dramatic scripts to two trios of preschool kids (one target child with AUTISM SPECTRUM DISORDER and two peers with typical development) within an inclusionary preschool classroom environment. All kids were taught each of three social roles (e.g., doctor, nurse, patient) using teacher instruction that was systematically reduced over time. Results revealed that interaction and generalization improved during free play periods at preschool, but effects depended on the continuation of teacher prompts and did not lead to increases in other social exchanges during the rest of the class day.

Less operant approaches to promoting social interaction also have been used. Wolfberg and Schuler 16 provided an overview of an integrated play-group model that uses a social constructivist framework (i.e., one that relies on the notion of play as an artifact of the “culture of childhood”). This framework requires ethnographic observations of play to avoid developing interventions that interfere with its organic structure. Thus, strategies include monitoring play initiations to discover their form in the particular “cultural group” of the target child's classroom, scaffolding interactions by acting as an interpreter for the target child and providing appropriate cues to interaction, guiding social communication by fostering invitations to play, enlisting reluctant peers, helping target kids respond to peers' cues, maintaining and expanding interactions with narrative language, and guiding play by incorporating the target child's unusual behaviors (e.g., lining up objects) into a meaningful play context (e.g., acting as clerk who neatens up shelves in a play store). Wolfberg and Schuler 16 present preliminary results of a case study that argue for the effectiveness of this approach.

Another naturalistic approach to social communicative intervention is referred to under the rubric of “friendship” activities 8. These approaches typically rely on educators' prompting kids to compliment and show affection for each other within the naturally occurring routines of the preschool day (unlike the more operant approaches that use more structured training in out-of-class environments). McEnvoy et al 17 have applied these techniques to preschool kids with Autistic spectrum disorders with some positive results.

Other approaches make use of “hybrid” methods, those that combine elements of operant techniques with more naturalistic methods. One hybrid approach that has been used to increase socialization in preschoolers with Autistic spectrum disorders is incidental teaching. This method involves arranging the environment so that objects and activities known to interest the youngster are in sight but out of reach, following the youngster's attentional lead to choose the focus of interactions, and using expectant waiting rather than prompts to elicit communication from the youngster, so that the youngster is the initiator. Incidental teaching approaches have been shown to promote language use and to enhance social initiations and responses in kids with autism 18, and results have been maintained over time 19.

Krantz and McClannahan 20 used script-fading procedures with preschoolers with minimal reading skills. The kids were taught to use the written cues “Look” and “Watch me” to initiate conversation with grown-ups who did not prompt but only responded to conversation directed to them. The scripts were faded by cutting away portions of the cue cards. Unscripted interactions were found to continue and generalize to new topics.

Quill 21 has presented a comprehensive curriculum for developing social and communicative skills in young kids with autism at various levels of functioning. The curriculum advocates highly structured and naturalistic approaches and suggests focusing on the target child's responsiveness to typical peers, rather than promoting initiations. Intervention guidelines include organization of the environment to facilitate participation and cooperation, careful selection of materials, and activities structured to foster the target child's participation. Activities early in this sequence include:

• A limited set of materials
• Activities that require no sharing, turn-taking, or waiting (e.g., parallel play)
• Closed-ended activities, such as putting features on a Mr. Potato Head
• Separate materials for each player

The target child is given coaching and practice in observing, responding to, and imitating the typical play partner to progress to activities that are more open-ended, use a wider variety of materials, and involve more interactive play. Coaching of typical peers to use strategies such as nonverbal cues to gain the target child's attention, to wait for a response, and to interpret unusual responses is also a part of this curriculum. Numerous examples of ways to embed these principles in typical preschool classroom activities are provided. As a synthetic, comprehensive curriculum, this program draws on methods devised in many of the earlier studies reported, but it does not provide any independent empiric validation of its efficacy.

Similarly, empiric studies that contrast hybrid approaches with naturalistic friendship techniques or more structured approaches like Goldstein et al 15 have not been reported. Moreover, most of the studies cited earlier involved single subject or very small group designs and used general outcome measures, such as social initiations, without looking more specifically at the use of particular communication strategies (e.g., pointing, signing, talking). Thus, we have much to learn before we can identify the most efficient teacher-directed approaches for promoting verbal means of social interaction in young kids with ASPERGERS.

Peer-mediated interventions—

The drawbacks of adult-mediated play interventions seem to be that target kids become dependent on adult input to continue interacting. Although some systematic fading procedures have attempted to address this problem 12, highly trained grown-ups are needed to implement them appropriately, and educators often express reluctance to engage in them 22. Brown and Conroy 8 point out that teacher interventions may even serve to interrupt direct child-to-child interactions.

For these reasons, recent approaches to enhancing social interactions in this population have turned to peers as primary agents of intervention. Initially, it was hoped that merely placing kids with disabilities in classrooms with typical peers would enhance social communication. Although modest improvements were observed in some studies 23, others failed to find any effects at all 24, 25. Further, these studies focused on kids with a range of developmental disabilities and did not focus on the specific difficulties in socialization presented by kids with Autistic spectrum disorders.

The work of Strain and colleagues represents the most sustained effort to develop successful peer-mediated socialization strategies and provides the strongest empiric support 26, 27, 28. In their approach, typical peers are taught to present and persevere in presenting “play organizers” to classmates with Autistic spectrum disorders. Organizers consist of sharing, helping, giving affection, and praising. Peers are taught these skills in role-playing activities with grown-ups and then are cued and reinforced by the grown-ups in play sessions with target kids. Reinforcements are carefully faded. Work by this group 27, 29 and in replication studies 30, 31 has demonstrated generalization and maintenance. Strain et al 32 also have shown that self-monitoring techniques can be used so that interactions are successfully maintained without adult reinforcement. The importance of delivering interventions within inclusive preschools rather than in laboratory settings for achieving generalization and maintenance also has been emphasized.

In a case study involving a high functioning youngster with AUTISM SPECTRUM DISORDER, Oke and Shreibman 33 extended this method by adding two components: they trained a typical peer to differentiate between parallel and interactive play, and trained the target child to initiate interaction with the peer. They found that these additions led to maintaining high rates of interaction, decreased inappropriate behaviors, and generalization across peers (but not across settings).

Despite the evidence supporting their success, these programs are difficult and labor-intensive to implement, requiring highly trained peers and precise adult control of the peer training. Although training manuals 34 and extensive discussions of the method in the research literature are available, educators outside of comprehensive university- or hospital-based settings object to implementing them 35. Moreover, Strain and Hoyson 36 have argued that a comprehensive inclusionary program implemented over a sustained period of time during the preschool period is necessary to achieve the levels of success reported in the literature, so that even if carefully implemented peer social communicative programs are instituted, they may not achieve maximum effectiveness without the other features offered by comprehensive programs.

As a consequence of these difficulties and limitations, some approaches have attempted to devise simpler forms of peer-mediated intervention. Goldstein and colleagues 37 have extended their script-based methods to include peer-mediation, for example. Their Buddy Skills Training Program teaches three simple strategies to peer “buddies:”

• PLAY with your buddy: maintain proximity while continuing to play with your partner (in programs specifically adapted for kids with Autistic spectrum disorders , partners are offered a choice of one activity each from a visual “choice board,” then are instructed to play with each partner's choice for half the “buddy period” session, usually 10–20 minutes)
• STAY with your buddy: maintain physical proximity to assigned partner
• TALK with your buddy: say your partner's name to establish joint attention, make suggestions for playing together, talk about the play, respond to what your partner says by repeating, saying more about it, or asking a question.

Research on this program demonstrated improvements in the frequency of social communication between buddies that persisted outside the specific “buddy time” sessions 38. English et al 38 noted that training the target kids in buddy skills did not increase social interactions any further, suggesting that training typical peers is adequate to achieve the observed increases in reciprocity. This program was not developed specifically for kids with Autistic spectrum disorders, but recent extensions with specific modifications for kids with Autistic spectrum disorders, such as visual choice boards, have shown promise.

Another attempt at a simplified program is presented by Garfinkle and Schwartz 39. Three kids with AUTISM SPECTRUM DISORDER were taught to imitate peers during small group activities in an inclusionary preschool classroom. Results suggest that participants increased peer imitation behaviors in the training setting, and also generalized them to free play settings. Increases in other social behaviors, such as proximity to peers and number of peer interactions, also were reported to increase.

There have been few studies that compare different procedures for enhancing social interaction at this developmental level. One study that compared structured play, adult instruction, peer instruction, and a combination of approaches found that peer-mediated methods resulted in largest effects and the greatest generalization and maintenance 27. Kids with autism, however, were not part of the subject group. Careful comparison studies among social communication training methods for kids with Autistic spectrum disorders are clearly needed.

Social communicative interventions for school-aged kids—

During the school age period, typically developing kids expand the purposes for which they use language. Much talk during the preschool period concerns the here-and-now, immediate, tangible environment. Language reflects what the youngster already knows about the world around. During school age, however, kids begin using language to acquire new information about objects and events with which they have no direct sensory experience 40. For example, individuals talk to preschool kids about where their shoes are. They talk to school-aged kids about where the Andes are. Talk between peers changes during the elementary school years also. One prominent change is a move away from socio-dramatic play as the primary context for social interaction to more topic-centered forms of interaction, such as discussing shared interests and playing games with rules. These changes result in necessary shifts in the contexts in which social skills training takes place.

School age is the time when higher functioning people with Autistic spectrum disorders begin to be aware of loneliness and isolation. Bauminger and Kasari 41 reported that 22 kids with autism (ages 7–14 years) reported significantly higher levels of loneliness and poorer quality of friendship than a matched group of typical peers in an interview study. Thus, kids with AS are likely to begin to experience social isolation in the elementary school years, and social communicative training should be an important part of their intervention programs. Like programs for younger kids with Autistic spectrum disorders, programs for school-aged kids fall at various points along the continuum of naturalness and make use of adult- and peer-mediated strategies.

Adult-mediated interventions—

Coe et al 42 used direct instruction and primary reinforcers to teach two kids with autism four steps (pick up, throw, initiate, praise) in a chain of actions involved in playing ball. The kids were found to increase their interactive behaviors in ball play, although generalization and maintenance were not reported.

Hwang and Hughes 43 reviewed 16 studies aimed at increasing social communication skills in kids with Autistic spectrum disorders. They examined five studies that used time delay (presenting a stimulus and waiting for specified periods before giving the youngster a prompt to respond) as the primary form of intervention for verbal kids with Autistic spectrum disorders. These studies resulted in increases in verbal responses during free play, but had little effect on eye contact. When time delay was combined with other strategies, such as teaching social amenities (please and thank you) and naturally occurring reinforcement, results were similar. Results of probes for generalization and maintenance were mixed, however, reinforcing that consistent carry-over is difficult to achieve with highly structured, adult-directed methods.

More child-centered methods for kids at this level also have been presented. Harris et al 44 and Tiegerman and Primavera 45 used contingent imitation, having the adult imitate the youngster's actions. Tiegerman and Primavera 45 reported that imitating the youngster's play behaviors led to increases in the frequency and duration of gaze toward the adult. Harris et al 44 had grown-ups imitate the youngster's self-stimulatory behaviors to increase positive affect and attention to others. Findings indicated positive changes, but generalization and maintenance were not examined. Gutstein and Sheely 46 produced a collection of exercises based on Greenspan and Wieder's 47 Relationship Development Intervention. Empiric data about effectiveness, generalization, and maintenance, however, are not available.

Another child-centered method that has attracted a good deal of interest in recent years is the use of social stories 48. The stories are written collaboratively between the youngster and the facilitator. They are usually focused on reducing maladaptive behaviors, rather than on social interaction, using a specified format. They state a problem (“Waiting in line is hard”), give a reason for the socially accepted action (“The teacher needs to make sure everyone gets outside safely without pushing”), give the youngster an acceptable action to perform (“I can wait in line. I can think about how much fun it will be to play outside while I am waiting”), and an evaluation (“My teacher will be happy when I wait quietly in line. I will feel good when I get outside”). An initial study used a multiple baseline approach to monitor changes in three social behaviors targeted in social stories for one girl with autism, and found changes in only one of the three 49.

More recent studies, however, have added some features to the intervention that seem to facilitate its efficacy. Hagiwara and Myles 50 used a computer-based format for social stories with three school-aged boys with AUTISM SPECTRUM DISORDER. Using a multiple baseline design, the study showed the intervention increased skill levels of some of the participants in certain settings, with some generalization to new settings. Cullain 51 used social stories to reduce anxiety and inappropriate behaviors in five elementary school kids with autism who were placed in inclusive classrooms. Using a treatment-withdrawal-treatment design, the study suggested a decrease in frequency of inappropriate behaviors and anxiety levels. Social stories, then, seem to be somewhat effective in reducing problem behaviors, but limited evidence of generalization or maintenance is available.

In another child-centered approach, Baker, Koegel, and Koegel 52 created group games for three high functioning kids with AUTISM SPECTRUM DISORDER based on each youngster's special interest, then taught the game to the target child and peers for use during a free period at school. Results suggested strong increases in peer interaction that were maintained through the follow up period and generalized to other activities. Increases in positive affect in target kids also were seen.

Hybrid methods of adult-mediated social communication programs provide high levels of structure and models while allowing the youngster to initiate social interactions. Two hybrid approaches reviewed by Hwang and Hughes 43 are naturally occurring reinforcement and environmental arrangement. These two approaches were combined in studies by McGee et al 53 and Pierce and Shreibman 54. Both trained peers through modeling, role playing, and direct instruction to use natural reinforcement and to arrange environmental events to elicit communication from verbal kids with autism. Both studies reported prolonged social interactions with peers. Pierce and Shreibman 54 also reported some generalization across persons and settings.

Another hybrid method that has been used in peer-mediated social skills programs is Pivotal Response Training (PRT). This approach involves choosing behaviors as targets that will have widespread, positive effects on a range of behaviors. In this way, PRT is believed to produce generalized improvements in areas that do not receive direct intervention. Pivotal areas that have been identified include responding to multiple cues and increasing motivation, self-initiation, and self-management 55. Most germane to social communication are programs that have aimed at self-initiation. Koegel et al 56 used asking questions as a pivotal behavior, and taught kids with autism to spontaneously initiate questions by putting objects in an opaque bag and, using prompt-fading procedures, training them to ask “What's that?” to be able to play with the object.

Results indicated that, after completion of training, subjects used the question to obtain labels for objects whose names they did not know, that responses were generalized to the home setting, and that expressive vocabulary size increased as a result of their requests for names of new objects. In another study using this method, Thorp et al 57 reported increases in appropriate language, social engagement and decreases in inappropriate behavior using this method, but less effect on social initiations. Generalization and maintenance were not assessed.

Jahr et al 58 investigated the way in which language can be used to support social skills learning. Six high functioning school-aged children with autism were taught cooperative play skills using two methods. The first involved observing two models enact a play scene, then having the target student take one of the roles in repeating the scene. The second method was the same, except that the student with autism was required to give a verbal description of the scene before reenacting it. Results showed that children failed to acquire cooperative play until the verbal description was included in the training. With verbal descriptions, the subjects were able to take longer turns within episodes than during pre-training, and skills generalized across play partners, setting, and time. This study demonstrates that for verbal children with autism, language can serve as an important support to skill acquisition.

Krantz and McClannahan 59 used printed cues within classroom routines to stimulate social initiations in four verbal children with autism. Peer initiations increased significantly, and all four subjects used novel language to initiate interaction. Effects were maintained when cues were faded, and generalized to new peers.

Another approach that has shown promise is the use of video modeling. Charlop and Milstein 60 successfully used this method to teach conversational skills to three high functioning boys with autism. The boys were shown a videotape containing simple, appropriate conversations, and then they practiced the same conversations with an adult. In a later study, Charlop et al 61 showed that video modeling resulted in faster acquisition of skills, such as spontaneous labeling of objects and greetings, than did modeling from live demonstrations, and was effective in promoting generalization. Corbett and Larson 62 also have used video modeling to teach social communicative skills.

Peer-mediated interventions—

One of the earliest investigations involving peer training for school-aged kids was done by Strain et al 63. Typical peers were taught to elicit, prompt, and reinforce social behavior in two pairs of kids with autism. Social behaviors were found to increase during treatment, but fell when interventions were withdrawn. Later studies have shown the importance of using natural contexts in achieving generalization. Shafer et al 64 used direct models and prompt training to teach peers to elicit interactive play with four kids with autism. Increases in responses and initiations in kids with autism were seen, were maintained over time, and were generalized to new peers when these joined the play groups. Lord 65 reviewed research by her group showing that daily exposure in peer play with trained peers increased several social behaviors in kids with autism, including proximity, appropriateness, and time spent looking at peers, although it did not increase initiations. These results also generalized to new trained peers. Findings were replicated with high functioning kids with autism.

Pierce and Shreibman 66 trained eight peers to deliver privotal response training (PRT) to two kids with autism. Multiple baseline results showed that each target student made gains in maintaining social interactions and generalized across individuals, settings, and materials. Follow up data demonstrated maintenance of skills over a 2-month period. Gains in initiations were not documented, however.

The difficulties of implementing these kinds of peer-mediated approaches are similar to those seen at the preschool level. They are labor-intensive and require constant monitoring and readjustment. Again, researchers have attempted to use simpler methods for achieving increased peer interaction. One method is the Social Skills Group. Kamps et al 67 conducted daily play sessions in groups of one target and three typical children. Scripted social skills instruction, including greeting, sharing, taking turns, and helping, was provided to the group for 10 minutes, followed by 10 minutes of play in a planned activity. Increases in social skills, length of interactions, and consistency of responding were found for target children. Follow up evaluation at the end of the school year showed that some skills were maintained over time.

Roeyers 68 presented another simplified approach. Kids with AUTISM SPECTRUM DISORDER aged 5–13 years were paired with peers who were simply told to stay “on the same level” as their partner. Although improvements in rate of interaction were seen, kids with autism still had difficulty managing social situations. Gunter et al 69 taught elementary school children to “prompt and praise” two children with autism while engaging in free play dyads. Prompts involved simple statements such as “Say hello to ----.” Peers also were taught to offer verbal praise to the target student when a prompt elicited the desired reply. A “multiple exemplar approach” in which several peers took turns with each student proved effective in increasing initiations by children with autism. Some generalization to untrained peers and environments was seen.

Peer networks are another strategy that has been used to increase social acceptance and involvement of kids with disabilities. Peer networks involve awareness training about disabilities for typical peers and supervised joint activities in which typical peers are taught to initiate and model appropriate social interactions. Kamps et al 70 applied this method to three children with autism. Two to five peers served as a support network for each target student during several 10–20-minute sessions during the school day, including reading, lunch, and game time. They were taught to structure activities using scripts, prompting, and reinforcement for interaction. Results showed increased interaction time for all target children and generalization to new settings for two of the three.

Other versions of the peer network approach include Special Friends and Circle of Friends 71, 72. These programs provide information about disabilities to children and educators, specific information about the target student (e.g., likes and dislikes, communication abilities), and ideas for support that peers can provide. Few data are available to support the efficacy of these programs, and there have been few instances in which they have been applied to children with autism. Whitaker et al 73 provide an initial report of the use of a Circle of Friends approach with six kids with AUTISM SPECTRUM DISORDER.

Social communicative training at the elementary school level strengthens the suggestions seen in research on preschoolers, as shown below.

• Although direct, teacher-directed instruction is effective in improving interaction skills, less direct, more child-centered and hybrid methods also can be successful.
• Although children with autism can be taught to respond to social interactions, training them to initiate socially seems to be more difficult.
• In adult-mediated approaches, direct instruction is the most effective method for initial skill acquisition.
• Peers are powerful mediators and greatly enhance the ability of children with AUTISM SPECTRUM DISORDER to participate in social interactions in natural environments. Peers who mediate these interactions, however, require direct instruction, repeated models, and practice.
• Using multiple peers who meet the above standards seems to be particularly powerful.

Social communicative interventions in adolescence—

In adolescence, typical young individuals begin to engage in social interaction primarily by “just talking.” Unlike younger kids whose social interactions are mediated by activities such as games, teenagers use language as the primary channel for interaction, as their long hours on the telephone, and now on Instant Messaging, attest. Although children with ASPERGERS may have the requisite language skills to engage in these kinds of interactions, they, like their younger counterparts, have severe difficulty in using the skills they have to engage in social interactions 74. As we saw with younger kids with AUTISM SPECTRUM DISORDER, intelligent people with these disorders frequently experience a haunting sense of aloneness that they feel powerless to overcome. Despite their command of language, they seem unable to marshal it to enter successfully into the social fray of adolescence.

These limitations not only affect their ability to form friendships, but also limit their vocational opportunities, often confining these very intelligent young individuals to menial jobs that make no use of their considerable talents because of their inability to function in interviews or to get along with coworkers 75. Intervention to address this social isolation remains crucial at this stage of development. In fact, for children with ASPERGERS, social communicative training may be the most important feature of intervention at the secondary school level.

Adult-mediated interventions—

Kyparissos 76 developed a strategy for teaching teens with AUTISM SPECTRUM DISORDER to engage in extended conversations with each other. Children were taught to extend conversations by asking a question about what the previous speaker had said. Training began with scripts that provided participants opportunities to ask questions. Scripts were gradually faded. Training scripts included what, where, and when questions; generalization was assessed on who, why, and how. Generalization was seen to untrained conversations, and participants were rated as improved in conversation skills by blind raters after the intervention was completed.

Self-management strategies are believed to be especially important for maintaining social behaviors, because real social situations provide infrequent, weak reinforcements. Koegel and Frea 77 reported improving conversation skills in two high functioning teenagers with autism by using reinforcement to teach social skills such as maintaining eye contact and appropriate topics. The children rapidly learned these behaviors, then they used wrist counters to tally their own frequency of appropriate behaviors, which was converted to points and exchanged for reinforcement. The reinforcement schedule was gradually thinned. Conversational behaviors were maintained for 30-minute intervals between token reinforcers, with generalization of skills to new situations. Improvement was seen in related, but not in entirely new conversation skills.

Peer-mediated strategies—

Morrison et al 78 combined peer mediation and self-monitoring in a study of four young teenagers with autism. The children were taught, together with a group of typical peers, to use and monitor social skills, including requesting, commenting, and sharing, during game play. Peer monitoring and self-monitoring were alternated. The investigators reported that both techniques increased initiations and social interaction time, with little difference between the two strategies. Generalization and maintenance were not reported.

Social skills groups also have been used at the adolescent level, as they have for elementary children. Ozonoff and Miller 79 used social skills groups to teach teens with autism about understanding others' mental states (Theory of Mind, ToM). Five teenagers with autism met weekly for 14 weeks. A structured curriculum on ToM was presented. Children improved in understanding others' mental states; however, generalized gains to other social skills failed to appear.

Haring and Breen 80 used Circle of Friends to create a social network for a junior high school student with autism. Typical peers volunteered to meet weekly for 30 minutes to plan social interactions with the target student. Peers were taught to initiate, prompt, and praise the student between class sessions. The intervention resulted in an increased frequency of social interactions with peers that were maintained over 2 months.

Social communicative interventions for teens are an essential, perhaps the most important, aspect of an intervention program. The small amount of research done on this age group suggests that, again, direct instruction in the skills to be learned is necessary. Teaching social skills, such as ToM, does not necessarily lead to improvement in general social interaction. All the programs developed for children at this level involve some form of peer-mediation. This approach stems from the great need to help children at this age develop direct peer interaction skills, and derives from a fact that seems clear from the bulk of this review: peer-mediated interactions are an extremely powerful intervention for improving social communication.

Implications for enhancing social communication for kids and teens with ASPERGERS—

This article attempts to review studies that have investigated a variety of social communication skills curricula that included kids with AUTISM SPECTRUM DISORDER. None of these studies, however, focused specifically on kids with ASPERGERS. What can be gleaned from this review that can inform the practice of clinicians faced with helping these youngsters to engage in social interaction?

First, social communication skills are arguably the skills most in need of attention and intervention in kids with AS, from the earliest point at which diagnosis is established and continuing throughout life. This implies that social communication skills should be a primary area within the Individualized Educational Plan of all children identified with ASPERGERS.

Second, the data reviewed suggests that for kids with Autistic spectrum disorders, social communication skills require direct, focused instruction on the actual target behaviors. Teaching ToM for example, improves ToM performance, but does not necessarily improve social interaction. Each skill the youngster needs to learn should be the focus of intensive instruction.

Third, the context for social communication training needs to be developmentally appropriate. At the preschool level, pretend, dramatic, and toy play are the best contexts in which to foster social interaction. Supportive visual information in the form of simple word cards and picture schedules can be helpful, for example, as can verbal rehearsal before entering play interactions. At the elementary grade level, games with rules, “lunch buddies,” and social skills groups focused around crafts or themes of interest are good venues. Visual support in the form of written schedules and calendars and verbal rehearsal continue to be useful. For teenagers, discussion groups of peers with ASPERGERS can be helpful for giving youngsters the opportunity to share feelings about their disability, much as other teens form social bonds through “just talking.” Social networks comprised of children with ASPERGERS and trained typical peers can help the target student negotiate the difficult transition times during the school day.

Fourth, in addition to intensive, focused instruction in the initial learning phase, kids with Autistic spectrum disorders require abundant opportunities to practice newly learned skills in varied, naturalistic contexts to achieve generalization and maintenance. Because most kids with ASPERGERS are placed in mainstream or inclusive educational settings, these opportunities should be fairly easy to engineer, and natural opportunities for interaction will arise out of their day-to-day experiences. Letting the youngster “sink or swim” in the natural environment, however, is not sufficient. To increase the chances for enduring improvements, the aid of peers must be enlisted.

Fifth, peers can aid target kids best when they receive training in techniques to facilitate inclusion and interaction with friends with Autistic spectrum disorders. Peer training can take a variety of forms. In programs with highly trained and motivated staff, intensive peer training programs have demonstrated efficacy. Even in programs with less ideal conditions, however, simpler forms of peer training are available and can be powerful in enhancing social interactions. These simpler programs seem to work best when several peers are trained and “trade off” so that each target child has repeated opportunities to interact with multiple trained peers.

Klin and Volkmar 75 have presented intervention guidelines for children with ASPERGERS in which they emphasize the need to teach social communication skills. They highlight the following elements for inclusion in social skills training programs designed for this population:

• Improving prosody. Children with ASPERGERS often show abnormal prosodic behavior 81. Again, this aspect of social communication has not yet been a focus of research, but prosodic behavior is known to affect social and vocational acceptance 82. Increasing awareness of appropriate prosodic patterns, modeling, and practice of prosodic changes can be an important aspect of intervention.
• Self-monitoring. It is essential to help children with ASPERGERS keep track of their own behavior and make on-line judgments about its appropriateness. Self-monitoring, too, requires direct instruction, and ongoing practice.
• Social perception training. In addition to training children with ASPERGERS to engage in social interactions, as the studies reviewed here have done, Klin and Volkmar suggest the need to help these children learn to “read” social cues given by others, as a way to facilitate appropriate interactions. ToM training could be one part of this aspect of social skills intervention.
• Training in conventional pragmatic and conversational rules. Again, studies to date have not addressed this issue, but direct instruction in increasing awareness of pragmatic and conversational conventions, and practicing appropriate conversations using scripts, visual supports, video modeling, and role playing various scenarios would seem to be logical avenues of intervention.
• Use of visual supports, including written and pictorial representations of expected activities and behaviors.

For children with ASPERGERS, several of the programs reviewed here would seem to be particularly germane. Schuler and Wolfberg's 5 guided participation model, using coaching by grown-ups and mediation by trained peers, provides an appropriate form of intervention for preschoolers with ASPERGERS who have the verbal skills to readily take advantage of these interventions. Incidental teaching methods aimed at increasing the quantity of verbal initiations also would seem to be useful at this stage of development. Krantz and McClannahan's 20 script-fading procedures also are promising in that they capitalize on the frequently advanced reading skills in this population and put print to a meaningful purpose. Research on using simpler peer mediating techniques with kids with autism is emerging that suggests techniques such as “Stay, Play, Talk” will be powerful 83.

For school-aged kids and teens with ASPERGERS, the data suggest hybrid techniques may be most effective, especially when aimed at pivotal verbal behaviors such as asking questions. Support of printed materials, such as visual schedules and calendars, and verbal rehearsal, are especially appropriate for highly verbal kids with ASPERGERS. Video modeling looks especially promising, and a combination of this approach with verbal rehearsal may be particularly useful in the ASPERGERS population. Peer-mediated approaches continue to be important. Simple programs that can be adapted for public schools and other community venues, such as Social Skills groups and peer networks, seem valuable.

Awareness programs such as Special Friends or Circle of Friends, however, seem inadequate in themselves, without providing more specific training for peers as to how to actively facilitate social interactions with children with ASPERGERS. This training, in the case of children with ASPERGERS, should focus on verbal scripts, written then faded, that address a range of specific pragmatic situations (e.g., making a date, inviting a friend to play a game, asking for help). Individual, more traditional speech therapy to address prosodic difficulties and to establish self-monitoring routines also should be considered.

Some of the best known social skills programs, such as Social Stories and Do-Watch-Listen-Say, have the least empiric support, whereas the best scientific evidence available supports the efficacy of many older but lesser known curricula, such as Play Organizers or Buddy Skills Training. This fact should alert us to the importance of “waiting until the facts are in” before adopting a highly touted new program. There are a good number of approaches to social skills training that have proven their effectiveness and that merit wider adoption in the educational programs of kids with ASPERGERS and other Autistic spectrum disorders.

Teaching Social Skills and Emotion Management


References:


[1]. [1] Mesibov G, Handlan S. Adolescents and adults with autism. In: Cohen D, Volkmar F editor. Handbook of autism and pervasive developmental disorders. NY: Wiley & Sons; 1997;p. 309–322.
[2]. [2] Klin A, Volkmar FR. Treatment and intervention guidelines. In: Klin A, Volkmar FR, Sparrow SS editor. Asperger syndrome. NY: Guilford; 2000;p. 340–366.
[3]. [3] Garvey C. Requests and responses in children's speech. J Child Lang. 1975;2:41–63.
[4]. [4] Patterson JL, Westby CE. The development of play. In: Haynes WO, Shulman BB editor. Communication development: foundations, processes and clinical applications. Englewood Cliffs (NJ): Prentice-Hall; 1994;p. 135–162.
[5]. [5] Schuler AL, Wolfberg PJ. Promoting peer play and socialization. In: Wetherby AM, Prizant BM editor. Autism spectrum disorders: a developmental perspective. Baltimore: Paul H. Brookesm; 2002;p. 251–278.
[6]. [6] Wolfberg PJ. Play and imagination in children with autism. NY: Teachers College Press; 1999;.
[7]. [7] Dawson G, Osterling J. Early intervention in autism. In: Guralnick MJ editors. The effectiveness of early intervention. Baltimore: Paul H. Brookes; 1997;p. 307–326.
[8]. [8] Brown WH, Conroy MA. Promoting peer-related social-communicative competence in preschool children. In: Goldstein H, Kaczmarek LA, English KM editor. Promoting social communication. Baltimore: Paul H. Brookes; 2002;p. 173–210.
[9]. [9] Lord C, McGee JP. Social development. In: Lord C, McGee JP editor. Educating children with autism. Washington (DC): National Academy of Sciences; 2001;p. 66–81.
[10]. [10] Rogers SJ. Interventions that facilitate socialization in children with autism. J Autism Dev Disord. 2000;30(5):399–409. MEDLINE | CrossRef
[11]. [11] Allen KE, Hart B, Buell JS, Harris FR, Wolf MM. Effects of social reinforcement on isolate behavior of a nursery school child. Child Dev. 1964;35:511–518. MEDLINE | CrossRef
[12]. [12] Odom SL, Chandler LK, Ostrosky M, McConnell SR, Reaney S. Fading teacher prompts from peer-initiation interventions for young children with disabilities. J Appl Behav Anal. 1992;25:307–317. MEDLINE | CrossRef
[13]. [13] McConnell SR, Sisson LA, Cort CA, Strain PS. Effects of social skills training and contingency management on reciprocal interaction of preschool children with behavioral handicaps. J Spec Ed. 1991;24:473–495.
[14]. [14] Drasgow E, Halle JW, Ostrosky MM, Habers HM. Using behavioral indication and functional communication training to establish an initial sign repertoire with a young child with severe disabilities. Topics in Early Childhood Special Education. 1996;16:500–521.
[15]. [15] Goldstein H, Wickstrom S, Hoyson M, Jamieson B, Odom S. Effects of sociodramatic play training on social and communicative interaction. Education and Treatment of Children. 1988;11:97–117.
[16]. [16] Wolfberg PJ, Schuler AL. Fostering peer interaction, imaginative play and spontaneous language in children with autism. Child Language Teaching and Therapy. 1999;15(1):41–52.
[17]. [17] McEvoy MA, Nordquist VM, Twardosz S, Heckaman K, Wehby JG, Denny RK. Promoting autistic children's peer interaction in an integrated early childhood setting using affection activities. J Appl Behav Anal. 1988;21:193–200. MEDLINE | CrossRef
[18]. [18] Krantz PJ. Interventions to facilitate socialization [commentary]. J Autism Dev Disord. 2000;30(5):411–414. MEDLINE | CrossRef
[19]. [19] McGee GG, Krantz PJ, McClannahan LE. The facilitative effects of incidental teaching on prepositional use by autistic children. J Appl Behav Anal. 1999;18:17–31. MEDLINE | CrossRef
[20]. [20] Krantz PJ, McClannahan LE. Social interaction skills for children with autism: a script-fading procedure for beginning readers. J Appl Behav Anal. 1998;31:191–202. MEDLINE | CrossRef
[21]. [21] Quill KA. Do-Watch-Listen-Say: social and communication intervention for children with autism. Baltimore: Paul H. Brookes; 2000;.
[22]. [22] McConnell SR, McEvoy MA, Odom SL. Implementation of social competence interventions in early childhood special education classes: current practices and future directions. In: Odom SL, McConnell SR, McEvoy MA editor. Social competence of young children with disabilities: issues and strategies for intervention. Baltimore: Paul H. Brookes; 1992;p. 277–306.
[23]. [23] Strain PS. Generalization of autistic children's social behavior change: effects of developmentally integrated and segregated settings. Anal Intervention Developmental Disabilities. 1983;3:23–34.
[24]. [24] McEvoy M.A., McConnell S.R., Odom S.L., Skellenger A. Analysis of an environmental arrangements intervention for young children with disabilities. Unpublished paper from the Vanderbilt-Minnesota Social Interaction Project, Vanderbilt University, John F. Kennedy Center, Nashville (TN); 1991.
[25]. [25] Odom SL, Brown WH. Social interaction skills interventions for young children with disabilities in integrated settings. In: Peck CA, Odom SL, Bricker D editor. Integrating young children with disabilities into community programs: ecological perspectives on research and implementation. Baltimore: Paul H. Brooks; 1993;p. 39–64.
[26]. [26] Odom SL, Strain PS. A comparison of peer initiation and teacher antecedent interventions for promoting reciprocal social interaction of autistic preschoolers. J Appl Behav Anal. 1986;19:59–72. MEDLINE | CrossRef
[27]. [27] Odom SL, McConnell SR, McEvoy MA, Peterson C, Ostrosky M, Chandler LK, et al. Relative effects of interventions for supporting the social competence of young children with disabilities. Topics in Early Childhood Special Education. 1999;19:75–92.
[28]. [28] Strain PS, Shores RE, Timm MA. Effects of peer social initiations on the behavior of withdrawn preschool children. J Appl Behav Anal. 1977;10:289–298. CrossRef
[29]. [29] Hoyson M, Jamieson B, Strain PS. Individualized group instruction of normally developing and autistic-like children: the LEAP curriculum model. J Div Early Childhood. 1984;27:157–172.
[30]. [30] Brady MP, Shores RE, McEvoy MA, Ellis D, Fox JJ. Increasing social interactions of severely handicapped autistic children. J Autism Dev Disord. 1987;17:375–390. MEDLINE | CrossRef
[31]. [31] Sainato DM, Goldstein H, Strain PS. Effects of self-evaluation on preschool children's use of social interaction strategies with their classmates with autism. J Appl Behav Anal. 1992;25:127–142. MEDLINE | CrossRef
[32]. [32] Strain PS, Kohler FW, Storey K, Danko CD. Teaching preschoolers with autism to self-monitor their social interactions: an analysis of results in home and school settings. J Emotional Behav Disord. 1994;2(2):78–88.
[33]. [33] Oke NJ, Shreibman L. Training social initiations to a high-functioning autistic child: assessment of a collateral behavior change and generalization in a case study. J Autism Dev Disord. 1990;20(4):479–497. MEDLINE | CrossRef
[34]. [34] Danko C.D., Lawry J., Strain P.S. Social skills intervention manual packet. 1998. Unpublished manuscript.
[35]. [35] Odom SL, McConnell SR, Chandler LK. Acceptability and feasibility of classroom-based social interaction interventions for young children with disabilities. Except Child. 1994;60:226–236.
[36]. [36] Strain PS, Hoyson M. The need for longitudinal, intensive social skills intervention: LEAP follow-up outcomes for children with autism. Topics in Early Childhood Special Education. 2000;20(2):116–122.
[37]. [37] Goldstein H, Wickstrom S. Peer intervention effects on communicative interaction among handicapped and nonhandicapped preschoolers. J Appl Behav Anal. 1986;19:209–214. MEDLINE | CrossRef
[38]. [38] English K, Goldstein H, Shafer K, Kaczmarek L. Promoting interactions among preschoolers with and without disabilities: effects of a buddy system skills training program. Except Child. 1997;63:229–243.
[39]. [39] Garfinkle A, Schwartz IS. Peer imitation: increasing social interactions in children with autism and other developmental disabilities in inclusive preschool classrooms. Topics in Early Childhood Special Education. 2002;22(1):26–38.
[40]. [40] Owens RE. Language Development. 4th edition. Boston: Allyn & Bacon; 1996;.
[41]. [41] Bauminger N, Kasari C. Loneliness and friendship in high-functioning children with autism. Child Dev. 2000;71(2):447–456. MEDLINE
[42]. [42] Coe D, Matson J, Fee V, Manikam R, Linarello C. Training nonverbal and verbal play skills to mentally retarded and autistic children. J Autism Dev Disord. 1990;20:177–187. MEDLINE | CrossRef
[43]. [43] Hwang B, Hughes C. The effects of social interactive training on early social communicative skills of children with autism. J Autism Dev Disord. 2000;30(4):331–343. MEDLINE | CrossRef
[44]. [44] Harris SL, Handleman JS, Fong PL. Imitation of self-stimulation: impact on the autistic child's behavior and affect. Child Fam Behav Ther. 1987;9:1–21.
[45]. [45] Tiegerman E, Primavera LH. Imitating the autistic child: facilitating communicative gaze behavior. J Autism Dev Disord. 1984;14:27–38. MEDLINE
[46]. [46] Gutstein SE, Sheely RK. Relationship development intervention with young children: social and emotional development activities for Asperger Syndrome, autism, PDD and NLD. London: J Kingsley Publishers; 1999;.
[47]. [47] Greenspan S, Weider S. A developmental approach to difficulties in relating and communicating in autism spectrum disorders and related syndromes. In: Wetherby AM, Prizant BM editor. Autism spectrum disorders: a developmental perspective. Baltimore: Paul H. Brookes; 2002;p. 279–306.
[48]. [48] Gray C. The new social story book. Arlington (TX): Future Horizons; 2000;.
[49]. [49] Norris C, Dattilo J. Evaluating effects of a social story intervention on a young girl with autism. Focus on Autism and Other Developmental Disabilities. 1999;14(3):180–186.
[50]. [50] Hagiwara R, Myles BS. A multimedia social story intervention: teaching skills to children with autism. Focus on Autism and Other Developmental Disabilities. 2001;14(2):82–95.
[51]. [51] Cullain RE. The effects of social stories on anxiety levels and excessive behavioral expressions of elementary school-aged children with autism. Diss Abstr. 2002;67(7–10):.
[52]. [52] Baker MJ, Koegel RL, Koegel LK. Increasing the social behavior of young children with autism using their obsessive behaviors. J Assoc Persons with Severe Handicaps. 1998;23(4):300–308.
[53]. [53] McGee GG, Almeida MC, Sulzer-Azaroff B, Feldman RS. Promoting reciprocal interactions by way of peer incidental teaching. J Appl Behav Anal. 1992;25:117–126. MEDLINE | CrossRef
[54]. [54] Pierce K, Shreibman L. Increasing complex social behaviors in children with autism: effects of peer-implemented pivotal response training. J Appl Behav Anal. 1995;28:285–295. MEDLINE | CrossRef
[55]. [55] Koegel LK, Koegel RL, Harrower JK, Carter CM. Pivotal response intervention I: overview of approach. J Assoc Persons with Severe Handicaps. 1999;24(3):174–185.
[56]. [56] Koegel RL, Carter CM, Koegel LK. Setting events to improve parent-teacher coordination and motivation for children with autism. In: Luiselli JK, Cameron MJ editor. Antecedent control: innovative approaches to behavioral support. Baltimore: Paul H. Brookes; 1998;p. 167–186.
[57]. [57] Thorp DM, Stahmer AC, Shreibman L. Effects of sociodramatic play training on children with autism. J Autism Dev Disord. 1995;14:27–38. MEDLINE
[58]. [58] Jahr D, Eldevik S, Eikeseth S. Teaching children with autism to initiate and sustain cooperative play. Res Dev Disabil. 2000;21:151–169. MEDLINE | CrossRef
[59]. [59] Krantz PJ, McClannahan LE. Teaching children with autism to initiate to peers: effects of a script-fading procedure. J Appl Behav Anal. 1993;26:121–132. MEDLINE | CrossRef
[60]. [60] Charlop MH, Milstein JP. Teaching autistic children conversational speech using video modeling. J Appl Behav Anal. 1989;22:275–285. MEDLINE | CrossRef
[61]. [61] Charlop-Christy MH, Le L, Freeman KA. A comparison of video modeling with in vivo modeling for teaching children with autism. J Autism Dev Disord. 2000;30:537–552. MEDLINE | CrossRef
[62]. [62] Corbett B., Larsson E. Video modeling: applications for children with autism spectrum disorders. Paper presented at the International Meeting for Autism Research, San Diego, CA; 2001.
[63]. [63] Strain PS, Kerr MM, Ragland EU. Effects of peer-mediated social initiations and prompting/reinforcement procedures on the social behavior of autistic children. J Autism Dev Disord. 1979;9:41–54. MEDLINE | CrossRef
[64]. [64] Shafer MS, Egel AL, Neef MA. Training mildly handicapped peers to facilitate changes in the social interaction skills of autistic children. J Appl Behav Anal. 1984;17:461–476. MEDLINE | CrossRef
[65]. [65] Lord C. The development of peer relations in children with autism. In: Morrison FJ, Lord C, Keating DP editor. Advances in applied developmental psychology. NY: Academic Press; 1984;p. 165–229.
[66]. [66] Pierce K, Shreibman L. Multiple peer use of pivotal response training to increase social behaviors of classmates with autism: results from trained and untrained peers. J Appl Behav Anal. 1997;30:157–160. MEDLINE | CrossRef
[67]. [67] Kamps DM, Leonard BR, Vernon S, Dugan EP, Delquadri J. Teaching social skills to students with autism to increase peer interactions in an integrated first grade classroom. J Appl Behav Anal. 1992;25:281–288. MEDLINE | CrossRef
[68]. [68] Roeyers H. A peer-mediated proximity intervention to facilitate the social interactions of children with pervasive development disorders. Br J Spec Ed. 1995;22:161–164.
[69]. [69] Gunter P, Fox JJ, Brady MP, Shores RE, Cavanaugh K. Non-handicapped peers as multiple exemplars: a generalization tactic for promoting autistic students' social skills. Behav Disord. 1988;14:3–14.
[70]. [70] Kamps DM, Potucek J, Lopez AG, Kravits T, Kemmerer K. The use of peer networks across multiple settings to improve social interaction for students with autism. J Behav Ed. 1997;7(3):335–357.
[71]. [71] Voeltz L, Hemphill N, Brown S, Kishi G, Klein R, Furehling R, et al. The special friends program: a trainer's manual for integrated school settings. Honolulu: University of Hawaii Press; 1983;.
[72]. [72] Forest M. More education/integration: a further collection of readings on the integration of children with mental handicaps into the regular school system. The G.A. Roeher Institute: Downsview, Ontario, Canada; 1987;.
[73]. [73] Whitaker P, Barratt P, Joy H, Potter M, Thomas G. Children with autism and peer group support: using circles of friends. Br J Spec Ed. 1998;25(2):60–64.
[74]. [74] Klin A, Volkmar FR, Sparrow SS. Asperger syndrome. NY: Guilford Press; 2000;.
[75]. [75] Klin A, Volkmar FV. Treatment and intervention guidelines for individuals with Asperger Syndrome. In: Klin A, Volkmar FV, Sparrow SS editor. Asperger syndrome. NY: Guildford Press; 2000;p. 340–366.
[76]. [76] Kyparissos N. Extending conversations among adolescent peers with autism. Diss Abstr Int. 1997;57(10–14):.
[77]. [77] Koegel RL, Frea WD. Treatment of social behavior in autism through the modification of pivotal social skills. J Appl Behav Anal. 1993;26:369–377. MEDLINE | CrossRef
[78]. [78] Morrison L, Kamps D, Garcia J, Parker D. Peer mediation and monitoring strategies to improve initiations and social skills for students with autism. J Pos Behav Interventions. 2001;3(4):237–250.
[79]. [79] Ozonoff S, Miller JN. Teaching theory of mind: a new approach to social skills training for individuals with autism. J Autism Dev Disord. 1995;25:415–433. MEDLINE | CrossRef
[80]. [80] Haring TG, Breen CG. A peer-mediated social network intervention to enhance the social integration of persons with moderate and severe disabilities. J Appl Behav Anal. 1992;25:319–333. MEDLINE | CrossRef
[81]. [81] Shriberg LD, Paul R, McSweeney JL, Klin A, Cohen DJ, Volkmar FV. Speech and prosody characteristics of adolescents and adults with high functioning autism and Asperger syndrome. J Speech Lang Hear Res. 2001;44:1097–1115. MEDLINE | CrossRef
[82]. [82] Shriberg LD, Widder CJ. Speech and prosody characteristics of adults with mental retardation. J Speech Hear Res. 1990;33:627–653. MEDLINE
[83]. [83] Menary L. Peer mediated social skills intervention for a pre-school child with autism. Paper presented at the Biennial Conference of the New Zealand Speech-Language Therapists' Association. Wellington, New Zealand; March, 2002.

Aspergers Teens and Threats of Suicide

Question: Do people with Aspergers often take action on the threats they make when they blow up? My sister (who died tragically 5 years ago) has a 18 yr old so with AS. When he gets really worked up, he threatens to kill himself and "take others with him." His threats of suicide are often paired with "if I don't get what I want", not "I am so depressed I want to die." These threats seem to be more of a bullying technique instead of a cry for help. I hesitate to call the police because there is no other topic that sets him off more than the police.

Click here for the answer...