Asperger Syndrome

Asperger syndrome (AS) is a type of autistic disorder, or autism. Commonly may be referred to as a type of higher-functioning autism. It is one of a group of neurological conditions called autistic spectrum disorders (ASDs) characterized by (1) impaired language and communication, and (2) repetitive or restrictive patterns of thought and behavior.

The three main distinguishing traits of people with AS are (1) trouble with social communication, including trouble understanding jokes, gestures, or common body language; (2) trouble with social interaction, including difficulty making friends and a tendency to behave inappropriately; and (3) trouble with social imagination, including difficulty guessing what others are feeling or thinking, which may come across to others as a lack of empathy even though that impression is often incorrect. In addition, they may have odd speech patterns and obsessive interests and routines. Usually from childhood on, people with AS are felt to be socially and physically clumsy. Adding to their apparent oddity, they often will have unexplained dislikes for specific foods, objects, texture, or even sounds

People with AS can lead seemingly normal lives: finish higher education, and remain employed, although the disorder certainly puts up hazards for them. AS was first described by a Dr. Asperger in 1944, however more recently became better known to the public-at-large through the life, works and books of Temple Grandin, who has AS. Some idea of her accomplishments can be gathered by the fact that half the beef cattle in North America are handled through systems she designed. .

Other names

 * Asperger's syndrome
 * Asperger's disorder

Terminology

 * Both AS and autistic disorder are subgroups of a larger diagnostic category, called either autistic spectrum disorders (ASD), mostly in European countries, or pervasive developmental disorders (PDD) in the United States. Other ASDs include classic autism, Rett syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS). (Unlike children with autism, children with AS retain their early language skills. In AS, the symptoms are less severe and there are no language delays. In fact, children with AS frequently have good or superior language and cognitive skills.)


 * People with Asperger syndrome, as well as people with other forms of autism, are sometimes are referred to as being "on the spectrum."


 * People with Asperger syndrome may refer to themselves as "Aspies."

Causes
Current research points to brain abnormalities as the cause of AS. Using advanced brain imaging techniques, scientists have revealed differences in both the structure and the function of certain parts of the brains of normal versus AS children. These differences are most likely caused by the abnormal migration of cells during development in the womb. The abnormal migration affects brain structure and “wiring,” and then goes on to affect the neural circuits that control thought and behavior.

For example, one study found less brain activity in the frontal lobe of AS children when they were asked to respond to tasks that required them to use their judgment. Another study found differences in activity when children were asked to respond to facial expressions. A different study investigating brain function in adults with AS revealed abnormal levels of specific proteins that correlate with obsessive and repetitive behaviors.

Scientists have always known that there had to be a genetic component to AS and the other ASDs because the disorders tend to run in families. Additional evidence can be seen in family members who have symptoms similar to AS, but in a more limited form. For example, the father of a child with AS may have slight difficulties with social interaction.

A specific gene for AS, however, has never been found. There is most likely a group of genes which, when abnormal, make a person vulnerable to developing AS.

There is no good evidence that vaccinations cause AS or autism.

Interests
A distinguishing symptom of AS is a child’s obsessive interest in a single object or topic to the exclusion of more age-appropriate, common interests. Some children with AS have become experts on vacuum cleaners, makes and models of cars, or even objects as odd as deep fat fryers. Children with AS want to know everything about their topic of interest and their conversations with others will be about little else. The conversation may seem like a random collection of facts or statistics, with no point or conclusion. Still, their expertise, high level of vocabulary, and formal speech patterns make them seem like “little professors.”

Social difficulties
People with AS have social impairment and difficulty understanding others' point of view. They tend to be socially awkward, eccentric, unaware of conventional social rules, or unempathic. They may make limited eye contact, seem to be unengaged in a conversation, and not understand gestures or nonverbal communication.

When they approach other people, they may make normal conversation impossible by inappropriate or eccentric behavior, or by wanting only to talk about their singular interest. They have difficulty engaging in reciprocal conversation; they are unsure how to engage in the typical back-and-forth that characterizes small talk and are not sure how to build on the other person's contributions to the conversation.

Speech
Though the grammar of AS patients’ speech is correct, it may sound peculiar due to an abnormal inflection and a repetitive pattern. There may be a lack of rhythm or a monotone pitch. Children with AS often lack the ability to modulate the volume of their voice to match their surroundings. For example, they may have to be reminded to talk softly every time they enter a library or a movie theatre. Adults may often repeat certain phrases over and over, or have an odd predilection for a specific set of rather esoteric words.

Clumsiness
Clumsiness may be prominent in people with AS, both in their articulation of words and in their motor behavior. Commonly, they are accused of "mumbling."

Children with AS usually have a history of developmental delays in motor skills such as pedaling a bike, catching a ball, or climbing outdoor play equipment. They are often awkward and poorly coordinated with a walk that can appear either stilted or bouncy.

Obsessive routines
People with AS may find routine very important and become distressed if their routine is disturbed.

Other problems
Many children with AS develop anxiety or depression in young adulthood. Other conditions that often co-exist with AS are ADHD, tic disorders such as Tourette syndrome, depression, anxiety disorders, and OCD.

Diagnosis
The diagnosis of AS is complicated by the lack of standards. In fact, because there are several ways to screen for AS, each way using different criteria, the same child could receive different diagnoses depending on the screening tool the doctor uses.

To further complicate the issue, some doctors believe that AS is not a distinct disorder. Instead, they call it high-functioning autism (HFA), and view it as being on the mild end of the ASD spectrum with symptoms that differ only in degree from classic autism. Some clinicians use the two diagnoses, AS or HFA, interchangeably. This makes gathering data about the incidence of AS difficult, since some children will be diagnosed with HFA instead of AS, and vice versa.

Most doctors rely on the following behaviors to alert them to the possibility of AS.


 * abnormal eye contact
 * aloofness
 * the failure to turn when called by name
 * the failure to use gestures to point or show
 * lack of interactive play
 * lack of interest in peers

Some of these behaviors may be apparent in the first few months of a child’s life, or they may appear later. Problems in at least one of the areas of communication and socialization or repetitive, restricted behavior must be present before the age of three.

The diagnosis of AS is a two-stage process. The first stage begins with developmental screening during a “well-child” check-up with a family doctor or pediatrician. The second stage is a team evaluation to either rule in or rule out AS. This team generally includes a psychologist, neurologist, psychiatrist, speech therapist, and additional professionals who have expertise in diagnosing children with AS.

The comprehensive evaluation includes the following:


 * neurologic and genetic assessment, with in-depth testing to establish IQ and evaluate other abilities
 * verbal and non-verbal communication strengths and weaknesses, including evaluation of:
 * * non-verbal forms of communication (gaze and gestures);
 * * the use of non-literal language (metaphor, irony, absurdities, and humor);
 * * patterns of inflection, stress and volume modulation;
 * * pragmatics (turn-taking and sensitivity to verbal cues);
 * * content, clarity, and coherence of conversation.


 * style of learning
 * independent living skills

The physician will look at the testing results and combine them with the child’s developmental history and current symptoms to make a diagnosis.

Treatment
There is no cure for AS, nor is there one single treatment for autism spectrum disorders. But there are ways to help reduce the symptoms of autism and to help a child learn.

The ideal treatment for AS coordinates therapies that address three core symptoms of the disorder: poor communication skills, obsessive or repetitive routines, and physical clumsiness. There is no single best treatment package for all children with AS, but most experts agree that the earlier the therapies start, the better.

While few programs are designed specifically to address AS, some of the treatment approaches used for people with high-functioning autism may be appropriate for a person with AS.

Applied behavioral analysis
Applied behavioral analysis (ABA) is based on the idea that behavior that is rewarded will more likely be repeated. ABA is typically done on a one-to-one basis and may focus on specific behaviors and communication skills.

Treatment & education of autistic and related communication of handicapped children
Treatment & education of autistic and related communication of handicapped children (TEACCH) was developed at the School of Medicine at the University of North Carolina as a structured teaching approach that used the child's visual and rote memory abilities to improve communication, social and coping skills. Pictures and charts that show a daily schedule help the child with AS to anticipate what will happen during the day. This is particularly important for children with AS since they usually have difficulties with changes in routine.

Other therapeutic options

 * Social skills training is a form of group therapy that teaches children with AS the skills they need to interact more successfully with other children.


 * Cognitive behavioral therapy is a type of “talk” therapy that can help the more explosive or anxious children to manage their emotions better and cut back on obsessive interests and repetitive routines


 * Occupational therapy is for patients with trouble processing sensory input or who have poor motor coordination. It helps patients find ways to adjust tasks to match their needs and abilities.


 * Physical therapy provides exercises and activities to build children’s motor control and improve posture and balance.


 * Specialized speech/language therapy helps children who have trouble with the ‘’pragmatics’’ of speech&mdash;that is, the give and take of normal conversation.

Educational / school-based options
In the United States, public schools are required by law to provide free, appropriate public education from age three through high school or age 21, whichever comes first.

Typically, a team of people, including the parents, teachers, caregivers, school psychologists, and other child development specialists work together to design an Individualized Education Plan to help guide the child with AS through school.

Medication and other treatment options
Currently there are no medications that can cure autism spectrum disorders or all of the symptoms. The U.S. Food and Drug Administration has not approved any medications specifically for the treatment of AS, but in many cases medication can treat some of the symptoms associated with autism.


 * Selective serotonin reuptake inhibitors (SSRIs), tricyclics, psychoactives/antipsychotics, stimulants, and anti-anxiety drugs are among the medications that may treat symptoms of autism spectrum disorders. However these drugs may be mainly treating the anxiety and/or depression associated with the difficulties of a life with AS, and not the syndrome itself. Nevertheless, there is likely some role of serotonin in the pathophysiology of AS.


 * Secretin, a hormone that helps digestion, has been suggested as a treatment for autism, but there is not enough evidence that it is effective, so it is not recommended.


 * A gluten-free, casein-free diet: There are many patient advocates who recommend a gluten-free and casein-free diet for people with autism/AS, a feat not easily accomplished. Unfortunately, the objective, clinical evidence for this is sparse. Nonetheless, anecdotal reports of marked improvement are numerous.

Parent training and support
Parent training and support is important so that parents can learn behavioral techniques to use at home.

Prognosis
With effective treatment, children with AS can learn to cope with their disabilities, but they may still find social situations and personal relationships challenging. Many adults with AS are able to work successfully in mainstream jobs, although they may continue to need encouragement and moral support to maintain an independent life.

Research
In the United States, many of the Institutes at the National Institutes of Health, including the National Institute of Neurological Disorders and Stroke (NINDS), are sponsoring research to understand what causes AS and how it can be treated.

One study is using functional magnetic resonance imaging (fMRI) to show how abnormalities in particular areas of the brain cause changes in brain function that result in the symptoms of AS and other ASDs. Another is examining whether cognitive-behavioral therapy helps people with Asperger.

NINDS is also supporting an international study to collect and analyze DNA from children with AS and HFA, as well as from their families, to find genes that might be altered in those disorders. Called the Autism Genome Project, it is a consortium of scientists around the world building a library of genetic data that allows researchers to look for the genetic “building blocks” of AS and the other ASDs.

Knowing the genetic profile of an ASD could mean early diagnosis of children at risk, and early treatments and therapies when they are likely to be the most successful.

Asperger as a different way of being
Some people with Asperger syndrome argue that their thinking patterns and approach to social interaction constitute a different, but equally acceptable way of life. There are groups of people with Aspergers that formally oppose, for example, prenatal testing, the idea of a cure, and the idea that autism and AS are tragic conditions.

Their opinions, based in part as they are on the idea of a shared autistic culture, may be likened to those of some deaf people who oppose cochlear implants on the grounds that such treatments would destroy deaf culture. Both groups feel that their conditions are not disabilities.

Vaccinations
Despite years of research, no evidence that vaccines or mercury cause autism or AS has been found.

Clinical Trials
For a list of American government-sponsored clinical trials that are currently recruiting AS patients, visit Asperger's Clinical Trials.

History
Hans Asperger, an Austrian physician, first described the syndrome in 1944.

Famous people
Temple Grandin is a renowned writer and lecturer on autism. She is exceptional because she is affected with autism herself, and is one of the first such people to have written about her experiences from a first-person perspective. In addition to having written numerous bestselling books, she has a Ph.D. and is a designer of animal-handling facilities by profession. She chose this career in part because she has long felt able to understand animals and how they view the world.

Other Resources
The Curious Incident of the Dog in the Night-time is a novel by Mark Haddon, written from the perspective of a high-functioning autistic boy.

A number of schools and camps have been founded to cater especially to the needs to children with Asperger syndrome.

Related Videos
Sam Wang (Neuroscientist, Princeton University) explores the state of autism prevention and therapy in this BigThink video "The Autistic Brain":