Asperger’s Disorderfor the General

Practitioner:Diagnosis, Misdiagnosis,

and Missed DiagnosisPresented by Debra Moore, Ph.D.Fall Creek Counseling Associates

www.sacramentopsychology.com

Could it be Asperger’s…?

Your child or teen clients who…

• Function below grade and cognitive level…• Are fearful, easily startled or frustrated…• Can’t adjust to change and have meltdowns when their routine is

disrupted…• Have been diagnosed with ADD/ADHD but don’t respond to

treatment…• Are ostracized or rejected by their peers and known as geeks…• Seem oblivious to their effects on others…• Just make things worse the harder they try…• Seem oblivious to trends…• Seem clumsy or uncoordinated…• Really truly ignore their siblings…• Relate better to younger kids or adults than to peers…• Have odd language or voice patterns…• Have a great rote memory and storehouse of trivia• Are more obsessed than most kids with certain toys, games, or

shows.• Would spend all of their time in their room playing video or fantasy

games if you let them…• Have unusual sensitivity to sound or touch…• Don’t seem to ‘get’ humor and takes everything literally…• Don’t know when they are insulting or boring others…• Don’t realize when they are invading someone’s personal space…

Your adult clients who…• Come in for 1-3 sessions and disappear…• Have a history of therapist shopping…• You just can’t “connect” with…• Seem to lack the ability to be introspective…• Use the session for a monologue…• You can’t figure out why you get tired or bored with…• Reject or just ignore your interventions…• Have spouses who say they are emotionally unavailable and/or

uncaring…• Can’t describe their partner to you beyond ‘the facts’… • Were truly miserable in high school and describe it as torture…• Have no apparent family of origin or attachment history that predicts

their current functioning or behavior…• Really don’t seem that bothered by their symptoms and are there at

someone else’s urging…• Are diagnosed with affective disorders or ADD who don’t respond to

standard behavioral or pharmacological interventions…• Are obviously intelligent but not functioning in line with their

cognitive abilities…• May be valued employees in jobs related to math, research,

engineering or computers, but have no interest in interacting with coworkers socially…

• Spend large amounts of time collecting, obsessing or pursuing specialized interests…

Diagnosis

Pervasive Developmental Disorders

• DSM-IV lists 5 categories of “Pervasive Developmental Disorders”

o Autistic Disorder (social & communication impairment; restricted, repetitive behaviors and interests)

o Rett’s Disorder (mostly female;head growth slows; motor impairment; retardation)

o Childhood Disintegrative Disorder (mostly males; normal til 2-4, then severe regression across domains)

o Asperger’s Disordero Pervasive Developmental Disorder, NOS

Pervasive Developmental Disorders• Developmental impairments which are:

o severeo pervasiveo multipleo distinctly deviant relative to developmental level or

mental age.• Usually evident in the first years of life.• Believed to be inheritable neurological

conditions.• Some of the 5 PDDs are probably more

neurologically related than others. Rett’s and Childhood Disintegrative Disorder appear less similar, and probably have unique genetic causes.

Autistic Spectrum Disorders

• Not a DSM-IV term, but now commonly used.

• The thinking is that Autism and Asperger’s Disorder are similar enough to warrant classifying them as Disorders “within the austistic spectrum”.

• The idea is that both disorders have similar impairments and both can range from mild (also called “high functioning” to severe).

DSM-IV1.Qualitative impairment in social

interaction, manifest by at least 2 of the following:

• marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction

• failure to develop peer relationships appropriate to developmental level

• a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)

• lack of social or emotional reciprocity

DSM-IV (continued)

B. Restricted repetitive & stereotyped patterns of behavior, interests, and activities, manifest by at least one of the following:• encompassing preoccupations with one or more stereotyped

and restricted patterns of interest that is abnormal either in intensity or focus

• apparently inflexible adherence to specific nonfunctional routines or rituals

• stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)

• Persistent preoccupation with parts of objects

DSM-IV (continued)

C. The disturbance causes clinically significant impairment in social, occupational or other important areas of functioning.

D. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years)

DSM-IV (continued)

E. 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.

F. Criteria are not met for another specific PDD or Schizophrenia.

The Question of Sensory Dysregulation

• Unusual sensory responses often observed, but not now in the DSM.

• Both hyper and hypo sensitivity, and can occur together.• May be unable to regulate or soothe self.• May need external stimulation for calming – heavy pressure,

sounds, rotating object.• May self stim to attend or relax – humming, rocking,

tapping.• May need separate space to decompress.• Sleep often irregular or reversed patterns.• Sense of time often impaired.• Proprioceptive sensory impairment – coordination, gait,

balance.• Pain perception impaired. Atypical pain from sensory input.• Feeding or eating behaviors affected.

Guidelines for Diagnosis• Utilize:

o Detailed developmental historyo Review of pediatric and academic recordso Parental (and grandparent) involvement

Independent observations and ratingso Videotapeso Targeted evaluation to assess

communication skills, general cognitive functioning and interests

• Compile:o Coherent model of child’s functioningo Practical interventions

Detailed Concrete

“Aspies”

“Neurotypicals”

The History of Asperger’s Disorder

• In Austria, in 1944, Hans Asperger observed a pattern of behavioral problems in certain boys he worked with in a Viennese clinic for disturbed children.

• He noted verbal and non-verbal communication impairment.

• Pedantic speech, long-winded, repetitive and one-sided communication involving the child’s favorite subject

• Monotonous or overly exaggerated voice, with little facial expression

• The boys misunderstood jokes and listener’s responses.

• All had deficits in eye contact and body language.

• Asperger described the disorder as primarily a dysfunction of social interaction.

• He thought it was inherited and recognised similar traits in the children’s parents.

History…………….

Asperger’s writings were basically ignored

for almost 20 years.

Then………..

………along came Lorna Wing……..

• In 1981, she published a classic paper which not only mentioned Asperger’s observations, but first referred to the cluster of behaviors as Asperger’s Disorder.

It took another 13 years before the term “Asperger’s Disorder” was included in the DSM.

• In 1994, the term was introduced.

• There is still no universal agreement about diagnostic criteria and there is much

controversy about the difference between Asperger’s and “high functioning Asperger's”.

Missed Diagnosis

3 important concepts

Theory of MindCentral Coherence

Executive Functioning

Theory of Mind(also called mentalizing)

a specific cognitive capacity: the ability to understand that others have beliefs, desires and intentions that are different from one's own.

thought to be hard wired.

• If the social behavior depends on mentalizing, it may show impairment in individuals with Asperger's.

• If mentalizing is not required, there will probably not be an impairment.

• It’s may be the mentalizing, not the socializing per se, that makes the difference.

Mentalizing & Social Behavior

Examples of social behavior that requires mentalizing:

• Buying “just the right” present for someone.

• Successfully playing hide and seek.

• Babies checking their mother’s expression before they try something (to see if she expresses pleasure or displeasure/fear).

• Pointing to share enjoyment (Look!)

Studies of social behavior in Asperger's:

• AS children may show their toys to their mother less than neurotypical children.

• Sharing their world does not necessarily occur to them.

• They may not remember faces as well as buildings or landscapes.

More studies:

• People with Asperger's may not be able to evaluate expressions if shown only the eyes.

• People with Asperger's may not follow the gaze of others. In most brains, it appears hardwired that we look up, for instance, if someone else looks up.

• Children with Asperger's may not automatically look at the right place when being read a story.

• Children with Asperger's can show attachment.

• (You do not have to have an awareness of mental states for attachment behavior.)

• Distress reactions are shown at parent leaving and pleasure at their return.

• Some people with Asperger's may, however, not want to form attachments.

Asperger's and empathy• “Instinctive” empathy is present in Asperger's.• Obvious suffering results in compassion.• The amygdala of both neurotypical and ASD people reacts to

certain emotional expressions.

• “Intentional” empathy requires ability to mentalize (to make assumptions about the reasons for another person’s reactions).

• Even if empathy is felt, there may be nothing to guide an appropriate response (for example, do I leave the person alone, hug them, talk to them?)

• Empathy will not be generated via a facial expression, but if someone with an ASD is directly told that someone is suffering, they will probably be compassionate.

• Example of school bus stopping for injured dog.

Language Impairment in Asperger's

phonology, the ability to handle speech sounds;syntax, the ability to operate rules of grammar;

semantics, the ability to understand and create meaning, pragmatics, the ability to use language for the purpose of

communication.

This last ability, pragmatics, is universally a problem in Asperger's.

Asperger’s and Language Acquisition

• Asperger's does not imply impairment in formal aspects of language acquisition.

• May have had early or unusual language use.

• Vocabulary often above average.• Grammar often excellent but formal.• Spelling may be excellent.

Conversational language in the absence of mentalizing:

• May reverse pronouns.• Sparse – just the facts.• No sense of taking turns. • Too much or too little eye contact.• No sense of the value of bringing interest into the

conversation.• No realization that repetition is boring.• May make honest, but inappropriate observations.• No sense of the value of varying voice qualities, such

as pace, volume, intonation, pitch. “Little Professor”• May have odd accenting or inflection.• May not understand figures of speech – literal

interpretation.• May use stock phrases or phrases borrowed from

other situations (movies, TV) or other people.• No sense of transitions, such as “by the way” – they

may never use it or always use it.

Central Coherence

• One’s ability to integrate information and to grasp the “big picture”.

• Assumes bell curve for neurotypicals on central coherence and another bell curve for Asperger’s at one end of the normal bell curve.

• Male relatives of those with ASD often show less central coherence. o High % of “systemizers” (piecemeal processing &

absense of links between data) in fatherso More engineers,computing, scientific jobs.

• Advantages of systemizing:o easily spot minor visual or auditory discrepancies.o great memory for detail.o many have perfect pitch.o above average at finding hidden figures.

Information in Context• Most people do better if they understand the

context of a situation.

• Those with Asperger’s may be the opposite.

• The info was never embedded in context to begin with.

• May have great reading/spelling ability, but not understand meaning of the words.o May understand abstract math, but can’t put to use.o On digit span or lists of words, ASD kids tend to

remember the last digits. Context doesn’t help. Normal kids use context.

where-is-the-ship-what-see-was-leaf

• Neurotypical kids remember:o Where-is-the-ship

• Those with Asperger’s may remember:o see-was-leaf

What is attended to: social vs. nonsocial

• Most neurotypical kids would recall details of faces/people.

• Those with Asperger’s may recall details of crowns.

Missing the big picture

Those with Asperger’s may use binoculars all the time, and isn’t interested in sharing the view with others.

Patterns

• Those with Asperger’s are not compelled to create patterns. (block design scores)

• Neurotypicals can’t help but create patterns.o Example, will automatically perseverate a pattern.

• Therefore, with increasing complexity, those with Asperger’s may do increasing poor compared to neurotypicals, because they do not use strategy of creating patterns.

“Stimulus over-selectivity”

• “What is this?”

• “Flower”

Attention and Asperger's

• Have peculiar, but not poor attention.

• Highly sustainable but inflexible attention.

• Basic executive function of processing and prioritizing data is impaired.

Sensations and repetitions

• Hypersensitivity to sensation also related to lack of coherence in perspective – everything is fragmented and unpredictable.

• Thus scary and upsetting.

• But…repetitions are predictable…thus comforting.

Routines and Rigidity

• Children with Asperger’s may restrict and repeat:o Given a xylophone with

four keys, may restrict use to 2.

o Given inks and stamps, they may restrict to one color, one pattern.

o Often restrict to 1 color food (often white).

The Appeal of Logic

• Timetables are comforting in their familiar logic and are a common obsession in Asperger's.

• There are associations of timetable collectors – 500 people belong in the U.S.

• All of them are male.

A Modern Fixation Tragedy

• In 1981, at age 13, Darius McCollum was 1st arrested for impersonating a subway conductor.

• After his 19th arrest, he was thrown into a maximum security prison for a 5-yr term.

When things aren’t logical – an obsession about imposing logic may appear.

• The weather is the ultimate omnipresent, uncontrollable, and unpredictable force.

• Weather reports and forecasting is also a common obsession.

Executive Functions• Frontal lobes control behaviors that are more

than just routine.o working memoryo switching taskso planning, searching methodicallyo generating new ideaso initiating action, inhibiting impulse.

• Many people with an ASD have impairment.o Get stuck “starting”; have a hard time “stopping”. o Inability to switch behaviors or change rules.

Executive functioning impairment& lack of central coherence…

• Can’t prioritize, can’t switch, can’t see big picture

• Difficult to regulate or modulate stimulation• Prone to overwhelm• Prone to perfectionism• One bad experience can “ruin” the day; can’t

let go of details.• Anxiety and/or meltdowns

Is Asperger’s Disorder hereditary?

• It appears so, and it appears that more than one gene is responsible.

• One study found 57% of children with Asperger’s had a parent who also had the disorder or similar traits.

• There may also be cases related to environmental causes which potentiate genetic vulnerability.

Diagnostic Rating Scales

for Asperger’s Disorder

The Australian Scale for Asperger's Disorder

by Tony Attwood, PhD.

• To identify behaviors and abilities indicative of AS in school age children.

• Also available in Dr. Attwood's book • Asperger's Disorder: A Guide For Parents and Professionals.

• This is a test developed by Dr. Simon Baron-Cohen at Cambridge University in the UK as a measurement of the extent of autistic traits in adults.

• 50 questions• It is available in his book “The Essential Difference”

AQ Test: Asperger's-Spectrum Quotient

GADS:

The Gilliam Asperger's Disorder ScaleJames E. Gilliam

• 4 subscales o Restricted Pattern of Behavioro Cognitive Patternso Pragmatic Skillso Early Development

• Can be completed by both parents and professionals.

• Dr. Gilliam also developed the GARS (Gilliam Asperger's Rating Scale).

Asperger Disorder Diagnostic Scale (ASDS) Brenda Smith Myles, Stacey Jones Bock and Richard L. Simpson

• Used for ages 5 - 18 who manifest characteristics of AS.

• Can be completed by teachers, parents and others who have had sustained contact with the individual.

• In addition to identifying persons who have AS, results of the ASDS may be used to document behavioral progress, target goals for change and intervention on a student's IEP and for research purposes.

Misdiagnosis

or is it…?

• High functioning autism? • Nonverbal learning disorder? • Pragmatic language disorder? • Semantic pragmatic language disorder?• Hyperlexia?• Sensory integration disorder?• ADD/ADHD?• Childhood onset bipolar disorder?• Depression?• Anxiety disorder?• Schizoid personality disorder?• Avoidant personality disorder?• Narcissistic personality disorder?• Antisocial personality disorder?• Borderline personality disorder?• Schizotypal personality disorder?• Schizophrenia?

High Functioning Autism: IQ over 70; 25% of Autistic population • DSM requires language delay for autism.

o AS kids often have early language and exhibit verbosity.

o AS dx has Verbal IQ higher than Performance IQo Autism is the opposite.

• Other thoughts – with AS…o Onset latero Outcome more positiveo Social and communication deficits less severeo Better eye contact and gaze followingo Circumscribed interests more pronouncedo Clumsiness seen more ofteno Family history more often positiveo Fewer co-morbid neurological conditions

Nonverbal Learning Disorder (NVLD)

• Not included in DSM at this point.• NVLD emphasizes impairment in spatial and

visual realms.• Educators tend to use the term.• Most features very similar to Aspergers.• NVLD does not include restricted interests.• NVLD sometimes includes social impairment.• NVLD does not emphasize executive function

impairment.

Semantic Pragmatic Language Disorder

• Not a DSM diagnosis.• Used more by speech and language

pathologists.• Delayed language development.• Does not imply social impairment or restricted

interests.

Hyperlexia

• Not a DSM term• Can refer to either:

o A splinter skill within autismo Separate from autism

• Refers to obsession with words or letters and precocious reading ability.

• Reading ability not matched by comprehension.

Sensory Integration Disorder

• Not a DSM term• Tends to be used by Ots• Refers to impairment in the

brain’s processing of information acquired through sensory channelso Visual, auditory, olfactory, tactile,

taste, proprioceptive, vestibular

ADD/ADHD

• Some estimate 60-70% of AS folks also have ADD• DSM says technically a PDD dx subsumes ADD – “do not

occur during the course of a PDD”.• Useful to draw attention to both issues in terms of

treatment and parent and teacher (IEP) intervention.• Some AS kids/adults respond well to stimulants; many do

not.• ADD children usually have developmental delays, but not

the variety and severity as PDD, including AS, kids.• ADD impairment is centered within executive

functioning; central coherence and theory of mind not necessarily impaired.

Childhood Onset Bipolar

• Sudden, intense rage can be similar.• In AS, typically after routine or obsession

disrupted.• Bipolar agitation or rage may last much

longer.• Both can have excited, pressured, loud

speech.o In AS, this is usually around areas of obsessional or

special interest or when overloaded by sensory stimulation.

• Theory of mind, central coherence, executive functioning not generally impaired in Bipolar.

Depression

• Similar presentations: withdrawn, isolated, lack of affect, poor eye contact, lack of facial expression, monotonous voice.

• Depression often comorbid – over 50%?• Often develops during late elementary school;

secondary to social impairment consequences.

• AS not characterized by feelings of helplessless or worthlessness.

• SSRIs often help both.

Anxiety disorder including OCD

• Anxiety is highly co-morbid with AS.• AS anxiety tends to be related to the unfamiliar and

sensory overload.• In AS, targets of obsessions change frequently.• In AS, obsessions are interest linked more than anxiety

linked.• Specific phobias sometimes develop in AS.• Restricted interests and executive functioning

impairment present in AS can look like hoarding.• Social avoidance in AS not due to anxiety. • Lack of appropriate mild anxiety may be present socially

in AS.

Personality Disorders

• Often have similarities to AS.• May be diagnosed more often because

therapists are better trained in this area. • Difference will be in underlying drivers

of the behavior.• Another difference will be lack of other

AS impairments.• On the other hand, how much is

“learned” and how much is “hard-wired” temperament?

Personality Disorders: Cluster A

• Paranoid• Schizoid • Schizotypal

Paranoid Personality Disorder

• AS inability to read facial cues can result in inaccurate attribution of anger o “You’re mad at me!”o “I’m in trouble!”

Schizoid Personality Disorder

• May have similar presentations:o No close friendso Isolation by choiceo Little or no interest in sexo Emotional detachment or flattened affect

• Clues to possible AS:o May desire friends but be socially inepto May in fact be over talkative or intrusive in attempting

to make friendso May choose to be with others if they share a special

interesto May take great pleasure in one or more areas of

interesto Are often highly sensitive to criticism

Schizotypal Personality Disorder• May have similar presentations:

o Odd beliefs inconsistent with cultural normso Unusual perceptual experienceso Odd thinking and speecho Suspiciousnesso Constricted affecto Odd appearanceo Lack of friends

• Clues to possible AS:o Odd beliefs have inherent logico Cultural norms are actively rejectedo Unusual perceptual experiences are sensory in natureo Speech is literal and repetitive more than vague or metaphoricalo Pure paranoia rare.o Social anxiety, if present, tends to stem from rejection versus

paranoia.

Personality Disorders: Cluster B

• Antisocial • (Histrionic)• Borderline• Narcissistic **

Asperger's vs. Antisocial

• May rigidly follow rules.• Cannot discriminate when it

makes sense to break a rule.

• Have instinctive empathy.• May not have mentalizing

ability.

• Show increased arousal when shown faces expressing fear or sadness.

• All rules can be broken.• Actively reject rules.• If I can get away with

it, I will break the rule.

• Do not have instinctive empathy.

• Have above superior mentalizing ability.

• Fail to react when shown faces expressing fear or sadness.

Borderline Personality Disorder

• Both may lack a perceived sense of self.

• Both may react abruptly and seem “over sensitive”.

• Both exhibit “black or white thinking” and “splitting”.

• Cutting behaviors can occur in AS.

• AS does not have intolerance of being alone.

• DBT (Dialectical Behavioral Therapy) can be useful for AS.

Narcissistic Personality Disorder

• Both can appear:o Self centeredo Isolatedo Aloof, haughty or rejecting of otherso Engrossed in own interestso Verboseo Depressed in reaction to rejection or slights o To have impaired reciprocal

communication.

Similarities stem from different origins

• Self centeredness and verbosityo NPD: Need to feed the ego, verbosity as a weapono AS: Theory of mind deficits

• Isolationo NPD: Exclusion of otherso AS: Withdrawal from or rejection by others

• Impaired Social Reciprocityo NPD: Willful choice based on whether the other feeds

narcissism. When this happens, the NPD becomes increasingly reciprocal.

o AS: Social ineptness that is basically constant.• Narcissists tend to be more occupationally/socially

“successful”.

Personality Disorders: Cluster C

• Avoidant• Dependent• Obsessive-

Compulsive

Avoidant Personality Disorder• May appear similar

o Avoidance of social arenao Restraint within intimate relationshipso Precoccupied with being rejectedo Views self as socially inepto Reluctant to try new activities

• Similarities stem from different originso AS expectation of rejection has proven trueo AS may say they don’t care what other’s

thinko AS not driven by fear of embarrassment

Avoidant: wants to go to the prom, but is too shy and nervous to ask anyone.If someone fixes him up with someone he is comfortable with, he’ll go and may have a good time.Schizoid: doesn’t particularly want to go and doesn’t ask anyone.Asperger’s: wants to go and asks the head cheerleader and doesn’t understand why she laughs at him.

Dependent Personality Disorder

• May appear similar:o Others assume responsibilities o Difficulty making everyday decisionso Has difficulty initiating

• Differences:o AS may be developmental unskilledo In AS, executive function impairment

accounts for difficulties deciding and initiating, not anxiety

Obsessive-Compulsive Personality Disorder

• May appear similar:o Preoccupation with details, rules, scheduleso Perfectionismo Work takes high precedence over socializingo Overconscientious, inflexble about moralityo Rigid and stubborn

• Differences:o AS behaviors not based on self denial or self

criticism dynamico AS not as influenced by authority figures

Schizophrenia

• Possible similar presentations:o Slow speech, poverty of speecho Tangential, irrelevant replieso Odd prosody of speech, odd expressionso Disorganizationo Fixed, inflexible, odd ideas or behaviorso Flattened affecto Social isolationo Preoccupation with topics or interests

Differences:

• Psychotic process not part of AS• Speech, while odd, is generally

logical if explained.• Gross disorganization in AS usually

a result of anxiety (often from a forced change in routine or exposure to the unknown) and goes away if stressors removed.

The End