All too often, I meet a parent who has come to my practice after years of frustration with the medical system, the time required to advocate for their child, and the confusion with discovering which clinical specialty services and that specialist.
The recent increase in diagnosis of Asperger’s Syndrome has brought a tremendous about of attention to this issue and the ongoing problem. Referrals are more frequent both for assessment purposes as well as providing helpful interventions for their child’s needs.
Most parents report that they knew something was different with their child during their infancy and toddler periods. Mrs. P reported that she could call to her son by name but he would not seem to recognize his own name or the need to turn towards her when called. Mr. S reported that his son wanted to have friends but found the whole social interchange to be beyond his abilities. He would reach out to peers, only to be rebuffed, bullied, or made fun of. One young boy that I worked with had developed the expertise in the area of sharks, another child was consumed with cars, and, yet another child with the environment. These interests alone are not a problem; however, their myopic interest and singular focus on sharing this information with others (especially when peers had no interest in discussing these topics) lead to more disenfranchising patterns with peers. Additionally, parents oftentimes reported a range of neurological symptoms from low body tone to sensory integration problems, struggles with non-verbal messages to the inability to manage metaphors though their child is very bright. What might be referred to as “common sense” is not common at all. It would appear that the rules that everyone else has learned are foreign to these children.
The cause of Asperger’s (along with the other diagnoses on the Autism Spectrum) is unknown. In the United States, Autism is now diagnosed at a rate of 1 in 150 children. Boys are diagnosed more frequently than girls. The pattern of symptoms can be quite broad. I oftentimes will point out to a parent, that once something is a neurological condition, all bets are off. Since, we don’t as of yet, know what causes the condition, the cognitive, social, behavioral, and emotional struggles can vary greatly. Though the origins of this diagnosis begins with Hans Aspergers, an Austrian Pediatrician in 1944, the diagnosis did not become integrated into the Diagnostic and Statistical Manual (DSM) until 1994.
One rather significant interpersonal struggle that applies to most individuals with ASD is the concept of “Theory of Mind”. Theory of Mind refers to an individual’s capacity to “see” or understand someone else’s point of view. These children are not being oppositional or defiant, they are unable to grasp a perspective that doesn’t match their point of view. This ability is vital for everyone in society. If you are unable to appreciate someone else’s point of view, you will invariably struggle to function with peers, co-workers, teachers, and bosses.
A lot of these youngsters struggle with the social scene. They desperately want to be accepted but find the nuances to be beyond the grasp. They oftentimes reach out only to be frustrated or rejected. They seem the meaning of non-verbal messages (e.g.; facial expressions, tone of voice). Not only do they struggle interpreting non-verbal clues, they may struggle generating non-verbal messages. A flat affect or an extreme affect may be their modus operand. Sense of humor might be a point of contention. They might struggle understanding others humorous anecdotes as well as generating their own entertaining observations. While they possess advanced vocabularies (hyperlexion) they struggle with idiosyncratic phrases and metaphors. They tend to understand the world in details that are concrete while getting lost in the clichés. Many of these individuals are “Truth-seekers”. They have a rigid pattern of interpreting rules in life. In reality, social rules are in fact not rules. They are merely suggestions imparted by our culture to increase the probability of social success. However, a rule that applied when you were 5 years old, may not apply when you are 15 years old. The rule that you learned regarding how to treat one gender may not be successful when applied to the other gender. I have all too often had a youngster that consistently corrected other children’s grammar. Needless to say, this did not go over to well with the other children.
Physical and sensory issues are frequently reported by caretakers. Sounds might be too overwhelming. The feel of certain garments of clothes on their skin can be a constant battle. They often are described as having low body tone regarding their muscle development. The term “clumsy” can be used to describe their coordination.
They are not overtly rejecting of all common rules as the proverbial “Bull in a China Shop” but rather they yearn for the connection, they seek approval and want to be accepted. Their pattern of bumping into mores, violating social expectations, and not necessarily fitting in, seems to be better described as a “Cow in the China Shop”. They don’t mean to offend, they don’t want to create problems, but their social skills lead to these problems.
When a child is involved with an evaluation to rule out this diagnosis, there are several procedures that might be utilized. The process should begin with a consultation with the parents/caregivers. Their insights and history is vital. Developmental milestones need to be identified and comparable challenges to age appropriate expectations need to be reviewed. The areas to discuss include; 1. motor coordination, 2. language development, and 3. social functioning. When did you notice the unique problems? Does your child have any hobbies or interests? Discuss their social life? How do they handle stress?
Several assessment measures can be used. These include;
– Autism Diagnostic Interview (ADI) Parent,
– Autism Diagnostic Observation Schedule (ADOS),
– Australian Scale for Asperger’s Syndrome (ASAS), and
– Gilliam Asperger’s Disorder Scales (GADS)
An intelligence test would be beneficial to determine the baseline cognitive functioning (as many of the Asperger’s children are above average). In addition, it would be advantageous to assess your child’s academic/achievement levels. This combination of measures would help to identify the potential for a learning disability or a processing disorder. It is subsequent to this evaluation that we often determine that the child or young adult possess exceptional intelligence along with an underlying processing disorder. These are two extremes which need to be considered when planning academic interventions and placement issues. It is by this fact in which many patients become referred to as “2E” or “Twice Exceptional”. If the academic intervention provides services only for the Gifted range of intelligence, the individual might find learning to be too overwhelming due to their particular learning challenges. On the other hand, if the academic intervention is not intellectually stimulating enough for the individual, they might not find the educational setting to be interesting, engaging or personally rewarding. Hence, the Twice Exceptional student possesses two divergent aspects that both need to be addressed.
A thorough intake with the parents is vital. Completion of questionnaires and family history is important. Parental observations as well as teacher observations are extremely vital at this point of the assessment. Providers oftentimes conduct real-life observations (in-school) of the child prior to the child ever meeting with this evaluator. I will conduct this type of evaluation prior to ever meeting the child or young adult. I find that by doing this, I can get a more accurate about learning styles, transitional behaviors and social/interpersonal methods of relating to others (peers or teachers).
Once a determination has been made of a diagnosis of Asperger’s treatment options can be exercised. The range of interventions include; Individual therapy, Family therapy, Vocational training, as well as Group Therapy. The following is a list of productive Group/Social Skills training programs.
– Social Skills in our Schools, Dunn
– Building Social Relationships, Bellini
– Navigating the Social World, McAfee
– Think Social, Garcia-Winner
– Do-Watch-Listen-Say, Quill
– Shape Knowledge Through Individualized Life Learning Systems (SKILLS) – ABA
The above is meant as a guide, not a formalized protocol. You should consider following up with national organizations (Center for Autism and Related Disorders – CARD), and associations, along with major medical institutions (Johns Hopkins, Harvard, Mayo, CDC, etc) for the full range of services.
Dr. Harold Shinitzky, Psy.D.
Licensed Psychologist
727-560-2697
Author – A Champion’s Mindset: 15 Mental Conditioning Steps to Becoming a Champion Athlete (www.amazon.com)