Asperger’s Disorder (AD) is a Pervasive Developmental Autism Spectrum Disorder characterized by normal IQ and normal developmental milestones including language and cognition. AD is considered the highest functioning classification within the autism spectrum. AD kids can be quirky with a keen sense of humor. Because they begin with some limits to their social skills, it is very rewarding to see them mature as treatment progresses. Some of my favorite patients have been AD kids and their families. AD families often appreciate and enjoy the uniqueness of their child. Unlike the rest of the autism spectrum, AD kids can do well academically. School trouble usually is related to temper outbursts or oppositional defiance. Since I began practicing, the incidence of AD has increased from 1 in 1000 to 1 in 50 children. The male to female ratio is listed as 1:5, but I have never seen or heard of a girl with AD.
AD is characterized by some impairment in social skills. I think of AD kids as lacking a “social skin” that mediates between their feelings and those of others. Children with AD also lack the normal filter between their feelings and their behavior. Psychoanalysts would say they have significantly impaired observing ego. AD kids even lack a normal sensory “skin” and often show exquisite sensitivity to a particular fabric or texture. AD patients appear standoffish, odd, eccentric, shy, socially insecure and socially clueless with peers, though they may relate well to adults. They often demonstrate diminished eye contact with fixed intense gaze. They have a decreased appreciation of social cues that makes it hard for them to make friends. They have a hard time with empathic play and with learning how to take turns. They often engage in parallel play.
Children with AD may have an odd sense of humor, often not understanding the jokes of others, while their peers fail to understand AD’s sense of humor. Therefore, these children often feel profoundly alone and depressed though they can occupy their time endlessly when they become fascinated by a particular activity. Thus they often appear to be “in their own world.” At times they may show an amazing encyclopedic knowledge of both commonplace or esoteric information. This marks the association of genius with AD.
Aside from social abnormalities, AD kids show other abnormal behaviors. They hate change and often react with anger when they have to change behavior. Temper outbursts that include full-blown meltdowns may occur. They come without warning and subside just as quickly. Children with AD sometimes have limited interests and can be hyper-focused or obsessive. Their behavior may be overly routinized. They may show motor incoordination including clumsy appearing nonverbal behavior. AD kids sometimes manifest speech pathology that may includes odd use of words, being hyper-verbal, or showing an abnormal rate, volume or intonation of speech. Sometimes AD kids make tic like noises, speak under their breath and often misuse idioms or slang. Tics are often characterized by odd facial or hand movements, while 15% of children with AD manifest full-blown Tourette’s syndrome. Lastly, 75% of ADs have ADHD which may further compromise school performance and behavior at home.
Because of issues with temper, ADHD and oppositionalism to any changes in routine, AD children are typically written off as “oppositional-defiant. Their school years may be marked by power struggles—which they invariably win because their stubborness (or better put, fear of change) knows no bounds.
Treatment involves psychopharmacology, individual and family therapy with emphasis on psychoeducation of the patient, the family and the school. Getting AD kids involved socially is crucial to their development of social skills, making friends and enhancing self-esteem. Early intervention by ages 3,4 or 5 is highly effective.Treatment clarifies that AD children suffer from a pervasive developmental disability and are not just bad or oppositional. Families become skilled at empathic interventions that limit power struggles while effectively setting necessary limits. Families can learn how to enjoy the eccentricities and uniqueness of their child. Getting children correctly classified by school as early as possible also strengthens treatment. Parents need to push here as under budgetary constraints schools will resist proper classification. I have attended a number of CSE meetings that have resulted in significant positive changes in the school’s approach to a child with AD.
A brief word on medication. I often find that mood stabilizers like lithium or depakote control temper meltdowns and moderate mood. Sometimes an atypical neuroleptic (second generation tranquilizer) provides a “second skin” that markedly diminishes the hypersensitivity of AD kids. When either or both of these drugs are used, ADHD medication works very well. Stimulants used alone often are poorly tolerated and result in increased anger and moodiness.
The most important take home message regarding AD is that most AD children go on to become functionally independent adults. Early psychiatric intervention can make everything go a bit smoother. I can think of few more rewarding treatment experiences than starting with a 6 year old with AD and in lots of trouble and ending with a 20 year old young man thriving in university.