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Asperger syndrome
ICD-10 F84.5
ICD-9 299.8
OMIM 608638
DiseasesDB 31268
MedlinePlus 001549
eMedicine ped/147
MeSH {{{MeshNumber}}}


Asperger syndrome — also referred to as Asperger's syndrome, Asperger's disorder, Asperger's, or just AS — is a formerly-used term for a subtype of autistic people. It generally described people who had no impairments in language or intelligence. It was merged into the general autism spectrum disorder label in the DSM-5 and the ICD-11. People with Asperger syndrome diagnoses are now described as having "autism spectrum disorder" instead.

Traits include social differences, literal thinking, stimming and other repetitive behaviors, intense interests, sincerity, and more. Every autistic person is unique and autism comes with both strengths and challenges. Some people are diagnosed in childhood, while others may not receive diagnosis and support until teen or adult years.

The label of Asperger syndrome was typically used for people who had no developmental delays in early childhood, who had no language delay, and/or had average or above average intelligence.[1][2]

Autism (including the Asperger syndrome subtype) is mainly genetic with a few prenatal environmental factors.[3] Treatment is based on an individual's needs, and the UK's National Health Service says that autism is not "a disease that can be removed or cured."[4] Autistic people may benefit from disability accommodations, counseling like cognitive behavior therapy, occupational therapy, parent training, and treatment for any co-occurring conditions.

Asperger syndrome was named for Hans Asperger (1906-1980), an Austrian psychiatrist and pediatrician, by researcher Lorna Wing, who first used the eponym in a 1981 paper.[5] In 1994, AS was recognized in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as Asperger's Disorder.[6]

Classification and diagnosis[]

Hans Aspergersmall

Hans Asperger, after whom the syndrome is named, described his young patients as "little professors".

Asperger syndrome is no longer diagnosed. The separation between autism and Asperger syndrome may be an artifact of how autism was discovered, rather than reflecting the true nature of the autism spectrum.[7][8]

Former DSM-IV criteria[]

AS correlates with Asperger's Disorder defined in section 299.80 of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) by six main criteria. These criteria define AS as a condition in which there is:

  1. Qualitative impairment in social interaction;
  2. The presence of restricted, repetitive and stereotyped behaviors and interests;
  3. Significant impairment in important areas of functioning;
  4. No significant delay in language;
  5. During the first three years of life, there can be no clinically significant delay in cognitive development such as curiosity about the existing environment or the acquisition of age appropriate learning skills, self-help skills, or adaptive behaviors (other than social interaction); and,
  6. The symptoms must not be better accounted for by another specific pervasive developmental disorder or schizophrenia.[6]

Traits[]

Asperger syndrome involves the same major traits as autism.

AS is characterized by:[6][9]

Every autistic person is unique. Some learn to "mask" their autistic traits to the detriment of their mental health.

Social differences[]

Autism Double Empathy 1

An autistic person (left) and a non-autistic person (right) struggle to understand each other.

Although there is no single feature that all people with AS share, difficulties with social behavior are nearly universal and are one of the most important defining criteria. People with AS lack the natural ability to see the subtexts of social interaction, and may lack the ability to communicate their own emotional state, resulting in well-meaning remarks that may offend, or finding it hard to know what is "acceptable".

The unwritten rules of social behavior that mystify so many with AS have been termed the "hidden curriculum".[10] People with AS must learn these social skills intellectually through logic rather than intuitively through normal emotional interaction.[11]

The "double empathy problem" describes how it is harder for non-autistic and autistic people to relate to each other.[12][13][14][15] Non-autistic people tend to judge autistic people more harshly than they judge non-autistic people.[16][17] However, they are less judgmental when they know the person is autistic and when they understand autism better,[18][19] suggesting that improving understanding of autism could help.

Speech and language differences[]

Autistic people find it easier to communicate with each other than with non-autistic people.[20]

People with AS typically have a highly pedantic way of speaking, using a far more formal language register than appropriate for a context. A five-year-old child with this condition may regularly speak in language that could easily have come from a university textbook, especially concerning their special area of interest.[21]

Literal thinking and interpretation is common. Attwood gives the example of a girl with AS who answered the telephone one day and was asked, "Is Paul there?" Although the Paul in question was in the house, he was not in the room with her, so after looking around to ascertain this, she simply said "no" and hung up. The person on the other end had to call back and explain to her that he meant for her to find him and get him to pick up the telephone.[22]

Individuals with AS may use words idiosyncratically, including new coinages and unusual juxtapositions. This can develop into a rare gift for humor (especially puns, wordplay, doggerel and satire). A potential source of humor is the eventual realization that their literal interpretations can be used to amuse others. Some are so proficient at written language as to qualify as hyperlexic. Tony Attwood refers to a particular child's skill at inventing expressions, e.g., "tidying down" (the opposite of tidying up) or "broken" (when referring to a baby brother who cannot walk or talk).[23]

Children with AS may show advanced abilities for their age in language, reading, mathematics, spatial skills, or music, sometimes into the 'gifted' range, but these talents may be counterbalanced by appreciable delays in the development of other cognitive functions.[24] Some other typical behaviors are echolalia, the repetition or echoing of verbal utterances made by another person, and palilalia, the repetition of one's own words.[25]

Narrow, intense interests[]

Many autistic people experience deep, narrow interests. Examples include vacuum cleaners, infrastructure, Chinese history, and writing poetry. Interests in how things work are common.[26] They may show sophisticated reasoning skills and excellent recollection of details in these areas.[27][28] Engaging with these interests can be a source of joy, relaxation, and skill development.

Other differences[]

Stim Toys 1

Stim toys owned by an autistic woman

Motor skills may be delayed. The person may move awkwardly or oddly. Handwriting legibility can be a challenge for youth with AS.[29]

In general, orderly things appeal to people with AS. Some researchers mention the imposition of rigid routines (on self or others) as a criterion for diagnosing this condition. It appears that changes to their routines cause inordinate levels of anxiety for some people with this condition.[30]

Sensory processing disorder is common in autistic people. Sensitivity to loud noises and hyperacusis is especially common. They may prefer soft clothing, certain "safe foods," and quiet environments. Some are uncomfortable with being touched, especially light touch. Sensory overload may trigger panicked outbursts or "shutdowns."

Stimming behavior is common for self-regulation. People with AS may find it helpful to engage in subtle or noticeable forms of fidgeting.[31] Some researchers and autistic advocates have argued that preventing people from stimming is harmful and that non-injurious stimming should be accepted.[32][33]

History[]

In 1944, the Austrian pediatrician Hans Asperger observed four children in his practice who had difficulty integrating socially. Although their intelligence appeared normal, the children lacked nonverbal communication skills, did not demonstrate typical empathy, and were physically clumsy. Their way of speaking was either disjointed or overly formal, and their all-absorbing interest in a single topic dominated their conversations. Dr. Asperger called the condition “autistic psychopathy” and described it as a condition primarily marked by social isolation.[34] He also stated that "exceptional human beings must be given exceptional educational treatment, treatment which takes into account their special difficulties. Further, we can show that despite abnormality, human beings can fulfill their social role within the community, especially if they find understanding, love and guidance".[2]

Hans Asperger and Leo Kanner identified essentially the same population, although the group identified by Asperger was perhaps more "socially functional" than Kanner's.[35] Traditionally, Kanner-style autism is characterized by significant cognitive and communicative deficiencies, including delays in or lack of language.[36] A person with AS will not show delays in language, however.

Asperger’s observations, published in German, were not widely known until 1981, when an English doctor named Lorna Wing published a series of case studies of children showing similar symptoms, which she called “Asperger’s Syndrome".[5] Wing’s writings were widely published and popularized. In 1992, the tenth published edition of the World Health Organization’s diagnostic manual and the International Classification of Diseases (ICD-10) included AS, making it a distinct diagnosis.[9] Later, in 1994, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the American Psychiatric Association’s diagnostic reference book also added AS.[6][37]

Uta Frith (an early researcher of Kanner-type autism) wrote that people with AS seem to have more than a touch of autism to them.[38] Others, such as Lorna Wing and Tony Attwood, share Frith's assessment. Dr. Sally Ozonoff, of the University of California at Davis's MIND Institute, argues that there should be no dividing line between "high-functioning" autism and AS,[39] and that the fact that some people do not start to produce speech until a later age is no reason to divide the two groups because they are identical in the way they need to be treated.

Research[]

Some research is to seek information about symptoms to aid in the diagnostic process. Other research is to identify a cause, although much of this research is still done on isolated symptoms. Many studies have exposed base differences in areas such as brain structure. To what end is currently unknown; research is ongoing, however.

Peter Szatmari suggests that AS was promoted as a diagnosis to spark more research into the syndrome: "It was introduced into the official classification systems in 1994 and has grown in popularity as a diagnosis, even though its validity has not been clearly established. It is interesting to note that it was introduced not so much as an indication of its status as a 'true' disorder, but more to stimulate research. its validity is very much in question."[40]

Research on infants points to early differences in reflexes, which may be able to serve as an "early detector" of AS and autism.[41]

Some professionals believe AS is not necessarily a disorder and thus should not be described in medical terms.[42]

Research into causes[]

Main article: Causes of autism

Autism is mostly genetic, with multiple genes playing a role.[3]

Autistic brains are different from non-autistic brains.[9][43]

Non-neurological factors such as poverty, lack of sleep, substance abuse by the mother during pregnancy, discrimination, trauma during early childhood, and abuse may also contribute.[49]

Other possible causative mechanisms include differences in serotonin and cerebullar function.[50][51]

Some genetic studies point to involvement of neuroligins in AS. Neuroligins are a family of proteins thought to mediate cell-to-cell interactions between neurons. Neuroligins function as ligands for the neurexin family of cell surface receptors. Mutations in two X-linked genes encoding neuroligins NLGN3 and NLGN4 have been reported. These mutations affect cell-adhesion molecules localized at the synapse and suggest that a defect of synaptogenesis may predispose to autism.[52]

Researchers suggest that gene/environment interactions cause some genes to turn on or turn off. This may impact the normal migration and wiring of embryonic brain cells during early development.[9]

Treatment[]

Main article: Autism therapies

Treatment for autism depends on the individual's needs. While autism can't be cured, the right support can improve quality of life.

Treatment could involve:[9]

Behavior therapy[]

The use of applied behavior analysis is controversial. Some researchers and disability activists have raised concerns about a weak evidence base and the potential for significant psychological harm.[53][54][55][56][57]

The TEACCH methodology is rooted in behavior therapy but involves cognitive elements, trying to understand the underlying stressors that cause challenging behavior.[58][59]

Risks[]

Unintended side effects of medication and intervention have largely been ignored in the literature about treatment programs for children or adults,[60] and there are claims that some treatments are not ethical and do more harm than good.[61][62]

Pseudoscientific approaches like chelation, ingesting bleach, and chiropractic treatment are common. Some are simply wastes of money while others may be harmful or lethal.[63][64] Scammers tend to target families of autistic people.

Prognosis[]

While people with AS can learn and grow, especially with the right support, social challenges tend to be lifelong. Many adults with AS are able to work successfully in mainstream jobs, although they may continue to need encouragement and moral support to maintain an independent life.[9]

People with AS are at increased risk for mental health difficulties[1] and suicidal thoughts/behaviors.[65][66] Risk is higher among those who mask their autistic traits.[67][68][69]

Autism acceptance can improve these risk. Experiencing autism acceptance in a supportive environment can improve mental health.[70][71] A study of neurodivergent students found that those who believe in the neurodiversity paradigm have higher self-esteem and career ambitions.[72]

Individuals with AS may make great intellectual contributions: published case reports suggest an association with accomplishments in engineering, computer science, mathematics, and physics. While living in a neurotypical world is challenging, many individuals experience positive outcomes, particularly those who are able to excel in areas less dependent on social interaction, such as mathematics, music, and the sciences.[1]

Social life[]

Autistic people bear the brunt of stress from the double empathy problem. Misunderstood and judged harshly by others, autistic teens and children may not know why other people treat them badly. Bullying victimization is common and people may choose not to support autistic victims. Eventually, they may withdraw[73] or act out.[74]

Autistic adults are often left with little support. They may find that other people, including employers, are less likely to give them a chance.[16] They also may be more vulnerable to poverty and homelessness than the general population, because of their difficulty finding (and keeping) employment, lack of proper education, social differences, and other factors.[75][76] At work and other situations, they may be misunderstood, taken advantage of, underpaid, and/or subject to bullying and harassment.[75] They may not know how to handle these situations.

Loneliness is a common problem.[77] A supportive environment is crucial for wellbeing. Autistic people may also find it helpful to make autistic friends, since they may find it easy to communicate with each other.[20]

On the other hand, many adults with AS do get married,[78] get graduate degrees, gain wealth, and hold jobs.[79] Intense focus and strong logical skills can help them succeed in technical fields. Work related to a special interest may be especially fulfilling. The child obsessed with naval architecture may grow up to be an accomplished shipwright.[80]

Autism research has historically focused on children. More research on adults is needed.[81]

Epidemiology[]

Main article: Frequency of autism
Increase in autism diagnosis

Rising frequency of autism diagnoses

Autism is diagnosed more often than it was in the past. Some or all of this may be due to better recognition of the condition. Common theories include:

  • Autism rates are constant. The reported rise is due to better recognition of autistic people.
  • Intelligent parents are more likely to have autistic children.[82] If more intelligent people produce offspring together, then more autistic children would be born.
  • Some environmental factor (e.g. pollution, diet, or societal changes) is making more fetuses autistic.
  • Autism is being over-diagnosed. People who would have been labeled as quirky or gifted are now receiving autism diagnoses. See clinomorphism for further discussion of this issue.

Researchers are continuing to investigate.

Comorbidities[]

Main article: Conditions comorbid to autism spectrum disorders

Most patients presenting in clinical settings with AS have other comorbid psychiatric disorders.[83] Children are likely to present with attention-deficit hyperactivity disorder (ADHD), while depression is a common diagnosis in adolescents and adults.[83] A study of referred adult patients found that 30% presenting with ADHD were autistic as well.[84]

Children with Asperger's Syndrome are prone to develop mood disorders[85]. Serious eating disorders, such as Anorexia Nervosa can also be associated with this condition. Between 18% and 23% of adolescent girls with anorexia also have signs of autism.[86][87]

Research indicates people with AS may be far more likely to have the associated conditions.[88] People with AS symptoms may frequently be diagnosed with clinical depression, oppositional defiant disorder, antisocial personality disorder, Tourette syndrome, ADHD, general anxiety disorder, bipolar disorder, obsessive compulsive disorder or obsessive-compulsive personality disorder.[89] Dysgraphia, dyspraxia, dyslexia or dyscalculia may also be diagnosed.[90]

The particularly high comorbidity with anxiety often requires special attention. One study reported that about 84 percent of individuals with a Pervasive Developmental Disorder (PDD) also met the criteria to be diagnosed with an anxiety disorder.[91] Social difficulties, mistreatment, need for routine, and other issues may contribute to anxiety. This can negatively affect multiple areas of one's life, including school, family, and work. Treatment of anxiety disorders can be handled in a number of ways, such as through medication or individual and group cognitive behavioral therapy, where relaxation or distraction-type activities may be used along with other techniques in order to diffuse the feelings of anxiety.[92]

Non-clinical perspective[]

Some professionals contend that, far from being a disease, AS is simply the pathologizing of neurodiversity that should be celebrated, understood and accommodated instead of treated or cured.[42]

Others relate AS to the concept of personality originated by psychiatrist Carl Jung[How to reference and link to summary or text] and extended by Myers and Briggs[How to reference and link to summary or text]. MacKenzie identified ISTJ as the most likely type to exhibit autistic-like behaviors.[93] Duke pointed out similarities between the I and J preferences and ASD, but specifically excluded the whole type ISTJ,[94] while Chester asserted that, "In terms of function pairs, NT is more likely than ST to be seen as having Asperger's Disorder," He also said, "For whole types, I_TPs appear to be at a greater risk of being diagnosed with Asperger's Disorder than any other type, especially as children."[95]

Shift in view[]

Main article: Neurodiversity paradigm

Autistic people have contributed to a shift in perception of autism spectrum disorders as complex syndromes rather than diseases that must be cured.[96] Proponents of this view reject the notion that there is an 'ideal' brain configuration and that any deviation from the norm is pathological. They demand tolerance for what they call their neurodiversity in much the same way physically handicapped people have demanded tolerance.[97] These views are the basis for the autistic rights and autistic pride movements.[98] Researcher Simon Baron-Cohen has argued that autism can be a "difference" and is not necessarily a "disability."[99] He contends that the term "difference" is more neutral, and that this small shift in a term could mean the difference between a diagnosis of AS being received as a family tragedy, or as interesting information, such as learning that a child is left-handed.

Autistic culture[]

Main article: Autistic culture
Autistic Culture 1

Autistic culture illustrated by autistic artist Luna Rose

With improvements in autism recognition and the rise of the internet, an autistic culture has begun to develop. Similar to Deaf culture, autistic culture is based in a belief that autism is a unique way of being and not a disorder to be cured. There are some commonalities which are specific to autism in general as a culture, not just "autistic culture".

Some autistic people fall in love and marry. They are more likely to marry other autistic or neurodivergent people. Multigenerational autistic families are fairly common.

The autism rights movement is a key aspect of autistic culture. Many autistic advocates advocate against the abuse and mistreatment of autistic people. They argue that harmless forms of self-expression and self-soothing, such as special interests and non-destructive stimming, should be accepted instead of punished.

Autistic culture has some parallels to geek and nerd culture.

See also[]

  • Groups

References[]

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Further reading[]

  • Attwood, T. (2006). The complete guide to Asperger’s syndrome. London: Jessica Kingsley.
  • Ehlers, S. & Gillberg, C. (1993) The epidemiology of Asperger’s syndrome: A total population study. Journal of Child Psychology and Psychiatry, 34, 1327–1350.

Gillberg, C. (2002). A guide to Asperger’s syndrome. Cambridge: Cambridge University Press. Hall, K. (2001). Asperger’s syndrome, the Universe and everything. London: Jessica Kingsley.

  • Klin, A., Volkmar, F. & Sparrow, S. (2000). Asperger’s syndrome. New York: Guilford.

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