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8.63: Asperger’s Disorder (299.80)

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    Introduction

    • Asperger’s disorder is defined in the DSM-IV-TR to include the same social interaction and behavior impairments as those diagnosed with autism (Hoffman, 2009).
      • This subtype, however, does not include language or cognitive deficits
        • Unlike those with autism, children with Asperger’s are interested in interacting with others.
          • Socially inappropriate, odd communication, or difficulty reading social cues inhibit formation of peer relationships.
          • Furthering their social isolation, children with Asperger’s are described as “little professors” in that they become experts in a particular area of interest often to the exclusion of other topics.
        • Verbal skills are superior to non-verbal
          • Exhibit motor difficulties
            • Visual-spatial abilities
            • Fine and gross motor skills
              • Poor coordination
              • Odd gait
              • Clumsiness
      • Impairments cannot be due to another PDD or schizophrenia.
      • More common in males
        • Estimated between a 5:1 to at least 9:1 male to female ratio
        • Hans Asperger first described this disorder as being attributed to familial heredity.
          • He characterized this disorder to include the following symptoms:
            • Decreased facial expression and gestures
            • Peculiarities is communication
            • Lack of empathy and intellectualization of feelings
            • School behavioral problems
              • i.e. aggression stemming from social deficits

    DSM-IV-TR criteria

    • A. Qualitative impairment in social interaction, as manifested by at least two of the following:
      • 1. 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
      • 2. failure to develop peer relationships appropriate to developmental level
      • 3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
      • 4. lack of social or emotional reciprocity
    • B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
      • 1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
      • 2. apparently inflexible adherence to specific, nonfunctional routines or rituals
      • 3. stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
      • 4. persistent preoccupation with parts of objects
    • C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.
    • D. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years).
    • E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), a curiosity about the environment in childhood
    • F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.

    Associated features

    Asperger’s Disorder has been associated with many mental disorders, such as Depressive Disorders. Also, on occasion, Mild Mental Retardation has been seen to be associated with Asperger’s Disorder. Individuals with this disorder generally seem to have strengths in verbal abilities and weaknesses in non-verbal abilities (i.e. mild motor clumsiness may be present). Overactivity and inattention are typically seen in individuals with Asperger’s Disorder.

    These individuals demonstrate relatively intact intellectual and language functioning accompanied by social impairments seen in autism. They tend to have appropriate but unusually intense interests, increased clumsiness and more object than people focused. There is little research to differentiate from high functioning autism such as with autism and PDD-NOS. They are considered distinct diagnoses in the DSM but instruments are hard to differentiate them effectively. Instead, diagnostic and clinical judgment must be relied on.

    Children with Asperger’s Disorder typically are higher functioning than those with Autism. They have difficulty interacting with peers and some children even have normal intelligence. They are often loners and are often characterized as having eccentric behaviors.

    People with Asperger syndrome have difficulty recognizing faces. They do not use the eye region to a great extent in face identification. The visual search strategies in normal functioning individuals are more effective and rely on the use of the “face information triangle”, i.e. the two eyes and the mouth, while individuals with Asperger syndrome have more fixations on other parts of the face suggesting a less effective use of the “face information triangle”(Falkmer, Larsson, Bjallmark, & Falkmer, 2010).

    When visual search strategies, particularly regarding the importance of information from the eye area, and the ability to recognize facially expressed emotions are compared between adults with Asperger syndrome and normal functioning individuals it is shown that adults with Asperger syndrome had greater difficulties recognizing basic emotion. Distortion of the eye area also affects the ability to identify emotions greatly for participants with Asperger syndrome (Falkmer, Bjallmark, Larsson, & Falkmer, 2011).

    Controversy surrounds the distinction between high-functioning autism (HFA) and Asperger disorder, but motor abnormalities are associated features of both conditions. An examination of motor cortical inhibition and excitability in HFA and Asperger disorder using transcranial magnetic stimulation (TMS) reveals a possible distinction between the two. Cortical inhibition is significantly reduced in people with HFA compared with both the Asperger disorder (p less than 0.001) and neurotypical (p less than 0.001) people, suggesting disruption of activity at gamma-aminobutyric acid A (GABAA) receptors. Cortical inhibition deficits may underlie motor dysfunction in autism, and perhaps even relate to specific clinical symptoms (e.g. repetitive behaviours). These findings provide novel evidence for a possible neurobiological dissociation between HFA and Asperger disorder based on GABAergic function (Enticott, Rinehart, Tonge, Bradshaw, & Fitzgerald, 2010).

    Physical activity is beneficial for youth with developmental disabilities. It was shown in a recent study that adolescents with Asperger syndrome scored significantly lower than the comparison group on all physical fitness subtests, including balance, coordination, flexibility, muscular strength, running speed, and cardio-respiratory endurance (p less than 0.001). Adolescents with Asperger syndrome were also less physically active (p less than 0.001)(Borremans, Rintala, & McCubbin, 2010).

    Participants with autism, but not with Asperger syndrome, displayed enhanced pitch discrimination for simple tones. However, no discrimination-thresholds differences were found between the participants with ASD and the typically developing persons across spectrally and temporally complex conditions. These findings indicate that enhanced pure-tone pitch discrimination may be a cognitive correlate of speech-delay among persons with ASD (Bonnel, McAdams, Smith, Berthiaume, Bertone, Ciocca, et al., 2010).

    An investigation on whether children with Asperger syndrome (AS) show superior competence in creativity, and an examination of the relationship between nonverbal creativity and nonverbal IQ and vocabulary size reveal that the participants with AS scored significantly higher in originality and elaboration, compared to their peers. Nonverbal divergent thinking was correlated to nonverbal IQ for participants with AS. It was observed that participants with AS drew the 12 incomplete figures mostly in the areas which interest them. This result may indicate better performances in originality and lesser performances in flexibility (Liu, Shih, & Ma, 2011).

    Child vs. adult presentation

    Different ages may present differently for Asperger’s Disorder. Often the social disability of individuals with Asperger’s Disorder can become more striking over time. By adolescence some people with the disorder may use areas of strength to compensate for weaker areas. Individuals with the disorder may feel victimization from others. Feelings of social isolation and an increasing understanding of self-awareness can lead to the development of depression and anxiety in adolescents and young adults.

    Gender and Cultural Differences in Presentation

    Asperger’s Disorder is at least 5 times more likely to be diagnosed in males than females. Asperger’s Disorder has no ethnic boundaries, Asperger’s is seen all around the world. Rates seem to be higher with the greater rates of populations. There has been no conclsive evedience to support that Asberger’s Disorder shows cultural differences.

    Epidemiology

    It is estimated that between 0.024% and 0.36% of the general population in North America and northern Europe have Asperger’s Disorder and it is more common in boys. Anxiety disorder and major depressive disorder are likely to be comorbid with Asperger’s disorder. It is estimated that 65% of people with Asperger’s also have one of them

    With effective treatment, children with AS can learn to cope with their disabilities, but they may still find social situations and personal relationships challenging. Many adults with AS are able to work successfully in mainstream jobs, although they may continue to need encouragement and moral support to maintain an independent life.

    Generally, there is about 5 to every 10,000 children that have Asperger’s Disorder.

    Asperger’s follows a lifelong course. Good verbal abilities may mask social dysfunction and mislead teachers–>

    Etiology

    The etiology of Asperger’s Disorder is not known but current studies suggest that the condition may run in families, particularly with histories of depression and bipolar disorder. Also, about fifty percent of patients with Asperger’s Disorder have a history of oxygen deprivation during birth, which leads to the hypothesis that it is caused by damage to the brain before or during childbirth.

    Empirically supported treatments

    Treatment for Asperger’s Disorder addresses the three main symptoms: reduced communication skills, obsessive or repetitive routines, and clumsiness. Most agree the earlier the intervention, the better. An effective treatment program takes the child’s interests into account, offers a predictable schedule, teaches tasks as simple steps, holds their attention, and helps strengthen behavior. The treatment may include social skills training, cognitive behavioral therapy, and medication for co-existing conditions. Individual psychotherapy to help process feelings of being “socially handicapped”. There are also specific medications for problems such as: hyperactivity, impulsivity, inattention, irritability, aggression, preoccupations, rituals, compulsions, and anxiety.

    DSM-5 is proposing that this disorder be subsumed into the existing, Autistic Disorder. There is some objection regarding the proposal among some people in the Asperger’s/Autism community.

    Links

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