Transcript Asperger`s Syndrome

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
Symptoms of
Asperger’s
Syndrome
•Impairments in social interaction, narrow
interests, an insistence on repetitive routines,
speech and language peculiarities, nonverbal 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
High Functioning Autism
• 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
• 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