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Asperger Syndrome From Childhood Into Adulthood

Asperger Syndrome From Childhood Into Adulthood

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 Asperger syndrome from childhood into adulthood 
341
 Advances in Psychiatric Treatment 
(2004), vol. 10. http://apt.rcpsych.org/ 
 
 Advances in Psychiatric Treatment (2004), vol. 10, 341–351
This article is the second in the series entitled ‘Life-span psychiatry’,which considers the developmental psychiatry of adulthood. The first article (Zwi & York, 2004; Invited commentaries: Asherson,2004; Coghill, 2004, this issue) looked at attention-deficit hyperactivity disorder. Subsequent topics will include earlydevelopmental aspects of psychopathy and psychosis, and trainingimplications.
Asperger syndrome comes not only with its owncharacteristics (Box 1), but also with a wide varietyof comorbid conditions such as depression, anxiety,obsessive–compulsive disorder, attention-deficithyperactivity disorder (ADHD) and alcoholism, andrelationship difficulties (including family/maritalproblems) (Tantam, 2003). It may predisposeindividuals to commit offences and can affect theirmental capacity and level of responsibility as wellas their ability to bear witness or to be tried. Thesyndrome can colour psychiatric disorder, affectingboth presentation and management, for children andadults across a wide range of functional ability.Families have taken an active legalistic approach,alleging misdiagnosis and mistreatment anddemanding clarity as to the relationship betweenAsperger syndrome and other diagnostic concepts.Seeking to describe the nub of this syndrome,Asperger coined the term ‘autistic psychopathy’ in1944 to distinguish its innate social distance fromthat which develops later in schizophrenia; theconcept was elaborated by van Kraevelen in 1963,Lorna Wing in 1981 and, most recently, ChristopherGillberg (Gillberg, 1998). There have been differentinterpretations of the syndrome and it has becomeincluded in the group of autistic-spectrum disorders.This review focuses primarily on clinical issues:more academic aspects have been reviewed byVolkmar
et al
(2004).
Diagnostic classification
As in autism, Asperger syndrome shows impairedreciprocal social interaction and restricted, repetitiveor stereotyped patterns of behaviour, interests andactivities. Unlike autism, intellectual ability andsyntactical speech are normal. Wing and Gillbergplace the emphasis on current presentation of normal IQ and speech, but ICD–10 and DSM–IVrequire their presence from early life. The latterpresentation is unusual but was stipulated in orderto define a disorder that would be an alternative toautism (rather than just a variant or subtype). It isdebatable whether many of the cases described byAsperger would have met ICD or DSM criteria.Gillberg and colleagues proposed a set of disgnostic criteria that approximate to Asperger’soriginal clinical descriptions (Leekam
et al
, 2000).Various symptoms have been suggested asdistinguishing Asperger syndrome from ‘high-functioning autism’ (i.e. autism without generalisedlearning disability) and the issue is clouded by thevariety of definitions in use. When allowance is madefor ability, there appears to be little real differencebetween the two except in terms of severity (Kugler,1998; Gilchrist
et al
, 2001; Howlin, 2003) althoughself-awareness remains to be explored (Tantam,2003).
Asperger syndrome from childhoodinto adulthood
Tom Berney
Tom Berney is a consultant in developmental psychiatry with the Northgate & Prudhoe NHS Trust (Prudhoe Hospital,Prudhoe, Northumberland NE42 5NT, UK. E-mail: t.p.berney@ncl.ac.uk) and at the Fleming Nuffield Child Psychiatry Unit,Newcastle upon Tyne. He is also honorary consultant to European Services for People with Autism, a registered charity thatprovides community services.
Abstract
Asperger syndrome, a form of autism with normal ability and normal syntactical speech, is associatedwith a variety of comorbid psychiatric disorders. The disorder is well known to child psychiatry, andwe are beginning to recognise the extent of its impact in adulthood. The article reviews the diagnosisand assessment of Asperger syndrome and its links with a wide range of psychiatric issues, includingmental disorder, offending and mental capacity. It also describes the broader, non-psychiatricmanagement of Asperger syndrome itself, which includes social and occupational support andeducation, before touching on the implications the disorder has for our services.
 
342
 Advances in Psychiatric Treatment 
(2004), vol. 10. http://apt.rcpsych.org/ 
 Berney
Is the label useful?
Autistic-spectrum disorders comprise a group of disorders of varied form and intensity that fall on adimensional spectrum of severity that shades into
neurotypical normality
(i.e. the absence of an autistic-spectrum disorder). In clear-cut cases (exemplifiedby Dustin Hoffman
s character in the film
 Rain Man
)individuals are helped by a categorical approachthat gives a shorthand explanation of theirdifficulties. The validity of categorisation is less clearfor those whose milder symptoms put them near the
normality
end of the spectrum as well as for thosewhose florid symptomatology is limited to only someof the key diagnostic areas. Even less clear is theposition of individuals who, appearing to besuperficially normal, have some of the subtle butdisabling psychological deficits associated withautism, affecting executive function, attention,perception and comprehension. Closer examinationoften reveals a mix of specific developmentaldisabilities which, should they include languageand social impairment, it is tempting to classifyunder autistic-spectrum disorder, sweeping in manyeccentric and isolated personalities.This desire to place all socially impaired patientssomewhere on the autistic spectrum is offset byefforts to split off syndromes such as pathologicaldemand avoidance (Newson
et al
, 2003) andsemantic pragmatic (Bishop & Norbury, 2002) ormultiplex developmental disorders (Towbin
et al
,1993). Complicated by synonyms such as right-hemisphere or non-verbal learning disorders(Fitzgerald, 1999), the result is a confusing groupingof specific disabilities on which we impose recognis-able constellations of clinical disorder (Willemsen-Swinkels & Buitelaar, 2002).Where should we set the boundaries of a dimen-sional disorder? As with the personality disorders,there needs to be a diagnostic threshold: it might bethe point at which the behaviour causes distress(either to the patient or to those around) or significantproblems in social functioning and performance, orat which it requires treatment. But can we fix athreshold in this way? The label of Aspergersyndrome may help the bullied schoolboy but berejected when he becomes a mathematical starenjoying university: a functional distinction of permanent traits from a disorder that depends onthe setting as much as the innate characteristics.That the presence of an autistic-spectrum disordermay make it difficult for the individual to acknowl-edge his disability complicates this concept.Autism used to be considered a rare disorder witha population prevalence of about 0.04%, of whom70
80% had a significant learning disability. Morerecently, the extended spectrum of autistic disordergives a population prevalence of at least 0.6%, of whom 70
90% are of normal learning ability. So far,the evidence is that this shift can be explained by
Box 1Characteristics of Asperger syndrome in adulthood
Childhood onsetLimited social relationships
social isolation
Few/no sustained relationships; relationships that vary from too distant to too intense
Awkward interaction with peers
Unusual egocentricity, with little concern for others or awareness of their viewpoint; little empathy orsensitivity
Lack of awareness of social rules; social blundersProblems in communication
An odd voice, monotonous, perhaps at an unusual volume
Talking
at
(rather than
to
) others, with little concern about their response
Superficially good language but too formal/stilted/pedantic; difficulty in catching any meaningother than the literal
Lack of non-verbal communicative behaviour: a wooden, impassive appearance with few gestures;a poorly coordinated gaze that may avoid the other
s eyes or look through them
An awkward or odd posture and body languageAbsorbing and narrow interests
Obsessively pursued interests
Very circumscribed interests that contribute little to a wider life, e.g. collecting facts and figures of little practical or social value
Unusual routines or rituals; change is often upsetting(After Gillberg
et al
, 2001)
 
 Asperger syndrome from childhood into adulthood 
343
 Advances in Psychiatric Treatment 
(2004), vol. 10. http://apt.rcpsych.org/ changing concepts and diagnostic boundaries aswell as by the wider recognition of autistic-spectrumdisorders rather than by any real substantialincrease (Fombonne, 2003).As the developmental model embraces moreof psychiatry, it appears increasingly difficult tomake a sharp distinction between autistic-spectrum disorder and other entities such as thepersonality disorders, simple schizophrenia andcatatonia; at times the diagnostic label reflects theclinician
s specialty rather than the syndrome.
How does Asperger syndromechange with age?
Like many other developmental disorders, autistic-spectrum disorders improve with age, although thesymptoms, such as stereotypies, may resurface witharousal, whether from anxiety, boredom, anger orexcitement. However, while the more overt symptomsof autism are usually at their most florid in earlychildhood, the symptoms of Asperger syndrome mayonly become obvious with the social and functionaldemands of adolescence.Besides an innate link with varied comorbidity,there is the stress of growing up with Aspergersyndrome that arises from unrecognised disability,limited achievement and a sense of failure, oftenrevealed by an increasing contrast with moreautonomous and successful siblings or peers. Inaddition, the syndrome distorts relationships withfamily and peers, who can be infuriated by theperson
s self-centred insensitivity, obsessivenessand rigid inflexibility. All this can add secondarydisability and result in a degree of dependency thatis out of proportion to the person
s intellectualability (Howlin
et al
, 2004).Over a third of people with autistic-spectrumdisorders develop epilepsy, the risk being linked tothe degree of developmental delay and receptivelanguage deficit. There is no specific study of epilepsy in Asperger syndrome, although therelatively normal ability and language suggest thatthe risk is lower, possibly 5
10%, and that it is morelikely to start later, in adolescence or early adulthood(Tuchman & Rapin, 2002).
The presentation in adulthood
Asperger syndrome in adults presents withparticular, and often subtle, difficulties, especiallyin communication, social relationships and interests.Not all individuals are affected as extremely as inthe descriptions below. In some it is questionablewhether they simply fall within the normal range of variation, particularly male, and whether theirbehaviour represents psychiatric disorder orisolated, specific developmental characteristics.
Communication
This is often obviously abnormal,
conversation
taking the form of one-sided, circumstantial lecturesdelivered impassively by a seemingly robotic figurewith a mechanical voice. However, less obviousconversational abnormality includes unrecognised,underlying discrepancies between verbal and non-verbal language, and between comprehension andexpression. These can lead both the affectedindividual and those around him to misjudge hisabilities, expectations being either too high or toolow. Very often, reading works where listening hasbrought incomprehension. Often, the life of someonewith Asperger syndrome can be transformed if asmuch as possible is presented to him in writing.
Social relationships
These are one-sided, distant or even absent, ratherthan really reciprocal. Behind this is an unempathicobjectivity that results in difficulties that range fromunderstanding friendship (and how friends differfrom acquaintances) through to making sexualrelationships and grasping the rules that dis-tinguish, for example, seduction from date rape. Theperson is not uninterested in relationships but,misunderstanding them, is too intense or toodetached.
 Interests
A key feature of Asperger syndrome is repetitive orfocused activities. At their most extreme, these resultin an eccentric whose life is characterised by itsroutine, rigid and systematic approach and whoseworld might narrow down to railway timetables orstamp collecting. Any development of an interestremains circumscribed (for example, restrictedsimply to collecting more of something rather thangaining wider expertise) and, far from becoming thebasis of a social network, is enjoyed in solitude.
Psychiatric diagnosisand assessment
D
iagnosis
on its own is of limited value, but it is thegateway to a great deal of information, specialistgroups and resources, including financial support.It is often not recognised that a diagnosis is simplya working hypothesis: it is a clinical judgement that

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