Asperger's Disorder in Children

Asperger's Disorder (AD) has a history somewhat like Tourette Syndrome (TS).  Both conditions were very carefully described and discussed by highly expert European specialists generations ago, but their publications were entirely in the French medical literature (TS), or German (AD).  TS was finally "re-discovered" and publications in English and American medical and psychiatric texts about TS emerged in the 1960's, and English/American publications about AD in the late 1980's.

Further analogous to TS, AD is a condition normally complicated by symptoms or traits of many other conditions, especially Attention Deficit Hyperactivity Disorder, Obsessive-Compulsive Disorder, and the various Pervasive Developmental Disorders.

In fact AD shares with all of the above conditions many remarkably identical symptoms, especially in children ages 3-6.

Further, some AD symptoms, in rather more severe cases, suggest possible Early Infantile Autism.  Avoidant eye contact, limited or minimal interest in productive and mutually satisfying social interaction, posturing or spinning or other evidently meaningless or odd behaviors, tremendous sensitivity to any transition or change in routine, self-stimulating behaviors, and bizarre and intense emotional overreaction to routine environmental stimuli (sounds, smells, lighting, noises, etc.) may often appear similar to typical symptoms of children who have Early Infantile ("Kanner") Autism.

Unlike children with Autism, children with AD typically develop fully normal language skills at a normative developmental schedule, respond to directions by their parents with attempts to comply, develop normal self-help skills (bathing, dressing, grooming, etc.) and usually enter pre-K and Kindergarten with language, mental, and cognitive skills within the normal range.

These differences are so specific, and so obvious, that many experts question AD being "categorized" within the broader spectrum of Autistic Disorders.  However, very careful multi-generational family studies typically discover one or more biological relatives in the "family tree" who have Early Infantile Autism, and others who have "TRAITS" of AD and Autism.

AD is a condition which confounds ANY diagnostician because many of the symptomatic behaviors are subtle, and may be easily confused with ADHD, OCD, and/or Tourette Syndrome.

There are a few key differences, although it must be emphasized they are often more in degree than in any clear "type."

  • Most children with AD are physically "awkward," and it is common to hear reports of underdeveloped gross motor coordination.  Fine motor coordination problems are common in children with ADHD: they cannot hold the pencil or crayon effectively, color between the lines, or write letters in an age-normative manner.  Children with AD typically are better with fine motor skills below their age level; they do not catch or throw well, nor do they climb, jump, etc. with typical skills and balance.  THERE ARE EXCEPTIONS, but most children with AD compared to classmates show some impairment in gross motor skills.


  • Over time most AD children do not develop outward evidence of interest in the ideas, feelings, or play activities of other children in the same manner as classmates.  They may state they have these interests, and say they want to play or join in , but they seem more unable than unwilling to do so.


  • Children learn all manner of "social cues" as they interact with each other.  AD children typically are comparatively less able to understand what these body mannerisms or facial expressions mean they notice the reaction, but do not understand it.


Of further concern, many or most AD children do not express social, emotional, or behavioral mannerisms and responses which convey to peers or family how they actually feel in a manner others would perceive and understand.  A certain "flatness" and "disconnect" of facial expression has been described in the AD literature for many years:  The child may express in words he feels "excited" and "terrific" about his academic progress, but to the observer look and act utterly disinterested: the facial expressions we normally "connect" with excitement and feeling so great are usually not evident.


Further, when a family member or a clinician carefully listens to and AD individual discuss these matters, there is often a further disconcerting experience: it is not merely the lack of facial or bodily expression, but the manner of speech, described in the European studies as "pedantic," as if delivering a lecture in a literature class, and sometimes very odd in "prosody," that is, rhythmic as if almost in poetic meter.  There is often a lack of what we might call spontaneity of expression: the words and phrases are technically correct, but expressed in an odd manner.


  • AD children typically have VERY SPECIFIC, and VERY INTENSE, and often QUITE UNUSUAL interests, frequently carried to a point parents describe as FIXATIONS.  In many cases the "fixations" are seemingly all-consuming, far beyond what anyone would merely call an "interest."  This remarkably intense object of focus/fixation often so ind=credibly transcends social, emotional, and family boundaries that parents and teachers - and certainly peers - may be quite disturbed:  EXAMPLE; Grandma June died last night and there is a family discussion about the funeral.  Without seeming understanding or appreciation of the social context, the AD child may repeat a need for 24 more 3.5 cm railroad ties for his/her train set, showing a complete disinterest in and lack of emotional reaction to Grandma June's death.


  • AD children are typically "concrete" or "literal."  They have difficulty understanding abstractions, analogies, idioms, or humor in an age-normative fashion.  They think and respond literally.  Office interview example a few weeks ago:  MOM:  "That's as clear as mud!"  CHILD: "Mud isn't clear."


This is a symptom which may, over time, confound and disturb parents and teachers: AD children typically "do not make the connection," and "don't get it," unless an instruction is presented in the most concrete format.  EXAMPLE:  "Please take your dirty clothes down to the washing machine."  PROBLEM:  an AD child may not understand "clothes."  He/she might respond well if Mom said "Underwear" or "Socks."  Further, trying to comply, an AD child may be found inspecting all of his/her clothes for evidence of dirt, and finding no actual dirt upon examining some clothes, really has no idea that they might be "dirty."


  • EXCEPTIONAL ANXIETY about very routine sensory experiences we all otherwise take for granted is very common in AD children.  When we as a family, walk into a store selling TVs or stereos, that may very noisy, but we do not expect our child to completely "freak out" and exhibit a most extraordinary emotional/behavioral reaction despite normal, typical, emotional reassurances from parents, siblings, etc.  This scene may become so very disturbing the family must leave the store.  Noises, lighting, smells: ANYTHING may trigger exceptionally bizarre emotional outbursts.


  • In a somewhat similar manner, AD children often simply appear to be, or react as if, anxious about anything unusual; any change.  AD children typically are unable to communicate anxiety in an understandable manner, but they are unable to cope with the transition(s).  This anxiety is easily misunderstood as "oppositional" or "defiant."


  • Over time, as they develop, certain oddities become more evident in AD childrens' patterns of speech: the words themselves are OK, but is the expression, the pronunciation, the manner in which comments are used, and by later childhood and adolescence the extraordinary perseverative nature of these comments or odd inflections or odd patterns.  The term "perseverative" means (in Psychiatric jargon) an extremely repetitive pattern of very odd, often "out of context," and typically unanswerable commentary: (in a current case:  KID:  "Dad, did I hurt your feelings?"  DAD:  "No."  KID: "But Dad, did I hurt your feelings?"  DAD: "No, I am perfectly OK!"


However, this scene may go on for 2-4 minutes, and no matter what Dad says, the child (in this case an 18 year old) repeats the very same question without registering/comprehending his father's response.  This is a pattern he often repeats, but cannot stop, about many other issues in many different settings.


  • Older children with AD tend to become increasingly socially withdrawn over time, and to develop very specific, highly individual, and often very idiosyncratic interests TO THE EXCLUSION OF VIRTUALLY ALL OTHER AGE-NORMATIVE PURSUITS.


One child was only interested in electronic circuits.  By age 15 his knowledge in the area was incredible.  However, in any social context in High School he was completely unable to respond to peers except when details of electronic circuits might become the focus of conversation.  Then he would ramble into extraordinary details no other teen could understand, and become agitated and frustrated when they express disinterest.  He was unable to comprehend the social cues, and simply could not stop in-depth explanation of nuances of the circuitry in time to avert a nasty scene.


  • It is something of a myth AD children, adolescents, and adults are in any respect "retarded."  Many are VERY BRIGHT, and some are Gifted, but over time most AD individuals are described by family and professional colleagues as very "odd."   They may be very successful in even very demanding occupations (including Law and Medicine) but have quite restricted social lives, VERY limited interests beyond their special area of expertise, and seem to exhibit (especially to their spouses) an extraordinary "distance" form, lack of identification with, or substantiative emptional attachment to their children.


  • The other side of this coin is: AD children often are incapable of exhibiting or expressing substantiative emotional attachment to and caring about family members or friends (as in the example of Grandma June's death).  This may very easily be confused with a condition (loosely) labeled in "psychological" terms Attachment Disorder, an observation I attribute to my colleague Thomas Blitsch, MFCC.  Indeed there is seemingly a lack of emotional reciprosity in  many of these children, but it is common for them to be very, very upset when a friend moves away or a family member dies, and after a period of apparent indifference repeatedly refer to, or ask about the friend or relative long after one might expect the matter would be forgotten or resolved in a manner normative for their age.  AD children may be unable to express " attachment" at the time one expects, but this does NOT mean it is entirely absent.


As you can certainly see, AD children are not easily diagnosed, and they are a challenge to treat!


Corydon G. Clark, M.D.



IMPORTANT ASPERGER'S DISORDER REFERENCES


B. Myles, R. Simpson ASPERGER DISORDER, paperback, Pro-Ed Publishers, 1998


Frith, U. AUTISM AND ASPERGER SYNDROME, hardcover, Cambridge University press, 1991


Attwood, A. ASPERGER SYNDROME: A Guide for Parents and Professionals, Jessica Kingsley Publishers, 1997


Please Note:


EDUCATORS:  The Myles and Simpson book is an outstanding reference devoted 75% or more to teaching interventions for AD children.


PHYSICIANS and PSYCHOLOGISTS: The book edited by Dr. Uta Frith is most highly recommended; it is a compilation of scientific papers from a variety of experts.  WARNING: HEAVY GOING and very technical.


PARENTS and PATIENTS:  Dr. Attwoods book is the outstanding reference in this field to date.