More On Aspergers

Since the Asperger's article was one of my more popular postings, I am saying more about that here.

Let's look at each of the DSM-IV criteria and try to understand them the best we can.

DIAGNOSTIC CRITERIA FOR ASPERGER'S DISORDER (DSM IV)

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

1) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction;

The issue here is whether the child can participate in social communication, not just using words but using the eyes, hands, and whole body.  Poor eye contact can be a tipoff to a problem in this area, but the criterion says that there has to be a deficit in multiple nonverbal behaviors, so poor eye contact alone would not be sufficient to meet this criterion.

2) failure to develop peer relationships appropriate to developmental level;

Aspergers children seem to prefer the company of adults or younger children.  Adults may be preferred because the language used among them is more "objective" and intellectual.  Children of a younger age may be preferred because the Aspergers child has not progressed developmentally as much as their age mates.  Communicating with age appropriate peers requires a high level of social skills.  Moreover, with one's peers there is always a type of competition for social status, or at least for inclusion, and the Aspergers child is not able to keep up in that competition.  They don't have to compete with adults, and they can compete more easily with younger children.

3) a lack of spontaneous seeking to share enjoyment, interests or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people);

The Aspergers child lives in their own world to some degree.  They do not necessarily want to bring things of interest to them and show them to other people.  They are happy with discovering things or playing with things on their own.

4) lack of social or emotional reciprocity.

What does this mean?  Well, I can tell you what I take it to mean.  Social reciprocity would mean being able to give help and receive help.  It could also mean playing a game with give and take rather than just playing with toys and games on one's own, or playing side by side with someone.  Emotional reciprocity would involve being caring and empathic for others.  If another person is hurt or feels sad, then most children have some sense of sadness.  If another person has something really good happen, then most children have some good feelings, too.  Again, it's all about whether they are in their "own world" socially and emotionally.

B . Restricted repetitive and 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;

An Aspergers child may be very focused on a normal activity but to an unsual degree, such as knowing more about insects than most adults, or knowing a great deal about racing cars, or video games.  One child was very interested in Pokemon--not unusual in itself.  But he had drawn every single Pokemon character and made two elaborate and well organized notebooks with all of the characters--an extreme investment of time.

Or the Aspergers child may have an interest in something very much outside the realm of most children's interests, such as learning the Russian language.

2) apparently inflexible adherence to specific, nonfunctional routines or rituals;

Sometimes these routines can look like Obsessive Compulsive Disorder.  For example, it might involve needing to have all of one's army soldiers standing up in a row before going to sleep.  Sometimes, this symptoms just looks like an overly strong insistence on routine.  E.g, the child has to put the shirt on, put their pants on, brush their teeth, pick up their books, pick up their lunch, in that order before going out the door.

3) stereotyped and repetitive motor mannerisms (eg: hand or finger flapping or twisting, or complex whole-body movements);

The extreme forms of this are unmistakable, such as hand flapping.  Other times, the child is doing something in a more subtle manner and hiding it from others.

4) persistent preoccupation with parts of objects

It's not the whole object and its associated purpose which may interest the child but some small part. One child in my office was intrigued by the bottom of a brass lamp, which was convex and had a funhouse mirror effect.  Another child played with toy cars by turning them upside down and spinning one of the wheels.  Many Aspergers children like to take things apart.

C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning. 

In other words, there has to be some impairment in functioning for the disorder to be diagnosed.  If they meet the above criteria, they are very likely to have some impairment in functioning.

D. There is no clinically significant general delay in language (eg: single words used by age 2 years, communicative phrases used by age 3 years). 

If there is, then a different pervasive developmental disorder may need to be diagnosed, possibly austism.

E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than social interaction), and curiosity about the environment in childhood. 

If there is, then a different pervasive developmental disorder may need to be diagnosed, possibly austism.

F. Criteria are not met for another specific Pervasive Developmental Disorder, or Schizophrenia. 

Other Pervasive Developmental Disorders would take precedence in the diagnostic decision making chart.  And if a full symptom picture of Schizophrenia is present, then Schizophrenia is diagnosed instead of Aspergers.

These criteria are being revised for DSM-5.  At that point, autism and aspergers will probably be subsumed under the diagnosis of Autism Spectrum Disorder.  I think this makes sense.  However, it will make my job a little more difficult--telling a parent that their child has Austism Spectrum Disorder.  The word autism carries a lot of emotional baggage with it that the term Aspergers does not.