Diagnosis of Asperger syndrome

Diagnosis of Asperger syndrome
Professor Tony Attwood
Clinical Psychologist
Summary of the Presentation
• Problems associated with the current diagnostic
criteria
• The diagnostic assessment for children and
adults
• The profile of abilities in girls and women with
Asperger’s syndrome
• Four reactions to having Asperger’s syndrome
• Explaining the diagnosis to a child
Hans Asperger
1930s
Vienna University Children’s Clinic
Hans Asperger
1906 - 1980
Lorna Wing
• In 1981, in London,
Lorna Wing first used the
eponymous term
Asperger’s syndrome
• One of the Autism
Spectrum Disorders
History of Asperger’s Syndrome
• 1988: The first international conference on
Asperger’s syndrome was held in London
• 1989: Diagnostic criteria were developed by
Christopher Gillberg in Sweden and similar
diagnostic criteria by Peter Szatmari and
colleagues in Canada
• 1993: World Health
Organization published
diagnostic criteria for A.S.
in ICD 10
• 1994: American Psychiatric
Association included
Asperger’s disorder in the
Diagnostic and Statistical
Manual of Mental Disorders
(revised in 2000)
Criticism of the DSM Criteria
• The DSM criteria do not reflect the original
descriptions of Hans Asperger (Miller &
Ozonoff 1997; Hippler & Klicpera 2003)
• The criteria do not reflect empirical
and clinical knowledge
• Provide only cursory guidelines
for the diagnostic assessment
and a superficial description of
the disorder
Criticism of the DSM Criteria
• Problems with the differential
criteria and precedence of
autism over Asperger’s disorder
• Little explanation of language
deviance, circumscribed
interests and motor clumsiness
No clinically significant
delay in language
• Single words by age two years, communicative
phrases by age three years is actually indicative of a
significant language delay (single words by one year,
sentences around two years)
• Early language skills do not accurately predict later
clinical symptoms (Eisenmajer et al. 1998; Dickerson
et al. 2001; Howlin 2003; Manjiviona & Prior 1999)
• Clinical opinion is that early language delay is not a
deterrent to a diagnosis of Asperger’s syndrome
No clinically significant delay in age appropriate
self-help skills and adaptive behaviour
• Information from parents indicates the need for
verbal reminders and supervision
• Lower than expected scores on Adaptive
Behaviour Scales
• Significant problems with anxiety and anger
management and the incidence of conduct
disorder
Changes in the profile of
abilities over time
• Moving from autism in early childhood to
Asperger’s syndrome
• Moving from Asperger’s syndrome to a profile of
abilities and behaviour that do not cause a
clinically significant impairment in social,
occupational or other important areas of
functioning (sub-clinical level)
Autism, high functioning Autism and
Asperger’s syndrome
Typical
development
Asperger’s
syndrome
High Functioning
Autism
Classic
Autism
Early childhood
Adolescence
Needs of clinicians and academics
• Research studies need clear and consistent
diagnostic criteria to describe the subjects and to
compare and replicate studies
• Clinicians have a more flexible approach to the
diagnostic criteria and are more concerned with
understanding and helping the child
• The diagnostic criteria are still a work in progress
Prevalence rates
• Using the Gillberg criteria, one child
in 250 has AS (Gillberg 2002)
• Perhaps 50% receive a diagnosis
• Percentage detection rates are
increasing
• Average age of diagnosis is 11
years (Howlin & Asgharian 1999)
Asperger’s Syndrome Clinic in
Brisbane, Australia, started in 1992
400
350
300
250
Male
Female
200
150
100
50
0
1950s
1960s
1970s
1980s
1990s
date of birth of clients with Asperger’s Syndrome
Australian Scale for Asperger’s
Syndrome ASAS-revised
• Based on the original ASAS by Garnett &
Attwood (1993)
• 140 items to measure ten factors based on
clinical experience, research studies and the
diagnostic criteria
• Currently being administered to over 300 families
Screening questionnaires
for adults
• Autism Spectrum Quotient
by Baron-Cohen et al. 2001
• Empathy Quotient (AQ) by
Baron-Cohen & Wheelwright
2004
• Reading the Mind in the
Eyes Test by Baron-Cohen,
Wheelwright & Hill 2001
The diagnostic assessment
• Training and experience in the
diagnostic procedures
Stages in friendship
1. Physical world
2. Wanting to have friends
3. Functional friends
4. Loneliness
5. Partner
Friendship and social play
skills with peers
• The signs of AS are more
apparent when the child is
with peers rather than
parents or adults
• Ability to make and keep
friendships
• Maturity in friendship skills
Ability to attribute social meaning
Noticing objects and
facts rather than
thoughts, feelings
and intentions
LDA Language
Cards: Emotions
LDA Language Cards: Emotions
Descriptions of
pictures and events
may not include
thoughts and feelings
Empathy and the
communication of emotions
• Facial expression may not reflect the inner mood
“People tell me to smile even though
I feel great inside” Tom
• Range of responses to the distress of another
person may be limited or unusual (mother crying)
Speech and language characteristics
Pragmatics, Prosody and Pedantry
According to Hans Asperger, language deviance
is one of the most dominant characteristics
The development of the special
interests
Stage 1
Parts of objects
Stage 2
Category of objects (typical and
eccentric). May pretend to be the
object. Often transport, animals and
electronics
Stage 3
Complex or abstract interests such as
periods of history, geography
Stage 4
Interest in a person, fantasy literature
and may have multiple interests
Nature of the interests
• Self-directed and self-taught
• Solitary and intuitive activity
• Development of a cataloguing system
• Creative arts, drawing, sculpture, music and
poetry
• Attention to detail
Clinician’s perspective
• Change in the person’s persona when talking
about the interest
• Macabre interests can be a sign of depression or
being bullied
• When severely stressed there can be a
progression from an activity for pleasure to a
compulsive act (OCD)
Motor clumsiness
• Immature ball catching skills
• Poor coordination when using
playground equipment
• Poor manual dexterity
• Untidy, large and slow
handwriting (macrographia)
Sensory sensitivity
•
•
•
•
Sound sensitivity
Tactile sensitivity
Sensitivity to the taste or texture of food
Stoic in response to pain or temperature
Profile of abilities in girls
• The invisible end of the spectrum (Ruth Baker)
• Same pattern as with boys but can be a less
severe expression
• Coping and camouflaging mechanisms of ‘hiding’
and mimicking
Profile of abilities in girls
• Tendency to ‘disappear’ in a crowd
• Doll play to replay and understand social
situations
• Peer support (not bitchy)
• Single friend who provides guidance and security
Profile of abilities in girls
• Observe and try to
understand before making
the first step
• Read fiction which helps
them learn about inner
thoughts and feelings
Profile of abilities in girls
• Less disruptive and so less likely
to be noticed
• Learn that if you are good, you
are left alone
• Have a faster rate of learning
social skills than do boys with AS
• Special interests which are more
likely to be unusual in terms of
the intensity rather than the focus
• Imaginary friends
Profile of abilities in girls
• May change name or adopt the persona of
another person
• Watch soap operas to understand interactions
and to provide a script of what to do
• Read self-help literature on relationships
Diagnostic criteria and
assessment of adults
• No single set of clinical criteria exists for
Asperger’s syndrome in adults
• Theory of mind tasks (The Eyes Test)
• Self report instruments (Autism Social Quotient
and the Empathy Quotient by Simon BaronCohen and colleagues)
• Quality and timing of responses ‘text book’ or
fractionally delayed
Diagnostic criteria and
assessment of adults
• Developmental history (validation from a relative)
• Photographs or films of childhood, and school
reports
• Description of self (referenced by actions not
social network)
• Initial awareness of being different. What were
the differences?
Diagnostic criteria and
assessment of adults
• Reluctance to seek a diagnosis from a
psychologist or psychiatrist due to a fear of being
labeled and treated as being insane
• Ability to ‘fake it’, to superficially pass for normal
Diagnostic criteria and
assessment of adults
The clinician needs:
• An objective description of the person by a
partner, relative or friend
• Work and relationship history
Diagnostic criteria and
assessment of adults
• Some adults have the symptoms but not the
impairment in functioning (due to a support
network or circumstances)
• It is not the severity of expression that is
important, but the expectations and coping
mechanisms
Age of diagnosis
• The diagnosis can only be made
with confidence after the age of
five years
• In the early years the signs are
more subtle and social interaction
is simpler
The child’s reaction to being
different before the diagnosis
Four reactions:
• Depression and isolation
• Arrogance and anger (God mode)
• Imagination and fantasy
• Imitation (good guys and bad guys)
Depression and isolation
• Increased social withdrawal
• Reduced motivation and energy
• Risk of self-harm and impulsive or planned
suicide attempts
• Need for Cognitive Behaviour Therapy, social
success and medication
Arrogance
• Over compensation for feeling incompetent in
social situations
• Invariably someone else’s fault (‘Teflon coated’)
• When experiencing a negative reaction in a
social situation, seek resolution or revenge by
inflicting equivalent discomfort (‘eye for an eye’)
• Argumentative: use accurate recall of what was
said or done to prove the point
Arrogance
• Limited ability to accept they may be wrong
• Desperate not to appear stupid in a social
context
• Due to delay in Theory of mind skills, tend to
attribute malicious intent to accidental or friendly
acts
Imagination
• Imaginary friends
• Inhabiting an imaginary world
• Interest in other worlds and role play games
• Become an author of fiction
Imitation
• Observe and absorb the speech, mannerisms
and character, even persona, of someone who is
socially successful
• Become an expert mimic (successful strategy
that is popular with peers)
• Use speech and drama lessons
• Learn how to act in real social situations
How to explain the diagnosis
• When to explain the diagnosis
• What the child knows and thinks about
Asperger’s syndrome
• The child’s and family’s view of his/her qualities
and difficulties (white board)
Qualities and difficulties
• honest
• making friends
• determined
• managing feelings
• an expert
• taking advice
• notice sounds others do not hear
• handwriting
• kind
• speak your mind
• knowing what someone is
thinking
• enjoy solitude
• avoiding being teased
• perfectionist
• showing as much affection
as others expect
• reliable friend
• good at art
• liked by adults
How to explain the diagnosis
• Advantages and disadvantages of having AS
• A different form of perception and thinking
• Not an excuse to avoid chores or consequences
• Asperger’s syndrome as the next stage of human
evolution