Autism Spectrum Disorder & Asperger’s Syndrome
Autism, Asperger’s Syndrome, & Autism Spectrum Disorder
The emergence of the diagnoses “autism” and “Asperger’s Syndrome” have a unique history. In 1944 Hans Asperger, an Austrian physician with training in both pediatrics and psychiatry, wrote a paper describing a group of four children, ages 6-11, who displayed pronounced difficulties in social skills, despite adequate cognitive and verbal abilities, and whom he described as “autistic.” At nearly the same time, American child psychiatrist Leo Kanner wrote about eleven similar children who he said displayed “early infantile autism.” Because World War II was ongoing at the time, they were unaware of each other’s work. It was not until 1981 that Asperger’s writings gained notoriety in the English-language literature, when Lorna Wing published a paper reporting on a larger number of similar-sounding cases, whereupon she proposed the term “Asperger’s Syndrome” to describe them.
The American Psychiatric Association’s Third Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; 1980) first offered the diagnoses of “Infantile Autism” and “Childhood Onset Pervasive Developmental Disorder” to describe these children. In 1994, DSM-IV revised these to “Autistic Disorder,” “Asperger’s Disorder,” and “Pervasive Developmental Disorder, Not Otherwise Specified.” Then in 2013, DSM-5 revised the area yet again with the over-arching term, “Autism Spectrum Disorder,” to include all of these diagnoses within a single categorical classification.
One of the major differences between Asperger’s Disorder and autism is that, by definition, there is no speech delay in Asperger’s. In fact, children with Asperger’s Disorder often have adequate language skills. However, their speech patterns may be unusual, lack inflection or may be formal, or perhaps too loud or high-pitched. They may not understand the subtleties of language, such as irony and humor, or they may not understand the give-and-take nature of a conversation. Individuals with Asperger’s Disorder usually want to fit in and have interaction with others, but often they don’t know how to do it. They may be socially awkward, not understand conventional social rules or show a lack of empathy. They may have limited eye contact, seem unengaged in a conversation and not understand the use of gestures or sarcasm. Their interests in a particular subject may border on the obsessive. They often like to collect categories of things, such as rocks or bottle caps. They may be proficient in knowledge categories of information, such as baseball statistics or Latin names of flowers. They may have good rote memory skills but struggle with abstract concepts. Finally, they frequently have motor skill delays and may appear clumsy or awkward.
PREVALENCE Interest in these children has steadily increased since 1981, and current estimates are that 1 in 42 boys (2.4%) and 1 in 189 girls (0.5%) can be accurately classified as having Autism Spectrum Disorder (ASD).
EVALUATION As in every evaluation with children, parents are met with first and interviewed thoroughly regarding the history of the child’s life and a detailed account of the child’s recent and current functioning socially, academically, and within the family. If it is appropriate, parents are asked to complete behavior rating scales that specifically target these diagnoses, as well as questionnaires that investigate a wider variety of childhood difficulties. With permission, similar information can be gathered from teachers, and other important adults in the child’s life. The child is then met with individually once or twice, so that he or she can be observed in a private, one-to-one setting, often involving play activities. Next, it is considered whether a full battery of psycho-educational testing would be useful (it often is), after which treatment recommendations are made.
TREATMENT—AN AUTISM CASE STUDY (NOTE: All identifying information in this case have been altered to protect the privacy of the individual and her family). In the mid-1990s, autism was really starting to come into public awareness full force. About that time, a close relative of mine gave birth to their second child, a little girl they named Jessica. Their firstborn, a boy two years older, was obviously very bright, talkative, socially comfortable, and assertive in all areas of life. However, by age 2½, Jessica was quite different—she seemed reluctant to play with other children and often isolated herself, she was very sensitive to a variety of experiences, including foods, sounds, and fabrics, and most noticeably, she had not yet begun to speak, not even a word. I urged her parents to have her evaluated professionally, and three separate pediatric clinicians—two psychologists and an occupational therapist— independently diagnosed her as having autism. Jessica’s parents were devastated. They blamed themselves, and for several weeks wrung their hands and feared the worst for their daughter’s future. Then they asked for my help. Although I already had extensive training and experience in evaluating and treating children of all ages, including toddlers, I was no expert in autism. But I was determined to become one, and so I immersed myself into learning and mastering the most effective treatment approaches. Fortunately, in my search I became exposed to the work of child psychiatrist, Stanley Greenspan, M.D., a pioneer in the treatment of autism, and the author of numerous books on that subject, as well as other books about the evaluation and treatment of children in general. In my opinion, his most important contribution in the area of autism has been in the development of a treatment technique he called “Floortime.” This approach is based on Greenspan’s observation that all human interaction is reciprocal, and involves what he calls “circles of communication.” For example, with an infant, we may get close to her face, open our eyes wide, and give a big smile; this often elicits a smile back from the baby. Or with a toddler, we’ll roll a ball to him, and he’ll often roll it back to us, with glee. However, the autistic child, who is absorbed in his own world, does not easily reciprocate. He might prefer to play on his own, ignoring our attempts to engage him. Jessica, for example, would spend lots of time encircling herself with a belt or string, pulling it around herself again and again, never looking up at anyone to join in with her.
The Floortime approach taught me how to intervene with an autistic child like Jessica by not allowing her to ignore me and play alone. I learned how to thoughtfully insert myself into Jessica’s isolated play and to engage her to respond in some fashion. For example, if she was playing alone with a stuffed animal, holding it and moving it around, I might take another stuffed animal and block her movements. At first, she wouldn’t like my interrupting her play and would grunt in protest. I’d smile, grunt back the same way, and then say something simple, like “Uh-oh!” In this way, I’d communicate friendliness with my smile, empathize with her grunt of protest, and invite her to imitate my simple words about the event. Soon Jessica began to try other responses to my move, such as using her animal to block mine, saying “Uh-oh,” and smiling back. Thus, our circles of communication began. I then met with her parents to teach and coach them in these techniques, so that they could constantly engage Jessica in this kind of play process several times each day, and she could get as much exposure as possible to these kind of therapeutic, growth-promoting experiences.
Of course, the various ways to use Floortime are endless, and can become quite complex as the play increases in complexity. Meanwhile, speech therapy for Jessica began in earnest. In addition to frequent sessions with the speech therapist, her parents were urged to conduct speech drills at home with Jessica whenever they were with her. They were taught the behavioral modification technique of “shaping,” where at first they would require her to say at least the first letter of the word for something she wanted, like “C-C-C” for “cookie” when she was standing at the pantry and whining for a cookie. Parents gradually required more complete words from her before meeting her demands, and soon she was speaking her first words. Now, Floortime could include verbalization, and Jessica could begin to associate words with actions and feelings.
At 3½, Jessica was re-evaluated and placed in a public school special education class for children with Autism Spectrum Disorder, which also included an equal number of same-aged kids without special needs. There were about 12 kids altogether in the class, and it offered a constant emphasis on speech development, and on the association of visual symbols with spoken words and activities—an important precursor to learning letters and how to read. All the while, Greenspan’s “Floortime circles of communication” philosophy was being applied by her parents at home to her play and almost every other activity in her life. Jessica was taught to read at about age five, where initially parents used a very consistent behavioral approach in conjunction with the excellent Hooked On Phonics program. She also began receiving occupational therapy to help with fine motor and gross motor coordination.
Following this year of special education, I urged Jessica’s parents to enroll her in a small, supportive, but mainstream (i.e., not special education) classroom situation for a year. The next year her parents decided, in consultation with me, to have her repeat this pre-k 4 year. Floortime exercises continued frequently, and Jessica was encouraged and assisted by myself and her parents to engage in imaginary play as much as possible, pretending to be a character she knew, like Ariel from “The Little Mermaid,” or Princess Jasmine from “Aladdin.” This required her to imagine what someone else might be thinking and feeling, thus helping her develop a greater capacity for empathy, a major social skill that is lacking in children with Autistic Spectrum Disorder.
Jessica then started kindergarten at age 6, again, in a small, supportive mainstream classroom environment, where she remained throughout elementary school. There, she began to make friends, have playdates, and became a devoted reader and successful student. This pattern continued in mainstream public middle school and high school classes, where she was quite popular, had a number of close friends, played on sports teams, joined clubs, and happily went with a date to her senior prom.
Jessica is now 21 and a junior in college, where her grades are excellent. She has a steady boyfriend, belongs to a sorority, is quite popular, and exercises regularly to stay fit. Everyone who meets her regards her as a happy, confident young woman; they have no idea that she is also a remarkable success story for the treatment of Autism Spectrum Disorder. If there is any single intervention that I can point to that most positively affected Jessica’s development, it was Dr. Greenspan’s Floortime, along with healthy doses of behavior modification, speech therapy, occupational therapy, and special education. I routinely recommend that parents with a similar child seek to learn how to customize such an elaborate treatment plan from a professional like myself.
REFERENCES (for further reading)
Klin, A. & Volkmar, F. (1997). Asperger’s Syndrome. In Cohen, D. & Volkmar, F. (Eds.) Handbook of Autism and Pervasive Developmental Disorders, 2nd Edition (pp. 94-122). New York: John Wiley & Sons.
American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders-Third Edition. Washington, D. C.: APA.
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition. Washington, D. C.: APA.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition. Arlington, VA: APA.
Autism Society (2014, August 8). Asperger’s Syndrome. Retrieved from http://www.autism-society.org/about-autism/aspergers-syndrome.
Centers for Disease Control and Prevention (2014, March 24). Autism Spectrum Disorder (ASD).Retrieved from
http://www.cdc.gov/ncbddd/autism/data.htmll.
Greenspan, S. & Wieder, S. (1998). The Child with Special Needs. Boston: Da Capo Press.
