Diagnostic Assessment for Asperger’s Syndrome

The Continuum of Autism:From the work of Tony Atwood

What is Asperger’s Syndrome?

• A disorder within the Autistic Spectrum Disorders

• Considered a Neurobiological disorder

• Major symptoms are Impairments in socialization, communication and imagination

• First discussed by Hans Asperger in 1944

• Brought to international attention in the 1990’s

• Suggested that the ratio of boys to girls is 10:1

Symptoms of Asperger’s Syndrome

•Impairments in social interaction, narrow interests, an insistence on repetitive routines, speech and language peculiarities, non-verbal communication problems and motor clumsiness

Aloof

• Avoid interactions• Mute• Behavior the main

means of communication

• Fascination with sensory experience

Passive• Approach adults for assistance with objects and for physical stimulation

• Prolonged solitary play

• Speech requires an external prompt, (echolalia, seeing an object/picture, dialogue “borrowed” from a favorite video)

• Fascination with symmetry and collecting specific objects

Active but Odd

• Often initiates interactions of short duration

• Repetitive questions (social echolalia, script, alternative meaning, reassurance)

• Lack of social play with others

• Fascination with a specific topic or person.

Six Pathways to a Diagnosis of Asperger’s Syndrome

• Diagnosis of autism in early childhood• Significant natural progress between 4 and 6 years of age•Effective early intervention programs•Progression along the continuum of autism

Recognition of Characteristics When First Enrolled at School

• No clear signs of autism in early childhood• Teacher notices conspicuous features• Avoids social play with peers• Unaware of the codes of social conduct• Unusual qualities in conversation and

imaginative play• Intense interest in a specific interest• Clumsiness when running, writing and

catching• Teacher completes a developmental

checklist for Asperger’s syndrome (ASAS)

Diagnosis of a Relative with Autism or Asperger’s Syndrome• Another family member has a diagnosis and knowledge of the continuum of autism leads to other family members being diagnosed

• Some families have Asperger’s syndrome within and between generations

Dual Diagnosis

• Attention deficit disorder

• Language disorder

• Cerebral palsy

• Tourette’s disorder

Secondary Psychiatric Disorder• Depression

• Anxiety disorder such as Obsessive Compulsive Disorder

• Anger management

• Schizophrenia

Residual Asperger’s Syndrome in an Adult• Self referral due to a

relative having the diagnosis or information from the media

• Agency referral from psychiatric services, forensic psychology and employment agencies

Diagnostic Assessment

• Social Impairment

Social Impairment

• Reciprocity (the balance between participants)• Inclusion (welcome, cooperation and control)

Pretending to be Normal

• “…the fun came from setting up and arranging things. Maybe this desire to organize things rather than play with things, is the reason I never had a great interest in my peers. They always wanted to use the things I had so carefully arranged. They would want to rearrange and redo. They did not let me control the environment.”

Social Impairment

• Level of maturity in deceit• Limited ability with team skills• Limited range of facial expressions and body language• Difficulty reading the facial expressions and body language of others• Limited ability to conceptualize the thoughts and feelings of others

Speech and Language Characteristics

• Pragmatics, Prosody and Pedantic

Pragmatic Aspects

• The art of conversation• Reciprocity• Repairing a conversation• Knowing when and how to interrupt• Inappropriate comments• Keeping on track• Primarily interested in an exchange

of information• Appropriate topics• Monologues or scripts• Recognizing and accepting

different points of view• Literal interpretation

Prosody or the Melody of Speech

• Lack of change of vocal tone and volume to indicate emotion and key words• Lack of variation in pitch, stress and rhythm• Accent not consistent with that of the local children• Difficulty understanding the relevance of the change in tone, inflection or emphasis on certain words when listening to the speech of others

Pedantic Speech

• Overly Formal• Excessive technical details• “Adult” quality, sophisticated grammar or phrases• Must correct errors• Precise intonation

Unusual Qualities of Speech

• Idiosyncratic use of words

• Neologisms

• Volume

• Vocalizing thoughts

• Verbal fluency affected by anxiety

• Late onset

Special Interests

• Dominate the person’s time and conversation

• Statistics, cataloguing and symmetry

• Idiosyncratic

Motor Clumsiness

• Locomotion (upper and lower limb coordination)

• Ball catching skills

• Manual dexterity

• Handwriting

• Movement disorder; Motor tics such as blinking and grimaces, vocal tics such as clicks and animal noises

Cognition• Problems with advanced Theory of Mind Skills• Weak Central Coherence• Impaired Executive Function• Profile on an Intelligence Test• Visualisers or verbalisers • Enclopedic memory• Solitary and idiosyncratic play• Preference for routines•Limited flexibility in thinking•Originality in problem solving

Sensory Sensitivity

• Sound sensitivity

• Tactile sensitivity

• Sensitivity to the taste or texture of food

• Stoic in response to pain or temperature

• Synaesthesia

Relevant Information

• Family history of similar individuals• Reports from teachers and therapists• Medical investigations and medicine• Developmental history• Prior diagnosis• Presence of a psychiatric disorder• Observation at school and home

Issues Relevant to the Diagnostic Assessment

• Profile of abilities in girls (same pattern, less severe expression, coping mechanisms, fewer referrals)

• Assessment procedures and criteria for adults (time to respond and the quality of the response, validity of the developmental history)

• Alternative explanations: shy, social phobia, gifted emotional neglect in infancy

• Choice of diagnostic criteria

Alternative Terms

• HFA and AS at the behavioral and treatment level, are more the same than different• Lack of expertise, experience and confidence in the diagnosis of AS

High Functioning Autism

• HFA more likely if the child has a developmental history of autism

• AS not a mild form of autism but a more subtle expression

• Diagnosis of HFA can provide automatic access to services

• Use the term that provides more resources

Developing Social Skills and Understanding Emotions

Social Play

• Observe and make notes of the social “play” of the child’s peers

• Note the “script” and “acts”• Rehearse with an adult acting as

a friend• Turn taking and help• “Rent a friend” as a “dress

rehearsal”• Practice with same age peers• Social Sandwich• Sharing experiences

Strategies for Social Integration

Inclusion with Ordinary Children

• Observation of appropriate social/emotional behavior• Peer group who know how to modify their behavior to accommodate and support the child

Knowledge of the Nature of Asperger’s Syndrome

• To recognize the challenges faced by the child

• To explain their behavior to other children and adults

• The Sixth Sense

Teach Theory of Mind Skills

• Photographs, text, drawings, games

• Metaphor• Social Stories• Comic Strip Conversations• Social Skills Groups

Encourage Friendship Skills

• Behavioral strategies of task analysis, shaping, prompting and rewards

• Cognitive strategies to learn the theory and script using Social Stories

Four Levels in the Development of Friendship

Level 1: Approximately 3 to 6 Years

• Recognition of turn taking• Egocentric conceptualization• One way assistance• Proximity and physical attributes• Why is….your friend?• “Because I like him”• “He lives next door”

Level 2: Approximately 6 to 9 Years

• Reciprocity and being fair

• Mutual assistance

• Like the same activities

• Aware of the preferences, feelings and thoughts of the other person

• Why is…your friend?

• “She comes to my party and I go to hers”

• “She’s nice to me”

Level 3: Approximately 9 to 13 Years

• Aware of other’s opinion of them and how their words and actions affect the feelings of others• Shared experiences and interests• Greater selectivity and durability• Gender split• Trust, loyalty and keeping promises

Level 4: Adolescence to Adult

• Peer group acceptance more important than the opinion of parents

• Greater depth and breadth of self disclosure

• Desire to be understood by friends

• Different types of friendships• “He/She accepts me for who I

am”• “We think the same way about

things”

Characteristics Associated with Asperger’s Syndrome

• Motivation for friendship

• Immaturity

• Control the activity

• Describe what a friend should not do

• Negative experiences

Checklist of Social Behaviors Used as an Index of Friendship Skills

• Entry Skills– Recognizing when and how to join in– The “welcome” provided for children who approach them

• Assistance– When and how to provide assistance– Seeking assistance from others

• Criticism– Knowing when criticism is appropriate and inappropriate– How to criticize– Tolerance of criticism

• Compliments– Compliments at appropriate times– Responding to a friend’s compliment

• Accepting Suggestions– Incorporating the ideas of others in the activity– Indicating agreement

• Reciprocity and Sharing– An equitable distribution of conversation, direction and

resources

Checklist of Social Behaviors Used as an Index of Friendship Skills - Con’t• Conflict Resolution

– Managing disagreement with compromise– Accepting the opinions of others– Not responding with aggression or immature resolution

mechanisms• Monitoring and Listening

– Regularly observing the other person to monitor their contribution and body language

– Their own body language indicating an interest in the other person

• Empathy– Recognizing when appropriate comments and actions

are required in response to the other person’s circumstances and positive and negative feelings

• Avoiding and Ending– Appropriate behavior and comments to maintain solitude– Appropriate behavior and comments to end the

interaction

Encouraging Friendship Skills

• Assess which skills are observed or absent

• Assess the quality and range of expression

• Use behavior and cognitive strategies to acquire and develop specific skills

• Task analysis, prompting, shaping and reward

• Reward all participants

• Teach the theory as well as the practices

• Social stories

Additional Strategies

• Friendship diary

• Matching individuals with similar interests

• Support groups for adults

• Local and pen pal registries

• Internet chat lines

• Books of friendship

• Recognizing when someone is not a friend

• Maintaining and ending friendships

• Tuition in characterization

Characterization Skills

• Unusual in their perception and description of the personality characteristics of others and themselves• Limited lexicon to describe the different types of character• Immaturity and predominance of physical attributes• One dimensional approach• Difficulty reading a person’s character and adapting their behavior accordingly

Teaching Characterization Skills• The Mr. Men and Little Miss books• Examples are Mr. Grumpy, Little

Miss Chatterbox and Mr. Nosey• Choosing an animal to represent

someone’s personality• Reading dictionary definitions of

character and identifying someone who has those characteristics

• Identifying the description of their own character

Social Skills Groups• Friendship

• Theory of mind skills

• Conversation skills

• Reading and expressing body language

The Understanding and Expression of Emotions

• A project on a specific emotion• Create a scrap book that illustrates the emotion• Compare and contrast other children’s scrap books• Identify the facial elements that express the emotion• A “thermometer” to measure the degree of intensity• Place photographs and words at the appropriate point on the “thermometer” • Point to the “degree” of expression in a particular situation

The Understanding and Expression of Emotions – Con’t

• Appropriate tone of voice

• Drama games for appropriate body language

• Mirror and video recordings

• Story books

• Sentence completion exercises

• Alternate positive and negative emotions

Imitation• Identify individuals skilled

in a specific ability

• Observe their actions and script

• Copy or mimic their style

• Speech and drama training