asperger’s syndrome: assessment and intervention in the mental health setting by ariadne v....
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Asperger’s Syndrome:Assessment and Intervention in the
Mental Health Setting
By Ariadne V. Schemm, MAPediatric Psychology Intern
Munroe-Meyer Institute for Genetics and Rehabilitation
University of Nebraska Medical Center
April 5, 2006
History of Asperger’s Syndrome
Hans Asperger and Leo Kanner first described similar forms of autism in the 1940’s
Asperger’s description differed from Kanner’s in that speech was less delayed, motor deficits were more common, the onset was later, and it appeared to be most prevalent in boys
Kanner’s work has defined recent views of autism, as a lack of responsiveness to other people and severe language impairments
There was growing concern that the diagnosis of Autism could no longer be given to children who had developed fluent speech and an interest in socializing with others. The term “Asperger’s Syndrome” was first used by Dr. Lorna Wing in 1981.
Current View
Asperger’s Syndrome is now considered to be a less severe form of autism and a Pervasive Developmental Disorder
The syndrome is also placed on the spectrum of autistic disorders and was recognized and provided with its own diagnostic criteria in 1994 in the DSM-IV
(Attwood, 2000)
Clinical Features
Lack of empathy and perspective-taking Naïve, inappropriate, one-sided
conversations Limited ability to form friendships Pedantic and repetitive speech Poor non-verbal communication Intense absorption in certain subjects (little
professor) Clumsy movements and odd postures
(Burgoine & Wing, 1983)
Asperger’s Syndrome 299.80
Qualitative impairment in social interaction (at least 2): Marked impairment in the use of
nonverbal behaviors Failure to develop peer relationships
appropriate to developmental level Lack of shared interest with others Lack of social or emotional reciprocity
Restricted repetitive and stereotyped patterns of behavior, interests, and activities (at least 2): Encompassing preoccupation with one
or more patterns of interest Inflexible adherence to rituals, routines,
and rules Repetitive motor movements Persistent occupation with object parts
Disturbance causes clinically significant impairment in social, occupational, or other areas of functioning
No clinically significant general delay in language, cognitive development, or adaptive behavior
Criteria are not met for other PDD or Schizophrenia
(APA, 2000)
What it’s not:
Children and adolescents with one of these characteristics do not meet the criteria for AS: Social akwardness or poor social skills Limited repertoire of interests Being described as a “weird kid”
These children fall between the criteria- “tweeners”
Statistics
Prevalence estimated at 20-25/10,000
More common in males
Genetics seem to play a larger role in AS than in autism
(Simon-Cohen, 2005)
Neurologically Based Disorder
Limited information on brain development differences in AS
In autism, absolute increases in the total brain volume, total CNS tissue, and lateral ventricular volume Especially in temporal/parietal/occipital
region Cerebrum
Decrease in neuronal size Increased cell packing density in the
limbic system
Differentiating Asperger’s Syndrome from Related Disorders
Autism
Rett’s Disorder
Asperger’s Syndrome
Childhood Disintegrative Disorder
Pervasive Developmental Disorder, NOS
Social Anxiety Fear/avoidance Child has capacity forof social situations age-appropriate
relationships; anxiety is situation specific
Mental Retardation Social & communication Impairments are impairments; quantitative rather repetitive behaviors than qualitative
Speech Disordered Delayed/Absent Social intact;language development socially motivated;
receptive language is higher
ADHD Impaired social Social quality betterfunctioning; easily distracted Distracted by anything
Behavior Disordered Inappropriate behavior Socially motivated; compared to peers; socially awareoppositional
Disorder Similarities Differences
Assessment Procedures
Initial Interview Rating Scales Observations Direct Interactions Environmental Assessment
Initial Interview
Developmental History (age onset, milestones, delays)
Medical History ( TBI, fragile X, ADHD, fetal alcohol)
Previous Evaluations (medical, psych, genetic, GI)
Presenting Concerns and Symptoms Severity of Symptoms (frequency, duration,
intensity)
Rating Scales
Gilliam Asperger’s Disorder Scale Easily completed by parents Items are confounded across domains Provides a nice interpretation guide Word of caution-norm group, over-identification
None are adequate to use independently in assessment
All are best used as screening devices
Consider having multiple raters across settings
Direct Observation
Interest is in observing behavior across the relevant domains
Interest is in observations not just of target child behavior but also of environment
Direct Observations
Child-teacher interactions (child behavior and teacher behavior)
Child-peer interactions (child behavior and peer behavior)
Child-parent interactions (child behavior and parent behavior)
Child-therapist interactions
Child-Therapist Interactions
Unstructured interview (school, home, friends, preferences)
Assessing perceptions of social norms (Dewey)
Perspective taking experiment (Frith)
Direct Interactions
Reinforcer Assessment
Successful intervention requires motivation to learn the skill
Generating motivation to learn requires functional reinforcers
Identifying functional reinforcers can be difficult
Function can change day-to-day and moment-to-moment
Assess the Environment
Do environments include demands that are within the capabilities of the child
Is there direct teaching of social interactions?
Is there limited social stimuli (noise, pace, crowd)
Collaboration between home and school
appropriate educational objectives
Look also for environments that: Use primarily positive motivation strategies
Prevent frequent errors and rely on prompting strategies
Identify functional reinforcers
Arrange consistency across settings and team members
Treatment and Intervention
Teach the acquisition of basic social interaction skills
Teach the acquisition of adaptive skills
Social Skill Training
Social skills will need to be taught in an explicit, scripted, and rote fashion
Skills taught may include: Appropriate nonverbal behavior Verbal decoding of other’s nonverbal
behaviors Social awareness and perspective-taking
skills(Klin & Volkmar,
1995)
Behavioral therapy vs. Psychotherapy
Individuals with AS have great difficulty with insight-oriented therapy
Standard problem-solving techniques are not effective as the socially appropriate response is not socially meaningful to a child with AS
More effective to script out appropriate reactions in problematic situations and practice.
Prognosis
Children with AS are more likely to become independently functioning adults than children with other forms of PDD
Adults with AS often gravitate to professions that mirror their own areas of special interest
They will continue to demonstrate difficulties in social interactions
It is estimated that 30-50% of adults with AS are never correctly diagnosed
(Bauer, 2006; Gillberg,
Resources
OASIS-Online Asperger Syndrome Information and Support
www.aspergersyndrome.org/ Autism Society of Nebraska
www.autismnebraska.org
Asperger’s Syndrome- Parent Support Group: Cindy Roden, 334-9594
or Celeste Montoya, 891-6166 Munroe-Meyer Institute, Psychology
Department: 559-6408
References
Attwood, T. (2000). Asperger’s Syndrome. New York: Jessica Kingsley Publishers.
American Psychiatric Association (2000). DSM-IV-TR. Arlington, Virgina: American Psychiatric Association.
Baron-Cohen, S. (2000). Is Asperger’s Syndrome/ High-Functioning Autism necessarily a disability? Special Millenium Issue of Developmental and Psychopathology.
Burgoine, E. & Wing, L. (1983). Identical triplets with Asperger’s Syndrome. Journal of Child Psychology and Psychiatry, 21, 303-313.
Klin, A. & Volkmar, F. R. (1995). Asperger’s Syndrome: Guidelines for Assessment and Diagnosis. New Haven, Connecticut: Learning Disabilities Association of America.