Transcript Asperger`s Syndrome - University of Nebraska Medical Center

Asperger’s Syndrome:
Assessment and Intervention in the Mental
Health Setting
By Ariadne V. Schemm, MA
Pediatric Psychology Intern
Munroe-Meyer Institute for Genetics and Rehabilitation
University of Nebraska Medical Center
April 5, 2006
History of Asperger’s Syndrome
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Hans Asperger and Leo Kanner first described similar forms of
autism in the 1940’s
Asperger’s description differed from Kanner’s in that speech was
less delayed, motor deficits were more common, the onset was
later, and it appeared to be most prevalent in boys
Kanner’s work has defined recent views of autism, as a lack of
responsiveness to other people and severe language impairments
There was growing concern that the diagnosis of Autism could no
longer be given to children who had developed fluent speech and
an interest in socializing with others. The term “Asperger’s
Syndrome” was first used by Dr. Lorna Wing in 1981.
Current View
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Asperger’s Syndrome is now considered to
be a less severe form of autism and a
Pervasive Developmental Disorder
The syndrome is also placed on the
spectrum of autistic disorders and was
recognized and provided with its own
diagnostic criteria in 1994 in the DSM-IV
(Attwood, 2000)
Clinical Features
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Lack of empathy and perspective-taking
Naïve, inappropriate, one-sided
conversations
Limited ability to form friendships
Pedantic and repetitive speech
Poor non-verbal communication
Intense absorption in certain subjects (little
professor)
Clumsy movements and odd postures
(Burgoine & Wing, 1983)
Asperger’s Syndrome 299.80
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Qualitative impairment in social
interaction (at least 2):
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Marked impairment in the use of
nonverbal behaviors
Failure to develop peer relationships
appropriate to developmental level
Lack of shared interest with others
Lack of social or emotional reciprocity
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Restricted repetitive and
stereotyped patterns of behavior,
interests, and activities (at least 2):
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Encompassing preoccupation with one
or more patterns of interest
Inflexible adherence to rituals,
routines, and rules
Repetitive motor movements
Persistent occupation with object parts
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Disturbance causes clinically
significant impairment in social,
occupational, or other areas of
functioning
No clinically significant general delay
in language, cognitive development,
or adaptive behavior
Criteria are not met for other PDD or
Schizophrenia
(APA, 2000)
What it’s not:
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Children and adolescents with one of these
characteristics do not meet the criteria for
AS:
 Social akwardness or poor social skills
 Limited repertoire of interests
 Being described as a “weird kid”
These children fall between the criteria“tweeners”
Statistics
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Prevalence estimated at 20-25/10,000
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More common in males
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Genetics seem to play a larger role in AS
than in autism
(Simon-Cohen, 2005)
Neurologically Based Disorder
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Limited information on brain development
differences in AS
In autism, absolute increases in the total
brain volume, total CNS tissue, and lateral
ventricular volume
 Especially in temporal/parietal/occipital
region
Cerebrum
 Decrease in neuronal size
 Increased cell packing density in the
limbic system
Differentiating Asperger’s
Syndrome from Related Disorders
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Autism
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Rett’s Disorder
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Asperger’s Syndrome
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Childhood Disintegrative Disorder
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Pervasive Developmental Disorder, NOS
Disorder
Similarities
Differences
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Social Anxiety
Fear/avoidance
of social situations
Child has capacity for
age-appropriate
relationships; anxiety
is situation specific
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Mental Retardation
Social & communication
impairments;
repetitive behaviors
Impairments are
quantitative rather
than qualitative
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Speech Disordered
Delayed/Absent
language development
Social intact;
socially motivated;
receptive language is
higher
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ADHD
Impaired social
functioning; easily distracted
Social quality better
Distracted by anything
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Behavior Disordered
Inappropriate behavior
compared to peers;
oppositional
Socially motivated;
socially aware
Assessment Procedures
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Initial Interview
Rating Scales
Observations
Direct Interactions
Environmental Assessment
Initial Interview
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Developmental History (age onset, milestones,
delays)
Medical History ( TBI, fragile X, ADHD, fetal
alcohol)
Previous Evaluations (medical, psych, genetic,
GI)
Presenting Concerns and Symptoms
Severity of Symptoms (frequency, duration,
intensity)
Rating Scales
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Gilliam Asperger’s Disorder Scale
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Easily completed by parents
Items are confounded across domains
Provides a nice interpretation guide
Word of caution-norm group, over-identification
None are adequate to use independently in
assessment
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All are best used as screening devices
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Consider having multiple raters across settings
Direct Observation
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Interest is in observing behavior
across the relevant domains
Interest is in observations not just
of target child behavior but also of
environment
Direct Observations
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Child-teacher interactions (child behavior
and teacher behavior)
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Child-peer interactions (child behavior and
peer behavior)
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Child-parent interactions (child behavior
and parent behavior)
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Child-therapist interactions
Child-Therapist Interactions
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Unstructured interview (school, home,
friends, preferences)
Assessing perceptions of social norms
(Dewey)
Perspective taking experiment (Frith)
Direct Interactions
Reinforcer Assessment
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Successful intervention requires motivation to
learn the skill
Generating motivation to learn requires functional
reinforcers
Identifying functional reinforcers can be difficult
Function can change day-to-day and moment-tomoment
Assess the Environment
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Do environments include demands that are within
the capabilities of the child
Is there direct teaching of social interactions?
Is there limited social stimuli (noise, pace,
crowd)
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Collaboration between home and school
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appropriate educational objectives
Look also for environments that:
 Use primarily positive motivation strategies
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Prevent frequent errors and rely on
prompting strategies
Identify functional reinforcers
Arrange consistency across settings and
team members
Treatment and Intervention
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Teach the acquisition of basic social
interaction skills
Teach the acquisition of adaptive
skills
Social Skill Training
Social skills will need to be taught in an
explicit, scripted, and rote fashion
Skills taught may include:
 Appropriate nonverbal behavior
 Verbal decoding of other’s nonverbal
behaviors
 Social awareness and perspective-taking
skills
(Klin & Volkmar, 1995)
Behavioral therapy vs. Psychotherapy
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Individuals with AS have great difficulty
with insight-oriented therapy
Standard problem-solving techniques are
not effective as the socially appropriate
response is not socially meaningful to a
child with AS
More effective to script out appropriate
reactions in problematic situations and
practice.
Prognosis
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Children with AS are more likely to become
independently functioning adults than
children with other forms of PDD
Adults with AS often gravitate to
professions that mirror their own areas of
special interest
They will continue to demonstrate
difficulties in social interactions
It is estimated that 30-50% of adults with
AS are never correctly diagnosed
(Bauer, 2006; Gillberg,
Resources
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OASIS-Online Asperger Syndrome
Information and Support
www.aspergersyndrome.org/
Autism Society of Nebraska
www.autismnebraska.org
Asperger’s Syndrome- Parent Support
Group: Cindy Roden, 334-9594
or Celeste Montoya, 891-6166
Munroe-Meyer Institute, Psychology
Department: 559-6408
Questions and Comments?
References
Attwood, T. (2000). Asperger’s Syndrome. New York:
Jessica Kingsley Publishers.
American Psychiatric Association (2000). DSM-IV-TR.
Arlington, Virgina: American Psychiatric Association.
Baron-Cohen, S. (2000). Is Asperger’s Syndrome/
High-Functioning Autism necessarily a disability?
Special Millenium Issue of Developmental and
Psychopathology.
Burgoine, E. & Wing, L. (1983). Identical triplets with
Asperger’s Syndrome. Journal of Child Psychology
and Psychiatry, 21, 303-313.
Klin, A. & Volkmar, F. R. (1995). Asperger’s Syndrome:
Guidelines for Assessment and Diagnosis. New
Haven, Connecticut: Learning Disabilities Association
of America.