Diagnostic Assessment for Aspergers Syndrome

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Diagnostic Assessment for Aspergers Syndrome

• The Continuum of Autism
• From the work of Tony Atwood

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What is Aspergers Syndrome?

• A disorder within the Autistic Spectrum
  Disorders
• Considered a Neurobiological disorder
• Major symptoms are Impairments in
  socialization, communication and imagination
• First discussed by Hans Asperger in 1944
• Brought to international attention in the 1990s
• Suggested that the ratio of boys to girls is
  101

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Symptoms of Aspergers Syndrome

• Impairments in social interaction, narrow
  interests, an insistence on repetitive routines,
  speech and language peculiarities, non-verbal
  communication problems and motor clumsiness

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Aloof

• Avoid interactions
• Mute
• Behavior the main means of communication
• Fascination with sensory experience

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Passive

• Approach adults for assistance with objects and
  for physical stimulation
• Prolonged solitary play
• Speech requires an external prompt, (echolalia,
  seeing an object/picture, dialogue borrowed
  from a favorite video)
• Fascination with symmetry and collecting
  specific objects

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Active but Odd

• Often initiates interactions of short duration
• Repetitive questions (social echolalia, script,
  alternative meaning, reassurance)
• Lack of social play with others
• Fascination with a specific topic or person.

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Six Pathways to a Diagnosis of Aspergers Syndrome

• Diagnosis of autism in early childhood
• Significant natural progress between 4 and 6
  years of age
• Effective early intervention programs
• Progression along the continuum of autism

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Recognition of Characteristics When First
Enrolled at School

• No clear signs of autism in early childhood
• Teacher notices conspicuous features
• Avoids social play with peers
• Unaware of the codes of social conduct
• Unusual qualities in conversation and
  imaginative play
• Intense interest in a specific interest
• Clumsiness when running, writing and catching
• Teacher completes a developmental checklist for
  Aspergers syndrome (ASAS)

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Diagnosis of a Relative with Autism or Aspergers
Syndrome

• Another family member has a diagnosis and
  knowledge of the continuum of autism leads to
  other family members being diagnosed
• Some families have Aspergers syndrome within
  and between generations

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Dual Diagnosis

• Attention deficit disorder
• Language disorder
• Cerebral palsy
• Tourettes disorder

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Secondary Psychiatric Disorder

• Depression
• Anxiety disorder such as Obsessive Compulsive
  Disorder
• Anger management
• Schizophrenia

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Residual Aspergers Syndrome in an Adult

• Self referral due to a relative having the
  diagnosis or information from the media
• Agency referral from psychiatric services,
  forensic psychology and employment agencies

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Diagnostic Assessment

• Social Impairment

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Social Impairment

• Reciprocity (the balance between participants)
• Inclusion (welcome, cooperation and control)

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Pretending to be Normal

• the fun came from setting up and arranging
  things. Maybe this desire to organize things
  rather than play with things, is the reason I
  never had a great interest in my peers. They
  always wanted to use the things I had so
  carefully arranged. They would want to rearrange
  and redo. They did not let me control the
  environment.

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Social Impairment

• Level of maturity in deceit
• Limited ability with team skills
• Limited range of facial expressions and body
  language
• Difficulty reading the facial expressions and
  body language of others
• Limited ability to conceptualize the thoughts
  and feelings of others

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Speech and Language Characteristics

• Pragmatics, Prosody and Pedantic

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Pragmatic Aspects

• The art of conversation
• Reciprocity
• Repairing a conversation
• Knowing when and how to interrupt
• Inappropriate comments
• Keeping on track
• Primarily interested in an exchange of
  information
• Appropriate topics
• Monologues or scripts
• Recognizing and accepting different points of
  view
• Literal interpretation

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Prosody or the Melody of Speech

• Lack of change of vocal tone and volume to
  indicate emotion and key words
• Lack of variation in pitch, stress and rhythm
• Accent not consistent with that of the local
  children
• Difficulty understanding the relevance of the
  change in tone, inflection or emphasis on certain
  words when listening to the speech of others

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Pedantic Speech

• Overly Formal
• Excessive technical details
• Adult quality, sophisticated grammar or
  phrases
• Must correct errors
• Precise intonation

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Unusual Qualities of Speech

• Idiosyncratic use of words
• Neologisms
• Volume
• Vocalizing thoughts
• Verbal fluency affected by anxiety
• Late onset

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Special Interests

• Dominate the persons time and conversation
• Statistics, cataloguing and symmetry
• Idiosyncratic

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Motor Clumsiness

• Locomotion (upper and lower limb coordination)
• Ball catching skills
• Manual dexterity
• Handwriting
• Movement disorder Motor tics such as blinking
  and grimaces, vocal tics such as clicks and
  animal noises

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Cognition

• Problems with advanced Theory of Mind Skills
• Weak Central Coherence
• Impaired Executive Function
• Profile on an Intelligence Test
• Visualisers or verbalisers
• Enclopedic memory
• Solitary and idiosyncratic play
• Preference for routines
• Limited flexibility in thinking
• Originality in problem solving

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Sensory Sensitivity

• Sound sensitivity
• Tactile sensitivity
• Sensitivity to the taste or texture of food
• Stoic in response to pain or temperature
• Synaesthesia

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Relevant Information

• Family history of similar individuals
• Reports from teachers and therapists
• Medical investigations and medicine
• Developmental history
• Prior diagnosis
• Presence of a psychiatric disorder
• Observation at school and home

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Issues Relevant to the Diagnostic Assessment

• Profile of abilities in girls (same pattern,
  less severe expression, coping mechanisms, fewer
  referrals)
• Assessment procedures and criteria for adults
  (time to respond and the quality of the response,
  validity of the developmental history)
• Alternative explanations shy, social phobia,
  gifted emotional neglect in infancy
• Choice of diagnostic criteria

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Alternative Terms
High Functioning Autism

• HFA and AS at the behavioral and treatment
  level, are more the same than different
• Lack of expertise, experience and confidence in
  the diagnosis of AS

• HFA more likely if the child has a developmental
  history of autism
• AS not a mild form of autism but a more subtle
  expression
• Diagnosis of HFA can provide automatic access to
  services
• Use the term that provides more resources

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Developing Social Skills and Understanding
Emotions
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Social Play

• Observe and make notes of the social play of
  the childs peers
• Note the script and acts
• Rehearse with an adult acting as a friend
• Turn taking and help
• Rent a friend as a dress rehearsal
• Practice with same age peers
• Social Sandwich
• Sharing experiences

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Strategies for Social Integration
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Inclusion with Ordinary Children

• Observation of appropriate social/emotional
  behavior
• Peer group who know how to modify their behavior
  to accommodate and support the child

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Knowledge of the Nature of Aspergers Syndrome

• To recognize the challenges faced by the child
• To explain their behavior to other children and
  adults
• The Sixth Sense

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Teach Theory of Mind Skills

• Photographs, text, drawings, games
• Metaphor
• Social Stories
• Comic Strip Conversations
• Social Skills Groups

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Encourage Friendship Skills

• Behavioral strategies of task analysis, shaping,
  prompting and rewards
• Cognitive strategies to learn the theory and
  script using Social Stories

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Four Levels in the Development of Friendship
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Level 1 Approximately 3 to 6 Years

• Recognition of turn taking
• Egocentric conceptualization
• One way assistance
• Proximity and physical attributes
• Why is.your friend?
• Because I like him
• He lives next door

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Level 2 Approximately 6 to 9 Years

• Reciprocity and being fair
• Mutual assistance
• Like the same activities
• Aware of the preferences, feelings and thoughts
  of the other person
• Why isyour friend?
• She comes to my party and I go to hers
• Shes nice to me

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Level 3 Approximately 9 to 13 Years

• Aware of others opinion of them and how their
  words and actions affect the feelings of others
• Shared experiences and interests
• Greater selectivity and durability
• Gender split
• Trust, loyalty and keeping promises

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Level 4 Adolescence to Adult

• Peer group acceptance more important than the
  opinion of parents
• Greater depth and breadth of self disclosure
• Desire to be understood by friends
• Different types of friendships
• He/She accepts me for who I am
• We think the same way about things

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Characteristics Associated with Aspergers
Syndrome

• Motivation for friendship
• Immaturity
• Control the activity
• Describe what a friend should not do
• Negative experiences

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Checklist of Social Behaviors Used as an Index of
Friendship Skills

• Entry Skills
• Recognizing when and how to join in
• The welcome provided for children who approach
  them
• Assistance
• When and how to provide assistance
• Seeking assistance from others
• Criticism
• Knowing when criticism is appropriate and
  inappropriate
• How to criticize
• Tolerance of criticism
• Compliments
• Compliments at appropriate times
• Responding to a friends compliment
• Accepting Suggestions
• Incorporating the ideas of others in the activity
• Indicating agreement
• Reciprocity and Sharing
• An equitable distribution of conversation,
  direction and resources

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Checklist of Social Behaviors Used as an Index of
Friendship Skills - Cont

• Conflict Resolution
• Managing disagreement with compromise
• Accepting the opinions of others
• Not responding with aggression or immature
  resolution mechanisms
• Monitoring and Listening
• Regularly observing the other person to monitor
  their contribution and body language
• Their own body language indicating an interest in
  the other person
• Empathy
• Recognizing when appropriate comments and actions
  are required in response to the other persons
  circumstances and positive and negative feelings
• Avoiding and Ending
• Appropriate behavior and comments to maintain
  solitude
• Appropriate behavior and comments to end the
  interaction

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Encouraging Friendship Skills

• Assess which skills are observed or absent
• Assess the quality and range of expression
• Use behavior and cognitive strategies to acquire
  and develop specific skills
• Task analysis, prompting, shaping and reward
• Reward all participants
• Teach the theory as well as the practices
• Social stories

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Additional Strategies

• Friendship diary
• Matching individuals with similar interests
• Support groups for adults
• Local and pen pal registries
• Internet chat lines
• Books of friendship
• Recognizing when someone is not a friend
• Maintaining and ending friendships
• Tuition in characterization

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Characterization Skills

• Unusual in their perception and description of
  the personality characteristics of others and
  themselves
• Limited lexicon to describe the different types
  of character
• Immaturity and predominance of physical
  attributes
• One dimensional approach
• Difficulty reading a persons character and
  adapting their behavior accordingly

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Teaching Characterization Skills

• The Mr. Men and Little Miss books
• Examples are Mr. Grumpy, Little Miss Chatterbox
  and Mr. Nosey
• Choosing an animal to represent someones
  personality
• Reading dictionary definitions of character and
  identifying someone who has those characteristics
• Identifying the description of their own character

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Social Skills Groups

• Friendship
• Theory of mind skills
• Conversation skills
• Reading and expressing body language

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The Understanding and Expression of Emotions

• A project on a specific emotion
• Create a scrap book that illustrates the emotion
• Compare and contrast other childrens scrap
  books
• Identify the facial elements that express the
  emotion
• A thermometer to measure the degree of
  intensity
• Place photographs and words at the appropriate
  point on the thermometer
• Point to the degree of expression in a
  particular situation

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The Understanding and Expression of Emotions
Cont

• Appropriate tone of voice
• Drama games for appropriate body language
• Mirror and video recordings
• Story books
• Sentence completion exercises
• Alternate positive and negative emotions

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Imitation

• Identify individuals skilled in a specific
  ability
• Observe their actions and script
• Copy or mimic their style
• Speech and drama training