We so often only We so often only diagnose what we diagnose what we

see above the see above the water, the other water, the other

eighty-seven eighty-seven percent remains percent remains

hidden.hidden.

William Shryer, DCSW, William Shryer, DCSW, LCSW Diablo Behavioral LCSW Diablo Behavioral

HealthCareHealthCare925-648-4800925-648-4800Danville, CADanville, CA

www.behaviorquest.cwww.behaviorquest.comom

Mother GooseMother Goose

• Georgie Porgie, puddin' and pie,Georgie Porgie, puddin' and pie,Kissed the girls and made them cry.Kissed the girls and made them cry.When the boys came out to play,When the boys came out to play,Georgie Porgie ran away.Georgie Porgie ran away.

• Could Georgy Porgie have been Could Georgy Porgie have been Asperger’s, or on the spectrum?Asperger’s, or on the spectrum?

High Functioning Autism & High Functioning Autism & Asperger's Syndrome Asperger's Syndrome Asperger’s disorder or “syndrome” is not a new Asperger’s disorder or “syndrome” is not a new

diagnosis, in fact it was described in the 1940’s.  diagnosis, in fact it was described in the 1940’s.  “Asperger's Syndrome was first identified in 1944, “Asperger's Syndrome was first identified in 1944, but was only officially but was only officially recognizedrecognized as a diagnostic as a diagnostic category in the DSM-IV in 1994. As a result, many category in the DSM-IV in 1994. As a result, many children and adults were children and adults were misdiagnosedmisdiagnosed over over the years as ADD/ADHD, avoidant, Autistic, OCD, or the years as ADD/ADHD, avoidant, Autistic, OCD, or even schizophrenic.”  While Hans Asperger was even schizophrenic.”  While Hans Asperger was describing this disorder in Austria, Leo Kanner was describing this disorder in Austria, Leo Kanner was describing something else a half a world away in describing something else a half a world away in Boston.  Kanner described Autism at almost the Boston.  Kanner described Autism at almost the same time.  The two disorders share some same time.  The two disorders share some symptoms, but the degree of disability can vary symptoms, but the degree of disability can vary widely.widely.

What is High functioning What is High functioning Autism?Autism?High Functioning Autism (HFA) is the traditional diagnosis for High Functioning Autism (HFA) is the traditional diagnosis for

individuals with severe social interaction and individuals with severe social interaction and communication deficits. Although the distinction with communication deficits. Although the distinction with Asperger’s is blurred and indeed, Asperger’s is often Asperger’s is blurred and indeed, Asperger’s is often considered a subset of HFA, people diagnosed with HFA, it considered a subset of HFA, people diagnosed with HFA, it was thought, tended to have a much higher Performance IQ was thought, tended to have a much higher Performance IQ (P-IQ) than Verbal IQ (V-IQ).(this has recently been proven (P-IQ) than Verbal IQ (V-IQ).(this has recently been proven false)HFA-ers tend to avoid social contact more, but are false)HFA-ers tend to avoid social contact more, but are less likely to feel embarrassed in social situations, being less likely to feel embarrassed in social situations, being relatively unconcerned by other people's opinions.  They relatively unconcerned by other people's opinions.  They also tend to have had slower language acquisition during also tend to have had slower language acquisition during childhood.  They frequently were late in their childhood.  They frequently were late in their developmental milestones.  Parent’s of these children developmental milestones.  Parent’s of these children frequently find this true when reviewing their baby books frequently find this true when reviewing their baby books for information on when their child said their first word, put for information on when their child said their first word, put several words together, and so forth.several words together, and so forth.

What is Asperger’s Disorder?What is Asperger’s Disorder?

Asperger's Syndrome is a neurobiological Asperger's Syndrome is a neurobiological disorder that is classified as one of the disorder that is classified as one of the Pervasive Developmental Disorders (PDD). Pervasive Developmental Disorders (PDD). It is also known as being on the autistic It is also known as being on the autistic spectrum. It is characterized by spectrum. It is characterized by “significant” impairment in social “significant” impairment in social interaction, as well as the development of interaction, as well as the development of repetitive and restricted fields of interest repetitive and restricted fields of interest and activities, however this varies widely and activities, however this varies widely from child to child.from child to child.

While there are some similarities with While there are some similarities with Autism, people with Asperger's Autism, people with Asperger's usually have average to above usually have average to above average IQ, and do not demonstrate average IQ, and do not demonstrate clinically significant delays in clinically significant delays in language or self help skills.language or self help skills.

Shared SymptomsShared Symptoms

• Both Asperger's syndrome and autism are Both Asperger's syndrome and autism are characterized by profoundly disturbed social characterized by profoundly disturbed social interactions and inflexible behavior and can be interactions and inflexible behavior and can be identified by:identified by:

• • • Deficits in nonverbal communication, such as facial Deficits in nonverbal communication, such as facial expressions, eye contact and body language.expressions, eye contact and body language.• A preference for interacting with objects rather • A preference for interacting with objects rather than peers.than peers.• Deep immersion in a single field of interest, such • Deep immersion in a single field of interest, such as meteorology.as meteorology.• Strict adherence to a daily routine.• Strict adherence to a daily routine.• Repetitive motions, such as hand flapping or finger • Repetitive motions, such as hand flapping or finger twisting.twisting.

• Source: Diagnostic and Statistical Manual of Mental Source: Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Revised.) Disorders (Fourth Edition, Revised.)

Screening Red FlagsScreening Red Flags

• Does not respond to nameDoes not respond to name

• Acts as if deafActs as if deaf

• Does not smile at othersDoes not smile at others

• Does not point or use other gestures by Does not point or use other gestures by 12m12m

• No babbling by 12m or words by 16mNo babbling by 12m or words by 16m

• Talks but does not try to communicateTalks but does not try to communicate

• Loss of any social or communication skillLoss of any social or communication skill

Shared SymptomsShared Symptoms

• Researchers at the MIND Institute and Researchers at the MIND Institute and others that work with these patients others that work with these patients see frequent mood instability. see frequent mood instability.

• AggressivenessAggressiveness• TantrumsTantrums• Family histories of mood lability are Family histories of mood lability are

common.common.• Is there an overlap with bipolar?Is there an overlap with bipolar?

They may have an extremely good They may have an extremely good command of language and have a command of language and have a very rich vocabulary, however they very rich vocabulary, however they are unable to use language are unable to use language appropriately in a social context and appropriately in a social context and often speak in a monotone with little often speak in a monotone with little nuance and inflection in their voice. nuance and inflection in their voice.

This is known as prosody of speech. This is known as prosody of speech.

Although parents often notice problems at Although parents often notice problems at an early age, diagnosis is usually made an early age, diagnosis is usually made during preschool age or later. While both during preschool age or later. While both boys and girls can have Asperger's, the boys and girls can have Asperger's, the syndrome is more common in boys.syndrome is more common in boys.

Could this be due to a different presentation Could this be due to a different presentation in girls? This is currently under review. in girls? This is currently under review. Could it be that girls are missed?Could it be that girls are missed?

Children with Asperger's may or may not Children with Asperger's may or may not seek out social interaction, but always seek out social interaction, but always have difficulty in interpreting and have difficulty in interpreting and learning the skills of social and learning the skills of social and emotional interaction with others, emotional interaction with others, leading to significant impairment in leading to significant impairment in relationships and peer interaction. relationships and peer interaction. They are frequently bullied and made They are frequently bullied and made fun of at school.fun of at school.

SymptomsSymptoms

• ““Significant” impairment in social interactionSignificant” impairment in social interaction

• Development of repetitive and restricted fields of Development of repetitive and restricted fields of interest, such asinterest, such as schedules, bugs, dinosaurs, schedules, bugs, dinosaurs, vacuum cleaners etc.vacuum cleaners etc.

• Sometimes poor eye contact, but not always.Sometimes poor eye contact, but not always.

• May have odd facial expressions, but not always.May have odd facial expressions, but not always.

• May show inflexible need for a particular routine.May show inflexible need for a particular routine.

• May show odd body movements at times.May show odd body movements at times.

SymptomsSymptoms

• Difficulty understanding the perspective of Difficulty understanding the perspective of others.others.

• May demonstrate odd behaviors when May demonstrate odd behaviors when excited.excited.

• May be oversensitive to taste, touch, sound or May be oversensitive to taste, touch, sound or other stimulus, such as tags in clothing, nubs other stimulus, such as tags in clothing, nubs in socks. May be sensitive to loud sounds etc.in socks. May be sensitive to loud sounds etc.

• Tend to take matters too literallyTend to take matters too literally

• Ability to use abstraction is impaired.Ability to use abstraction is impaired.

Likely difficultiesLikely difficulties

• Understanding cause and effectUnderstanding cause and effect

• Understanding abstraction and other forms Understanding abstraction and other forms of speech.of speech.

• Making and keeping friends and the Making and keeping friends and the likelihood of being made fun of and treated likelihood of being made fun of and treated poorly in school. Rarely being invited to poorly in school. Rarely being invited to others parties.others parties.

• Anger at others for their predicament.Anger at others for their predicament.

• (Frequently directed towards parents)(Frequently directed towards parents)

ANXIETY ANXIETY

• Most with Asperger’s Disorder have Most with Asperger’s Disorder have significant distress.significant distress.

• Frequently bullied at school.Frequently bullied at school.

• Often misdiagnosed due to poor Often misdiagnosed due to poor training by those in the Health Care training by those in the Health Care Arena.Arena.

• Improper treatment causes symptoms Improper treatment causes symptoms to increase.to increase.

Non Verbal Learning Non Verbal Learning DisorderDisorder• What is nonverbal learning disability (NLD)? Is it a What is nonverbal learning disability (NLD)? Is it a

distinct diagnostic category?distinct diagnostic category?• Nonverbal learning disability (NLD) is believed by Nonverbal learning disability (NLD) is believed by

some to be a neuropsychological disability. some to be a neuropsychological disability. Although it has been studied for the past 30 years Although it has been studied for the past 30 years (by Byron Rourke, Ph.D. and others), it has not yet (by Byron Rourke, Ph.D. and others), it has not yet been included as a diagnostic category in the been included as a diagnostic category in the Diagnostic and Statistical Manual of Mental Diagnostic and Statistical Manual of Mental DisordersDisorders, 4th Edition, Text Revision (DSM-IV TR). , 4th Edition, Text Revision (DSM-IV TR). Many characteristics associated with NLD are Many characteristics associated with NLD are similar to those that describe other, more similar to those that describe other, more “established” disorders, such as Asperger’s “established” disorders, such as Asperger’s Syndrome and specific learning disabilities. Syndrome and specific learning disabilities.

• What characteristics are associated What characteristics are associated with NLD?with NLD?

• NLD is usually defined by a NLD is usually defined by a distinct distinct pattern of specific strengths and pattern of specific strengths and difficultiesdifficulties

• Individuals thought to have NLD Individuals thought to have NLD typically demonstrate strengths in typically demonstrate strengths in the following areas:the following areas:

• Intelligence quotient (IQ)Intelligence quotient (IQ) which is which is typically in the average to above-average typically in the average to above-average range. Children with NLD tend to haverange. Children with NLD tend to have verbal IQ scoresverbal IQ scores that are higher than their that are higher than their performance scores, (Ozanoff et al recently performance scores, (Ozanoff et al recently reported that this is not a valid predictor) a reported that this is not a valid predictor) a factor that distinguishes them from kids factor that distinguishes them from kids with language-based learning disabilities with language-based learning disabilities such as dyslexia.such as dyslexia.

• Rote verbal and expressive and Rote verbal and expressive and receptive language skillsreceptive language skills, such as , such as the ability to memorize and repeat a the ability to memorize and repeat a great deal of information presented great deal of information presented to them in spoken form. They also to them in spoken form. They also exhibit early language development.exhibit early language development.

• Auditory processing skillsAuditory processing skills, which , which entail learning better through entail learning better through hearinghearing information, rather than information, rather than seeing it (visual processing) seeing it (visual processing)

• Motor skillsMotor skills, such as graphomotor , such as graphomotor skills (related to printing and cursive skills (related to printing and cursive writing), physical coordination, and writing), physical coordination, and balance is often problematic.balance is often problematic.

• Complex conceptual skillsComplex conceptual skills involved in involved in problem-solving, understanding cause-effect problem-solving, understanding cause-effect relationships, and seeing the “big picture” relationships, and seeing the “big picture” versus focusing on details similar to versus focusing on details similar to Asperger’s Disorder.Asperger’s Disorder.

• Visual-spatial-organizational skillsVisual-spatial-organizational skills, such , such as visualizing information and understanding as visualizing information and understanding spatial relations is frequently a problem area.spatial relations is frequently a problem area.

• Social skillsSocial skills, such as using and , such as using and understanding nonverbal communication understanding nonverbal communication (e.g., gestures, facial expressions), dealing (e.g., gestures, facial expressions), dealing with new information and situations, with new information and situations, transitioning between situations, transitioning between situations, conversation skills, and understanding the conversation skills, and understanding the nuances of spoken language (e.g., hidden nuances of spoken language (e.g., hidden meanings, figurative language)meanings, figurative language)

• Activity levelActivity level: hyperactivity (when : hyperactivity (when younger), and hypoactivity (as they grow younger), and hypoactivity (as they grow older) older)

Our practice finds that these are the Our practice finds that these are the children most likely to have very high children most likely to have very high IQ’s and behave oddly. They are an at IQ’s and behave oddly. They are an at risk population and do need special risk population and do need special attention and awareness by the school attention and awareness by the school personnel. They meet the criteria for personnel. They meet the criteria for Asperger’s Disorder but are less likely Asperger’s Disorder but are less likely to have difficulty with eye contact.to have difficulty with eye contact.

Treatment/InterventionsTreatment/Interventions

• Comprehensive historyComprehensive history

• This is a genetic neurobiological This is a genetic neurobiological disorder that runs in families.disorder that runs in families.

• The apple doesn’t fall far from the The apple doesn’t fall far from the tree.tree.

• Parent/teacher/community educationParent/teacher/community education

• Treatment of the child/teen and Treatment of the child/teen and medications if indicated.medications if indicated.

Mood DysregulationMood Dysregulation

• Coexists with Asperger’s Disorder.Coexists with Asperger’s Disorder.

• Often misdiagnosed as Attention Often misdiagnosed as Attention Deficit DisorderDeficit Disorder

• The wrong medications and diagnosis The wrong medications and diagnosis makes the matter worse.makes the matter worse.

• Can look like Bipolar at times.Can look like Bipolar at times.

Interviewing TechniquesInterviewing TechniquesFor a child with suspected For a child with suspected

Asperger’s DisorderAsperger’s Disorder• Be very concreteBe very concrete

• Do not use abstract examplesDo not use abstract examples

• Do not use multipart questionsDo not use multipart questions

• Engage them with the area of Engage them with the area of interest they haveinterest they have

• Back off if you sense their anxiety Back off if you sense their anxiety risingrising

We so often only We so often only diagnose what we diagnose what we

see above the see above the water, the other water, the other

eighty-seven eighty-seven percentpercent

remains hidden. remains hidden.

William Shryer, DCSW. William Shryer, DCSW. LCSW Diablo Behavioral LCSW Diablo Behavioral

HealthCareHealthCareDanville, CADanville, CA

925-648-4800925-648-4800

www.behaviorquest.cwww.behaviorquest.comom