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We so often only diagnose what we see above the water, the other eighty-seven percent remains hidden. William Shryer, DCSW, LCSW Diablo Behavioral HealthCare 925-648-4800 Danville, CA www.behaviorquest.com Mother Goose • Georgie Porgie, puddin' and pie, Kissed the girls and made them cry. When the boys came out to play, Georgie Porgie ran away. • Could Georgy Porgie have been Asperger’s, or on the spectrum? High Functioning Autism & Asperger's Syndrome Asperger’s disorder or “syndrome” is not a new diagnosis, in fact it was described in the 1940’s. “Asperger's Syndrome was first identified in 1944, but was only officially recognized as a diagnostic category in the DSM-IV in 1994. As a result, many children and adults were misdiagnosed over the years as ADD/ADHD, avoidant, Autistic, OCD, or even schizophrenic.” While Hans Asperger was describing this disorder in Austria, Leo Kanner was describing something else a half a world away in Boston. Kanner described Autism at almost the same time. The two disorders share some symptoms, but the degree of disability can vary widely. What is High functioning Autism? High Functioning Autism (HFA) is the traditional diagnosis for individuals with severe social interaction and communication deficits. Although the distinction with Asperger’s is blurred and indeed, Asperger’s is often considered a subset of HFA, people diagnosed with HFA, it was thought, tended to have a much higher Performance IQ (P-IQ) than Verbal IQ (V-IQ).(this has recently been proven false)HFA-ers tend to avoid social contact more, but are less likely to feel embarrassed in social situations, being relatively unconcerned by other people's opinions. They also tend to have had slower language acquisition during childhood. They frequently were late in their developmental milestones. Parent’s of these children frequently find this true when reviewing their baby books for information on when their child said their first word, put several words together, and so forth. What is Asperger’s Disorder? Asperger's Syndrome is a neurobiological disorder that is classified as one of the Pervasive Developmental Disorders (PDD). It is also known as being on the autistic spectrum. It is characterized by “significant” impairment in social interaction, as well as the development of repetitive and restricted fields of interest and activities, however this varies widely from child to child. While there are some similarities with Autism, people with Asperger's usually have average to above average IQ, and do not demonstrate clinically significant delays in language or self help skills. Shared Symptoms • Both Asperger's syndrome and autism are characterized by profoundly disturbed social interactions and inflexible behavior and can be identified by: • • Deficits in nonverbal communication, such as facial expressions, eye contact and body language. • A preference for interacting with objects rather than peers. • Deep immersion in a single field of interest, such as meteorology. • Strict adherence to a daily routine. • Repetitive motions, such as hand flapping or finger twisting. • Source: Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Revised.) Screening Red Flags • • • • • • • Does not respond to name Acts as if deaf Does not smile at others Does not point or use other gestures by 12m No babbling by 12m or words by 16m Talks but does not try to communicate Loss of any social or communication skill Shared Symptoms • Researchers at the MIND Institute and others that work with these patients see frequent mood instability. • Aggressiveness • Tantrums • Family histories of mood lability are common. • Is there an overlap with bipolar? They may have an extremely good command of language and have a very rich vocabulary, however they are unable to use language appropriately in a social context and often speak in a monotone with little nuance and inflection in their voice. This is known as prosody of speech. Although parents often notice problems at an early age, diagnosis is usually made during preschool age or later. While both boys and girls can have Asperger's, the syndrome is more common in boys. Could this be due to a different presentation in girls? This is currently under review. Could it be that girls are missed? Children with Asperger's may or may not seek out social interaction, but always have difficulty in interpreting and learning the skills of social and emotional interaction with others, leading to significant impairment in relationships and peer interaction. They are frequently bullied and made fun of at school. Symptoms • “Significant” impairment in social interaction • Development of repetitive and restricted fields of • • • • interest, such as schedules, bugs, dinosaurs, vacuum cleaners etc. Sometimes poor eye contact, but not always. May have odd facial expressions, but not always. May show inflexible need for a particular routine. May show odd body movements at times. Symptoms • Difficulty understanding the perspective of • • • • others. May demonstrate odd behaviors when excited. May be oversensitive to taste, touch, sound or other stimulus, such as tags in clothing, nubs in socks. May be sensitive to loud sounds etc. Tend to take matters too literally Ability to use abstraction is impaired. Likely difficulties • Understanding cause and effect • Understanding abstraction and other forms of • • • speech. Making and keeping friends and the likelihood of being made fun of and treated poorly in school. Rarely being invited to others parties. Anger at others for their predicament. (Frequently directed towards parents) ANXIETY • Most with Asperger’s Disorder have significant distress. • Frequently bullied at school. • Often misdiagnosed due to poor training by those in the Health Care Arena. • Improper treatment causes symptoms to increase. Non Verbal Learning Disorder • What is nonverbal learning disability (NLD)? Is it a • distinct diagnostic category? Nonverbal learning disability (NLD) is believed by some to be a neuropsychological disability. Although it has been studied for the past 30 years (by Byron Rourke, Ph.D. and others), it has not yet been included as a diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV TR). Many characteristics associated with NLD are similar to those that describe other, more “established” disorders, such as Asperger’s Syndrome and specific learning disabilities. • What characteristics are associated with NLD? • NLD is usually defined by a distinct pattern of specific strengths and difficulties • Individuals thought to have NLD typically demonstrate strengths in the following areas: • Intelligence quotient (IQ) which is typically in the average to above-average range. Children with NLD tend to have verbal IQ scores that are higher than their performance scores, (Ozanoff et al recently reported that this is not a valid predictor) a factor that distinguishes them from kids with language-based learning disabilities such as dyslexia. • Rote verbal and expressive and receptive language skills, such as the ability to memorize and repeat a great deal of information presented to them in spoken form. They also exhibit early language development. • Auditory processing skills, which entail learning better through hearing information, rather than seeing it (visual processing) • Motor skills, such as graphomotor skills (related to printing and cursive writing), physical coordination, and balance is often problematic. • Complex conceptual skills involved in • problem-solving, understanding cause-effect relationships, and seeing the “big picture” versus focusing on details similar to Asperger’s Disorder. Visual-spatial-organizational skills, such as visualizing information and understanding spatial relations is frequently a problem area. • Social skills, such as using and understanding • nonverbal communication (e.g., gestures, facial expressions), dealing with new information and situations, transitioning between situations, conversation skills, and understanding the nuances of spoken language (e.g., hidden meanings, figurative language) Activity level: hyperactivity (when younger), and hypoactivity (as they grow older) Our practice finds that these are the children most likely to have very high IQ’s and behave oddly. They are an at risk population and do need special attention and awareness by the school personnel. They meet the criteria for Asperger’s Disorder but are less likely to have difficulty with eye contact. Treatment/Interventions • Comprehensive history • This is a genetic neurobiological disorder that runs in families. • The apple doesn’t fall far from the tree. • Parent/teacher/community education • Treatment of the child/teen and medications if indicated. Mood Dysregulation • Coexists with Asperger’s Disorder. • Often misdiagnosed as Attention Deficit Disorder • The wrong medications and diagnosis makes the matter worse. • Can look like Bipolar at times. Interviewing Techniques For a child with suspected Asperger’s Disorder • Be very concrete • Do not use abstract examples • Do not use multipart questions • Engage them with the area of interest they have • Back off if you sense their anxiety rising We so often only diagnose what we see above the water, the other eighty-seven percent remains hidden. William Shryer, DCSW. LCSW Diablo Behavioral HealthCare Danville, CA 925-648-4800 www.behaviorquest.com