Sunday, December 3, 2023

Asperger's Syndrome


Ruwan M Jayatunge M.D. PhD (in progress) 

Asperger’s Syndrome (AS) is named after the Austrian physician Hans Asperger, who first identified and described the behavioral profile of a group of children having issues with social interaction and communication skills in 1944 (Romagnoli et al., 2019). These boys had awkward motor skills and their motor clumsiness was significant. They had difficulties in tasks requiring balance and coordination. Although these children had marked social problems, they had good language and cognitive skills. At around this time in the United States, Leo Kanner was studying a similar but more disabled group of children whom Kanner described as having early infantile autism (Gail, 2020).  

Asperger's syndrome is a neurodevelopmental disorder that is pervasive and usually manifested in childhood (Casanova et al., 2002).  The syndrome can color psychiatric disorder, affecting both presentation and management, for children and adults across a wide range of functional abilities (Berney, 2004).  It is estimated that about 1% of the population of children ages 3 to 17 in the United States has an ASD.

Asperger's syndrome is one of the autism spectrum disorders (Roy et al., 2009). However, Asperger’s syndrome can be distinguished from childhood autism mainly by the absence of significant delay in language and cognitive development (Lehti et la., 2015). Generally, AS children have normal intelligence, and adequate language skills in the areas of grammar and vocabulary (Casanova et al., 2002). They have a qualitative impairment in social interactions (Rojo et al., 2019). Individuals with Asperger's disorder have a better prognosis than people with high-functioning autism (Macintosh & Dissanayake, 2004).  

Although there is no decrease in intelligence or linguistic functionality in Asperger's syndrome, they can have strange speaking patterns (Tarazi et ai., 2015) with rigid and repetitive interests (McPartland & Klin, 2006).  They speak fluently but have problems engaging in reciprocal conversation (Woods et al., 2013). Individuals with Asperger's syndrome have difficulties in social interactions, verbal, and non-verbal communication, and may display behavioral oddities, with stereotypes and limited interests (Mirkovic & Gérardin, 2019).

Lack of social reciprocity, and empathy, and severe difficulties in social integration have been identified in AS individuals (Baskin & Sperber, 2006).  They may have problems with non-verbal cues and reciprocal interaction and often have trouble processing social meaning (David et al., 2010). Furthermore, they have extremely restricted interests with social awkwardness (social difficulties) and it can be a vicious cycle for them (Woods et al., 2013).

According to Mirkovic and Gérardin (2019), they show no language delay, and their cognitive development is not marked by an overall delay but by specific impairments in certain areas such as executive functions. Affected individuals display considerably impaired capacity for social interaction, unusual special interests, and a tendency towards ritualized behavior (Roy et al.,   2009).

People with AS also often have some degree of motor clumsiness (Khouzam et al., 2004). They often display an odd or uneven gait when walking or running, trouble with ball skills, difficulty with balance, poor handwriting skills, and difficulty imitating or mirroring others’ postures, gestures, or movements (Attwood, 1998). Toth and King (2008) describe marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction failure to develop peer relationships appropriate to developmental level, lack of spontaneous seeking to share enjoyment, interests, or achievements with other people in children diagnosed with AS.

Some AS children display tactile defensiveness and they may avoid touch. They have hypersensitivity to lights and sounds. They become upset at any small changes in routines. Some have learning difficulties and easily fall behind in completing assignments. Poor organizational skills make them less efficient and less effective. They have difficulties interacting with peers.  Compulsive talking and the inability to understand societal norms have been noticed in AS. Often they do not understand the concept of personal space. They have intense absorption in certain subjects and obsessively pursue interests.

Asperger's disorder usually manifests itself at preschool age (Khouzam et al., 2004).  ASDs in general occur more frequently in boys than girls (Woods et al., 2013). Most cases are diagnosed between the ages of five and nine, with some diagnosed as early as age three.

Although the etiology of Asperger's disorder is still undetermined, a multifactorial origin is accepted.  Ylisaukko-oja and team (2004) indicate a genetic component especially chromosomes 1, 3, and 13 seem to be involved.  Imaging studies revealed significant reductions in gray matter in frontostriatal and cerebellar regions in the brains of AS patients (Tarazi et al., 2015).

Diagnosing AS can be tricky, as the diagnostic criteria are not differentiated from those defining autistic disorder (Toth & King, 2008). The diagnosis of AS requires at least two symptoms of social interaction impairment and one symptom of behavioral and interest restriction, normal cognitive functioning, and the absence of significant general delay in language (de Giambattista et al., 2019).  

The diagnostic concept of Asperger's Syndrome was introduced in the diagnostic manuals of both the APA and the WHO in the 1990s (Attwood, 2006). The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM, 2013) has classified Asperger’s Syndrome, Autistic Disorder, and Pervasive Developmental Disorder-Not Otherwise Specified within a single diagnostic category called Autism Spectrum Disorder (ASD) (Romagnoli et al., 2019).

Asperger’s syndrome may be present with several comorbid disorders including attention deficit hyperactivity disorder, anxiety, schizophrenia, bipolar disorder, depression, and Tourette’s syndrome (Tarazi et al., 2015). Depression and anxiety are higher in people with AS than in the general population (Weiss, 2010). Parkinson (2014) states that patients with Asperger's syndrome are prone to obsessive preoccupations. 

For the treatment symptom oriented pharmacological and psychotherapeutic (sociobehavioral therapy and cognitive behavioral therapy) approach is suitable (Roy et al.,2009). Donoghue and colleagues (2011) discuss the therapeutic effectiveness of Cognitive Behavioral Therapy (CBT) in children and young people diagnosed with Asperger’s Syndrome. Romagnoli et al (2019) state that Occupational therapy (OT) interventions help with AS. Scattone (2008) suggests social stories with video modeling.  Rao and team (2008) highlight social skills training in AS.  Family Therapies, especially parent training help to assist individuals with Asperger’s Syndrome. As described by Motlani and colleagues (2022) mostly the treatment aims to reduce core impairments, increase functional ability, and reduce harmful behaviors that could limit functional skills. 



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