Friday, November 11, 2011

What is Asperger's?

Asperger's Syndrome, like everything on the autistic spectrum, is incredibly hard to describe because it varies so widely between people. One of the more common lines I've seen is "If you've met one person with Asperger's Syndrome you've met one person with Asperger's Syndrome." However, there is still the possibility of a basic description.

Asperger's Syndrome is an autistic spectrum disorder (ASD) along with Autistic Disorder (also known as classic autism or Kanner's autism - classic autism being my preference but not the label in the diagnostic manuals), and PDD-NOS. Asperger's Syndrome is often thought of as "milder" or "higher functioning" than classic autism, though these words mean little and there is a wide range of severity of symptoms among people in all parts of the spectrum.

Specifically, Asperger's Syndrome is an ASD in which there is no delay in speech, self-help skills, or creativity about the environment.  It is specifically associated with the descriptions given by Hans Asperger, an austrian physician who described the similarity of traits between 4 patients of his in a 1944 paper. As his paper was not translated into English until 1989, and autism as a concept separate than schizophrenia was first made in 1943, Asperger's Syndrome is a relatively new diagnosis.

Possibly the best way to define what Asperger's Syndrome is by the set of various diagnostic criteria.

The current version of the DSM, the diagnostic standards manual which is how diagnoses are made in the US is the DSM-IV, which came out in 1994. It was the first diagnosis manual with a diagnosis for Asperger's.

DSM-IV diagnostic criteria for Asperger's Syndrome

  1. Qualitative impairment in social interaction, as manifested by at least two of the following:

    1. marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, 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, interest 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

  2. Restricted repetitive & 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

  3. The disturbance causes clinically significant impairments in social, occupational, or other important areas of functioning.
  4. 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)
  5. 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) and curiosity about the environment in childhood.
  6. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.

Note that this specifically talks about what people see rather than what's going on.

Also meaningful is noting the additional criteria for classic autism as something like 80% of people with Asperger's technically meet the criteria.

Additional Criteria for Autistic Disorder

Qualitative impairments in communication as manifested by at least one of the following:
  1. delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
  2. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
  3. stereotyped and repetitive use of language or idiosyncratic language
  4. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:
  1. social interaction
  2. language as used in social communication
  3. symbolic or imaginative play

However, other diagnostic criteria are likely far more useful. There is a new proposed version for the DSM-5 (which is coming out in 2013), in which the Asperger's diagnosis is merged in with classic autism and PDD-NOS into just "autistic spectrum disorder".

That diagnostic criteria is:

DSM-5 Proposed Diagnostic Criteria

  1. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following:

    1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction,
    2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures.
    3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play; and in making friends; to an apparent absence of interest in people
  2. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:
    1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).
    2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes).
    3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
    4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).
  3. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)
  4. Symptoms together limit and impair everyday functioning.
The most descriptive criteria, and closest to Asperger's writing, is however the Gillberg criteria, one which is rarely used but tends to be a very good description of Asperger's. This criteria is actually descriptive.

The Gillberg Criteria for Asperger's Syndrome

All of the following six criteria must be met for confirmation of diagnosis:
  1. Severe impairment in reciprocal social interaction (at least two of the following)
    1. inability to interact with peers
    2. lack of desire to interact with peers
    3. lack of appreciation of social cues
    4. socially and emotionally inappropriate behavior
  2. All-absorbing narrow interest (at least one of the following)
    1. exclusion of other activities
    2. repetitive adherence
    3. more rote than meaning
  3. Imposition of routines and interests (at least one of the following)
    1. on self, in aspects of life
    2. on others
  4. Speech and language problems (at least three of the following)
    1. delayed development
    2. superficially perfect expressive language
    3. formal, pedantic language
    4. odd prosody, peculiar voice characteristics
    5. impairment of comprehension including misinterpretations of literal/implied meanings
  5. Non-verbal communication problems (at least one of the following)
    1. limited use of gestures
    2. clumsy/gauche body language
    3. limited facial expression
    4. inappropriate expression
    5. peculiar, stiff gaze
  6. Motor clumsiness: poor performance on neurodevelopmental examination

I personally find this last criteria by far the most informative, and tend to use it to show people for what's different between just being "socially awkward" and Asperger's.

The thing that does need to be noted about all of these diagnostic criteria is that they're made for children. While plenty of of us still fully meet the criteria as adults, and in fact, if you don't meet the criteria you cannot be diagnosed even if you met it when you were younger, there will be changes between a child and an adult. Adults often have learned how to make eye contact (at least to some degree), have made progress on physical clumsiness, and have created large numbers of coping skills of various levels of effectiveness. This does not change that this is a description of that person, even when they are able to memorize a script of what is to be said in each situation and have learned that carrying certain items make drastic changes to their abilities.

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