Asperger syndrome

Asperger syndrome
Specialty	Psychiatry

Asperger syndrome (also referred to as Asperger's syndrome, Asperger's disorder, Asperger's, or AS) is a disorder on the autistic spectrum. It manifests in various ways and can have both positive and negative effects on a person. It is typically characterized by issues with social and communication skills. Due to the mixed nature of its effects, it remains controversial among researchers, physicians, and people who are diagnosed with Asperger's Syndrome.

Asperger syndrome is not differentiated from other autistic spectrum disorders by a minority of clinicians who instead refer to it as high-functioning autism (HFA) because the claim that the normal early development and lack of any language delay mean that the symptoms differ only in degree from classic autism. Early in life people with AS can have learning disabilities. However, IQ tests may show superior intelligence or very high memory capacity in diagnosed individuals.

The diagnosis of AS is complicated because of the lack of standardized diagnostic criteria. Instead, several different screening instruments and sets of diagnostic criteria are used. AS is often not identified in early childhood, and many individuals are not diagnosed until they are adults. Assistance for core symptoms of AS consists of therapies that apply behaviour management strategies and address poor communication skills, obsessive or repetitive routines, and physical clumsiness. Many individuals with AS can adopt strategies for coping and do lead fulfilling lives - being gainfully employed, having successful relationships, and having families. In most cases, they are aware of their differences and can recognize if they need any support to maintain an independent life.

History

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Dr. Hans Asperger, after whom the syndrome is named.

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Dr. Asperger described his young patients as "little professors".

Asperger syndrome was named in honor of Hans Asperger by the English psychiatrist Lorna Wing, who first used the term in a 1981 paper. In 1994, AS was recognized in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as Asperger's Disorder.

In 1944, Hans Asperger (1906–1980), an Austrian psychiatrist and pediatrician, observed four children in his practice who had difficulty integrating socially. Although their intelligence appeared normal, the children lacked nonverbal communication skills, failed to demonstrate empathy with their peers, and were physically clumsy. Their way of speaking was either disjointed or overly formal, and their all-absorbing interest in a single topic dominated their conversations. Dr. Asperger called the condition “autistic psychopathy” and described it as a condition primarily marked by social isolation. He also stated that "exceptional human beings must be given exceptional educational treatment, treatment which takes into account their special difficulties. Further, we can show that despite abnormality, human beings can fulfill their social role within the community, especially if they find understanding, love and guidance".

The Austrian-American child psychiatrist Leo Kanner identified a very similar syndrome in 1943, although the population characterized by Kanner was perhaps less "socially functional" than Asperger's. Kannerian autism is therefore characterized by significant cognitive and communicative deficiencies, including delays in language development or complete lack of language. (In contrast, AS is characterized by normal language acquisition.)

Asperger’s observations, published in German, were not widely known until 1981, when Lorna Wing published a series of case studies of children showing similar symptoms, which she called "Asperger’s Syndrome". Wing’s writings were widely published and popularized. In 1992, the tenth published edition of the World Health Organization’s diagnostic manual and the International Classification of Diseases (ICD-10) included AS, making it a distinct diagnosis. Later, in 1994, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the American Psychiatric Association’s diagnostic reference book also added AS.

Uta Frith (an early researcher of Kannerian autism) wrote that people with AS seem to have more than a touch of autism to them. Others, such as Lorna Wing and Tony Attwood, share Frith's assessment. Dr. Sally Ozonoff, of the University of California at Davis's MIND Institute, argues that there should be no dividing line between "high-functioning" autism and AS, and that the fact that some people do not start to produce speech until a later age is no reason to divide the two groups because they are identical in the way they need to be treated.

In January 2006, Professor Simon Baron-Cohen of the University of Cambridge, regarded as one of the leading current researchers in this field, proposed the theory that people with AS tend to hyper-systemise; that they tend to seek to approach all spheres of life, including the social sphere, by developing systems or sets of laws to operate to.

Classification and diagnosis

Asperger's Disorder (Asperger Syndrome) is defined in section 299.80 of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) by six main criteria:

1. Qualitative impairment in social interaction;
2. The presence of restricted, repetitive and stereotyped behaviors and interests;
3. Significant impairment in important areas of functioning;
4. No significant delay in language;
5. During the first three years of life, there can be no clinically significant delay in cognitive development such as curiosity about the existing environment or the acquisition of age appropriate learning skills, self-help skills, or adaptive behaviors (other than social interaction); and,
6. The symptoms must not be better accounted for by another specific pervasive developmental disorder or schizophrenia.

AS is an autism spectrum disorder (ASD), one of five neurological conditions characterized by difference in language and communication skills, as well as repetitive or restrictive patterns of thought and behavior. The four related disorders or conditions are autism, Rett syndrome, childhood disintegrative disorder, and PDD-NOS (pervasive developmental disorder not otherwise specified).

The diagnosis of AS is complicated by the use of several different screening instruments. The diagnostic criteria of the Diagnostic and Statistical Manual are criticized for being vague and subjective. Other sets of diagnostic criteria for AS are the ICD 10 World Health Organization Diagnostic Criteria, Szatmari Diagnostic Criteria, Gillberg Diagnostic Criteria, and Attwood & Gray Discovery Criteria. The ICD-10 definition has similar criteria to the DSM-IV version. Asperger's syndrome had at different times been called Autistic psychopathy and Schizoid disorder of childhood, although those terms are now understood as archaic and inaccurate, and are therefore no longer accepted in common use.

Some doctors believe that AS is not a separate and distinct disorder, referring to it as high functioning autism (HFA). The diagnoses of AS or HFA are used interchangeably, complicating prevalence estimates: the same child can receive different diagnoses, depending on the screening tool the doctor uses, and some children will be diagnosed with HFA instead of AS, and vice versa. Many experienced clinicians apply the early onset of High Functioning Autism or the regressive pattern of development as the distinguishing factor in differentiating between AS and HFA. The current classification of the pervasive developmental disorders (PDDs) is unsatisfying to many parents, clinicians, and researchers, and may not reflect the true nature of the conditions. Peter Szatmari, a Canadian researcher of PDD, feels that greater precision is needed to better differentiate between the various PDD diagnoses. The DSM-IV and ICD-10 focus on the idea that discrete biological entities exist within PDD, which leads to a preoccupation with searching for cross-sectional differences between PDD subtypes rather than recognition of the conditions as distinct points on a spectrum, a strategy which has not been very useful in classification or in clinical practice.

A self-diagnosis tool now commonly used, including within Aspie communities, is the AQ (Asperger Quotient) questionnaire developed by Professor Simon Baron-Cohen. This can be found here and elsewhere on the Internet. However note the caveats; as above, Asperger conditions vary widely.

Clinical features

AS is characterized by:

• Narrow interests or preoccupation with a subject to the exclusion of other activities
• Repetitive behaviors or rituals
• Peculiarities in speech and language
• Extensive logical/technical patterns of thought
• Socially and emotionally inappropriate behavior and interpersonal interaction
• Problems with nonverbal communication
• Clumsy and uncoordinated motor movements

The most common and important characteristics of AS can be divided into several broad categories: social impairments, narrow but intense interests, and peculiarities of speech and language. Other features are commonly associated with this syndrome, but are not always regarded as necessary for diagnosis. This section mainly reflects the views of Attwood, Gillberg, and Wing on the most important characteristics of AS; the DSM-IV criteria represent a slightly different view. Unlike most forms of PDDs, AS is often camouflaged, and many people with the disorder blend in with those who do not have it. The effects of AS depend on how an affected individual responds to the syndrome itself.

Social differences

Although there is no single feature that all people with AS share, difficulties with social behavior are nearly universal and are one of the most important defining criteria. People with AS may lack the ability to communicate their own emotional state (alexithymia) and the natural ability to see the subtexts of social interaction, resulting in well-meaning remarks that may offend, or finding it hard to know what is "acceptable". The unwritten rules of social behavior that mystify so many with AS have been termed the "hidden curriculum". People with AS must learn these social skills intellectually through seemingly contrived, dry, math-like logic rather than intuitively through normal emotional interaction.

Non-autistics are able to gather information about other people's cognitive and emotional states based on clues gleaned from the environment and other people's facial expression and body language, but, in this respect, people with AS are impaired; this is sometimes called mind-blindness. Mind-blindness is also known as a lack of theory of mind. Without theory of mind, AS individuals lack the ability to recognize and understand the thoughts and feelings of others. Deprived of this insightful information, they are unable to interpret or understand the desires or intentions of others and thereby are unable to predict what to expect of others or what others may expect of them. This often leads to social awkwardness and inappropriate behavior. In Asperger's Syndrome: Intervening in Clinics, Schools and Communities, Tony Attwood categorizes the many ways that lack of "theory of mind" can negatively impact the social interactions of people with Asperger's:

1. Difficulty reading the social and emotional messages in the eyes: those with AS don't look at eyes often, and when they do, they can't read them.
2. Making literal interpretation: AS individuals have trouble interpreting colloquialisms, sarcasm, and metaphors.
3. Being considered disrespectful and rude: prone to egocentric behavior, individuals with Asperger's miss cues and warning signs that this behavior is inappropriate.
4. Honesty and deception: children with Asperger's are often considered "too honest", and may even proclaim themselves to be "honest" or "frank" as a way of explaining their behavior. They have difficulty being deceptive, even at the expense of hurting someone's feelings.
5. Inadequate nonverbal communication: their facial expressions, hand gestures, and other forms of body language, are usually limited.
6. Becoming aware of making social errors: as children with Asperger's mature, and become aware of their inability to connect, their fear of making a social mistake, and their self-criticism when they do so, can lead to social phobia.
7. Differences in speech: they display less speech intonation than neurotypical persons. Their speech may be perceived as "flat". However, those with AS also possess superficial fluency in day-to-day conversation.
8. A sense of paranoia: because of their inability to connect, persons with Asperger's have trouble distinguishing the difference between the deliberate or accidental actions of others, which can in turn lead to a feeling of paranoia.
9. Managing conflict: being unable to understand other points of view can lead to inflexibility and an inability to negotiate conflict resolution. Once the conflict is resolved, remorse may not be evident.
10. Awareness of hurting the feelings of others: a lack of empathy often leads to unintentionally offensive or insensitive behaviors.
11. Repairing someone's feelings: lacking intuition about the feelings of others, people with AS have little understanding of how to console someone or how to make them feel better.
12. Recognizing signs of boredom: inability to understand other people's interests can lead AS persons to be inattentive to others. Conversely, people with AS often fail to notice when others are uninterested.
13. Introspection and self-consciousness: individuals with AS have difficulty understanding their own feelings or their impact on the feelings of other people.
14. Clothing and personal hygiene: people with AS tend to be less affected by peer pressure than others. As a result, they often do what is comfortable and are unconcerned about their impact on others.
15. Reciprocal love and grief: since people with AS have difficulty emotionally, their expressions of affection and grief are often short and weak.
16. Lack of participation in chitchat: they are not generally interested in, and do not participate in idle chat and gossip.
17. Preference of routine: they prefer routine work, and are not able to cope well to changes, even small ones. Such disruptions from routine can cause stress and anxiety.
18. Coping with criticism: people with AS are compelled to correct mistakes, even when they are made by someone in a position of authority, such as a teacher. For this reason, they can be unwittingly offensive.
19. Formal mannerisms and etiquette: their etiquette is formal, even within the family. Their speech may be interlaced with "thank you" or "please" or "good evening" more than necessary. Some persons with AS may even insist that other members of their family follow this ritual.
20. Speed and quality of social processing: because they respond through reasoning and not intuition, AS individuals tend to process social information more slowly than the norm, leading to uncomfortable pauses or delays in response. This means that although the AS individual will tend to make a more reasoned and balanced understanding and/or decision, it can lead to the AS individual being told to use their 'common sense' to solve problems, a concept they cannot understand or use in the way a neurotypical person can.
21. Faithfulness towards family: people with AS are staunchly faithful to their spouses and/or immediate members of their family.
22. Exhaustion: as people with AS begin to understand theory of mind, they must make a deliberate effort to process social information. This often leads to mental exhaustion.

A person with AS may have trouble understanding the emotions of other people: the messages that are conveyed by facial expression, eye contact and body language are often missed. They also might have trouble showing empathy with other people. Thus, people with AS might be seen as egotistical, selfish or uncaring. In most cases, these are unfair labels because affected people are neurologically unable to understand other people's emotional states. They are usually shocked, upset and remorseful when told that their actions are hurtful or inappropriate. It is clear that people with AS do not lack emotions. The concrete nature of emotional attachments they might have (i.e., to objects rather than to people), however, often seems curious or can even be a cause of concern to people who do not share their perspective. This deficit in the ability to read one's own and other's emotions goes by the name alexithymia, a Greek term coined in 1972 by P.E. Sifneos meaning literally "lack of words for emotions." Recent studies have confirmed that 85% of people with ASD's have alexithymia, a finding which raises important questions for future research regarding how to explain the high co-morbidity. According to Tony Attwood, alexithymia may also account for difficulties AS individuals have with anger management where the inability to express feelings using words predisposes the individual to use physical acts to articulate the mood and release the emotional energy.

The problem may be exacerbated by the responses of those neurotypical people who interact with AS-affected persons. An Asperger patient's apparent emotional detachment may confuse and upset a neurotypical person, who may in turn react illogically and emotionally — reactions that many Asperger patients find especially irritating. This can often become a vicious cycle and can sometimes cause families with Asperger-affected members to become especially dysfunctional.

Failing to show affection — or failing to do so in conventional ways — does not necessarily mean that people with AS do not feel affection. Understanding this can lead partners or care-givers to feel less rejected and to be more understanding. Increased understanding can also come from learning about AS and any comorbid disorders. Sometimes, the opposite problem occurs: the person with AS is unusually affectionate to significant others; and misses or misinterprets signals from the other partner, causing the partner stress.

Another important aspect of the social differences often found in people with Asperger's is a lack of central coherence. People who have poor central coherence may be so focused on details that they miss "the big picture". A person with a central coherence deficit might remember a story or an incident in great detail but be unable to make a statement about what the details mean. Another might understand a set of rules in detail but be unclear how or where they apply. Frith and Happe explore the possibility that attention to details may be a bias rather than a deficit. There certainly appear to be many advantages to being detail-oriented, particularly in activities and professions that require a high level of meticulousness. One also can see that this would cause problems if most non-autistic (but certainly not all) people are able to move fluidly between detail and big-picture orientations.

Speech and language differences

People with AS typically have a highly pedantic way of speaking, using a far more formal language register than appropriate for a context. A five-year-old child with this condition may regularly speak in language that could easily have come from a university textbook, especially concerning his or her special area of interest.

Literal interpretation is another common, but not universal, hallmark of this condition. Attwood gives the example of a girl with AS who answered the telephone one day and was asked, "Is Paul there?" Although the Paul in question was in the house, he was not in the room with her, so after looking around to ascertain this, she simply said "no" and hung up. The person on the other end had to call back and explain to her that he meant for her to find him and get him to pick up the telephone.

Individuals with AS may use words idiosyncratically, including new coinages and unusual juxtapositions. This can develop into a rare gift for humor (especially puns, word play, doggerel and satire). A potential source of humor is the eventual realization that their literal interpretations can be used to amuse others. Some are so proficient at written language as to qualify as hyperlexic. Tony Attwood refers to a particular child's skill at inventing expressions, e.g., "tidying down" (the opposite of tidying up) or "broken" (when referring to a baby brother who cannot walk or talk).

Children with AS may show advanced abilities for their age in language, reading, mathematics, spatial skills, or music, sometimes into the 'gifted' range, but these talents may be counterbalanced by appreciable delays in the development of other cognitive functions. Some other typical behaviors are echolalia, the repetition or echoing of verbal utterances made by another person, and palilalia, the repetition of one's own words.

A 2003 study investigated the written language of children and youth with AS. They were compared with neurotypical peers in a standardized test of written language skills and legibility of handwriting. In written language skills, no significant differences were found between standardized scores of both groups; however, in hand-writing skills, the AS participants produced significantly fewer legible letters and words than the neurotypical group. Another analysis of written samples of text, found that people with AS produce a similar quantity of text to their neurotypical peers, but have difficulty in producing writing of quality.

Tony Attwood states that a teacher may spend considerable time interpreting and correcting an AS child's indecipherable scrawl. The child is also aware of the poor quality of his or her handwriting and may be reluctant to engage in activities that involve extensive writing. Unfortunately for some children and adults, high school teachers and prospective employers may consider the neatness of handwriting as a measure of intelligence and personality. The child may require assessment by an occupational therapist and remedial exercises, but modern technology can help minimize this problem. A parent or teacher aide could also act as the child's scribe or proofreader to ensure the legibility of the child's written answers or homework.

Narrow, intense interests

AS in children can involve an intense and obsessive level of focus on things of interest, many of which are those of ordinary children. The difference in children with AS is the unusual intensity of the interest. Some have suggested that these "obsessions" are essentially arbitrary and lacking in any real meaning or context; however, researchers note that these "obsessions" typically focus on the mechanical (how things work) as opposed to the psychological (how people work). Those with an artistic proclivity may be more interested in music or art, rather than in fiction.

Sometimes these interests are lifelong; in other cases, they change at unpredictable intervals. In either case, there are normally only one or two interests at any given time. The interests are often linked in some way that is logical only to the AS individual. In pursuit of these interests, people with AS often manifest extremely sophisticated reasoning, an almost obsessive focus, and a remarkably good memory for trivial facts (occasionally even eidetic memory). Hans Asperger called his young patients "little professors" because he thought his patients had as comprehensive and nuanced an understanding of their field of interest as university professors.

Some clinicians do not entirely agree with this description. For example, Wing and Gillberg both argue that, in children with AS, these areas of intense interest typically involve more rote memorization than real understanding, despite occasional appearances to the contrary. Such a limitation is an artifact of the diagnostic criteria, even under Gillberg's criteria, however.

People with AS may have little patience for things outside these narrow interests. In school, they may be perceived as highly intelligent underachievers or overachievers, clearly capable of outperforming their peers in their field of interest, yet persistently unmotivated to do regular homework assignments (sometimes even in their areas of interest). Others may be hypermotivated to outperform peers in school. Symptoms may be seen by obsessional absorption with inanimate objects, such as watches and clocks; or a predominant interest in systematic things like numbers, indices, telephone directories, encyclopedias, dictionaries, and measuring scales. The combination of social problems and intense interests can lead to unusual behavior, such as greeting a stranger by launching into a lengthy monologue about a special interest rather than introducing oneself in the socially accepted way. However, in many cases adults can outgrow this impatience and lack of motivation and develop more tolerance to new activities and meeting new people.

Other differences

Those affected by AS may show a range of other sensory, developmental, and physiological anomalies. Children with AS may evidence a slight delay in the development of fine motor skills. In some cases, people with AS may have an odd way of walking, and may display compulsive finger, hand, arm or leg movements, including tics and stims.

In general, orderly things appeal to people with AS. Some researchers mention the imposition of rigid routines (on self and/or others) as a criterion for diagnosing this condition. It appears that changes to their routines cause inordinate levels of anxiety for some people with this condition.

Some people with AS experience varying degrees of sensory overload and are extremely sensitive to touch, smells, sounds, tastes, and sights. They may prefer soft clothing, familiar scents, or certain foods. Some may even be pathologically sensitive to loud noises (as some people with AS have hyperacusis), strong smells, or dislike being touched; for example, certain children with AS exhibit a strong dislike of having their head touched or their hair disturbed while others like to be touched but dislike loud noises. Sensory overload may exacerbate problems faced by such children at school or indeed adults at work, where levels of noise in the classroom/workplace can become intolerable for them. Some are unable to block out certain repetitive stimuli, such as the constant ticking of a clock. Whereas most children stop registering this sound after a short time and can hear it only if they consciously attend to it, a child with AS can become distracted, agitated, or even (in cases where the child has problems with regulating emotions such as anger) aggressive if the sound persists.

Strip-lighting, and computer monitors at low refresh rates (either of which may often be encountered in schools) can be very disturbing visual stimuli for AS people, contributing to otherwise inexplicable headaches, bad moods and agitation.

Also related to sensory overload, is that AS children can have or appear to have irrational fears, for example, closed doors, flushing toilets.

A study of parent measures of child temperament found that children with autism were rated as presenting with more extreme scores than typically-developing children.

Clinical perspective

Research

Some research is to seek information about symptoms to aid in the diagnostic process. Other research is to identify a cause, although much of this research is still done on isolated symptoms. Many studies have exposed base differences in areas such as brain structure. To what end is currently unknown; research is ongoing, however.

Peter Szatmari suggests that AS was promoted as a diagnosis to spark more research into the syndrome: "It was introduced into the official classification systems in 1994 and has grown in popularity as a diagnosis, even though its validity has not been clearly established. It is interesting to note that it was introduced not so much as an indication of its status as a 'true' disorder, but more to stimulate research ... its validity is very much in question."

Research into causes

Main article: Causes of autism

The direct cause(s) of AS is unknown. Even though no consensus exists for the cause(s) of AS, it is widely accepted that AS has a hereditary factor. It is suspected that multiple genes play a part in causing AS, since the number and severity of symptoms vary widely among individuals. Studies regarding the mirror neurons in the inferior parietal cortex have revealed differences which may underlie certain cognitive anomalies such as some of those which AS exhibits (e.g., understanding actions, learning through imitation, and the simulation of other people's behavior). Non-neurological factors such as poverty, lack of sleep, substance abuse by the mother during pregnancy, discrimination, trauma during early childhood, and abuse may also contribute.

Other possible causative mechanisms include a serotonin dysfunction and cerebellar dysfunction. Simon Baron-Cohen proposes a model for autism based on his empathising-systemising (E-S) theory. The E-S theory holds that the female brain is predominantly hard-wired for empathy, while the male brain is predominantly hard-wired for understanding and building systems, and that AS is an extreme of the male brain.

Some genetic studies point to involvement of neuroligins in AS. Neuroligins are a family of proteins thought to mediate cell-to-cell interactions between neurons. Neuroligins function as ligands for the neurexin family of cell surface receptors. Mutations in two X-linked genes encoding neuroligins NLGN3 and NLGN4 have been reported. These mutations affect cell-adhesion molecules localized at the synapse and suggest that a defect of synaptogenesis may predispose to autism.

In 2006 a group of French researchers, lead by Thomas Bourgeron from the Institut Pasteur, published in the journal Nature Genetics their work relating anomalies in chromosome 22 to the diagnosis of Autism and Asperger syndrome in five children. The distal tip of the long arm of the chromosome 22 contains the SHANK3 gene, which is supposed to have a role in the maturation and maintenance of brain synapses. The deletion of this part of the chromosome was found in low-functioning autistic subjects (See 22q13 deletion syndrome), and its duplication was found in a subject diagnosed with Asperger's Syndrome.

Other research

There are other studies linking autism with differences in brain-volumes such as enlarged amygdala and hippocampus. Current research points to structural abnormalities in the brain as a cause of AS. These abnormalities impact neural circuits that control thought and behavior. Researchers suggest that gene/environment interactions cause some genes to turn on or turn off, or turn on too much or too little in the wrong places, and this interferes with the normal migration and "wiring" of embryonic brain cells during early development.

Other finds include brain region differences, such as decreased gray matter density in portions of the temporal cortex which are thought to play into the pathophysiology of ASDs (particularly in the integration of visual stimuli and affective information), and differing neural connectivity. Research on infants points to early differences in reflexes, which may be able to serve as an "early detector" of AS and autism.

Some professionals believe AS is not necessarily a disorder and thus should not be described in medical terms.

Treatment

Main article: Autism therapies

The preferred treatment coordinates therapies that address three core symptoms of Asperger's syndrome: poor communication skills, obsessive or repetitive routines, and physical clumsiness. AS and high-functioning autism may be considered together for the purpose of clinical management.

A typical treatment program generally includes:

• social skills training, to teach the skills to more successfully interact with others;
• cognitive behavioral therapy, to help in better managing emotions that may be explosive or anxious, and to cut back on obsessive interests and repetitive routines;
• medication, for co-existing conditions such as depression, anxiety, and ADD/ADHD;
• nutrition, related to improvement of Asperger tendencies, such as magnesium/vitaminB6 tablets. Gluten (wheat) and dairy-free diets are sometimes proposed, although there appear few studies supporting these;
• occupational or physical therapy, to assist with sensory integration problems or poor motor coordination;
• specialized speech therapy, to help with the trouble of the "give and take" in normal conversation;
• parent training and support, to teach parents behavioral techniques to use at home; and,
• counseling to support individuals with AS to increase self-awareness skills and to help them develop and manage the emotions around social experiences.

The techniques described above will not cure AS, but help those diagnosed with AS better function in society.

Many studies have been done on early behavioral interventions. Most of these are single case with one to five participants. The single case studies are usually about controlling non-core autistic problem-behaviors like self-injury, aggression, noncompliance, stereotypies, or spontaneous language. Packaged interventions such as those run by UCLA or TEACCH are designed to treat the entire syndrome and have been found to be somewhat effective.

Behavioral interventions, such as Applied Behavior Analysis (ABA), have been researched for many years. Empirical data demonstrate its effectiveness in the treatment of autism spectrum disorders because it is an individualized set of programs. In addition, ABA has the benefits of individualized functional analyses of exhibited behaviors. In 1982 Becker and Gersten found that ABA techniques were indeed educationally beneficial because they provide "motivational programs based on positive reinforcement such as a token system and a systematic task analysis for developing academic skills". ABA also promotes the foundation for academic and living skills. Once certain skills have been acquired, it is possible through ABA to generalize these skills and add new skills to the "existing repertoire through various techniques of shaping, extinction, backward chaining, and prompting". (Schreibman, 1975, Sulzer & Mayer, 1972, Wolery et al, 1988)

Unintended side effects of medication and intervention have largely been ignored in the literature about treatment programs for children or adults, and there are claims that some treatments are not ethical and do more harm than good.

Prognosis

People with AS usually have normal lifespans but have an increased prevalence of comorbid psychiatric conditions such as depression, mood disorders, and obsessive-compulsive disorder.

Children with normal IQs (above 70) who have AS are seen to improve naturally. This may be relevant to the validity of purported 'cures' for various forms of autism spectrum disorder (ASD) which claim success without correcting for the natural course of improvement. Developmental pediatrician James Coplan, M.D., states, "We can offer the hopeful message to parents that many children with ASD will improve as part of the natural course of the condition."

Children with AS can learn to manage their differences, but they may continue to find social situations and personal relationships challenging. Adults with AS are able to work successfully in mainstream jobs and live an independent life.

Individuals with AS may make great intellectual contributions: published case reports suggest an association with accomplishments in art, music, engineering, computer science, mathematics, and physics. The deficits associated with AS may be debilitating, but many individuals experience positive outcomes, particularly those who are able to excel in areas less dependent on social interaction, such as mathematics, music, and the sciences.

In fact, AS may be a highly significant factor behind many valuable contributions in the fields and areas that benefit most from the type of thinking and attention to detail that only individuals with AS are able to put forward.

Epidemiology

The prevalence of AS is not well established, but conservative estimates using the DSM-IV criteria indicate that two to three of every 10,000 children have the condition, making it rarer than autistic disorder itself. Three to four times as many boys have AS compared with girls. The universality of AS across races, and validity of epidemiologic studies to date, is questioned.

A 1993 broad-based population study in Sweden found that 36 per 10,000 school-aged children met Gillberg's criteria for AS, rising to 71 per 10,000 if suspected cases are included. The estimate is convincing for Sweden, but the findings may not apply elsewhere because they are based on a homogeneous population. The Sweden study demonstrated that AS may be more common than once thought and may be currently underdiagnosed. Gillberg estimates 30–50% of all persons with AS are undiagnosed. A survey found that 36 per 10,000 adults with an IQ of 100 or above may meet criteria for AS.

Leekam et al. documented significant differences between Gillberg's criteria and the ICD-10 criteria. Considering its requirement for "normal" development of cognitive skills, language, curiosity and self-help skills, the ICD-10 definition is considerably more narrow than Gillberg's criteria, which more closely matches Hans Asperger's own descriptions.

Like other autism spectrum disorders, AS prevalence estimates for males are higher than for females, but some clinicians believe that this may not reflect the actual incidence rates. Tony Attwood suggests that females learn to compensate better for their impairments due to gender differences in the handling of socialization. The Ehlers & Gillberg study found a 4:1 male to female ratio in subjects meeting Gillberg's criteria for AS, but a lower 2.3:1 ratio when suspected or borderline cases were included.

The prevalence of AS in adults is not well understood, but Baron-Cohen et al. documented that 2% of adults score higher than 32 in his Autism Spectrum Quotient (AQ)questionnaire, developed in 2001 to measure the extent to which an adult of normal intelligence has the traits associated with autism spectrum conditions. All interviewed high-scorers met at least 3 DSM-IV criteria, and 63% met threshold criteria for an ASD diagnosis; a Japanese study found similar AQ Test results.

Comorbidities

Main article: Conditions comorbid to autism spectrum disorders

Most patients presenting in clinical settings with AS have other comorbid psychiatric disorders. Children are likely to present with attention-deficit hyperactivity disorder (ADHD), while depression is a common diagnosis in adolescents and adults. A study of referred adult patients found that 30% presenting with ADHD had ASD as well.

Research indicates people with AS may be far more likely to have the associated conditions. People with AS symptoms may frequently be diagnosed with clinical depression, oppositional defiant disorder, antisocial personality disorder, Tourette syndrome, ADHD, general anxiety disorder, bipolar disorder, obsessive compulsive disorder or obsessive-compulsive personality disorder. Dysgraphia, dyspraxia, dyslexia or dyscalculia may also be diagnosed.

The particularly high comorbidity with anxiety often requires special attention. One study reported that about 84 percent of individuals with a pervasive developmental disorder (PDD) also met the criteria to be diagnosed with an anxiety disorder. Because of the social differences experienced by those with AS, such as trouble initiating or maintaining a conversation or adherence to strict rituals or schedules, additional stress to any of these activities may result in feelings of anxiety, which can negatively affect multiple areas of one's life, including school, family, and work. Treatment of anxiety disorders that accompany a PDD can be handled in a number of ways, such as through medication or individual and group cognitive behavioral therapy, where relaxation or distraction-type activities may be used along with other techniques in order to diffuse the feelings of anxiety.

Non-clinical perspective

Some professionals contend that, far from being a disease, AS is simply the pathologizing of neurodiversity that should be celebrated, understood and accommodated instead of treated or cured. Others relate AS to the concept of personality originated by psychiatrist Carl Jung and extended by Myers and Briggs. MacKenzie identified the Jungian personality type ISTJ as the most likely type to exhibit autistic-like behaviors. Duke pointed out similarities between the I and J preferences and ASD, but specifically excluded the whole type ISTJ, while Chester asserted that, "In terms of function pairs, NT is more likely than ST to be seen as having Asperger's Disorder," He also said, "For whole types, I_TPs appear to be at a greater risk of being diagnosed with Asperger's Disorder than any other type, especially as children."

Shift in view

Autistic people have contributed to a shift in perception of autism spectrum disorders as complex syndromes rather than diseases that must be cured. Proponents of this view reject the notion that there is an 'ideal' brain configuration and that any deviation from the norm is pathological. They demand tolerance for what they call their neurodiversity. These views are the basis for the autistic rights and autistic pride movements. Researcher Simon Baron-Cohen has argued that high-functioning autism is a "difference" and is not necessarily a "disability." He contends that the term "difference" is more neutral, and that this small shift in a term could mean the difference between a diagnosis of AS being received as a family tragedy, or as interesting information, such as learning that a child is left-handed.

Autistic culture

Main article: Autistic culture

People with AS may refer to themselves in casual conversation as "aspies", coined by Liane Holliday Willey in 1999, or as an "Aspergian". The term neurotypical (NT) describes a person whose neurological development and state are typical, and is often used to refer to people who are non-autistic.

A Wired magazine article, The Geek Syndrome, suggested that AS is more common in the Silicon Valley, a haven for computer scientists and mathematicians. It posited that AS may be the result of assortative mating by geeks in mathematical and technological areas. AS can be found in all occupations, however, and is not limited to those in the math and science fields.

The popularization of the Internet has allowed individuals with AS to communicate with each other in a way that was not possible to do offline due to the rarity and the geographic dispersal of individuals with AS. As a result of increasing ability to connect with one another, a subculture of "Aspies" has formed. Internet sites like WrongPlanet.net have made it easier for individuals to connect with each other.

Notable cases

Main articles: List of autistic people and People speculated to have been autistic

AS is sometimes viewed as a syndrome with both advantages and disadvantages, and notable adults with AS or autism have achieved success in their fields. Prominent AS-diagnosed individuals include Nobel Prize-winning economist Vernon Smith, electropop rocker Gary Numan, Vines frontman Craig Nicholls and Satoshi Tajiri, the creator of Pokémon franchise. Colorado State University professor and author Temple Grandin was diagnosed with autism at a young age, and has used her autism to her advantage in her profession as an animal behaviorist specializing in livestock handling.

The syndrome was in the news in 2007 because of the suicide of Nikki Bacharach, the only child of the songwriter Burt Bacharach and his former wife, Angie Dickinson. The younger Bacharach had AS. A month later, Daniel Tammet, the subject of the television documentary Brainman, published Born On a Blue Day: Inside the Extraordinary Mind of an Autistic Savant (Free Press), a memoir of his life with AS, and was profiled in The New York Times.

Some AS researchers speculate that well-known figures, including Thomas Jefferson, Jeremy Bentham, Albert Einstein, Isaac Newton, Glenn Gould and Ludwig Wittgenstein, had AS because they showed some AS-related tendencies or behaviors, such as intense interest in one subject, and/or social problems. These speculative diagnoses, especially posthumous ones, remain controversial, as they work only from biographical information and sometimes ignore documented traits that would indicate against Asperger syndrome. Autistic-rights activists use such speculative diagnoses to argue that it would be a loss to society if autism were cured.

See also

• Groups

• Aspies For Freedom
• Wrong Planet
• National Alliance for Autism Research
• Cure Autism Now
• Aspergers Society of Ontario

• Lists

• List of fictional characters on the autistic spectrum
• List of further reading on Asperger syndrome
• List of people on the autistic spectrum

• General

• Picture thinking
• Autistic Pride Day
• Controversies about functioning labels in the autism spectrum
• Mozart and the Whale
• Cluttering, a related speech disorder

External links

• Template:Dmoz
• MedlinePlus Asperger Syndrome Resources
• AS-IF - A website with a comprehensive introduction to the subject written from the viewpoint of a person with Asperger's syndrome
• Asperger syndrome fact sheets - Fact sheets on diagnosis, early intervention, behaviors, family issues & personal stories
• CDC's "Learn the Signs. Act Early.” campaign - Information for parents on early childhood development and developmental disabilities
• Fresh Air with Terry Gross - National Public Radio (NPR) Program on Asperger's (2004 May 5)
• Boston Globe article on a woman with Asperger's Syndrome
• Radio Times with Marty Moss-Coane Real audio feed of hour long public radio segment on coping with Asperger's (2007 February 7)