Asperger's Syndrome: Early Detection Helps

The wider range of symptoms found in Asperger's syndrome makes the disorder a challenge to diagnose and treat.

Only Recently Recognized as a Disorder, AS Affects Children and Teens

"What’s wrong with our 2-year-old son?” parents may ask. They’ve noticed that he is quite different from other children of his age. He looks sad, doesn’t make good eye contact, and is really bothered by noise. He cries a lot when dropped off at day care, and has trouble relating to other children. It upsets him when toys are scattered or out of order. Not surprisingly, parents are often the first to notice behaviors in their child that may be Asperger’s syndrome (AS).

Asperger’s syndrome, also called Asperger’s disorder, is a type of pervasive development disorder (PDD) characterized by severe and enduring impairment in social skills and restrictive and repetitive behaviors and interests.^1,2 Although the condition is similar to autism and sometimes termed “high functioning autism,” a child with AS typically has normal language and intellectual development.

Many children with AS also have coexisting conditions including attention-deficit/hyperactivity disorder (ADHD); social anxiety disorder; depression; obsessivecompulsive disorder (OCD); and nonverbal learning disorder. PDDs are a group of conditions that involve delays in the development of many basic skills, most notably the ability to socialize with others, communicate, and use imagination. AS was named for the Austrian doctor, Hans Asperger, who first described the disorder in 1944.^2,3 People identifying with AS sometimes refer to themselves in casual conversation as “aspies,” a term coined by Liane Holliday Willey in 1999.⁴

Symptoms

The symptoms for AS during childhood range from mild to severe.^1,2 The main symptom is significant trouble with social situations. Because of the wide variety of symptoms, no 2 children with AS present identically. Children with AS may not pick up on social cues and may lack inborn social skills, such as being able to read others’ body language, or start or maintain a conversation. Many children with AS are overly interested in parts of a whole.

Children

Common AS symptoms in children include:

• Difficulties with social skills— Children generally have difficulty interacting with others, are awkward in social situations, and have trouble making friends.^1,4-6

• Repetitive behaviors—Children may develop odd, repetitive movements, such as hand wringing or finger twisting. ^1,7,8

• Rituals—Children may develop rigid practices that they refuse to alter, such as getting dressed in a specific order. They dislike any changes in routines.^1,2

• Difficulties with communication— Children may not make eye contact when speaking with someone, have trouble using facial expressions and gestures and understanding body language, talk a lot, have a formal style of speaking that is advanced for their age, and have difficulty understanding figurative language and tend to use language literally.^1,2,9

• Limited range of interests—Children may develop an intense, almost obsessive, interest in areas, such as sports schedules, weather, or maps.^1,2,9

• Special skill or talent—Children may be exceptionally talented or skilled in a particular area, such as music or math.^1,2

Adolescents and Teens

Generally, AS symptoms identified during early-late childhood may improve over time, but many symptoms continue to be problematic during the teen years.^1,2 Adolescents will probably continue to have difficulty “reading” others’ behavior. Teens may want friends but may feel shy or intimidated when approaching other teens. Although most teens place emphasis on being and looking “cool,” teens with AS may find it frustrating and emotionally draining to try to fit in. All of these difficulties can cause them to become withdrawn and socially isolated, and display depression or anxiety.

Teens with AS also are typically uninterested in following social norms, fads, or conventional thinking.^1,2 Their preference for rules and honesty may lead them to excel in the classroom and as citizens. Many children with this condition are overly interested in parts of a whole. They may show an unusual interest in certain topics such as snakes, names of stars, or dinosaurs. They may be unable to recognize subtle differences in speech tone, pitch, and accent that alter the meaning of others’ speech. They may not understand a joke or may take a sarcastic comment literally. And their speech may be flat and hard to understand because it lacks tone, pitch, and accent.^1,2

Adults

Generally symptoms tend to stabilize over time, and improvements are often seen, but AS is a lifelong condition.^1,2 Adults usually have a better understanding of their own strengths and weaknesses and they are able to learn social skills, including how to read others’ social cues. Some traits that are typical of AS, such as attention to detail and focused interests, can increase chances of college and career success.

Prevalence and Causes

AS has only recently been recognized as a unique disorder. For that reason, the exact number of people with the disorder is unknown, although it is more common than autism. Estimates suggest AS affects about 1 in 300 children, affecting boys more commonly than girls by 10 to 1. AS is usually first diagnosed in children between the ages of 2 and 6 years.^1,2,10,11

The exact cause of AS is unknown and there is no known way to prevent its occurrence. Most research suggests all autism spectrum disorders have shared genetic mechanisms, but AS may have a stronger genetic component than autism.¹² There may be a common group of genes where particular alleles render an individual more vulnerable to developing AS.¹³ Neuroanatomical studies and the associations with teratogens strongly suggest that the mechanism includes alteration of brain development soon after conception. ¹⁴ Irregular migration of embryonic cells during developmental stages may affect the final synaptic and physiological structure of the brain, resulting in alterations in the neural circuits that control thought and behavior.¹⁵

AS Diagnosis

There are currently no specific clinical tests to diagnosis AS, and physicians often perform complete medical and physical exams, x-rays, and blood tests to help determine if a physical disorder is causing AS symptoms.^1,2 If no physical disorder is found, a child may be referred to a specialist in childhood development disorders, for example, a child and adolescent psychiatrist or psychologist, pediatric neurologist, developmental pediatrician, or another health care professional who is specially trained to diagnose and treat AS.^3,13,16 Also, the diagnosis may be based on the child’s level of development, and the doctor’s observation of the child’s speech, behavior, ability to socialize with others, and input from the child’s parents, teachers, and other adults. When these steps are not followed, many children with AS are initially misdiagnosed with ADHD.^1,2,16

The “gold standard” in diagnosing AS combines clinical judgment with the Autism Diagnostic Interview-Revised (ADI-R)—a semistructured parent interview, and the Autism Diagnostic Observation Schedule (ADOS)—a conversation and play-based interview with the child.¹⁷

However, one of the proposed changes in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, set to be published in May 2013,¹⁸ would eliminate Asperger’s syndrome as a separate diagnosis, and place it under autistic disorder (autism spectrum disorder), which would be rated on a severity scale.¹⁹

Treatment for AS

Currently, there is no cure for AS; however, early diagnosis and treatment may improve functioning and reduce undesirable behaviors.²⁰ Intervention is aimed at improving symptoms and function. The mainstay of management is behavioral therapy, addressing poor communication skills, obsessive or repetitive routines, and physical clumsiness.¹³ Most children improve as they mature to adulthood.¹⁷

Pharmacotherapy

The atypical antipsychotic medications risperidone and olanzapine have been shown to reduce the associated symptoms of AS.^1,2 Risperidone can reduce repetitive and self-injurious behaviors, aggressive outbursts and impulsivity, and improve stereotypical patterns of behavior and social relatedness. Commonly reported side effects include weight gain, fatigue, increased risk for extrapyramidal symptoms such as restlessness and dystonia,²¹ and increased serum prolactin levels.²² Sedation and weight gain are more common with olanzapine,²³ which has also been linked with diabetes.²⁴

The selective serotonin reuptake inhibitors (SSRIs) fluoxetine, fluvoxamine, and sertraline have been effective in treating restricted and repetitive interests and behaviors.^1-3,21 SSRIs can lead to manifestations of behavioral activation such as increased impulsivity, aggression, and sleep disturbance.²¹

Summary

Without a cure for AS, early detection and proper management strategies are critical for AS patients to function independently in society.^1,2,17 The Internet has allowed individuals with AS to communicate and celebrate their uniqueness in a way that was not previously possible. Many people with AS will marry, have children, and can have very successful careers. A number of respected historical figures have had symptoms of Asperger’s, including Wolfgang Amadeus Mozart, Albert Einstein, Marie Curie, and Thomas Jefferson. PT

Mr. Brown is professor emeritus of clinical pharmacy and a clinical pharmacist at Purdue University College of Pharmacy, Nursing, and Health Sciences, Department of Pharmacy Practice, in West Lafayette, Indiana. This article is based on current studies and references, but it may be changed without notice with newer studies or with different patient populations.

References:

1. American Psychiatric Association (2000). Diagnostic criteria for 299.80 Asperger’s Disorder (AD). Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision DSM-IV-TR.

2. McPartland J, Klin A. Asperger’s syndrome. Adolesc Med Clin. 2006;17(3): 771-788.

3. Baskin JH, Sperber M, Price BH. Asperger syndrome revisited. Rev Neurol Dis. 2006;3(1):1-7.

4. Willey LH. Pretending to be Normal: Living with Asperger’s Syndrome. London, UK: Jessica Kingsley Publishers; 1999.

5. Klin A. Autism and Asperger syndrome: an overview. Rev Bras Psiquiatr. 2006;28(suppl 1):S3-S11.

6. Ghaziuddin M. Should the DSM V drop Asperger syndrome? J Autism Dev Disord. 2010; 40(9):1146-1148.

7. Brasic JR. Asperger’s Syndrome. Medscape Medicine. 2010;7:7.

8. Sanders JL. Qualitative or quantitative differences between Asperger’s Disorder and autism? historical considerations. J Autism Dev Disord. 2009;39(11):1560-1567.

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11. Fombonne E. Epidemiological surveys of pervasive developmental disorders. In: Volkmar FR. Autism and Pervasive Developmental Disorders. 2nd ed. Cambridge University Press; 2007.

12. Foster B, King BH. Asperger syndrome: to be or not to be? Curr Opin Pediatr. 2003;15(5):491-494.

13. National Institute of Neurological Disorders and Stroke (NINDS) (2007-07-31). Asperger syndrome fact sheet.

14. Arndt TL, Stodgell CJ, Rodier PM. The teratology of autism. Int J Dev Neurosci. 2005;23(2-3):189-199.

15. Rutter M. Incidence of autism spectrum disorders: changes over time and their meaning. Acta Paediatr. 2005;94(1):2-15.

16. Fitzgerald M, Corvin A. Diagnosis and differential diagnosis of Asperger syndrome. Adv Psychiatric Treat. 2001;7(4):310-318.

17. Woodbury-Smith MR, Volkmar FR. Asperger syndrome. Eur Child Adolesc Psychiatry. 2009;18(1):2-11.

18. [AUTHOR: SUPPLY URL. IS THIS THE SAME AS REFERENCE 19?]DSM-5 development. American Psychiatric Association. 2010.

19. [AUTHOR: SUPPLY URL. IS THIS THE SAME AS REFERENCE 18?]Asperger’s Disorder. DSM-5 Development. American Psychiatric Association. 2010.

20. Towbin KE. Strategies for pharmacologic treatment of high functioning autism and Asperger syndrome. Child Adolesc Psychiatr Clin N Am. 2003;12(1):23-45. [THIS IS ALSO REF #12]

21. Foster B, King BH. Asperger syndrome: to be or not to be? Curr Opin Pediatr. 2003;15(5):491-494.

22. Chavez B, Chavez-Brown M, Sopko MA, et al. Atypical antipsychotics in children with pervasive developmental disorders. Pediatr Drugs. 2007;9(4):249-266.

23. Staller J. The effect of long-term antipsychotic treatment on prolactin. J Child Adolesc Psychopharmacol. 2006;16(3):317-326.

24. Newcomer JW. Antipsychotic medications: metabolic and cardiovascular risk. J Clin Psychiatry. 2007;68(suppl 4):8-13.