Ashley, who was three-years old at the time, had bright blue eyes and tawny hair. She was evaluated at our clinic for possible autism services. She was alert, but exhibited very little eye contact, was preoccupied with playing with a toy merry-go-round and associated animals, and she talked incessantly, using vocabulary far beyond her age. Though she talked she didn’t seem to listen to adult responses to her comments. Any attempt to redirect her led to a severe tantrum with screaming and hitting. She was overwhelmed with intolerance for change and perfectionism. She had little self-regulation and exhibited little empathy. Today, after 18 months of naturalistic early behavioral intervention, she is enrolled in a regular education science magnet school and is largely indistinguishable from her peers.
Yasar was also three years old at intake assessment. His sparkling dark brown eyes gave his facial expression a mischievous quality. His family was bilingual, but intervention was in English. He exhibited no eye contact at program onset. He was a whirling dervish of non-stop physical activity, climbing on and under furniture. He paid little attention to adult direction. If his parents forced him to stop one activity and begin another, he descended into a tantrum. He had little empathy, except for his older brother Jamal. Despite these limitations he had a surprisingly large vocabulary and learned very rapidly. It was obvious that he was very bright. He was intensively preoccupied with vehicles and Legos as well as several other construction activities. He and his brother were constantly fighting over access to toys. Therapy was largely discrete trial at the beginning and gradually transitioned, so for the last year it was entirely naturalistic. After three years of intervention, he is now enrolled in a regular education classroom without special education support.
Ashley and Yasar are typical of the children diagnosed with Asperger Disorder by their referring mental health professionals who have been referred to our clinic. The challenge was to develop early behavioral intervention strategies that matched their developmental profiles. This article provides background about Asperger Disorder, how it differs from Autism (or doesn’t), and implications for intervention.
HANS ASPERGER: An Austrian pediatrician, Hans Asperger, published an article in Februrary 1944 that described the behavior of four boys, who were between the ages of 6 and 1l years of age whom he identified as exhibiting a pattern of behavior and abilities that he called "autistic psychopathy." The pattern included a lack of empathy, little ability to form friendships, one-sided conversation, intense absorption in a special interest, and clumsy movements. Hans Asperger called children with AS, "little professors" because of their ability to talk about their favorite subject in great detail. The children Asperger identified did not engage in ma
Asperger employed an empathetic nurse named Sister Viktorine, or Viktorine Zak, as she was called. They opened a school for children with AS in October 1944 that provided music, speech therapy, play and exercise. However, the school only lasted for four months. It was destroyed during an allied air raid in February 1945. Sister Viktorine was killed, and as a result, much of Hans Asperger's work was lost. Asperger’s original 1944 article was finally translated into English by Utta Frith in 1991 in her book Autism and Asperger. Hans Asperger, who some people believe demonstrated Asperger behavioral traits himself, died in Vienna on Tuesday 21st October 1980, at the age of 74. [From Kevin Phillips Asperger's Syndrome site]
DIAGNOSIS: According to modern diagnostic criteria (DSM-IV TR) to qualify for an AS diagnosis the child must exhibit at least two fo the following:
A) marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction
(B) failure to develop peer relationships appropriate to developmental level
(C) a lack of spontaneous seeking to share enjoyment, interest or achievements with other people, (e.g.. by a lack of showing, bringing, or pointing out objects of interest to other people)
(D) lack of social or emotional reciprocity.
In addition, the child must also exhibit at least one of the following:
Restricted repetitive & stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following:
• (A) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
• (B) apparently inflexible adherence to specific, nonfunctional routines or rituals
• (C) stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements)
• (D) persistent preoccupation with parts of objects
In addition, the child must have no clinically significant general delay in language (e.g. single words used by age 2 years, communicative phrases used by age 3 years) and have no clinically significant delay in cognitive development or in the development of age-appropriate self help skills, adaptive behavior (other than in social interaction) and curiosity about the environment in childhood. To meet the diagnostic criteria for AS, the foregoing symptoms must interfere with daily family social interactions and ability to function in the school and community. Although it not required for diagnosis, physical clumsiness and atypical use of language (often called hyperlexia) are frequently reported.
CONTROVERSIES; Controversies about AS persists in two respects. Increasingly, many experts doubt that Asperger Disorder is really qualitatively distinct from high functioning autism. It has been proposed that the diagnosis of Asperger's be eliminated, to be replaced by a diagnosis of autism spectrum disorder on a severity scale in DSM-V. This view is strongly opposed by professionals as well as parents and individuals with AS.
A second controversy concerns whether Asperger Disorder is different from Non-Verbal Learning Disability (NLVD), which shares many (most?) features. Some researchers (often neuropsychologists) have reported differences, such as the NLD group showing particular difficulty on visual-spatial, visual-motor, and abstract reasoning measures compared to the AS group. Other research indicates the NLD and AS groups both experience difficulty understanding emotional and nonverbal cues, and show more signs of sadness and social withdrawal compared to the other groups of children (e.g. ADHD). As a practical matter, intervention strategies for HFA, NLVD and Asperger Disorder are not distinctively different. Many Occupational Therapists emphasize the hypothesized executive function and visual perceptual motor function difficulties in NLVD (contrasted with HFA and Asperger Disorder), but it is noteworthy that both of the latter share similar features.
In practice, early behavioral intervention for children with AS will be similar to that for children with NLVD, with emphasis on effective communication, social skills and organization.
Bibliography
Asperger, H. (1944). Die 'aunstisehen Psychopathen' im Kindesalter. Archiv fur psychiatrie und Nervenkrankheiten117,76-136.
Frith, U. (1991) Autism and Asperger. Cambridge University Press.
Kamp-Becker, I. et. al. (2010) Categorical and dimensional structure of autism spectrum disorders: the nosologic validity of Asperger Syndrome. J. Autism Dev. Disord. 40: 921-9.
Semrud-Clikeman, M. et. al. (2010)Neuropsychological differences among children with Asperger syndrome, nonverbal learning disabilities, attention deficit disorder, and controls. Dev Neuropsychol. 35: 582-600.
Semrud-Clikeman, M. et.al. (2010) Direct and indirect measures of social perception, behavior, and emotional functioning in children with Asperger's disorder, nonverbal learning disability, or ADHD. J. Abnorm. Child Psychol. 38: 509-19.
Williams, DL, et. al. (2008) Do individuals with high functioning autism have the IQ profile associated with nonverbal learning disability? Res. Autism Spect. Disord. 2: 353-61.
Wing, L. (1981) Asperger Syndrome: A Clinical Account. Psychological Medicine. 11: 115-129
[* The children’s names are fictitious to protect confidentiality, but they refer to actual children with AS]