Asperger syndrome (AS), also known as Asperger’s,is defined by the WHO as one of the autism spectrum disorders or pervasive development disorders that are characterized by abnormalities of social interaction and communication that pervade the individuals normal functioning,and by restricted repetitive interests and behavior.
In 2013, the diagnosis of Asperger’s was removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and people with these symptoms are now included within the autism spectrum disorder along with autism and pervasive developmental disorder not otherwise specified. It remains within the International Classification of Diseases as of 2019, as a subtype of autism spectrum disorder.
Standard diagnostic criteria require impairment in social interaction and repetitive and stereotyped patterns of behavior, activities, and interests, without significant delay in language or cognitive development.
Diagnosis is most commonly made between the ages of four and eleven. A comprehensive assessment involves a multidisciplinary team that makes observations across multiple settings, and includes neurological and genetic assessment as well as tests for cognition, psychomotor function, verbal and nonverbal strengths and weaknesses, style of learning, and skills for independent living.
Delayed or mistaken diagnosis can be traumatic for individuals and families as misdiagnosis can lead to incorrect medication prescriptions that may worsen behavior.
The exact cause of Asperger’s is unknown. While it is largely inherited, the underlying genetics have not been determined conclusively. Environmental factors are also believed to play a role but none has been confirmed by scientific investigation. A few ASD cases have been linked to exposure to teratogens,agents that cause birth defects, during the first eight weeks from conception. Although this does not exclude the possibility that ASD can be initiated or affected later, it is strong evidence that ASD arises very early in development.
A lack of demonstrated empathy affects aspects of communal living for persons with Asperger syndrome.Individuals with AS experience difficulties in basic elements of social interaction, which may include a failure to develop friendships or to seek shared enjoyments or achievements with others, a lack of social or emotional reciprocity and impaired nonverbal behaviors in areas such as eye contact, facial expression, posture, and gesture.
People with AS may not be as withdrawn around others, compared with those with other, more debilitating forms of autism; they approach others, even if awkwardly. For instance,they may engage in a one-sided, long-winded speech about a favorite topic, while misunderstanding or not recognizing the listener’s feelings or reactions, such as a wish to change the topic of talk or end the interaction.
However, not all individuals with AS will approach others. Some of them may even display selective mutism, not speaking at all to most people and excessively to specific others. Some may choose only to talk to people they like.
Not understanding social cues that are obvious to other folks like body language or facial expressions.
The cognitive ability of children with AS often allows them to articulate social norms in a laboratory context, where they may be able to show a theoretical understanding of other people’s emotions; however, they typically have difficulty acting on this knowledge in fluid, real-life situations. People with AS may analyze and distill their observations of social interaction into rigid behavioral guidelines and apply these rules in awkward ways, such as forced eye contact, resulting in a demeanor that appears rigid or socially naïve.
Restricted and repetitive interests and behavior
People with Asperger syndrome can display behavior, interests, and activities that are restricted and repetitive and are sometimes abnormally intense or focused. They may stick to inflexible routines, move in stereotyped and repetitive ways, preoccupy themselves with parts of objects, or engage in compulsive behaviors like lining objects up to form patterns.
Pursuit of specific and narrow areas of interest is one of the most striking among possible features of AS.Individuals with AS may collect volumes of detailed information on a relatively narrow topic such as weather data without necessarily having a genuine understanding or interest of the broader topic. These special interests however change from time to time and typically become more unusual. Because narrow topics often capture the interest of children, this symptom may go unrecognized.
Stereotyped and repetitive motor behaviors are a core part of the diagnosis of AS and other ASDs. They include hand movements such as flapping or twisting, and complex whole-body movements. These are typically repeated in longer bursts and look more voluntary or ritualistic.
Motor and sensory perception
Individuals with Asperger syndrome may have signs or symptoms that are independent of the diagnosis, but can affect the individual or the family. These include differences in perception and problems with motor skills, sleep, and emotions.
Individuals with AS often have excellent auditory and visual perception. Children with ASD often demonstrate enhanced perception of small changes in patterns such as arrangements of objects or well-known images.
They may be unusually sensitive or insensitive to sound, light, and other stimuli;these sensory responses are found in other developmental disorders and are not specific to AS or to ASD.
Physical clumsiness. Children with AS may be delayed in acquiring skills requiring dexterity, such as riding a bicycle or opening a jar, and may seem to move awkwardly or feel “uncomfortable in their own skin”. They may be poorly coordinated or have an odd or bouncy gait or posture, poor handwriting, or problems with motor coordination.
Children with AS are more likely to have sleep problems, including difficulty in falling asleep, frequent nocturnal awakenings, and early morning awakenings.
AS is also associated with high levels of alexithymia, which is difficulty in identifying and describing one’s emotions.
Asperger syndrome treatment attempts to manage distressing symptoms and to teach age-appropriate social, communication, and vocational skills that are not naturally acquired during development Although progress has been made, data supporting the efficacy of particular interventions are limited.
Managing AS ideally involves multiple therapies that address core symptoms of the disorder. While most professionals agree that the earlier the intervention, the better, there is no treatment combination that is recommended above others. AS treatment resembles that of other high-functioning ASDs, except that it takes into account the linguistic capabilities, verbal strengths, and nonverbal vulnerabilities of individuals with AS. A typical program generally includes:
- Applied behavior analysis (ABA) procedures, including positive behavior support (PBS),or training and support of parents and school faculty in behavior management strategies to use in the home and school, and social skills training for more effective interpersonal interactions.
- Cognitive behavioral therapy to improve stress management relating to anxiety or explosive emotions and to help reduce obsessive interests and repetitive routines.
- Medication for coexisting conditions such as major depressive disorder and anxiety disorders.
- Occupational or physical therapy to assist with poor sensory processing and motor coordination.
- Social communication intervention, which is specialized speech therapy to help with the pragmatics and give-and-take of normal conversation.
Despite the popularity of social skills training, its effectiveness is not firmly established. A randomized controlled study of a model for training parents in problem behaviors in their children with AS showed that parents attending a one-day workshop or six individual lessons reported fewer behavioral problems, while parents receiving the individual lessons reported less intense behavioral problems in their AS children.
Vocational training is important to teach job interview etiquette and workplace behavior to older children and adults with AS, and organization software and personal data assistants can improve the work and life management of people with AS.
No medications directly treat the core symptoms of AS. Although research into the efficacy of pharmaceutical intervention for AS is limited, it is essential to diagnose and treat co-morbid conditions. Deficits in self-identifying emotions or in observing effects of one’s behavior on others can make it difficult for individuals with AS to see why medication may be appropriate.
Medication can be effective in combination with behavioral interventions and environmental accommodations in treating co-morbid symptoms such as anxiety disorders, major depressive disorder, inattention, and aggression.
The most common antipsychotic medications risperidone, olanzapine and aripiprazole have been shown to reduce the associated symptoms of AS; risperidone can reduce repetitive and self-injurious behaviors, aggressive outbursts, and impulsivity, and improve stereotypical patterns of behavior and social relatedness.
The selective serotonin reuptake inhibitors (SSRIs) fluoxetine, fluvoxamine, and sertraline have been effective in treating restricted and repetitive interests and behaviors, while stimulant medication, such as methylphenidate, can reduce inattention.
Care must be taken with medications, as side effects may be more common and harder to evaluate in individuals with AS, and tests of drugs’ effectiveness against comorbid conditions routinely exclude individuals from the autism spectrum.
Abnormalities in metabolism, cardiac conduction times, and an increased risk of type 2 diabetes have been raised as concerns with antipsychotic medications, along with serious long-term neurological side effects.
SSRIs can lead to manifestations of behavioral activation such as increased impulsivity, aggression, and sleep disturbance.
Risperidone has been linked to weight gain and fatigue. It may lead to increased risk of extrapyramidal symptoms such as restlessness and dystonia and increased serum prolactin levels
Olanzapine has been linked to sedation,weight gain and diabetes. Sedative side-effects in school-age children have ramifications for classroom learning. Individuals with AS may be unable to identify and communicate their internal moods and emotions or to tolerate side effects that for most people would not be problematic.
There is some evidence that children with AS may see a lessening of symptoms; up to 20% of children may no longer meet the diagnostic criteria as adults, although social and communication difficulties may persist. As of 2006, no studies addressing the long-term outcome of individuals with Asperger syndrome are available and there are no systematic long-term follow-up studies of children with AS.
Individuals with AS appear to have normal life expectancy, but have an increased prevalence of comorbid psychiatric conditions, such as major depressive disorder and anxiety disorders that may significantly affect prognosis.
Although social impairment may be lifelong, the outcome is generally more positive than with individuals with lower-functioning autism spectrum disorders as ASD.
Although many attend regular education classes, some children with AS may utilize special education services because of their social and behavioral difficulties. Adolescents with AS may exhibit ongoing difficulty with self-care or organization, and disturbances in social and romantic relationships.
Despite high cognitive potential, most young adults with AS remain at home, yet some do marry and work independently. The “different-ness” adolescents experience can be traumatic. Anxiety may stem from preoccupation over possible violations of routines and rituals, from being placed in a situation without a clear schedule or expectations, or from concern with failing in social encounters.
Education of families is critical in developing strategies for understanding strengths and weaknesses;helping the family to cope improves outcomes in children. Prognosis may be improved by diagnosis at a younger age that allows for early interventions, while interventions in adulthood are valuable but less beneficial.There are legal implications for individuals with AS as they run the risk of exploitation by others and may be unable to comprehend the societal implications of their actions.