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Asperger Syndrome or Autistic Disorder? The Diagnostic Dilemma.

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Title: Asperger Syndrome or Autistic Disorder? The Diagnostic Dilemma.
Language: English
Authors: Freeman, B. J., Cronin, Pegeen, Candela, Pete
Source: Focus on Autism and Other Developmental Disabilities. Fall 2002 17(3):145-151.
Peer Reviewed: Y
Page Count: 7
Publication Date: 2002
Document Type: Guides - Non-Classroom
Information Analyses
Journal Articles
Descriptors: Asperger Syndrome, Autism, Classification, Clinical Diagnosis, Communication Skills, Elementary Secondary Education, Evaluation Criteria, Evaluation Methods, Interpersonal Communication, Language Acquisition, Medical Evaluation, Psychological Evaluation, Social Development, Student Characteristics
ISSN: 1088-3576
Abstract: This article examines the difficulties in diagnosing Asperger syndrome (AS) and differentiating AS from autism. It stresses the need for gathering a developmental history and reviews considerations in conducting different assessments related to medical condition, psychological condition, communication, language, occupational and physical therapy, family, mental status, and social interaction. (Contains references.) (CR)
Notes: Special Issue on Asperger Syndrome.
Journal Code: CIJMAR2003
Entry Date: 2003
Accession Number: EJ655487
Database: ERIC
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  Value: <anid>AN0007408274;fdd01sep.02;2002Nov05.09:37;v1.9</anid> <title id="AN0007408274-1">Asperger Syndrome or Autistic Disorder? </title> <sbt id="AN0007408274-2">The Diagnostic Dilemma</sbt> <p>The diagnosis of Asperger syndrome (AS) has been plagued with controversy and confusion since it was introduced into the psychiatric nomenclature, in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association [APA], 1994). This quandary has been portrayed in both the popular media, including newsmagazines and movies, and the scientific literature. Similarly, different views of the syndrome have emerged over the years as different diagnostic criteria were developed and investigated. Connotations that have become popular include high-functioning autism, adults with autism, eccentric people, and "nerds." Confusion remains as to whether AS is in fact a separate diagnostic category, distinct from autistic disorder (AD), or is on a spectrum of social communication learning disability with autistic disorder. The latter question results directly from the significant overlap of diagnostic criteria for AS and AD in DSM-IV and its text revision (DSM-IV-TR; APA, 2000). Klin, Volkmar, and Sparrow (2000) recently summarized the state of the science regarding Asperger's syndrome and its relationship to other disorders. The purpose of the present article is to provide a brief overview of the diagnostic concept of AS and to help clinicians with diagnostic decisions. Regardless of the diagnostic category, a significant number of children and adults with social communication learning disability require intervention.</p> <p>In 1943, Kanner described as autistic a group of children who, he said, were basically normal but had withdrawn into their psychotic world. Asperger, in 1944, described a group of four boys who had problems with social interaction, communication, and idiosyncratic patterns of interest. The initial cases presented in boys, and similar social problems were observed in family members, particularly the fathers. Asperger noted that the boys in his sample were different from Kanner's in that their speech was not delayed, they had motor delays, and social difficulties appeared later. Intense absorption and circumscribed interests, clumsy motor movements, and odd postures characterized the boys Asperger described. In contrast to Kanner, who provided specific diagnostic criteria for autistic disorder (AD), Asperger did not delineate specific diagnostic criteria.</p> <p>Wing (1981) translated Asperger's (1944) original paper into English and stated that Asperger basically described the same group of children as Kanner (1943), noting that in the children was a lack of empathy, naivete, inappropriate one-sided reactions, pedantic and monotonic speech, and poor nonverbal communication. Previously, in 1979, Wolff and Barlow described a similar group of children with schizoid personality disorder; the criteria for that diagnosis included social deficits, behavioral rigidity, odd communication, and increased risk of other psychiatric problems. These diagnostic impressions were considered stable personality traits, whereas autistic disorder was considered a developmental disability.</p> <p>Rourke (1989) described another group of children with a neuropsychological profile identified as nonverbal learning disability (NLD). These children had difficulties with tactile perception, psychomotor coordination, visual-spatial organization, nonverbal problem-solving skills, and affect expression, but exhibited well-developed rote verbal skills.</p> <p>In the 1990s, different views of Asperger syndrome (AS) were put forth (Gillberg, 1989; Szatmari, Tuff, Finlayson, & Bartolucci, 1990). The question was whether AS was a distinctive disorder. Was it related to autism? Was it a condition that needed further study? In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association [APA], 1994) field trials, 977 participants from 21 sites were evaluated by 125 raters or diagnosticians. Interrater reliability was found across sites. The goal was to avoid overdiagnosis in individuals with mental retardation and underdiagnosis in individuals with higher cognitive abilities. Across the same sites and raters, 48 cases were identified with AS, but 12 did not meet the "restricted interest" criterion, and there was no reliability or agreement between raters across sites for diagnosis of these 48 individuals.</p> <p>The consensus in the DSM-IV field trial was that there was enough information to include AS as one of the Pervasive Developmental Disorders (PDD). However, the criteria have created a number of difficulties for diagnosticians. In the DSM-IV the criteria for AS of impairment in social interaction and restricted, repetitive, and stereotypic patterns of interest are the same as those for AD. However, to make a diagnosis of AS there has to be a lack of any clinically significant delay in language and a lack of any clinically significant delay in cognitive development, including development of age-appropriate self-help skills. In addition, for AD, speech delay is not required but, rather, is one of the possible signs of deviance in language development.</p> <p>There is also a threshold problem with DSM-IV in that if an individual meets criteria for the diagnosis of AD, the diagnosis of Asperger syndrome must be excluded. These are just a few of the issues that make it extremely difficult to accurately diagnose people with AS using the DSM-IV criteria. The majority of children and individuals with AS show delays in other areas of adaptive functioning, causing further confusion. DSM-IV does not elaborate on the symptoms that must be present when making the diagnosis.</p> <hd id="AN0007408274-3">Is There a Spectrum?</hd> <p>A number of studies have attempted to look at the validity of the diagnosis of AS, reviewing the differentiation between AD and AS. Kulger (1998) reviewed similarities and differences in symptomatology with reference both to the history of AS and to current research. Symptoms that have been suggested as possibly differential for diagnosis (e.g., problems with motor skills, language abilities, and cognitive functioning) and shared diagnostic features were considered separately. Although the paucity of reliable research findings allows few definitive conclusions to be drawn, it is suggested that attempts to identify subgroups and achieve a better understanding of the behavioral heterogeneity within an autism spectrum of PDD are crucial to improving clinical practice and research.</p> <p>Szatmari, Archer, Fisman, Streiner, and Wilson (1995) examined differences in the behavior, cognition, and adaptive functioning of 47 children with autism and 21 with AS. These participants differed from other individuals with PDD in their delayed and deviant language development. Participants were administered the Autism Diagnostic Interview, Vineland Adaptive Behavior Scales, Leiter International Performance Scale, Stanford Binet Intelligence Scale, Reynell Developmental Language Scale, and developmental tests of visual motor integration. Significant differences between the groups existed on many PDD symptoms, adaptive behaviors, and cognitive measures of language competence, but the groups did not differ on aspects of nonverbal communication, nonverbal cognition, or motor development. The authors hypothesized that subtypes of children with PDD can be identified that differ on variables relatively independent of defining characteristics.</p> <p>Later, Satzmari (2000) reviewed the current classification of PDD as conceptualized in both the DSM-IV and the International Classification of Diseases-10th Edition (ICD-10; World Health Organization, 1993). He sought to determine whether the diagnostic validity of the various disorders simply lacked empirical data for full substantiation or the overall conception of the category had some fundamental problems. He concluded that the overall conceptualization had fundamental flaws. Szatmari reviewed the literature up to that point, summarized recent empirical data on issues of reliability and validity, and suggested the need for a different approach to understanding AS.</p> <p>Eisenmajer et al. (1996) compared two groups of children: one diagnosed clinically with high-functioning autism (AD) and the other diagnosed with AS. They reported that there were three diagnostic differences between the two groups in the preschool years: (a) The communication and imagination impairments for AD were not present for AS; (b) there was no clinically significant language delay for AS (i.e., single words by age 2 years, phrases by 3 years); and (c) there was no significant delay in cognitive development or developmentally age-appropriate self-help skills and adaptive behaviors other than in social interaction and curiosity about the environment. When these children were followed up at a later age, the investigators reported that few clinical differences existed between high-functioning AD and AS, as characterized by the clinician. Normal onset of speech did not preclude later language or communication problems. They concluded that children with AS, as a group, present with fewer significant delays than AD and tend to be identified somewhat later relative to their chronological ages.</p> <p>The only difference reported by Eisenmajer et al. (1996) was that the group with AS tended to have a higher incidence of co-morbid attention-deficit/ hyperactivity disorder (ADHD) than the group with AD. Of particular significance was that the groups did not differ on any of the classic autistic impairments. Deficits were evident in both groups in (a) imagination, (b) imitation, (c) nonverbal communication, (d) awareness of social rules, (e) stereotypic movements, (f) spontaneity and accommodating change, and (g) figurative understanding of language. They concluded that clinicians were identifying a subgroup of children with autism who desired friends; were less likely to have speech delays; exhibited pedantic language; and had narrow, circumscribed interests. Their results suggested that AS was on a continuum with AD and not a separate disorder.</p> <p>Mayes, Calhoun, and Crites (2001) studied forty-seven 2- to 12-year-olds with normal intelligence who had clinical features of AD. These groups were divided into whether or not the children had a speech delay. The purpose of this study was to determine if clinical meaningful differences existed between the two groups and would support absence of speech delay as the DSM-IV criteria for AS. Clinical development and demographic data were analyzed, and no significant differences were found between the 23 children with speech delay and the 24 children without speech delay on any of the 71 variables analyzed, including autistic symptoms and expressive language. Results suggested that early speech delay may be irrelevant to later functioning in children who have normal intelligence and a clinical diagnosis of AD or AS, and that the DSM-IV distinction of speech delay between AS and AD may not be warranted.</p> <p>In a later study, Eisenmajer et al. (1998) looked at comparative data on the developmental history and current behaviors of a large sample of high-functioning 3- to 21-year-olds with a diagnosis of AD, AS, and other related disorders. These individuals provided the basis for a taxonomic analysis of diagnostic subgroups. Most participants also completed theory-of-mind tasks. Three clusters of subgroups were obtained with differences in scores on theory-of-mind tasks and performance and nonverbal abilities. Although subgroups were identified that bore some similarities to clinical differentiation of AD or AS and pervasive developmental disorder not otherwise specified (PDD NOS), the nature of the differences among them seemed to be strongly related to ability variables. Examination of the kinds of behaviors that differentiated the groups suggested that a spectrum of autistic disorders explained the findings that children differ primarily in terms of social and cognitive impairment.</p> <p>Ozonoff, South, and Miller (2000) compared 23 children with high-functioning autism and 12 children with AS. They used DSM-IV (1994) criteria and matched the groups on chronological age and intellectual abilities. They examined the groups for differences in cognitive function, current symptomatology, and early history and found few differences in the current presentation of cognitive functioning between the groups, but many in early development. The children diagnosed with AS tended to have milder symptoms in early development. The group differences seemed to be related to the diagnostic process. These results suggest that individuals with AS and high-functioning AD exhibit the same fundamental symptoms, differing only in their severity. However, there was a major methodological problem with the study in that a circular definition was used and differences found could be attributed to the diagnostic process alone.</p> <p>Leekam, Libby, Wing, Gould, and Gillberg (2000) compared ICD-10 criteria for AS with Gillberg's (1991) criteria. The ICD-10 criteria are the same as those in the DSM-IV. Gillberg's criteria were as follows: impairments in social interaction (including inappropriate public behavior), narrow interests, repetitive routines, speech and language deficits, nonverbal communication deficits, and motor clumsiness. Leekam et al. studied 200 children and adults using the Diagnostic Interview for Social and Communication Disorder (DISC) and found differences depending on the diagnostic criteria used. If the ICD-10/DSM-IV criteria were applied strictly, only 3 of 200 children, or 1% of the population, met criteria for AS. On the other hand, if the Gillberg criteria were utilized, 91 out of 200, or 45%, of the children met criteria for AS. The result was attributed to the requirement for ICD-10/DSM-IV AS criteria of normal onset of cognitive and adaptive abilities. These investigators concluded that ICD-10/DSM-IV identified a subgroup with no delay in early cognitive, language, or adaptive development. Furthermore, the ICD-10 and DSM-IV identified a subgroup even though clinical features later were the same as AD. They also reported that Gillberg's criteria seemed to be consistent with the DSM-IV criteria for Atypical Autism or PDD NOS, a subgroup of individuals with autism that tends to have better language and more intellectual interests. They concluded that their results questioned the validity of defining a separate subgroup and suggested that a dimensional approach to AS was more appropriate than a categorical approach. That is, AS is not a distinctive disorder.</p> <hd id="AN0007408274-4">AD and AS as Separate Diagnostic Categories</hd> <p>McLaughlin-Cheng (1998) reviewed and synthesized clinical and diagnostic criteria, empirical data, and studies on AS and AD from an historical perspective. The results of the synthesis suggest that these two groups of children differ in cognitive and adaptive behavior deficits and therefore do not fall on the same autism continuum. McLaughlin-Cheng's meta-analysis procedure compared children and adolescents with AS to those with AD on various cognitive measures and using various adaptive behavior scales. Overall, the results suggested that children and adolescents with AS perform better than those with AD on intelligence and cognitive measures and measures of adaptive behavior functioning, thus AS should be viewed as a distinctive diagnostic category, separate from AD.</p> <p>Klin et al. (2000) reviewed in detail diagnostic issues surrounding AS and reported that the issues involved include the definition, avoiding circularity, and comparison groups other than persons with AS. The authors indicated that if AS is indeed a distinctive disorder, clinical features have to be identified that are not a part of the confounding definition. The analysis of research to date by Klin and others continues to identify gross social deficits in both individuals with AD and those with AS, with no significant differences in cognitive or adaptive functioning. At times, "milder symptoms" in early development differentiate participants with AS from those with AD. The natural course of the disorder and its neuropsychology, biological markers, and associated features, along with the person's family history, need to be different to make it a meaningful concept. The Yale Learning Disabilities project, in their work to determine whether AS and AD can be reliably differentiated, is also using a theory-of-mind task and salient social skills measures to study differences between high-functioning persons with AD and those with AS. Their research also focuses on brain structure and function, visual tracking, behavioral manifestations, family and molecular genetics, and psychopharmacology to identify whether external differences exist between AD and AS. Whether AS and AD are distinctive disorders remains an empirical question.</p> <hd id="AN0007408274-5">Diagnosing Asperger Syndrome</hd> <p>Currently, AS, like AD, is a clinical diagnosis. Therefore, it is mandatory to have trained and experienced providers to coordinate the results of the complex diagnostic process and to determine the variety, intensity, and comprehensiveness of services required. The American Academy of Child and Adolescent Psychiatry published practice parameters for the assessment of individuals with AD and PDD (Volkmar, Cook, Pomeroy, Realmuto, & Tanguay, 1999). A multiaxial approach was suggested, to interpret specific behaviors in the context of intellectual, communication, social, emotional, and other skills. Evaluators must be knowledgeable of the full range of symptoms in both AD and AS.</p> <p>Second, it is important to assess all areas of development independently and identify the child's relative strengths and weaknesses. Independent assessment in terms of intellect, communication, behavioral presentation, and functional adjustment must be noted throughout the evaluation. Results should indicate a diagnosis, organize specific services, measure efficacy of intervention, and provide prognostic information. Because AS and AD both imply that multiple areas of development are affected, all areas must be evaluated in the context of developmental level.</p> <p>Similarly, behaviors must be examined for developmental delay or deviance. Issues in assessment will vary with the age of the child examined and the context of the evaluation. The certainty of a diagnosis will always depend on the reliability and certainty of data obtained from multiple sources. It is mandatory that a child be observed in both structured and unstructured environments. Parents or primary caregivers must provide historical information, with additional information supplied by other professionals.</p> <hd1 id="AN0007408274-6"> Developmental History </hd1> <p>Pertinent developmental information includes (a) pregnancy, neonatal, and postnatal history, with a specific focus on social, communication, and motor skills; (b) medical history, including a discussion of possible seizure and sensory deficits, such as ones involving hearing and vision; (c) history of behavior-modifying medications; (d) family history of developmental disorder and psychiatric illness; and (e) family and psychosocial factors. Aspects of the assessment will vary depending on the child's age, history, and previous evaluations; however, the first and most important step is to gather historical information (developmental milestones) by interviewing the primary caregiver. When gathering a developmental history, one should ask parents or caregivers about their initial concerns about the individual's development. The clinician must be aware of features important in the differential diagnosis, such as the nature of social relatedness in the first year of life, inconsistencies in speech and communication development, and atypical responses to the environment.</p> <p>For parents of older children, it is sometimes helpful to describe a major event in the child's history, such as his first birthday party. Information from photo albums, baby books, and videos is also useful. The clinician may use rating scales and symptom checklists to gather information (but never in isolation to make a diagnosis). The clinician should obtain a history of interventions, that is, which interventions have been attempted, their quality, intensity, and appropriateness, and the benefit derived. In addition, it is important to obtain information from teachers and other professionals.</p> <p>Early social communication skills are an important area of focus. Typical children, by 4 to 5 months of age, are attempting to interact with their parents and caregivers. Thus, parents or caregivers should be asked whether the child played baby games. Although the response is often "yes," when they are asked if the child initiated baby games, deficits become evident. Other areas of inquiry include, Did the child (a) show separation anxiety at the appropriate age? (b) wave good-bye at 12 months? (c) incorporate other nonverbal gestures? (d) imitate at the appropriate age? and (e) let the parent or caregiver know if he or she was wet or hungry and, if so, how? Descriptions of the child's first nursery school experience, and concerns the nursery school teacher might have reported, are pertinent to the evaluation process. With this information, behavioral changes, adaptation, and development are documented.</p> <hd1 id="AN0007408274-7"> Use of Rating Scales </hd1> <p>Structured, systematic assessment provides further information for diagnostic clarification; however, rating scales were not designed to be used in isolation to make a diagnosis. They are useful to the clinician but are only one source of qualitative information for a comprehensive clinical assessment.</p> <p>Specific instruments that have been widely used in diagnostic evaluations of autism spectrum disorders include the Checklist for Autism in Toddlers (CHAT; Baron-Cohen, Allen, & Gillberg, 1992), used for assessment of children prior to 18 months of age; the Autism Behavior Checklist (ABC; Krug, Arick, & Almond, 1980), a screening instrument completed by the parents or teachers; the Childhood Autism Rating Scale (CARS; Schopler, Reichler, & Renner, 1998), which requires training and primarily assesses sensory motor behaviors; the Autism Diagnostic Interview-Revised (ADI-R; Lord, Rutter, & LeConteur, 1994) a structured interview for parents; and the Autism Diagnostic Observation Schedule (ADOS; Lord et al., 1989), a measure of social communication. Both the ADI and the ADOS require training to administer. Furthermore, they are most useful in discriminating between the absence and the presence of ASD, AD, or PDD. They have not yet been standardized for further diagnostic clarification.</p> <p>A number of rating scales specific to AS have been developed, but as these are new instruments, there is little research on them. The Asperger Syndrome Diagnostic Scale (ASDS; Myles, Bock, & Simpson, 1998), is a self-report measure with normative data on 227 responders; the Autism Screening Questionnaire (ASSQ; Ehlers, Gillberg, & Wing, 1999) differentiated learning disabilities from disruptive behaviors in 110 consecutive referrals to a clinic; the Australian Scale for Asperger's Syndrome (ASAS; Attwood, 1998) does not have normative data or cutoff scores; and the Autism Screening Questionnaire (ASQ; Berument, Rutter, Lord, Pickles, & Bailey, 1999) has cutoff scores and was normed on 200 individuals with a variety of neuropsychiatric diagnoses. All of these questionnaires have been designed as screening measures only and cannot be substituted for clinical assessment.</p> <hd1 id="AN0007408274-8"> Medical Assessment </hd1> <p>The goal of a medical assessment is to search for a treatable medical condition. A medical assessment includes a careful medical history, physical examination, auditory and visual examinations, neurological assessment, and laboratory studies, if necessary. Currently, there are no specific medical tests recommended for individuals in association with the diagnosis of AS.</p> <hd1 id="AN0007408274-9"> Psychological Assessment </hd1> <p>To allow diagnosis of a developmental disability, including PDD, the evaluation must include both a cognitive (intelligence) and an adaptive assessment. The psychological assessment includes developmental and intelligence testing. It is critical to independently assess verbal and nonverbal skills. In addition, skills and abilities typically measured to identify mental retardation develop inconsistently in individuals with AS and AD, so it is not possible to diagnose mental retardation in children under 5 years of age who also have ASD. Extreme caution is necessary to avoid a diagnosis of mental retardation too early in development.</p> <p>Measuring adaptive skills is an important part of the psychological assessment. Specifically, this includes a current summary of the individual's independent daily functioning in the areas of communication, self-help skills, social skills, and motor skills. In typical development, when a skill is mastered, it is used and generalized. For example, when a child masters toileting, he toilets appropriately in all environments. In children who have mental retardation, difficulties and delays are evident in developmental and cognitive measures but are not as prominent in social adaptive skills. The opposite is often true in children with ASD: Children perform well on the developmental/ intelligence measures but exhibit significant impairments in adaptive skills. The Vineland Adaptive Behavior Scales (Sparrow, Ball, & Cicchetti, 1984) are extremely useful for assessing social adaptive skills.</p> <p>In addition to assessment of development/intelligence and adaptive skills, it is important to assess academic skills independent of intelligence testing in the school-age child. There are children with ASD who develop academic skills at a faster rate than their intellectual skills. For example, a child may read before learning to speak.</p> <hd1 id="AN0007408274-10"> Assessment of Communication </hd1> <p>To evaluate communication, one must first ask the question, Is the child verbal or mute? If the child is mute, is there any attempt at nonverbal communication? If the child is verbal, does he or she initiate and maintain a conversation? What is characteristic of the child's language? Qualitatively, is the child's speech fluent (full sentences), echolalic (including pronoun reversals) or characterized by pedantic language? Is the voice quality monotonic? Does the child pursue one topic regardless of the conversation? Does the child make inferences, understand humor, respond to indirect requests, and take into account the perspective of his conversational partner? And, finally, is there any suggestion of disturbances in thought process or content?</p> <hd1 id="AN0007408274-11"> Language Assessment </hd1> <p>Speech, language, and communication assessments are important for indicating the deficits evident in language processing and pragmatics. Primary deficits do not always include an inability to speak or receptive and expressive vocabulary deficits. Therefore, an evaluation for speech is insufficient and should be accompanied by a comprehensive communication assessment. In early diagnosis, the question is, In the absence of language, has the child developed an alternative means of communicating to compensate? If so, how does he or she communicate? Clearly, an assessment needs to indicate goals for the intervention required to teach a child communication skills.</p> <hd1 id="AN0007408274-12"> Occupational and Physical Therapy Assessment </hd1> <p>In addition to the prior evaluations mentioned, occupational and physical therapy assessments are often an important part of the initial process of determining whether a child has any motor delays or hypo-or hypersensitivities to sensory stimuli. Many children with AS present with gross and fine motor delays.</p> <hd1 id="AN0007408274-13"> Family Assessment </hd1> <p>Assessment of the family and parental support system is mandatory, including the effects of the diagnosis on typical siblings. This is particularly important for preschool children, as the family is the most important source of their support and is integral to coordinating educational and community services.</p> <hd1 id="AN0007408274-14"> Mental Status Assessment </hd1> <p>Once historical information is obtained, it becomes important for the examiner to assess the child's behavioral presentation in a mental status examination. The examination must occur in both structured and unstructured settings and must include observation of the child's relationships and behavior with familiar and nonfamiliar people. The mental status examination, as well as the developmental history, should attend to the areas relevant for diagnosis, including social interactions, communication skills, restricted range of interest, and unusual behaviors.</p> <hd1 id="AN0007408274-15"> Assessment of Social Interaction </hd1> <p>Observational queries include the following: Is the child interested in social interaction or is he or she aloof ? How does the child respond to peers' overtures? Does the child passively accept social interactions but not initiate? Is the child interested in a variety of social interactions, or is he limited to his eccentricities or restricted interests? Does the child use eye contact to regulate social interactions? Does the child use any other nonverbal behaviors to regulate social interaction? What is the nature of the child's attachment to the family? Does the child share in the enjoyment of others? Does the child have friends? Are his or her peer relationships appropriate to his or her developmental level?</p> <hd1 id="AN0007408274-16"> Restricted Range of Interests </hd1> <p>Once social interaction and communication skills have been assessed, it is necessary to assess whether or not the child has a restricted range of interests and displays unusual behaviors. The questions should include, Does the child have a particular preoccupation or special interest? If the child has a special interest, does it interfere with functioning? Does the individual have difficulty with change? Does he or she have difficulty with transitions or have specific routines? Are stereotypic motor movements present, and if they are present, when do they occur and can they be interrupted? Is the child preoccupied with parts of objects? Does the child have hand-wringing behavior often associated with Rett's Disorder?</p> <hd1 id="AN0007408274-17"> Other Assessments </hd1> <p>In addition to attending to the areas of diagnostic concern and the criteria listed in DSM-IV-TR, it is also important to assess play behaviors in the young child and leisure activities in the older individual. Questions that pertain to both the young child and the developmental history of the older individual include the following: Were play materials used in a truly imaginative way? Have unusual aspects of the play material, such as the feel or the sound, preoccupied the child? Was play repetitive and stereotypic in nature? In addition, by observing play in young children, it is possible to obtain an estimate of a child's cognitive ability, as play reflects cognitive abilities. The examiner should note the current developmental level of play (e.g., sensory-motor, functional-symbolic, simple constructive, imaginative, dramatic and social play). Often, in children with ASD, the developmental level of play is lower than their measured cognitive abilities.</p> <hd1 id="AN0007408274-18"> Differential Diagnosis </hd1> <p>Because there is so much confusion around the diagnosis of AS, it is difficult to assess comorbidity and other diagnoses. To date, the literature has relied primarily on case reports. Conditions that have been reported to be associated with AS include psychosis, depression, obsessive-compulsive disorder, ADHD, oppositional-defiant disorder, and intermittent explosive disorder. Tantum (2000) reviewed the literature on comorbid psychiatric conditions with persons diagnosed with AS and suggested that all of these comorbid conditions are secondary to the core social deficits in AS.</p> <p>Studies of prognosis for children with AS have been fraught with similar methodological problems. Howlin (2000) reviewed the outcomes studies to date and found that they are confounded by the fact that AS and AD are difficult to separate. A summary of studies to date suggests that persons with high-functioning AD and AS may succeed as adults but with a great deal of difficulty, and most rely on their families. Social contacts usually center on their special interests, rather than close friendships. The constant pressure to fit in may lead to other psychiatric difficulties. Most of the people who have been studied to date have not had early intervention; there is a need for better educational, vocational, social, and emotional support programs to help people challenged by AD and AS.</p> <hd id="AN0007408274-19">Summary</hd> <p>The difference between AS and AD remains an interesting research issue. Unfortunately, this poses significant challenges for clinicians when assigning either of these diagnoses. Most research indicates a great deal of overlap in symptomatology, specifically in the core social deficits. However, differences between AS and AD persist in early child development, specifically related to language and cognitive abilities, comorbid conditions and symptoms, and adaptive functioning. Although AS and AD may be distinct diagnostic categories, a spectrum exists in each category. Regardless, if AS is shown to be a disorder distinct from AD, we need to develop differences related to phenomenology, the natural course of the disorder, neurobiological markers, family history, response to treatment, and appropriate behavioral and psychopharmacological interventions. In the interim, there are clearly groups of children who are very verbal and have intense interests who require (early) diagnosis and appropriate early intervention, with a particular focus on improving social, communication, and vocational skills. In addition, there continues to be an increased need for public awareness of the abilities, not disabilities, of people diagnosed with ASD, including inaccurate depictions in the media.</p> <ref id="AN0007408274-20"> <title> REFERENCES </title> <blist> <bibl id="bib1" type="bt"></bibl> <bibtext>American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.</bibtext> </blist> <blist> <bibl id="bib2" type="bt"></bibl> <bibtext>American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th edition, text rev.). Washington, DC: Author.</bibtext> </blist> <blist> <bibl id="bib3" type="bt"></bibl> <bibtext>Asperger, H. (1944). Die "Autistischen Psychopathen" im Kindesalter. Archiv fur Psychiatrie und Nervenkrankheiten, 117, 76-136.</bibtext> </blist> <blist> <bibl id="bib4" type="bt"></bibl> <bibtext>Attwood, T. (1998). Asperger's syndrome: A guide for parents and professionals. 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Outcome in adult life for more able individuals with autism or Asperger's syndrome. Autism: The International Journal of Research and Practice, 4(1), 63-84.</bibtext> </blist> <blist> <bibl id="bib13" type="bt"></bibl> <bibtext>Kanner, L. (1943). Autistic disturbances of affective contact. Nervous Child, 2, 217-253.</bibtext> </blist> <blist> <bibl id="bib14" type="bt"></bibl> <bibtext>Klin, A., Volkmar, F. R., & Sparrow, S. S. (2000). Asperger's syndrome. New York: Guilford Press.</bibtext> </blist> <blist> <bibl id="bib15" type="bt"></bibl> <bibtext>Krug, D. A., Arick, J., & Almond, P. (1980). Behavior checklist for identifying severely handicapped individuals with high levels of autistic behavior. Journal of Child Psychology and Psychiatry, 21, 221-229.</bibtext> </blist> <blist> <bibl id="bib16" type="bt"></bibl> <bibtext>Kugler, B. (1998). The differentiation between autism and Asperger's syndrome. Autism, 1, 11-31.</bibtext> </blist> <blist> <bibl id="bib17" type="bt"></bibl> <bibtext>Leekam, S., Libby S., Wing, L., Gould, J., & Gillberg, C. (2000). Comparison of ICD-10 and Gilberg's criteria for Asperger's Syndrome. Autism, 4 (1), 11-28.</bibtext> </blist> <blist> <bibl id="bib18" type="bt"></bibl> <bibtext>Lord, C., Groode, S., Heemsbergen, J., Jordan, H., Mawhood, L., & Rutter, M. (1989). Autism Diagnostic Observation Schedule: A standardized observation of communicative and social behavior. Journal of Autism and Developmental Disorders, 19, 185-212.</bibtext> </blist> <blist> <bibl id="bib19" type="bt"></bibl> <bibtext>Lord, C., Rutter, M., & LeConteur, A. (1994). Autism Diagnostic Interview-Revised: A revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorder. Journal of Autism and Developmental Disorders, 24, 659-685.</bibtext> </blist> <blist> <bibl id="bib20" type="bt"></bibl> <bibtext>Mayes, S. D., Calhoun, S. L., & Crites, D. L. (2001). Does DSM-IV Asperger's disorder exist? Journal of Abnormal Child Psychology, 3, 263-271.</bibtext> </blist> <blist> <bibl id="bib21" type="bt"></bibl> <bibtext>McLaughlin-Cheng, E. (1998). Asperger syndrome and autism: A literature review and meta-analysis. Focus on Autism and Other Developmental Disabilities, 13, 234-245.</bibtext> </blist> <blist> <bibl id="bib22" type="bt"></bibl> <bibtext>Myles, B. S., Bock, S. J., & Simpson, R. L. (1998). Asperger syndrome diagnostic scale. Austin: PRO-ED.</bibtext> </blist> <blist> <bibl id="bib23" type="bt"></bibl> <bibtext>Ozonoff, S., South, M., & Miller, J. (2000). DSM-IV-defined Asperger's Syndrome: Cognitive, behavioral and early history differentiation from high-functioning autism. Autism, 1, 29-46.</bibtext> </blist> <blist> <bibl id="bib24" type="bt"></bibl> <bibtext>Rourke, B. P. (1989). Nonverbal learning disabilities: The syndrome and the model. New York: Guilford Press.</bibtext> </blist> <blist> <bibl id="bib25" type="bt"></bibl> <bibtext>Schopler, E., Reichler, R. J., & Renner, B. R. (1998). The childhood autism rating scale (CARS). Los Angeles: Western Psychological Services.</bibtext> </blist> <blist> <bibl id="bib26" type="bt"></bibl> <bibtext>Sparrow, S., Balla, D., & Cicchetti, D. V. (1984). Vineland adaptive behavior scales, interview edition. Circle Pines, MN: AGS.</bibtext> </blist> <blist> <bibl id="bib27" type="bt"></bibl> <bibtext>Szatmari, P. (2000). Perspectives on the classification of Asperger's syndrome. In A. Klin, F. Volkmar, & S. Sparrow (Eds.), Asperger's syndrome (pp. 403-417). New York: Guilford Press.</bibtext> </blist> <blist> <bibl id="bib28" type="bt"></bibl> <bibtext>Szatmari, P., Archer, L., Fishman, S., Streiner, D. L., & Wilson, F. (1995). Asperger's syndrome and autism: Differences in behavior, cognition, and adaptive functioning. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1662-1671.</bibtext> </blist> <blist> <bibl id="bib29" type="bt"></bibl> <bibtext>Szatmari, P., Tuff, L., Finlayson, M. A. J., & Bartolucci, G. (1990). Asperger's syndrome and autism: Neurocognitve aspects. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 130-136.</bibtext> </blist> <blist> <bibl id="bib30" type="bt"></bibl> <bibtext>Tantum, D. (2000). Psychological disorder in adolescents and adults with Asperger's syndrome. Autism, 4 (1), 47-62.</bibtext> </blist> <blist> <bibl id="bib31" type="bt"></bibl> <bibtext>Volkmar, F., Cook, E., Pomeroy, J., Realmuto, G., & Tanguay, P. (1999). Practice parameters for the assessment and treatment of children, adolescents, and adults with autism and other pervasive developmental disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 32S-54S.</bibtext> </blist> <blist> <bibl id="bib32" type="bt"></bibl> <bibtext>Wing, L. (1981). Asperger's syndrome: A clinical account. Psychological Medicine, 11, 115-129.</bibtext> </blist> <blist> <bibl id="bib33" type="bt"></bibl> <bibtext>Wolff, S., & Barlow, A. (1979). Schizoid personality in childhood: A comparative study of schizoid, autistic and normal children. Journal of Child Psychology and Psychiatry, 20, 19-46.</bibtext> </blist> <blist> <bibl id="bib34" type="bt"></bibl> <bibtext>World Health Organization. (1993). International classification of diseases & related health problems. (10th rev.). Geneva: Author.</bibtext> </blist> </ref> <aug> <p>By B. J. Freeman; Pegeen Cronin and Pete Candela</p> <p></p> <p>B. J. Freeman, PhD, is a psychologist and professor of medical psychology in the Department of Psychiatry and Biobehavioral Science at the University of California, Los Angeles, School of Medicine. Currently, she is the co-director of an early intervention and assessment partial hospitalization program for children diagnosed with developmental disabilities between the ages of 3 and 7 years. In addition, she is the director of the Autism Evaluation Clinic in the outpatient department of psychiatry.</p> <p>Pegeen Cronin, PhD, is a psychologist and associate director of the outpatient Autism Evaluation Clinic in the Department of Psychiatry at UCLA. She has been working with Dr. Freeman since the inception of this clinic 4 years ago, and continues to provide services and training to both the inpatient and partial hospitalization services. In addition, with Dr. Freeman, Dr. Cronin has been a contributing member to the variety of research projects related to autistic disorder.</p> <p>Pete Candela, MS, has extensive experience working with children and families affected by autistic disorder. He works as a case manager in assisting families as they seek educational and community services. In addition, he leads social skills groups for children who present with autism. Address: B. J. Freeman, UCLA Neuropsychiatric Institute, Department of Child and Adolescence Psychiatry, 300 UCLA Medical Plaza Room 1261, Box 956967, Los Angeles, CA 90095-6967.</p> </aug>
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  Data: Asperger Syndrome or Autistic Disorder? The Diagnostic Dilemma.
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  Data: <searchLink fieldCode="SO" term="%22Focus+on+Autism+and+Other+Developmental+Disabilities%22"><i>Focus on Autism and Other Developmental Disabilities</i></searchLink>. Fall 2002 17(3):145-151.
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  Data: This article examines the difficulties in diagnosing Asperger syndrome (AS) and differentiating AS from autism. It stresses the need for gathering a developmental history and reviews considerations in conducting different assessments related to medical condition, psychological condition, communication, language, occupational and physical therapy, family, mental status, and social interaction. (Contains references.) (CR)
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