Aspergers: A Clinical Account

=====> The many patterns of abnormal behavior that cause diagnostic confusion include one originally described by the Austrian psychiatrist, Hans Asperger (1944, 1968, 1979). The name he chose for this pattern was 'autistic psychopathy' using the latter word in the technical sense of an abnormality of personality. This has led to misunderstanding because of the popular tendency to equate psychopathy with sociopathic behavior. For this reason, the neutral term Aspergers is to be preferred and will be used here...

Not long before Asperger' s original paper on this subject appeared in 1944, Kanner (1943) published his first account of the disorder he called early infantile autism. The two conditions are, in many ways, similar, and the argument still continues as to whether they are varieties of the same underlying abnormality or are separate entities.

Whereas Kanner's work is widely known internationally, Aspergers contribution is considerably less familiar outside the German literature. The only published discussions of the subject in English known to the present author are by Van Krevelen (1971), Isaev & Kagan (1974), Mnukbin & Isaev (1975) (translation from Russian), Wing (1976), Chick et al (1979), Wolff & Barlow (1979) and Wolff & Chick (1980). In addition, a book by Bosch in which autism and Aspergers are compared, originally appearing in German in 1962, has been translated into English (Bosch, 1962). A paper given by Asperger in Switzerland in 1977 has appeared in an English version (Asperger, 1979). Robinson & Vitale (1954) and Adams (1973) gave clinical descriptions of kids with behavior resembling Aspergers, but without referring to this diagnosis.

In the present paper the disorder will be described, illustrated with case histories, and the differential diagnosis and classification discussed. The account is based on Aspergers descriptions and on 34 cases, ranging in age from 5 to 35 years, personally examined and diagnosed by the author. Of these, 19 had the history and clinical picture of the disorder in more or less typical form and 15 showed many of the features at the time they were seen, though they did not all have the characteristic early history (see below). Six of those in the series were identified as a result of an epidemiological study of early childhood psychoses in the Camberwell area of south-east London (Wing & Gould, 1979). The rest were referred to the author for diagnosis - 11 by their moms and dads, through the family doctor, two by head educators and 15 by other psychiatrists.

The following general description includes all the most typical features. But, as with any psychiatric disorder identifiable only from a pattern of observable behavior, there are difficulties in determining which are essential for diagnosis. Variations occur from person to person and it is rare to find, in any one case, all the details listed below.

The clinical picture—

Illustrative case histories based on those of kids and grown-ups seen by the present author are to be found in the Appendix. Throughout the paper, the numbers in parentheses refer to these histories.

Aspergers description of the disorder:

Asperger noted that the disorder was very much more common in males than in females. He believed that it was never recognized in infancy and usually not before the third year of life or later. The following description is based on Aspergers accounts.

Speech:

The youngster usually begins to speak at the age expected in normal kids, whereas walking may be delayed. A full command of grammar is sooner or later acquired, but there may be difficulty in using pronouns correctly, with the substitution of the second or third for the first person forms (No. 1). The content of speech is abnormal, tending to be pedantic and often consisting of lengthy disquisitions on favorite subjects (No.2). Sometimes a word or phrase is repeated over and over again in a stereotyped fashion. The youngster or adult may invent some words. Subtle verbal jokes are not understood, though simple verbal humor may be appreciated.

Non-verbal communication:

Non-verbal aspects of communication are also affected. There may be little facial expression except with strong emotions such as anger or misery. Vocal intonation tends to be monotonous and droning, or exaggerated. Gestures are limited, or else large and clumsy and inappropriate for the accompanying speech (No. 2). Comprehension of other individual’s expressions and gestures is poor and the person with Aspergers may misinterpret or ignore such non-verbal signs. At times he may earnestly gaze into another person's face, searching for the meaning that eludes him.

Social interaction:

Perhaps the most obvious characteristic is impairment of two-way social interaction. This is not due primarily to a desire to withdraw from social contact. The problem arises from a lack of ability to understand and use the rules governing social behavior. These rules are unwritten and unstated, complex, constantly changing, and affect speech, gesture, posture, movement, eye contact, choice of clothing, proximity to others, and many other aspects of behavior. The degree of skill in this area varies among normal individuals, but those with Aspergers are outside the normal range. Their social behavior is naive and peculiar. They may be aware of their difficulties and even strive to overcome them, but in inappropriate ways and with signal lack of success. They do not have the intuitive knowledge of how to adapt their approaches and responses to fit in with the needs and personalities of others. Some are over-sensitive to criticism and suspicious of other individuals. A small minority have a history of rather bizarre antisocial acts, perhaps because of their lack of empathy. This was true of four of the present series, one of whom injured another boy in the course of his experiments on the properties of chemicals.

Relations with the opposite sex provide a good example of the more general social ineptitude. A young man with Aspergers observes that most of his contemporaries have girl friends and eventually marry and have kids. He wishes to be normal in this respect, but has no idea how to indicate his interest and attract a partner in a socially acceptable fashion. He may ask other individuals for a list of rules for talking to females, or try to find the secret in books (No. 1). If he has a strong sex drive he may approach and touch or kiss a stranger, or someone much older or younger than himself, and, as a consequence, find himself in trouble with the police; or he may solve the problem by becoming solitary and withdrawn.

Repetitive activities and resistance to change:

Kids with Aspergers often enjoy spinning objects and watching them until the movement ceases, to a far greater extent than normal. They tend to become intensely attached to particular possessions and are very unhappy when away from familiar places.

Motor co-ordination:

Gross motor movements are clumsy and ill-coordinated. Posture and gait appear odd (No.1). Most individuals with Aspergers (90% of the 34 cases mentioned above) are poor at games involving motor skills, and sometimes the executive problems affect the ability to write or to draw. Stereotyped movements of the body and limbs are also mentioned by Asperger.

Skills and interest:

Those with the disorder in most typical form have certain skills as well as impairments. They have excellent rote memories and become intensely interested in one or two subjects, such as astronomy, geology, the history of the steam train, the genealogy of royalty, bus time-tables, prehistoric monsters, or the characters in a television serial, to the exclusion of all else. They absorb every available fact concerning their chosen field and talk about it at length, whether or not the listener is interested, but have little grasp of the meaning of the facts they learn. They may also excel at board games needing a good rote memory, such as chess (No.2), and some have musical ability. Seventy-six per cent of the present author's series had special interests of this kind. However, some have specific learning problems, affecting arithmetical skills, reading, or, as mentioned above, writing.

Experiences at school:

This combination of school and communication impairments, and certain special skills gives an impression of marked eccentricity. The kids may be mercilessly bullied at school, becoming, in consequence, anxious and afraid (Nos. I and 2). Those who are more fortunate in the schools they attend may be accepted as eccentric 'professors', and respected for their unusual abilities (No.4). Asperger describes them as unsatisfactory students because they follow their own interests regardless of the teacher's instructions and the activities of the rest of the class (Nos. 3 and 4). Many eventually become aware that they are different from other individuals, especially as they approach adolescence, and, in consequence, become over-sensitive to criticism. They give the impression of fragile vulnerability and a pathetic youngsterishness, which some find infinitely touching and others merely exasperating.

Modifications of Aspergers account:

The present author has noted a number of additional items in the developmental history, not recorded by Asperger, which can sometimes be elicited by appropriate questioning of the moms and dads. During the first year of life there may have been a lack of the normal interest and pleasure in human company that should be present from birth. Babbling may have been limited in quantity and quality. The youngster may not have drawn attention to things going on around him in order to share the interest with other individuals. He may not have brought his toys to show to his moms and dads or visitors when he began to walk. In general, there is a lack of the intense urge to communicate in babble, gesture, movement, smiles, laughter and eventually speech that characterizes the normal baby and toddler (No.3).

Imaginative pretend play does not occur at all in some of those with the disorder, and in those who do have pretend play it is confined to one or two themes, enacted without variation, over and over again. These may be quite elaborate, but are pursued repetitively and do not involve other kids unless the latter are willing to follow exactly the same pattern. It sometimes happens that the themes seen in this pseudo-pretend play continue as preoccupations in adult life, and form the main focus of an imaginary world (see the case history of Richard L. in Bosch, 1962).

There are also two points on which the present author would disagree with Aspergers observations. First, he states that speech develops before walking, and refers to 'an especially intimate relationship with language' and 'highly sophisticated linguistic skills'. Van Krevelen (1971) emphasized this as a point of differentiation from Kanner's early childhood autism, in which, usually, walking develops normally, or even earlier than average, whereas the onset of speech is markedly delayed or never occurs. However, slightly less than half of the present author's more typical cases of Aspergers were walking at the usual age, but were slow to talk. Half talked normally but were slow to walk, and one both walked and talked at the expected times. Despite the eventual good use of grammar and a large vocabulary, careful observation over a long enough period of time discloses that the content of speech is impoverished and much of it is copied inappropriately from other individuals or books (No.3). The language used gives the impression of being learned by rote. The meanings of long and obscure words may be known, but not those of words used every day (No.5). The peculiarities of non-verbal aspects of speech have already been mentioned.

Secondly, Asperger described individuals with his disorder as capable of originality and creativity in their chosen field. It would be more true to say that their thought processes are confined to a narrow, pedantic, literal, but logical, chain of reasoning. The unusual quality of their approach arises from the tendency to select, as the starting point for the logical chain, some aspect of a subject that would be unlikely to occur to a normal person who has absorbed the attitudes current in his culture. Usually the result is inappropriate, but once in a while it gives new insight into a problem. Asperger also believed that individuals with his disorder were of high intelligence, but he did not quote the results of standardized intellectual tests to support this. As will be seen from the case histories in the Appendix, the special abilities are based mainly on rote memory, while comprehension of the underlying meaning is poor. Those with the disorder are conspicuously lacking in common sense.

It must be pointed out that the individuals described by the present author all had problems of adjustment or superimposed psychiatric illnesses severe enough to necessitate referral to a psychiatric clinic. Nine had left school or further education. Of these, three were employed, three had lost their jobs, and three had not obtained work. The author is also acquainted, through their moms and dads who are members of The National Society for Autistic Kids, with a few young grown-ups reported to have some or all of the features of Aspergers, and who are using their special skills successfully in open employment. It would be inappropriate to give precise numbers or to include these in the series, because the author does not have access to case histories or assessment. For this reason, the series described here is probably biased towards those with more severe handicaps.

Course and prognosis—

The published clinical descriptions are of kids and young grown-ups. No studies of the course and prognosis in later life are available.

Asperger emphasized the stability of the clinical picture throughout childhood, adolescence and at least into early adult life, apart from the increase in skills brought about by maturation. The major characteristics appear to be impervious to the effects of environment and education. He considered the social prognosis to be generally good, meaning that most developed far enough to be able to use their special skills to obtain employment. He also observed that some who had especially high levels of ability in the area of their special interests were able to follow careers in, for example, science and mathematics.

As Bosch (1962) pointed out, it is possible to find individuals with all the features characteristic of Aspergers other than normal or high intelligence. This applied to 20% of the series described here. If these are accepted as belonging to the same diagnostic category, then Aspergers rather hopeful view of the prognosis has to be modified to take such cases into account (see the case history of J.G., Appendix No.5).

The prognosis is also affected by the occurrence of superimposed psychiatric illnesses. Clinically diagnosable anxiety and varying degrees of depression may be found, especially in late adolescence or early adult life, which seem to be related to a painful awareness of handicap and difference from other individuals (Nos. 2 and 3). Wolff & Chick (1980), in a follow-up study of 22 individuals with Aspergers, reported one who appeared to have a typical schizophrenic illness and another in whom this diagnosis was made, but less convincingly. Five of the 22 had attempted suicide by the time of early adult life.

The present author's series included 18 who were aged 16 and over at the time they were seen. Of these, four had an affective illness; four had become increasingly odd and withdrawn, probably with underlying depression; 1 had a psychosis with delusion and hallucinations that could not be classified; I had had an episode of catatonic stupor; one had bizarre behavior and an unconfirmed diagnosis of schizophrenia; and two had bizarre behavior, but no diagnosable psychiatric illness. Two of the foregoing had attempted suicide and one had talked of doing so. These two were referred because of their problems in coping with the demands of adult life.

Though it appears that the risk of psychiatric illness in Aspergers is high, it is difficult to draw firm conclusions because of the nature of the samples that were studied. The 13 individuals mentioned above, before they were seen by the present author, had been referred to adult services because of superimposed psychiatric conditions, so the series was highly biased. Wolff's cases were somewhat less selective since they were referred as kids and followed up into adult life, but, even so, they were clinic and not population based. Asperger (1944) noted that only one of his 200 cases developed schizophrenia. The true prevalence of psychiatric illnesses can be calculated only from an epidemiological study, including individuals with the disorder not referred to psychiatric services.

Even in the absence of recognizable psychiatric disorder, adolescence may be a difficult time. The development of partial insight and increasing sexual awareness can cause much unhappiness (No. I) and may lead to socially unacceptable behavior. Peculiarities which may be ignored in a small youngster become very obvious in a young adult.

The degree of adjustment eventually achieved appears to be related to the level and variety of skills available and also to the temperament of the individual concerned. Good self-care, a special ability that can be used in paid employment, and a placid nature are needed if a person with Aspergers is to become socially independent.

Aetiology and pathology—

Asperger (1944) considered his disorder to be genetically transmitted. He reported that the characteristics tended to occur in the families, especially the fathers of those with the disorder. Van Krevelen (1971) stated that, in many cases, the antecedents for generations back had been highly intellectual. In the present author's series, 55% had fathers who were in professional or managerial occupations, but the personalities of the moms and dads were not studied systematically. In many cases, the mother alone was seen. The purpose of the interview was to discuss the problems of the youngster, not to investigate the moms and dads. Including only those concerning whom some tentative conclusions could be drawn (from clinical impressions or evidence from other sources), it appeared that 5 out of 16 fathers and 2 out of 24 mothers had, to a marked degree, behavior resembling that found in Aspergers. No features of the clinical picture appeared to be associated with higher or lower social class, level of education of the moms and dads, or their personalities.

It is difficult to interpret the findings on social class, since the cases referred to clinics having a special interest in such problems are a selected group, with a strong bias towards higher social class and intellectual occupations in the moms and dads. Schopler et al (1979) and Wing (1980) noted a similar bias in the fathers of classically autistic kids referred to clinics, which was not reflected in less selected groups with the same diagnosis. The findings concerning the moms and dads' personalities have to be treated with caution because of the way they were obtained and the lack of any comparison group.

The disorder can be found in kids and grown-ups with history of pre-, pen- or post-natal conditions, such as anoxia at birth, which might have caused cerebral damage. This was true of nearly half of those seen by the present author (Nos. 3 and 4). Mnukhin & Isaev (1975) considered that the behavior pattern was due to organic deficiency of brain function.

Emotional causes or abnormal youngster-rearing methods have been suggested, especially where the moms and dads or siblings show similar peculiarities to the patient, but there is no evidence to support such theories.

Detailed epidemiological studies, based on total populations, are needed in order to establish which, if any, of these aetiological factors are relevant.

No specific organic pathology has been identified. No particular abnormalities of face or body have been reported. In childhood the physical appearance is usually, but by no means always, normal. In adolescence and adult life, the inappropriate gait, posture and facial expression produce an impression of oddness.

In general, on psychological assessment, tests requiring good rote memory are performed well, but deficits are shown with those depending on abstract concepts, or sequencing in time. Visuo-spatial abilities vary and the scores on testing may be markedly lower than those for expressive speech (No.4). The results of psychological testing will be described in more detail elsewhere.

Epidemiology—

As already mentioned, no detailed, large-scale epidemiological studies have been carried out, so that the exact prevalence of Aspergers is unknown. A major difficulty in designing such a study would be the establishment of criteria for distinguishing the disorder from other similar conditions, as will be discussed later.

Wing & Gould (1979) carried out a study in which all the mentally and physically handicapped kids aged under 15 in one area of London were screened in order to identify cases of early childhood psychosis and severe mental retardation. In this study, two kids (0.6 per 10,000 aged under 15) showed most of the characteristics of Aspergers, though they were in the mildly retarded range on intelligence tests, and 4 (1.1 per 10,000) could have been diagnosed as autistic in early life, but came to resemble Aspergers later. There were a total of 35,000 kids aged under 15 in the area.

Wing & Gould did not use methods designed to identify mild cases of Aspergers, so that any kids who were attending normal school and had not come to the attention of the educational, social or medical services would not have been discovered. The prevalence rate for the typical disorder given above is almost certainly an underestimate.

The disorder appears to be considerably more common in males than in females. Asperger originally believed it to be confined to males, though he modified this view later (personal communication). Wolff & Barlow (1979) mentioned that the clinical picture could be seen in females. In their series the male:female ratio was 9:1. In the present author's series there were 15 males and 4 females with the disorder in fairly typical form, and 13 males and 2 females who had many of the features. The females tended to appear superficially more sociable than the males, but closer observation showed that they had the same problems of two-way social interaction.

Differential diagnosis—

As with any condition identifiable only from a pattern of abnormal behavior, each element of which can occur in varying degrees of severity, it is possible to find individuals on the borderlines of Aspergers in whom diagnosis is particularly difficult. Whereas the typical case can be recognized with ease by those with experience in the field, in practice it is found that the disorder shades into eccentric normality, and into certain other clinical pictures. Until more is known of the underlying pathology, it must be accepted that no precise cut-off points can be defined. The diagnosis has to be based on the full developmental history and presenting clinical picture, and not on the presence or absence of any individual item.

Normal variant of personality:

All the features that characterize Aspergers can be found in varying degrees in the normal population. Individuals differ in their levels of skill in social interaction and in their ability to read nonverbal social cues. There is an equally wide distribution in motor skills. Many who are capable and independent as grown-ups have special interests that they pursue with marked enthusiasm. Collecting objects such as stamps, old glass bottles, or railway engine numbers are socially accepted hobbies. Asperger (1979) pointed out that the capacity to withdraw into an inner world of one's own special interests is available in a greater or lesser measure to all human beings. He emphasized that this ability has to be present to marked extent in those who are creative artists or scientists. The difference between someone with Aspergers and the normal person who has a complex inner world is that the latter does take part appropriately in two-way social interaction at times, while the former does not. Also, the normal person, however elaborate his inner world, is influenced by his social experiences, whereas the person with Aspergers seems cut off from the effects of outside contacts.

A number of normal grown-ups have outstandingly good rote memories and even retain eidetic imagery into adult life. Pedantic speech and a tendency to take things literally can also be found in normal individuals.

It is possible that some individuals could be classified as suffering from Aspergers because they are at the extreme end of the normal continuum on all these features. In others, one particular aspect may be so marked that it affects the whole of their functioning. The man described by Luria (1965), whose visual memories of objects and events were so vivid and so permanent that they interfered with his comprehension of their significance, seemed to have behaved not unlike someone with Aspergers. Unfortunately, Luria did not give enough details to allow a diagnosis to be made.

Even though Aspergers does appear to merge into the normal continuum, there are many cases in whom the problems are so marked that the suggestion of a distinct pathology seems a more plausible explanation than a variant of normality.

Schizoid personality:

The lack of empathy, single-mindedness, odd communication, social isolation and over-sensitivity of individuals with Aspergers are features that are also included in the definitions of schizoid personality (see review by Wolff & Chick, 1980). Kretschmer (1925) outlined some case histories of so-called schizoid grown-ups, one or two of which were strongly reminiscent of this condition, although he did not provide sufficient detail to ensure the diagnosis. For example, one young man had no friends at school, was odd and awkward in social interaction, always had difficulty with speech, never took part in rough games, was oversensitive, and very unhappy when away from home. He thought out fantastic technical inventions and, together with his sister, invented a detailed imaginary world.

There is no question that Aspergers can be regarded as a form of schizoid personality. The question is whether this grouping is of any value. This will be discussed below in the section on classification.

Schizophrenia:

Grown-ups with Aspergers may be diagnosed as suffering from schizophrenia. The differential diagnosis of schizophrenia has been discussed elsewhere (J.K.Wing, 1978). The main difficulty arises from the fact that schizophrenia has been defined loosely by some and strictly by other workers.

If a loose definition of schizophrenia is accepted, based only on characteristics such as social withdrawal and speech disorder, then a case could perhaps be made for including Aspergers in this group. As with schizoid personality, the question is whether doing so has any advantages. Poverty of social interaction and abnormalities of speech can have many different causes, so the diagnosis of chronic or simple schizophrenia tends to cover a variety of conditions having little in common with each other.

Careful observation of speech in Aspergers discloses differences from thought blocking and the 'knight's move' in thought described by Bleuler (1911). In Aspergers, speech may be slow, and there may be irrelevant or tangential replies to questions, but these problems are due partly to a tendency to become stuck in well-worn conversational grooves rather than to produce new ideas. Utterances are always logical, even if they are unrelated to the question, or originated from an unusual point of view. Thus one young man, when asked a general knowledge question about organized charities, said 'They do things for unfortunate individuals. They provide wheelchairs, stilts and round shoes for individuals with no feet'. There is a marked contrast between the vague woolliness of schizophrenic thought and the concrete, pedantic approach found in Aspergers.

The term schizophrenia can be used more strictly. It can be confined to those who have, currently or in the past, shown the florid first-rank symptoms described by Schneider (1971). In this case, the differentiation of Aspergers rests on accurate definition of the clinical phenomena. Unless they have a superimposed schizophrenic illness, individuals with Aspergers do not experience thought echo, thought substitution or insertion, thought broadcast, voices commenting on their actions, voices talking to each other, or feelings that external forces are exerting control over their will, emotions or behavior. The young man, L.P. (Appendix No. 2), when asked if he had such experiences, gave the matter long and careful thought and then said, 'I believe such things to be impossible'.

During clinical examination it is necessary to be aware that comprehension of abstract or unfamiliar concepts is impaired in Aspergers. Those with the more severe form of the handicap may have a habit of answering 'yes' to any question they do not understand, this being the quickest way to cut short the conversation. Some may also pick up and repeat phrases used by other individuals, including other patients in a hospital ward, making diagnosis even more difficult.

Other psychotic disorders:

The tendency found in individuals with Aspergers to sensitivity and over-generalization of the fact that they are criticized and made fun of may, if present in marked form, be mistaken for a paranoid psychosis. Those who are pre-occupied with abstract theories or their own imaginary world may be said to have delusions or hallucinations. One boy, for example, was convinced that Batman would arrive one day and take him away as his assistant. No rational argument could persuade him otherwise. This type of belief could be called a delusion, but is probably better termed an 'over-valued idea'. It does not have any specific diagnostic significance, since such intensely held ideas can be found in different psychiatric states.

Severe social withdrawal, echopraxia and odd postures may be noted. These may become more marked at times, and then they could be regarded as catatonic phenomena. Such catatonic symptoms can be associated with various conditions (including encephalitis) and, on their own, should not be considered as indicative of schizophrenia.

Obsessional neurosis:

Repetitive interests and activities are part of Aspergers, but the awareness of their illogicality and the resistance to their performance characteristic of the classic case of obsessional neurosis are not found in the former It would be of interest to investigate the relationship between Aspergers, obsessional personality, obsessional illness, and post-encephalitic obsessional conditions.

Affective conditions:

The quietness, social withdrawal, and lack of facial expression in Aspergers might suggest a depressive illness. Shyness and distress when away from familiar surroundings could make an anxiety state a possible diagnosis, or excited talking about a rather fantastic grandiose, imaginary world might bring to mind hypomania. However, the full clinical picture and the early developmental history should clarify the diagnosis.

More difficult problems occur when affective illnesses are superimposed on Aspergers. Then a double diagnosis has to be made on the history and present state.

Early childhood autism:

Asperger acknowledged that there were many similarities between his disorder and Kanner's early infantile autism. Nevertheless, he considered they were different because he regarded autism as a psychotic process, and his own disorder as a stable personality trait. Since neither psychotic process nor personality trait has been defined empirically, little more can be said about whether they can be distinguished from each other.

Van Krevelen (1971) and Wolff & Barlow (1979) agreed with Asperger that his disorder should be differentiated from autism. They differ in their accounts of the distinguishing features and the impression gained from their papers is that, although there are some differences, the disorders are more alike than unalike. The variations could be explained on the basis of the severity of the impairments, though the authors quoted above would not agree with this hypothesis. Thus the autistic youngster, at least when young, is aloof and indifferent to others, whereas the youngster with Aspergers is passive or makes inappropriate one-sided approaches. The former is mute or has delayed and abnormal speech, whereas the latter learns to speak with good grammar and vocabulary (though he may, when young, reverse pronouns), but the content of his speech is inappropriate for the social context and he has problems with understanding complex meanings. Non-verbal communication is severely impaired in both conditions. In autism, in the early years, there may be no use of gesture to communicate.

In Aspergers there tends to be inappropriate use of gesture to accompany speech. In both conditions, monotonous or peculiar vocal intonation is characteristic. The autistic youngster develops stereotyped, repetitive routines involving objects or individuals (for example, arranging toys and household objects in specific abstract patterns, or insisting that everyone in a room should cross the right leg over the left), whereas the person with Aspergers becomes immersed in mathematical abstractions, or amassing facts on his special interests. Abnormal responses to sensory input - including indifference, distress and fascination - are characteristic of early childhood autism and form the basis of the theories of perceptual inconstancy put forward by Ornitz & Ritvo (1968) and of over-selectivity of attention suggested by Lovaas et al (1971). These features are associated with greater severity of handicap, and lower mental age. They are not described as typical of Aspergers, and they are rarely seen in older autistic individuals with intelligence quotients in the normal range.

The one area in which this type of comparison does not seem to apply is in motor development. Typically, autistic kids tend to be good at climbing and balancing when young. Those with Aspergers, on the other hand, are notably il1-co-ordinated in posture, gait and gestures. Even this may not be a particularly useful point of differentiation, since kids who have typical autism when young tend to become clumsy in movement and much less attractive and graceful in appearance by the time of adolescence (see DeMyer, 1976, 1979 for a discussion of motor skills in autism and autistic-like conditions).

Bosch (1962) considered that Aspergers and autism were variants of the same condition. This author pointed out that, although Asperger and Van Krevelen (1971) listed features in the early history which they thought distinguished the two conditions, in practice these did not cluster into two groups often enough to justify the differentiation. The youngster in Appendix No. 6 illustrates this problem (see also Everard 1980).

Classification—

Asperger regarded the disorder he described as a disorder of personality that could be distinguished from other types of personality abnormalities although he recognized the similarities to early childhood autism. Wolff & Barlow (1979) argued that it should be classified under the heading of schizoid personality. In support of this view, Wolff & Chick (1980) reviewed the literature in which schizoid characteristics are described. As discussed above, the disorder can be placed in this group, and further work in this field would be of interest, but, at the moment, classification under this heading has no useful practical implications. Although Wolff & Chick have listed five features, operationally defined, that they regard as core characteristics of schizoid personality, this term, as generally used, is so vague and ill-defined a concept that it covers a wide range of clinical pictures in addition to Aspergers. The aim should be not to enlarge, but to separate sub-groups from the broad category and thus to increase diagnostic precision.

Furthermore, the word schizoid was originally chosen to underline the relationship of the abnormal personality to schizophrenia. The latter can occur in a person with Aspergers, but, as already discussed, there is no firm evidence of a special link between Aspergers and schizophrenia, strictly defined. To incorporate such an untested assumption into the name of the condition must give rise to confusion.

The reasons for personality variations are so obscure that classifying Aspergers under this heading does not lead to any testable hypotheses concerning cause, clinical phenomena, pathology or management. A more limited, but more productive, view of the problem is to consider it as a consequence of impairment of certain aspects of cognitive and social development.

As mentioned above, Wing & Gould (1979) carried out an epidemiological study of all mentally or physically handicapped kids in one area of London, in an attempt to identify all those with autism or autistic-like conditions, whatever their level of intelligence. The results confirmed the following hypothesis. Certain problems affecting early youngster development tend to cluster together: namely, absence or impairment of two-way social interaction; absence or impairment of comprehension and use of language, non-verbal as well as verbal; and absence or impairment of true, flexible imaginative activities, with the substitution of a narrow range of repetitive, stereotyped pursuits. Each aspect of this triad can occur in varying degrees of severity, and in association with any level of intelligence as measured on standardized tests.

When all kids with this cluster of impairments were examined, it was found that a very few resembled the description given by Asperger and some had typical Kanner's autism. A number could, tentatively, be classified as having disorders described by authors such as De Sanctis (1906, 1908), Earl (1934), Heller (see Hulse, 1954) and Mahler (1952), although the definitions given by these writers were not precise enough for easy identification. The remainder had features of more than one of these so-called disorders and under the general, but unsatisfactory, heading of early childhood psychosis. The justification for regarding them as related is that all the conditions in which the triad of language and social impairments occurs, whatever the level of severity, are accompanied by similar problems affecting social and intellectual skills. Furthermore, individuals with the triad of symptoms all require the same kind of structured, organized educational approach, although the aims and achievements of education will vary from minimal self-care up to a university degree, depending on the skills available to the person concerned.

This hypothesis does not suggest that there is a common gross aetiology. This is certainly not the case, since many different genetic or pre-, peri- or post-natal causes can lead to the same overt clinical picture (Wing & Gould, 1979). It is more likely that all the conditions in which the triad occurs have in common impairment of certain aspects of brain function that are presumably necessary for adequate social interaction, verbal and non-verbal communication and imaginative development. It is possible that these are all facets of one underlying in-built capacity - that is, the ability actively to seek out and make sense of experience (Ricks & Wing, 1975). Included in this would be the innate ability to recognize other human beings as distinct from the rest of the environment and of special importance. If this basic skill were diminished or absent, the effects on development would be profound, as is the case in all early childhood psychoses.

The full range of clinical material can be sub-divided in many different ways, depending on the purpose of the exercise, but no aetiological classification is possible as yet. Sub-grouping on factors such as level of intelligence (Bartak & Rutter, 1976) or on degree of impairment of social interaction (DeMyer, 1976; Wing & Gould, 1979) has more useful practical implications for education and management than any based on the eponymous disorders mentioned above.

In the light of this finding, is there any justification for identifying Aspergers as a separate entity? Until the aetiologies of such conditions are known, the term is helpful when explaining the problems of kids and grown-ups who have autistic features, but who talk grammatically and who are not socially aloof Such individuals are perplexing to moms and dads, educators and work supervisors, who often cannot believe in a diagnosis of autism, which they equate with muteness and total social withdrawal. The use of a diagnostic term and reference to Aspergers clinical descriptions help to convince the individuals concerned that there is a real problem involving subtle, but important, intellectual impairments, and needing careful management and education.

Finally, the relationship to schizophrenia of Aspergers, autism and similar impairments can be reconsidered. Although they are dissimilar in family history, childhood development and clinical pictures, both groups of conditions affect language, social interaction and imaginative activities. The time of onset and the nature of the disturbances are different, but there are similarities in the eventual chronic defect states that either may produce. It is not surprising that autism and schizophrenia have, in the past, been confused. Progress has been made in separating them and it is important to continue to improve precision in diagnosis, despite the many difficulties met in clinical practice.

Management and education—

There is no known treatment that has any effect on the basic impairments underlying Aspergers, but handicaps can be diminished by appropriate management and education.

Both kids and grown-ups with Aspergers, like all those with the triad of language and social impairments, respond best when there is a regular, organized routine. It is important for moms and dads and educators to recognize the subtle difficulties in comprehension of abstract language, so that they can communicate with the youngster in ways he can understand. The repetitive speech and motor habits cannot be extinguished, but, with time and patience, they can be modified to make them more useful and socially acceptable. Techniques of behavior modification as used with autistic kids can possibly be helpful if applied with sensitivity. However, Asperger (1979) expressed considerable reservations about using these methods with kids with his disorder who are bright enough to be aware of and, as Asperger put it, 'to value their freedom'.

Education is of particular importance because it may help to develop special interests and general competence sufficiently to allow independence in adult life. The teacher has to find a compromise between, on the one hand, letting the youngster follow his own bent completely, and, on the other, insisting that he conform. She also has to ensure that he is not teased and bullied by the rest of the class. There is no type of school that is particularly suitable for those with Aspergers. Some have performed well in schools for normal kids, while others have managed better in schools for various kinds of handicaps. Educational progress depends on the severity of the youngster's impairments, but also on the understanding and skill of the teacher.

Most individuals with Aspergers who settle in open employment have jobs with a regular routine. They also have sympathetic employers and workmates who are willing to tolerate eccentricities. In many instances, work has been found by moms and dads who persevere in approaching employers, despite all the difficulties.

Finding appropriate living accommodation also presents problems. Living with moms and dads is the easiest solution, but cannot last forever. Hostels or lodgings with a helpful landlady are the most usual answer. Tactful supervision may be needed to ensure that rooms are kept clean and tidy and clothes are changed regularly.

Superimposed psychiatric illnesses, if they occur, should be treated appropriately. Emotional distress in adolescents and young grown-ups due to partial insight may be reduced to some extent by counseling from someone who has a full understanding of the disorder. Such counseling consists mainly of explanation, reassurance and discussion of fears and worries. The counselor has to adopt a simple and concrete approach in order to stay within the limits of the client's understanding. Psychoanalysis, which depends upon the interpretation of complex symbolic associations, is not useful in this condition.

Moms and dads, in their youngster's early years, are usually confused and distressed by his strange behavior. They need a detailed explanation of the nature of his problems if they are to understand and accept that he is handicapped.


Appendix—

Case histories:

As mentioned above, the following case histories are those of individuals who have been referred to psychiatric services. The high achievers mentioned by Asperger (1944) are not represented.

Case l

This is a typical example of the disorder.

Mr K.N. first presented as a psychiatric out-patient when he was aged 28, complaining of nervousness and shyness.

As a baby he was always placid and smiling and rarely cried. He used to lie in his pram for hours, laughing at the leaves on the trees. His mother remembered he did not point things out for her to look at, in contrast to his sister. He continued to be quiet and contented as a toddler. If other kids took his toys he did not protest. Walking was somewhat delayed and he was slow in acquiring self-care skills, though not enough for his moms and dads to worry.

He began to talk around one year of age. He had several words at this time, but, after seeing and hearing a car crash which startled him, he stopped talking and did not begin again until he was three years old. His moms and dads thought his understanding of speech was normal. K. developed good grammar, though he referred to himself in the third person till 4-5 years old. He has never been communicative. Even as an adult he gives information only if questioned and then replies as briefly as possible. His facial expression and gestures are limited, and his voice is monotonous.

As a youngster he was attached to his mother, he never made any friends, and he was much teased at school. He remains a shy and socially isolated person though he would like to be able to make social contacts.

K. had no stereotyped movements, but has always been ill-coordinated and very poor at games. He does not swing his arms when he walks. He attended a private school and did well in subjects needing a good rote memory, such as history and Latin, but fell behind at the stage when comprehension of abstract ideas became necessary. He was in the army for a short time, but was not allowed to take part in marches and parades because of his clumsiness and inability to do the right thing at the right time. He was discharged because of these peculiarities.

K. did not object to changes imposed by others, but he was, and still is, orderly in his own daily routines and in arranging his own possessions.

From early in his life he liked toy buses, cars and trains. He amassed a large collection and would notice at once if a single item were missing. He would also make models with constructional kits. He played with such toys, on his own, for as long as he was allowed to continue. He had no other pretend play and never joined in with other kids. The interest in means of transport has remained with him. In his spare time he reads factual books on the subject, watches cars and trains and goes on trips to see trains with fellow train-enthusiasts. He has no interest in fiction or any other type of non-fiction.

K. has been employed for many years in routine clerical work. He enjoys his job and his hobby, but is very sad and anxious because he is aware of his own social ineptness and would like to have friends and to marry. He writes many letters to advice columns in magazines, hoping for help with these problems. His concern over what he terms his 'shyness' finally made him ask for help from a psychiatrist.

The WAIS gave K. an IQ in the dull normal range, with similar verbal and non-verbal scores. He was particularly poor at sub-tests needing comprehension of a sequence of events.

Case2

The second case history is also typical, but complicated by severe depression with onset in early adult life.

Mr L.P. was admitted to a psychiatric hospital at age 24 because of a suicide attempt. He was born four weeks premature and had feeding problems in the first week or two. He was an easy, placid, rather unresponsive baby who rarely cried. He acquired motor and self-care skills, but his moms and dads later realized that he passed these milestones more slowly than his sister, though they did not worry at the time. His father had a vague premonition that there was something odd about L. but not enough to seek advice.

He did not begin to speak until he was three years old, but this was attributed to the fact that the family was bilingual. However, by the time he went to school he was speaking in long, involved, pedantic sentences that sounded as if they had come from books. He tended to interpret words in odd ways. For example, when hearing someone described as 'independent' he thought this meant they always jumped in at the deep end of the swimming pool. He still takes jokes very seriously. He used to ask the same questions over and over again, regardless of the answers he was given. He did not initiate or join in conversations except by repetitive questioning.

L. remained placid and obedient throughout his childhood. He rarely initiated any activity, but waited to be told what to do. As a small youngster he used to rock himself when unoccupied. He had no imaginative play. He went to normal school, but did not join in with the other kids and had no friends until he was about 14 years old. Then he did begin to mention one or two companions and referred to them as friends, but has lost touch since.

He was bullied at school and remembers it as an unhappy time.

L. has always been concerned that his possessions should be orderly and that the daily routine should be followed exactly.

He is poor at games needing gross motor skills and at tasks requiring hand-eye co-ordination. His posture and gait are markedly odd. His face has a faintly bewildered expression that rarely changes. He uses large, jerky, inappropriate gestures to accompany speech. The odd impression he conveys is exacerbated by his old-fashioned choice of clothing.

L.' s memory is excellent and this enabled him to pass exams in subjects that can be learnt by rote. He is a very good chess player and enjoys taking part in matches. He can read well and enjoys books on physics and chemistry, concerning which he has memorized a large number of facts. He is particularly interested in time. He wears two watches, one set at Greenwich Mean Time and one at local time, even when these are the same.

His major problem is his social ineptitude. He will, for example, go on talking about his special subjects despite the most obvious signs of boredom in his audience. He makes inappropriate, often quite irrelevant, remarks in company and appears gauche and youngsterish. He is painfully aware of his deficiencies, but is unable to acquire the skills necessary for social interaction. Nevertheless, he is kind and gentle and, if he realizes someone is ill or unhappy, he will be most sympathetic and do his best to help.

Since leaving school he has been employed as a filing clerk, and lives in a hostel.

L.'s moms and dads did not seek psychiatric help when he was a youngster, but he has been in contact with psychiatric services since reaching adolescence. On the first occasion he had become agitated because of worries about sex. On the second, he was anxious and losing sleep because of a minor change in his routine at work. On the third he was admitted as an in-patient following attempted suicide, once again precipitated by the possibility of re-organization in the office where he works. He tried to drown himself, but failed because he is a good swimmer. He then tried to strangle himself, without success. Commenting on this he said 'The trouble is I am not a very practical person'. At admission he was disheveled in appearance, deeply distressed and sad. His speech was painfully slow with long pauses between phrases. Its content was coherent, although, in his replies to questions, L. tended to add information that was correct, and related to the subject in hand, but not relevant in the context. For example, when asked about relations with his father L. said 'My father and I get on well. He is a man who likes gardening'.

L. blamed himself for all his problems, describing himself as an unpleasant person, whom no one could like and who could not manage his own life. He said he had heard individuals saying things about him such as 'L. is stupid', 'L. is a bad person', 'L. is a chemistry fanatic'. Careful questioning and subsequent observation showed that these were misinterpretations of overheard conversations and never occurred when L. was alone. For the first two admissions, the referring agency diagnosed an anxiety state, and for the third, schizophrenia. The final diagnosis was Aspergers complicated by anxiety and depression (not schizophrenia).

L. scored in the average range on the WAIS, his verbal being rather higher than his performance score, mainly because of his large vocabulary.

Case 3

The third case history is that of a boy where abnormality was recognized from infancy.

B.H. is aged 10. He was delivered by forceps and had difficulty with breathing and cyanosis after birth, remaining in special care for two weeks. He was a large, placid baby, who would lie without moving for long periods. He was not eager to use gestures, to clap or to wave goodbye. His mother was worried about him from the beginning, partly because of the difficult birth and partly because of his behavior.

His moms and dads were certain that he replied 'Yes' appropriately to questions at 11 months. At around 14 months he began to speak in a fluent, but incomprehensible 'language' of his own.

He made no effort to crawl, but one day, aged 17 months, he stood up and walked. He learnt to crawl after this.

He retained his own language until aged three years, when he started to copy clearly words he heard, and then went on to develop understandable speech. His comprehension of language has always lagged behind his expression. By the age of four he could read. His moms and dads said they did not teach him - he presumably learnt from the television. At the age of five he had a reading age of nine years, but his comprehension was poor.

In his early years, B. remained quiet and passive, showing little emotion of any kind. He seemed to prefer a regular routine, but did not react at all to changes. He was not demanding and gave no trouble.

B. did not develop imaginative pretend play at the usual age. At the age of about six years he became fascinated with means of transport, read all about them and learned all the technical terms. He enacts actions involving cars, airplanes and so on, but never with other kids.

He appears clumsy and ill-coordinated, has problems with buttons and laces, and is afraid of climbing.

B. attends a special school. When first admitted he ignored the other kids and carried on with his usual preoccupations. He appeared astounded when the teacher indicated that he should obey her instructions and follow the rest of the class. Gradually he began to fit in and to make active social approaches, though in a naive and inappropriate fashion. He has difficulty in following the rules of any game.

He speaks in a pedantic style, in an accent quite unlike that of his local environment. For example, he referred to a hole in his sock as 'a temporary loss of knitting'. Many of his phrases are, like this one, inappropriately adapted quotations from television or books.

B. is now aware of and sensitive to other individual’s criticism, but appears unable to learn the rules of social interaction.

When tested at age seven, he had a word recognition age of 12 years, scored at his age level on performance tasks, but was well below this on tests needing recall and comprehension of language.

Case 4

In the following example of the disorder, the diagnosis is complicated by a history of illness and psychological stress in early life, and by visual impairment.

Miss F.G. is aged 26. Pregnancy and delivery were normal, but F. had a series of illnesses and operations, including a subdural hemorrhage of unknown aetiology and correction of strabismus before the age of three years. She has poor eyesight and has to peer very closely to see, but can read, write and type.

F. talked fluently at an early age, and had a large vocabulary. Her moms and dads thought she was developing normally until the operation on her eyes at 2 1/2 years. Following this she was socially withdrawn for several months. No detailed description could be obtained, but her mother was quite certain that there was a marked change in behavior. Despite the problems of social interaction, F.'s speech remained clear, with good vocabulary and grammar. She always had a remarkable memory for anything she had heard or read, including any statistical information. F. gradually became more friendly and, by about three years of age, she was making social approaches to her moms and dads and others in the family. However, she did not interact much with other kids. She copied her mother's activities a little, but did not develop normal pretend play or social play.

Her main interests as a young youngster were drawing and, later on, reading. She also collected costume dolls, which she arranged in rows that must not be disturbed.

F. went to a normal comprehensive school. She loved history and geography, and would memories facts in these subjects with ease, but her teacher reported that she would do no work in any subject that did not interest her, such as mathematics.

She was accepted at school but recognized as odd. Her conversation contained many long quotations from books and she also often made irrelevant remarks.

F. was never good at practical tasks. Her moms and dads tended to do things for her. They found that, if they asked her to do some task, she would begin, but soon stop and turn to her own preferred activity - usually reading a book.

After leaving school she obtained work as a typist. She proved an excellent copy typist and was outstandingly accurate at spelling. She made no friends with the other members of staff. After four years the pressure of work increased. F. became distressed and unable to cope. She left work and has been unemployed for three years. During this time she has been anxious and agitated and unable to do anything on her own. She spends her time reading and amassing facts. She tends to have childish temper tantrums if thwarted in any way.

The WAIS showed that F. had a verbal score in the average normal range, but performance was very much lower, being in the mildly retarded range. The verbal skills depended on her good vocabulary. She did poorly on any task where the elements bad to be organized into a coherent whole.

Case 5

This is the history of a young man who showed the features of Aspergers, but who was mentally retarded and did not achieve independence as an adult.

Mr J. G. is aged 24 and attends a training centre for mentally retarded grown-ups. J. was a quiet, unresponsive baby. He began to say a few words at the age of two, but did not walk until 21/2 years old. At first he echoed, used phrases repetitively and had poor pronunciation. He learnt to read at the age of 51/2 and always did well on reading tests, though his comprehension was poor. He knew many unusual or technical words, such as 'aeronautical' and 'pterodactyl' but would be puzzled by familiar ones such as 'yesterday'.

He was not aloof, but gentle and passive, tending to stand and watch other kids, wanting to join in but not knowing how. He was very affectionate towards his own family. At age 24 he is still unable to interact socially, though is happy to be a passive member of a group.

He is clumsy in gait and posture and slow on tests of manual dexterity. J.'s special interests are music and cars. He can recognize any make of car, even if shown only a small part of the whole vehicle.

He attended a special school for mentally retarded kids. He was described by his teacher as 'showing no initiative'. He was eventually placed in an adult training centre near his home, where he is happily settled.

His WAIS score at the age of 17 was on the borderline between mild and severe retardation, with the verbal level being very slightly better than the performance. His reading age was still well in advance of all other skills.

Case 6

The following case history is of a boy who at first was classically autistic and later developed the characteristics of Aspergers.

C.B. is aged 13. His mother dates C.'s problems from the age of six months when his head was accidentally bruised. From this time he became socially aloof and isolated, and spent most of his time gazing at his hands which he moved in complicated patterns in front of his face. At one year old he began to watch the passing traffic, but still ignored individuals. He continued to be remote, with poor eye contact, until five years of age. He passed his motor milestones at the usual ages and, as soon as he was physically able, he spent hours running in circles with an object in his hand, and would scream if attempts were made to stop him. At the age of three he began to be able to recognize letters of the alphabet and rapidly acquired skill at drawing. He then drew the salt and pepper pots, correctly copying the names written on them, over and over again. For a time this was his sole activity. Following this he became fascinated with pylons and tall buildings and would stare at them from all angles and draw them.

He did not speak till the age of four, then for a long time used single words. After this, he acquired repetitive phrases and reversed pronouns. C. had many stereotyped movements as a young youngster, including jumping, flapping his arms and moving his hands in circles.

After the age of five, C.'s speech and social contact markedly improved. He attended a special school until aged 11, where they tolerated a range of bizarre, repetitive routines. At one point, for example, he insisted that all his class and the teacher should wear watches that he had made from plasticine before lessons could begin. Despite all the problems, he proved to have excellent rote memory, absorbed all that he was taught, and could reproduce facts verbatim when asked. C. was transferred to a normal comprehensive school at the age of II - He has good grammar and a large vocabulary, though his speech is naive and immature and mainly concerned with his own special interests. He has learnt not to make embarrassing remarks about other individual’s appearances, but still tends to ask repetitive questions. He is not socially withdrawn, but he prefers the company of grown-ups to that of kids of his own age, finding it difficult to understand the unwritten rules of social interaction. He said of himself, 'I am afraid I suffer from bad sportsmanship'. He enjoys simple jokes but cannot understand more subtle humor. He is often teased by his classmates.

His main interest is in maps and road signs. He has a prodigious memory for routes and can draw them rapidly and accurately. He also makes large, complicated abstract shapes out of any material that comes to hand, and shows much ingenuity in ensuring that they hold together. He has never had pretend play but is deeply attached to his toy panda to which he talks as if it were an adult when he needs comfort.

His finger dexterity is good, but he is clumsy and ill-coordinated in large movements and therefore is never chosen by the other kids for sports and team games.

C. is of average intelligence on the WISC, with better verbal than performance skills. He does well on tasks needing rote learning, but his educators are deeply puzzled and concerned about his poor comprehension of abstract ideas and his social naivety. They find him appealing but sadly vulnerable to the hazards of everyday life.


My Aspergers Child: Preventing Meltdowns in Aspergers Children


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Aspergers: Answer to Diagnostic Mysteries?

As a young child, Jayne was consumed by Pokemon, the collectible card game of animated creatures originated in Japan. It was no mere pastime, but an all-encompassing interest that engaged her considerable vocabulary to the exclusion of all other age-appropriate attachments or interests. And it was accompanied by other troubling signs: an inability to make eye contact with others, to engage with peers in a reciprocal fashion, and to make friends.

As Jayne matured, her social isolation deepened, as did the uncommon and all-consuming nature of her interests. As a teen, she developed an exhaustive knowledge about everything related to a fast-food chain in the state where she resides. At an age when conformity to the norm is at a premium and castigation of those who deviate is most severe, Jayne inhabits an island of her own inaccessible idiosyncrasy.

As little as 14 years ago, she also may have had difficulty getting a psychiatric diagnosis that fit. Too verbal and intellectually adept for autism, she was liable to get a diagnosis of obsessive-compulsive disorder (OCD), a personality disorder, or even schizophrenia.

Today, Jayne's primary condition is recognized as Aspergers, a close relative of autism distinguished by severe and sustained impairment in social interaction, but without the clinically significant delay in language acquisition characteristic of autism; also distinctive is the presence of restrictive, highly idiosyncratic interests.

First introduced in DSM-IV in 1994, Aspergers is still prone to being overlooked or labeled as something else. As in the case of Jayne, OCD is often diagnosed – she exhibits some of those features and receives medication for them. But overlooked before she was diagnosed with Aspergers was the severe and sustained impairment in social interaction, dating back to her earliest years.

Even a decade ago people had a good understanding about autism, but these “Aspergers-like” children fell between the cracks. They didn't fall neatly into any psychiatric diagnosis, and they didn't look like they had autism because their language was so well developed. People knew they were odd, but no one knew what to do with them. As a clinician in child mental health, it has been a great relief to have this diagnosis as something you can hang your hat on. These children have tremendous needs that must be met by schools and the medical community.

They Talk Before They Walk—

These are children who talk before they walk. Words are their lifeline, and from a research perspective, that's a critical observation that captures the difference from autism.

The Aspergers description went “underground” for several decades, but during an international field trial of autism conducted by Volkmar and others in the 1980s, a number of clients consistently surfaced, across cultures and languages, who matched the definition. From this emerged a consensus definition for inclusion of Aspergers in DSM-IV in 1994.

Now the criteria are in need of refinement and will likely be updated in the next edition of DSM. Chief among the difficulties with the current criteria is dependence upon the absence of criteria normally present in autism—namely, the lack of delay in acquisition of language at age 2 or 3—and the stipulation that if autism cannot be ruled out, it should be the diagnosis of choice.

While Aspergers individuals do not lack vocabulary or speech production and are often precocious in this area, they have trouble fitting language into context and lack other skills requiring intuition of social context. They may have a variety of language weaknesses as toddlers including delayed onset of speech, rattling on in tangential ways, and speech articulation problems. But they are of a different quality than those found in high-functioning autism, such as mutism or very severe deficits in vocabulary.

Clinicians say a client's history of language acquisition is difficult enough to ascertain when a patient first presents at the age of 10 or 12, let alone as an adult. When you see these children in the clinic, it feels somewhat artificial to make a distinction just because they had an early language delay.

If they had a language delay at age 3 or 4, I am forced by DSM to call it autism, and if they didn't and have a normal IQ, to call it Aspergers. That's not a problem because those who have the language delay often continue to have signs of autism. And often, the more severe cases end up being called autism and the less severe cases are Aspergers. But not always, and it can seem arbitrary eight or nine years down the road. If the family is overwhelmed, the least of their concerns is remembering exactly when the child first uttered single words and phrases.

Confusion over diagnosis, combined with a relative paucity of research, has resulted in extremely wide-ranging estimates of prevalence of Asperger's—between 3 and 48 per 10,000. Nonetheless, there are real differences between Aspergers and autism, and they need to be better spelled out.

So what should clinicians look for?

In making the diagnosis, clinicians should look for three bell-ringer traits. These are impaired social interactions, especially difficulty with social reciprocity; idiosyncratic interests or activities; and odd, mechanical, or socially inappropriate speech patterns.

As with Jayne, treatment may involve medication of secondary symptoms such as obsessive-compulsive tendencies or attention-deficit problems; antidepressants, anxiolytics, or atypical antipsychotic medications may be useful.

Social-skills training targeted at teaching specific, often rudimentary social rules and protocols is the other component of treatment. Social algorithms—how to respond to different social situations and verbal cues—allow patients with Aspergers to learn conversation and other social skills cognitively so they can approximate an intuitive sense of how to behave.

In contrast to autism, you want to use the verbal capacities of Aspergers clients as a pathway to treatment.

The long-term prognosis is not necessarily bleak; the intensity of interest and volume of knowledge that clients may bring to idiosyncratic subjects can make them highly valued workers as adults. Along a continuum the symptoms of Aspergers can at some point “fade to normal,” and there are those in the community of people with autism-spectrum disorders who resist being labeled as disordered. For young people, especially teenagers, the “different-ness” they experience can be traumatic.

Even when these children don't meet criteria for depression, they are very much at risk for demoralization. In middle school especially they can experience self-hatred and anger as they try to make friends and find more and more that people aren't interested in their favorite topics and aren't patient with their social awkwardness.

So there is a place in treatment for supportive therapy and psycho-education. Sometimes I will give them things to read about Aspergers, and they are incredibly relieved to know there is a disorder, and that other people have it – and have found a way to lead happy lives.

My Aspergers Child: Preventing Meltdowns and Tantrums in Aspergers Children

Aspergers: Diagnosis and Clinical Features

The diagnosis of Aspergers requires the demonstration of qualitative impairments in social interaction and restricted patterns of interest, criteria which are identical to autism. In contrast to autism, there are no criteria in the cluster of language and communication symptoms, and onset criteria differ in that there should be no clinically significant delay in language acquisition, cognitive and self-help skills. Those symptoms result in significant impairment in social and occupational functioning. In some contrast to the social presentation in autism, children with Aspergers find themselves socially isolated, but are not usually withdrawn in the presence of others.

Typically, they approach others but in an inappropriate or eccentric fashion. For example, they may engage the interlocutor, usually an adult, in one-sided conversation characterized by long-winded, pedantic speech, about a favorite and often unusual and narrow topic. They may express interest in friendships and in meeting people, but their wishes are invariably thwarted by their awkward approaches and insensitivity to the other person's feelings, intentions, and non-literal and implied communications (e.g., signs of boredom, haste to leave, and need for privacy).

Chronically frustrated by their repeated failures to engage others and form friendships, some children with Aspergers develop symptoms of an anxiety or mood disorder that may require treatment, including medication.

They also may react inappropriately to, or fail to interpret the valence of the context of the affective interaction, often conveying a sense of insensitivity, formality, or disregard to the other person's emotional expressions.

They may be able to describe correctly, in a cognitive and often formalistic fashion, other people's emotions, expected intentions and social conventions; yet, they are unable to act upon this knowledge in an intuitive and spontaneous fashion, thus losing the tempo of the interaction.

Their poor intuition and lack of spontaneous adaptation are accompanied by marked reliance on formalistic rules of behavior and rigid social conventions. This presentation is largely responsible for the impression of social naiveté and behavioral rigidity that is so forcefully conveyed by those with Aspergers.

Although significant abnormalities of speech are not typical of children with Aspergers, there are at least three aspects of communication patterns that are of clinical interest:

1. The communication style of children with Aspergers is often characterized by marked verbosity. The youngster may talk incessantly, usually about a favorite subject, often in complete disregard to whether the listener might be interested, engaged, or attempting to interject a comment, or change the subject of conversation. Despite such long-winded monologues, the child 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.

2. Speech may often be tangential and circumstantial, conveying a sense of looseness of associations and incoherence. Even though in a very small number of cases this symptom may be an indicator of a possible thought disorder, the lack of contingency in speech is a result of the one-sided, egocentric conversational style (e.g., unrelenting monologues about the names, codes, and attributes of innumerable TV stations in the country), failure to provide the background for comments and to clearly demarcate changes in topic, and failure to suppress the vocal output accompanying internal thoughts.

3. Speech may be marked by poor prosody, although inflection and intonation may not be as rigid and monotonic as in autism. They often exhibit a constricted range of intonation patterns that is used with little regard to the communicative functioning of the utterance (e.g., assertions of fact, humorous remarks). Rate of speech may be unusual (e.g., too fast) or may lack in fluency (e.g., jerky speech), and there is often poor modulation of volume (e.g., voice is too loud despite physical proximity to the conversational partner). The latter feature may be particularly noticeable in the context of a lack of adjustment to the given social setting (e.g., in a library, in a noisy crowd).

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

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

My Aspergers Child: Preventing Meltdowns

Asperger Syndrome: Epidemiology

Given the lack of consensual definitions of diagnosis until recently, it is not surprising that the prevalence of Aspergers is unknown, although a rate of 2 to 4 in 10,000 has been reported.

There is little doubt that the condition is more prevalent in boys than girls, with a reported ratio of 9 to 1.

In the past few years, there have been a proliferation of parent support groups organized around the concept of Aspergers, and there are indications that this diagnosis is being given by clinicians much more frequently than even just a few years ago; there are also indications that Aspergers is currently functioning as a residual diagnosis given to normal-intelligence young people with a degree of social disabilities who do not fulfill criteria for autism, overlapping in this way, with the DSM-IV term PDD-NOS.

Possibly the most common usage of the term Aspergers is as synonymous or a replacement to autism in children with normative or superior IQs. This pattern has diluted the concept and reduced its clinical utility. Empirical validation of specific diagnostic criteria is badly needed, although this will have to await reports of rigorous studies employing standard diagnostic procedures, and “validators” truly independent of the diagnostic definition such as neuropsychological, neurobiological and genetic data.

The Aspergers Comprehensive Handbook

The History Behind "Aspergers"

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

In 1944, Hans Asperger, an Austrian pediatrician with interest in special education, described four kids who had difficulty integrating socially into groups. Unaware of Kanner's description of early infantile autism published just the year before, Asperger called the condition he described "autistic psychopathy", indicating a stable personality disorder marked by social isolation.

Despite preserved intellectual skills, the kids showed marked paucity of nonverbal communication involving both gestures and affective tone of voice, poor empathy and a tendency to intellectualize emotions, an inclination to engage in long winded, one-sided, and sometimes incoherent speech, rather formalistic speech (he called them "little professors"), all-absorbing interests involving unusual topics which dominated their conversation, and motoric clumsiness. Unlike Kanner's patients, these kids were not as withdrawn or aloof; they also developed, sometimes precociously, highly grammatical speech, and could not in fact be diagnosed in the first years of life.

Discarding the possibility of a psychogenic origin, Asperger highlighted the familial nature of the condition, and even hypothesized that the personality traits were primarily male transmitted. Aspergers work, originally published in German, became widely known to the English speaking world only in 1981, when Lorna Wing published a series of cases showing similar symptoms. Her codification of the syndrome, however, blurred somewhat the differences between Kanner's and Aspergers descriptions, as she included a small number of girls and mildly mentally retarded kids, as well as some kids who had presented with some language delays in their first years of life. Since then, several studies have attempted to validate AS as distinct from autism without mental retardation, although comparability of findings has been difficult due to the lack of consensual diagnostic criteria for the condition.3

Aspergers was not accorded official recognition before the publication of ICD-10 and DSM-IV, although it was first reported in the German literature in 1944. Aspergers work was known primarily in German speaking countries, and it was only in the 1970's that the first comparisons with Kanner's work were made, primarily by Dutch researchers such as Van Krevelen, who were familiar with both English and German literatures. The initial attempts at comparing the two conditions were difficult because of major differences in the patients described – Kanner's patients were both younger and more cognitively impaired. Also, Aspergers conceptualization was influenced by accounts of schizophrenia and personality disorders, whereas Kanner had been influenced by the work of Arnold Gesell and his developmental approach.

Attempts at codifying Aspergers prose into a categorical definition for the condition were made by several influential researchers in Europe and North America, but no consensual definition emerged until the advent of ICD-10. And given the reduced empirical validation of the ICD-10 and DSM-IV criteria, the definition of the condition is likely to change as new and more rigorous studies emerge in the near future.

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Aspergers Children and Social Skills Interventions

In this post, we will look at the ingredients that are critical to making “social skills interventions” successful for kids with Aspergers. Here you will find basic principles for teaching social skills that capitalize on the strengths of such kids, while specifically addressing their deficits:

Make the abstract concrete—

Relative to some academic skills, teaching social competence involves abstract skills and concepts. Because kids with Aspergers tend to be concrete and literal, the abstract nature of these interpersonal skills such as kindness, reciprocity, friendships, thoughts, and feelings makes them especially difficult to master. A first critical step is to define the abstract social skill or problem in clear and concrete terms. The behavior must be explicitly operationalized and the youngster taught to identify it and differentiate it from other behaviors (Is this a friend or not a friend? Is this a quiet or a loud voice? Were you being teased or not? Are you following directions or not?). Kids learning eye contact may respond better to the more concrete “point your eyes” than to “make eye contact” or even “look at me.” Personal space can be defined concretely as “an arm away” or “a ruler away” instead of “too close.” “If-then” rules can be taught when the social behaviors involved are predictable and consistent. For example, “If someone says ‘thank you,’ then you say ‘you're welcome’.” Short menus of behavior options can be presented for particular social situations for kids to choose among (e.g., three things you can do to deal with teasing).

Visually-based instruction is another example of a way to make the abstract concrete. Many kids with Aspergers, even those who are high functioning and who have considerable verbal skill, demonstrate a visual preference or learn best with visually cued instruction. Incorporating visual cues, prompts, and props to augment verbal instruction can make abstract social skills more tangible and easily understood. Pictures can be used to define concepts or clarify definitions. Examples of intermediate and finished products can be used to demonstrate steps in activities or projects. Written lists can be used to summarize discussion topics. Voice volume or affect intensity can be depicted visually, in a thermometer-like format. In the PROGRESS Curriculum, a large “Z” made of cardboard is used to depict the back-and-forth of a conversation. Similarly, kids are taught to look at the eyes of others using a cardboard arrow. They are instructed to hold the arrow on the side of their face, next to their right eye, and point it at the eyes of the person to whom they are speaking. This aligns their face and eyes in the correct direction. Once this skill has been practiced using this concrete visual cue, use of the arrow is faded. When a youngster needs a reminder to look in someone's eyes, the arrow can be held up unobtrusively as a cue. Such visual prompts can then be faded and the skill can be practiced in more natural contexts.

Structure and predictability—

In most group therapy, including social skills training, topics and session content change from week to week. One way to ease the anxiety that this may cause, while also facilitating transitions between activities and increasing comprehension, is to provide structure, predictability, and routines. Specifically, maintaining a consistent opening, lesson, and closing format, regardless of session topic, can be helpful, as can predictable group rituals, such as weekly songs or joke time. For example, younger kids might always begin with a singing routine that welcomes each participant by name. Older kids and adolescents might start each session with a routine in which each member recounts a positive and a difficult event from the previous week. The greeting might always be followed by an instructional activity. Although the content, focus, and technique would change from week to week, the sequence of this instruction always following the group greeting would provide some measure of predictability. Group instruction might always be followed by a snack, with accompanying conversation on an identified topic of interest or joke telling. A closing routine should always signal the end of the session. This routine could include a review of the session's topic, a song, a story, a quiz, or a goodbye to each participant. The essential ingredient is the predictability of the routine, not its specific content.

Visual cues, such as picture schedules and written lists, also can clarify the sequence of events during group and prepare members for upcoming transitions, new activities, or unexpected changes. The session schedule used in the PROGRESS Curriculum resembles a traffic light with picture-word icons depicting each activity. The icons in the upper-most green circle of the traffic light begin the session, those in the yellow circle occur during the middle of the session, and those in the bottom red circle close the group. As an activity is completed, the icon is removed from the traffic light.

Engaged transitions—

Another way to ease the anxiety and behavior difficulties often associated with transitions is to focus participants' attention on a concrete task that naturally leads them from one activity to the next. For example, when transitioning from the structured group activity to the snack period, kids might work in pairs to put away materials and prepare the room for the snack. This focuses them on a specific task, as opposed to the change of activity. The PROGRESS Curriculum transitions kids from the opening group circle to the structured skill development activity in a novel way. The transition is facilitated by an activity called “Pick-and-Pass,” which uses a large container decorated with question marks that contains objects, pictures, or words that are used in the subsequent activity. Each youngster removes an item from the can and passes it to the next youngster as the rest of the group chants “Pick and pass” while clapping. This is usually met with great excitement as the kids select an item or wait for the can to be passed, easing the transition between activities.

Scaffolded language support—

There is a complex interplay between social skills, cognitive function, and language. Kids with Aspergers have not only social challenges, but also communication and cognitive challenges. It is therefore vitally important to consider the cognitive and language abilities of the kids participating in social skills intervention and to adapt the intervention as needed. Social skills curricula can be designed to meet the needs of kids with Aspergers at a variety of ages, developmental levels, and language abilities. One way to do this is to group kids by general language ability, so that those who need extra structure, support, and language scaffolding are treated together. Then activities can be adapted to the amount and level of language support and structure required by the participants. For kids who do not have fluent language, directions and activities need to be visually clear, concrete, and hands-on. Language models or scripts can be provided so that group members need little or no spontaneous language to participate. Conversely, activities for kids with fluent expressive language (e.g., those with Asperger syndrome or high functioning autism) would require greater independence in generating spontaneous language. Fewer concrete supports would be needed and activities enabling them to practice social skills in more natural social interactions would be more appropriate.

The following example demonstrates how an activity from the PROGRESS Curriculum has been modified for kids at two different language ability levels. In the friendship unit, one session is devoted to learning more about other people. One activity uses a board game format, in which the cards that advance players around the board require them to ask other group members personal questions. For kids with more fluent language, a card might read “Find out three things (name) likes to do.” For kids with greater language difficulties, a comparable card would use words and picture icons to read “(name), what is your favorite color?” If the peer cannot respond verbally, pictures of different colors are available so he or she can point. Thus, fewer expressive language skills are required. Questions are more specific, address concrete attributes, and avoid abstract concepts. Responses are more circumscribed and less open-ended in this format. Yet the goal of finding out about others is fulfilled, just as for kids with more verbal fluency.

Another example of language scaffolding from the PROGRESS Curriculum comes from the conversation skills unit, in an activity that teaches contingent commenting. Kids with fluent language sit in a circle, spin a topic spinner that visually depicts several categories (e.g., food, animals, movies), and comment on the topic indicated. This same activity is redesigned for kids with limited language skills to provide significantly more language modeling, visual prompts, and concrete directions. Kids are given a card with a carrier phrase written on it, such as “I have a ___.” The group leader reads the words for the kids, if necessary. A tray of interesting objects is then placed in the middle of the circle. Each youngster selects an object and uses the carrier phrase to comment, “I have a (item from tray).”

The length and complexity of the opening and closing songs also can be adapted to the language abilities of the participants. For example, in the PROGRESS Curriculum, the opening song for kids with limited language use is (to the tune of Goodnight Ladies): “Hello (name), hello (name), hello (name), I'm glad you came to group.” This song is elaborated for kids who are functioning at a higher language level by including an extra verse tailored to preview the session's topic. For example, during a lesson on teasing, the opening song is (to the tune of Frere Jacques): “Hello (name), hello (name). How are you? How are you? Sometimes people tease me, I don't like it, how about you? How about you?”

Multiple and varied learning opportunities—

Although many kids with Aspergers demonstrate strengths in visual processing, there is still diversity in their interests, preferences, and learning styles. Some kids learn best while moving their bodies, others need to sit and focus to learn. Some kids learn well through reading, others are not yet literate. Some kids find music calming and facilitating, whereas others find it a distraction or even an irritant. Just as kids with typical development demonstrate multiple “intelligences”, so too do kids with Aspergers. Varying the learning opportunities, techniques, and approaches within and across sessions maximizes the likelihood that the particular learning styles or preferences of participants will be tapped. Different learning modalities include construction tasks, games, role plays, craft or cooking projects, gross motor activities, reading or writing tasks, drawing or art activities, and countless others. At different times, kids can practice working in dyads, small groups, and large groups.

As an example, the PROGRESS Curriculum's session focused on sharing starts by reading a story about sharing. The kids then transition into pairs by selecting objects from the Pick and Pass can that are part of a pair of toys (e.g., miniature baseball and miniature bat) and matching up with their partner. In these pairs, they then share a toy that encourages turn-taking. At snack, the kids pair up with the peer beside them and are given a single, large piece of cake. They must agree on how to decorate the cake together. Once completed, they share the piece of cake by cutting it in half. The group then plays a group game, “Musical Shares” (an analog of Musical Chairs). The kids walk around on mats while music is playing. Each time the music stops, they must find a mat to share with a new friend. In this way, sharing is practiced in a variety of different ways and through a variety of different activities.

“Other”-focused activities—

In positive social group environments, the members typically have a sense of community and friendship that develops over time, through repeated interactions. For kids with Aspergers, a feeling of “group belonging” is rarely achieved. The desire to attend to the interests of others, get to know others, and do things for others is often impaired. One way to facilitate the development of these skills is to ensure that all or most activities in the curriculum are “other”-focused. Nothing that can be done in a pair or group is ever done alone. Kids help others, rather than help themselves. For example, in art activities, kids can make something for a peer, rather than for themselves. They may be required to find out information about a peer, and then use that peer's favorite colors and preferences to develop a picture for him or her. During snack, kids can serve each other, rather than themselves. If they need more food, they must request it from another youngster rather than get it on their own. Through repeated, required social opportunities and practice, cooperation and partnership become the culture of the group, over time creating an environment of group camaraderie. Through this process, it is hoped that the participants come to recognize that social interaction can be rewarding and enjoyable.

Perspective taking and sharing the interests of others is also encouraged in the PROGRESS Curriculum through a weekly routine called “Special Spotlight.” During this part of the session, one youngster shares a topic of special interest with the group. Another youngster in the group is designated as the “spotlight partner.” His or her role is to learn about the “spotlight” youngster's interest and bring something to share or discuss related to that topic. This exercise serves to expand the partner's own repertoire of interests and knowledge, while also improving the ability to take another person's perspective. The other kids in the group are encouraged to make comments or ask questions about the spotlight topic. Assignments for the “special spotlight” and “spotlight partner” are made in advance so that the kids can prepare by bringing relevant items, developing a list or script, and so forth. Topics chosen by the kids have ranged from pets, dinosaurs, and video games to bus schedule collections, lectures on the solar system, and theme park brochures. Although the primary goal of the “spotlight” activity is to promote interest in others, it also serves as a way to focus or channel the circumscribed interests of group members into a specific part of the session, so that they do not distract from the rest of the group's activities.

Fostering self-awareness and self-esteem—

Most kids with Aspergers experience frequent social failure and rejection by peers. Because social encounters are seldom reinforcing, kids with Aspergers often avoid social interaction. Over time, they may develop negative attitudes about themselves and others. The poor self-esteem that may result makes it difficult to further attempt social interaction and thus, the cycle continues. Therefore, another essential ingredient of social skills interventions is fostering self-awareness, self-appreciation, and self-acceptance. It is only within a positive and nurturing environment that a straightforward examination of strengths and weaknesses can be achieved and the process of self-value initiated. Opportunities for self-awareness and self-acceptance can be incorporated throughout the curriculum. Positive attributes and strengths should be the focus whenever possible. Many kids with Aspergers are more used to a focus on their deficits and express surprise that Aspergers also involves much strength (e.g., memory, visualization, reading, rule-following, passion and conviction). To foster self-acceptance, group leaders can regularly comment on members' strengths. Kids can be taught the concept of complimenting and can be regularly required to compliment peers. In the University of Utah's adolescent group, participants give positive and constructive feedback to each other at the end of each session.

The adolescent group also includes a specific unit devoted to self-awareness. In one session, the game Bingo is adapted to focus on aspects of the Aspergers style and help individuals become more aware and accepting of their “quirks” or behaviors. The Bingo card lists strengths and weaknesses associated with the autism spectrum (e.g., “hard to point my eyes,” “like to flap my hands,” “know a lot about computers,” “good memory”). The group leader then reads these characteristics aloud one by one, with participants placing a marker on any trait they notice in themselves. Occasionally, several participants achieve “Bingo” (five characteristics in a row, column, or diagonal) at once. The teens are usually surprised and fascinated to find that they share behaviors with others. This activity can be especially helpful in the development of self-acceptance, as many comment that they have never met anyone else like themselves.

Select relevant goals—

Difficulty with social skills is not isolated to kids with Aspergers. Many kids exhibit difficulties with a variety of social skills for a variety of different reasons. As described at the beginning of this article, however, curricula developed to address general social impairments do not adequately tackle the social skills deficits specific to Aspergers. Thus, when selecting social goals for intervention, it is critical to prioritize and address the skill deficits that are most relevant and salient to Aspergers. For example, eye contact is probably a greater priority than manners or negotiation skills, given its centrality to social interaction (e.g., to monitor other people's reactions, to indicate interest or engagement). Related to this, it is important that all activities have an underlying social purpose. In our experience, it is a great deal easier to design fun activities than it is to design fun activities that target specific and relevant goals.

The PROGRESS Curriculum addresses five broad topic units that the authors believe are particularly relevant to Aspergers: basic interactional skills, conversational skills, play and friendship skills, emotion-processing skills, and social problem-solving skills. The Interaction Basics unit teaches the nonverbal behaviors that are important to social interaction, such as appropriate eye contact, social distance, voice volume, and facial expression. The second unit, Conversation Skills, covers basic elements of how to start, maintain, and end a conversation. The more subtle aspects of conversations, like taking turns in conversation, joining a conversation already underway, making comments, asking questions of others, using nonverbal indicators to express interest, and choosing appropriate topics, are included. The third unit teaches basic friendship and relationship skills. The concept of friendship and the important qualities of being a good friend are discussed, listed, and practiced. This unit also includes greeting others and responding to greetings, joining groups, sharing and taking turns, compromising, and following group rules. Next comes a unit on understanding thoughts and feelings of self and other people. The curriculum begins by increasing emotion recognition and vocabulary skills, as many kids with Aspergers are not familiar with emotional terms beyond the basics. Perspective taking and empathy training are included in this unit, requiring the kids to act out situations in which different people think different things or have different underlying motives. The final unit addresses social problem solving, such as what to do when a youngster is teased, feels left out, or is told “No.” The focus is on the development of practical solutions, coping mechanisms, and self-control for these difficult interpersonal situations.

It is important to make clear to the participants how and why the goals selected are relevant for them. For most people, whether they have Aspergers or not, learning is facilitated when the necessity of the learning or its application is made clear. Teaching the relevance of the social skill is believed to facilitate improved skill awareness and use in natural, daily settings for kids with Aspergers. One way to do this is to use Social Stories to introduce new social skills. Social Stories are written, sometimes illustrated, vignettes that present social information. Although they provide some specific guidance about what to do or say in a social situation, they also highlight social cues, peoples' motives or expectations, and other information that the person with Aspergers may not have appreciated. Thus, Social Stories can provide a rationale for why the youngster or kids should do or say what we tell them they should do or say. In addition, regular reminders regarding the importance of the skill being practiced should be regularly infused within group activities. For example, if a youngster is not making eye contact when requesting an item from a peer, he or she might be reminded, “Point your eyes and body so your friend knows you are talking to him.”

In addition to choosing group goals that are relevant to Aspergers, individualized goals can be identified for each group member. Each youngster should be aware of his or her personal target goal and should be reinforced for meeting it throughout the session. Individual goals may be consistent across weeks, or vary from session to session, depending on the needs of the youngster. A variety of different systems can be used, including reinforcement charts posted on the wall, individual goal or point cards, or cups in which the goal is affixed and tokens are placed. Reinforcement schedules can be individualized as needed to best promote skill acquisition and maintenance. For new or emerging skills, kids might be reinforced the moment the skill is displayed spontaneously. Once the skill is established, maintenance can be promoted by reinforcing after longer time periods or at the end of an activity or session.

Sequential and progressive programming—

Skills taught in isolation or without adequate practice and repetition most likely result in poor skill mastery and limited generalization and use. It is essential that the skills and behaviors addressed across the curriculum have relevance to each other and build on each other. As more complex, higher-order skills are learned, basic skills learned early on must continually be practiced. This not only promotes skill maintenance, but also integrates the individual skills into a larger, more fluid, social competence. Complex behaviors must be broken down into specific skills that are taught sequentially and then integrated.

This goal is achieved in the PROGRESS Curriculum in the following manner. Each topic unit consists of five sessions. In the first week of the curriculum, the new unit topic and set of skills are introduced, defined, or described (Introduction Phase). In the second and third weeks (Skill Development Phase), specific individual skills or situations are addressed and practiced. In the fourth week (Integration Phase), skills practiced individually in the previous 3 weeks are integrated and practiced. In the last week (Generalization Phase), the group meets out in the community to practice specific skills, socialize, and participate in natural age-appropriate activities with invited peers and friends. For example, the first session of the conversation unit describes the importance of conversation and outlines the three distinct skills that follow: starting, maintaining, and ending a conversation. Then one skill, such as greeting, is introduced. The following week, another skill is taught (e.g., making a comment) while the first skill (greeting) continues to be practiced and reinforced. In the next week, yet another skill is added (e.g., asking a question), as the previous two skills continue to be practiced and reinforced. In the fourth week, all three of the previously isolated skills are integrated (e.g., greet a peer: “Hi, Mike!”, make a comment: “I like your picture”, then ask a question: “How did you do it?”). In the final week, the skills are practiced in less structured and more typical environments during a community outing; for example, the group gathers at a local restaurant and practices conversation skills while eating pizza.

A similar sequential and progressive plan should exist across the curriculum units. Skills learned in the first unit should be relevant to and practiced in the subsequent units. For example, eye contact is first introduced as an isolated skill in Unit One, Basic Interactional Skills. In Unit Two, Conversation Skills, group members are regularly reminded to point their eyes at their peers as they learn to greet, make comments, and ask questions. In Unit Three, Play and Friendship, the kids, as needed, are encouraged to make eye contact and use appropriate greetings as they learn to share and take turns with others, and so forth.

Programmed generalization and ongoing practice—

Skill mastery and generalization require significant practice and repetition in a variety of settings. As described earlier, providing multiple and varied learning opportunities promotes generalization, as does practice of skills in more naturalistic settings through community outings. Another way to promote generalization is to practice skills with a variety of different people. Unfamiliar adults or peers can be invited to group parties or to snack so that kids have the opportunity to practice their new skills with others.

When group social skill intervention is provided in a clinic setting, transfer of skills to the home or school also can be enhanced through “generalization activities” (akin to homework). A written handout can be provided to moms and dads, teachers, or others, briefly describing the week's target skill and describing a specific activity that practices this skill outside of the group. For example, to generalize conversation skills, moms and dads might be prompted to ask their youngster to tell them three things that happened at school each day, using visual prompts (e.g., photographs or relevant objects) or multiple-choice lists as necessary. Or kids might call another group member on the phone to practice back-and-forth conversation, using a list of prearranged topics or a script as necessary. Generalization may be further enhanced through a concurrent parent training group that apprises moms and dads of the skills their kids are learning and provides ideas on how to practice the skills or implement specific techniques at home or in the neighborhood.

Generalization of behaviors learned in a social skills group to the “real world” may be greater when the group is offered in a natural social setting, such as a school. At the least, the same training model and format described in this article can be implemented in a school, rather than a clinic. Additional methods will likely be necessary to generalize such training to more natural school settings, however, if the training is conducted in a segregated setting (e.g., a separate room, with special education personnel). Written handouts describing the youngster's target skills and individual goals can be provided to the classroom teacher or other school staff. The handout might identify natural opportunities throughout the school day when staff can prompt students to use their skills with peers (e.g., during a small group classroom activity, at lunch). A description of how to best prompt the youngster can be included. It is ideal if classroom teachers or other relevant school staff have the opportunity to observe the social skills group to learn and use the same prompting techniques and teaching strategies. Generalization also might be enhanced by including the social skills group leader in the Individualized Education Plan meeting so that social skills goals can be included in the youngster's overall educational goals and objectives. The benefits of offering social skills intervention and generalization within the school setting include teaching skills in the environment in which they will be used, creating positive social communities with peers who interact daily, and having regular contact among staff members who can promote skill use in natural settings.

More resources for parents of children and teens with High-Functioning Autism and Asperger's:

==> How To Prevent Meltdowns and Tantrums In Children With High-Functioning Autism and Asperger's

==> Parenting System that Significantly Reduces Defiant Behavior in Teens with Aspergers and High-Functioning Autism

==> Launching Adult Children with Asperger's and High-Functioning Autism: Guide for Parents Who Want to Promote Self-Reliance

==> Teaching Social Skills and Emotion Management to Children and Teens with Asperger's and High-Functioning Autism

==> Parenting Children and Teens with High-Functioning Autism: Comprehensive Handbook

==> Unraveling The Mystery Behind Asperger's and High-Functioning Autism: Audio Book


==> Parenting System that Reduces Problematic Behavior in Children with Asperger's and High-Functioning Autism

Aspergers Tantrums, Rage, and Meltdowns

At the moment if the situations are not done exactly his way he has a meltdown. Symptoms are: Extreme ear piercing screaming, intense crying, to falling down on the floor saying he is going to die. I have tried to tell him to breathe but his meltdown is so intense that his body just can't listen to words. 

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