Research in Autism Spectrum Disorders 2 (2008) 237248

http://ees.elsevier.com/RASD/default.asp

Strategies for assessing Aspergers syndrome:

A critical review of data based methods
Johnny L. Matson *, Jessica A. Boisjoli
Department of Psychology, Louisiana State University, Baton Rouge, LA 70806, United States

Abstract
Aspergers syndrome has gained tremendous recognition and popularity in the last 20 years. However,
controversy around the nature of the disorder, whether it is distinct from high functioning autism, and
whether it can be reliably and validly diagnosed has continued throughout this period unabated. Fortunately,
there has been a strong tradition of developing systematic data based methods of differential diagnosis in the
autism spectrum disorders. The bulk of the effort has been in autism, but there has been moderate, yet
consistent efforts to develop data based methods to diagnose Aspergers syndrome as well. The present
paper provides an up to date critical review of the existing literature on the topic. Strengths, weaknesses of
the research, and avenues for future efforts are discussed.
# 2007 Published by Elsevier Ltd.
Keywords: Aspergers syndrome; Assessment; Children; Data based

Aspergers syndrome (AS), first described in 1944 (Asperger, 1944), was little known in the
English speaking countries until the paper of Wing in 1981. Her use of the term Aspergers
syndrome was used to heighten awareness about this particular type of autism spectrum disorder
(ASD; Frith, 2004). Since that time, the disorder has become one of the most written about disorders
in mental health, with over 1000 papers published on the topic (Matson, Rojahn, & Wilkins, 2007).
Despite that, controversy still centers around whether this disorder exists as a distinct entity or might
be better subsumed under autism, using the term high functioning autism (HFA; Howlin, 2003;
Howlin & Asgharian, 1999; Schopler, Mesibov, & Kunce, 1998; Willemsen-Swimkels & Buitelaar,
2002). Leekam, Libby, Wing, Gould, and Gillberg (2000), for example, question the value of an AS
diagnosis and posit the notion that a dimensional versus a categorical approach to classification
might be more appropriate. Thus, the primary issue is not whether AS individuals meet criteria for
ASD, but rather whether there should be a separate category in ASD for AS. The primary argument

* Corresponding author. Tel.: +1 225 578 4104; fax: +1 225 578 4125.
E-mail address: johnmatson@aol.com (J.L. Matson).
1750-9467/$ see front matter # 2007 Published by Elsevier Ltd.
doi:10.1016/j.rasd.2007.06.003

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for a categorical approach, and it is a very powerful one, is the historical movement of dichotomous
groupings that has dominated the field of differential diagnosis. However, a major shift to spectrums
in DSM-V may add considerable momentum to the spectrum model. Efforts appear to be underway
to sort this out, but this goal can only be achieved through rigorous empirical study of these
diagnostic issues (Matson & Minshawi, 2006).
Fortunately, the field of ASD has had a tradition of developing diagnostic measures to assist in
differential diagnosis and for measuring treatment outcome (Matson, 2007a,b; Matson, NebelSchwalm, & Matson, 2007). Thus, while clinical judgements are still emphasized as the gold
standard for differential diagnosis of ASD, quantitative tests are typically employed along with
clinical assessment to provide objective evidence methods of differential diagnosis
(McConachie, LeConteur, & Honey, 2005). Developing quantitative methods to establish a
diagnosis among the five ASD of autism, Aspergers Syndrome, PDD-NOS, Retts Syndrome,
and Childhood Disintegrative Disorder would seem to be needed most for AS at this time. We say
this given the controversies surrounding the nosology and diagnosis of the condition, the
differences in prognosis, types of interventions, and tremendous life long cost of providing
adequate care that is evident with the AS group (Jarbrink, McCrone, Fombonne, Zanden, &
Knapp, 2007). The development of qualitative methods would seem to be particularly salient for
not only diagnosing but for better defining AS in the context of other ASD. These concerns are
further underscored by recent research on the significant difficulties parents encounter in
obtaining a relevant diagnosis. Siklos and Kerns (2007), for example report that the average
parent needed 3 years and saw an average of 4.5 professionals before a relevant diagnosis could
be obtained. Thus, adequate scale development might further aid in the diagnostic process by
serving as a needed aid to educate clinicians about what symptoms do and do not constitute AS.
Finally, better delineated scaling methods and diagnostic precision should prove valuable as a
shorthand concerning what symptoms and challenging behaviors to expect, as well as to assist in
the linkage of assessment to specific treatment methods (Crocket, Fleming, Doepke, & Stevens,
2007; Dominick, Davis, Lainhart, Tager-Flusberg, & Folstein, 2007; Hill & Furniss, 2006).
1. Scales
1.1. Tests for Aspergers syndrome
The number of scales which have been used to evaluate AS is remarkable when put into the
context of the size of the assessment literature as a whole. By this, we mean that there are a
substantial number of scales, but none have been well developed empirically at this point. Typically
13 studies have been published on a given measure. Many of these tests are designed specifically to
look at the core symptoms of the disorder, but other measures are employed to look at ancillary but
related issues such as I.Q. For conveniences and ease of review, we have grouped these measures
into four general categories (see Table 1). These groups of tests are designated core symptoms,
measures of intelligence, tests of social and neuropsychological problems, and tests for comorbid
psychopathology and challenging behaviors. We have selected these categories based on the fact
that they are representative of the current published literature on the topic.
1.2. Measures of core symptoms
What would appear to be a straightforward issue, the development of Aspergers scales to
measure the disorder in fact becomes considerably more complicated when the literature is

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239

Table 1
Measures used in Asperger assessment research
Measures of core symptoms

Measures of autism
Autism Diagnostic Interview
(ADI; LeCouteur,
Rutter, Lord, & Rios, 1989)

Autism Diagnostic InterviewRevised (ADI-R; Lord,

Rutter, & LeCouteur, 1994)

Autism Diagnostic Observation

Schedule-Generic (ADOS-G;
Lord, Rutter, DiLavore,
& Risi, 2000)
Autism Spectrum Quotient
(AQ; Baron-Cohen,
Wheelwright, Skinner,
Martin, & Clubley, 2001)
Autism Spectrum Screening
Questionnaire (ASSQ; Ehlers,
Gillberg, & Wing, 1999)

CARS-TV (Kurita, Miyake,

& Katsuno, 1989)

Measures of Asperger syndrome

Adult Asperger Assessment
(AAA; Baron-Cohen,
Wheelwright, Robinson,
& Woodbury-Smith, 2005)
Asperger Syndrome Diagnostic
Interview (ASDI; Gillberg,
Gillberg, Rastam,
& Wentz, 2001)

Measures of
intelligence

Social and
neuropsychological
problems

Measures of comorbid
psychopathology and
challenging behaviors

Stanford Binet Fourth

Edition (SB-IV;
Thorndike, Hagen,
& Sattler, 1986)

Cambridge
Neuropsychological Test
Automated Battery
(CANYAB; Robbins
et al., 1994)
Clinical Evaluation of
Language FundamentalsThird Edition (CELF-III;
Semel et al., 1995)

DSM-IV (APA, 1994)

Clinical Evaluation of
Language Fundamentals
(Semel et al., 2003)

Repetitive Behavior
Questionnaire
(Turner, 1997)

Diagnostic Interview
of Social and
Communication Disorders
(DISCO; Leekam, Libby,
Wing, Gould, & Taylor, 2002)
Empathic Accuracy
Task (Ickes, 1997;
Ponnet et al., 2004)

Beck Depression
Inventory (Beck,
Steer, & Gorbin, 1988)

Wechsler Adult
Intelligence Scale
for Children- Third
Edition (WISC-III;
Psychological
Corporation, 1986)
Wechsler Adult
Intelligence
Scale-Revised
(WAIS; Psychological
Corporation, 1986)
Leiter International
Performance Scale
(Levine, 1983)

Test of Nonverbal
Intelligence
(Brown et al., 1990)

FMRI (Herrinton
et al., 2007)
Matson Evaluation of
Social Skills with
Youngsters (MESSY;
Matson, Rotatori,
& Helsel, 1983)
Social Skills Rating Scale
(SSRS; Gresham &
Elliott, 1990)

ICD-10 (WHO, 1992)

Isle of Wight
Semistructured
Informant and Child
Interview (IOWI;
Green et al., 2000)
Isle of Wight Subject
Interview (IOWS;
Green et al., 2000)

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Table 1 (Continued )
Measures of core symptoms

Measures of
intelligence

Social and
neuropsychological
problems

Measures of comorbid
psychopathology and
challenging behaviors

Asperger Syndrome Diagnostic

Scale (ASDS; Boggs, Gross,
& Gohm, 2006; Myles,
Bock, & Simpson, 2001)
Australian Scale for Asperger
Syndrome (Garnett &
Attwood, 1995; Melfesen,
Walitza, Attwood, &
Warneke, 2005)
Childhood Asperger Syndrome
Test (Scott, Baron-Cohen,
Bolton, & Brayne, 2002)
Die Marburger Beurteilungsskala
zum Asperger Syndrome
(MBAS; Kamp-Becker,
Mattejat, Wolf-Ostermann,
& Remschmidt, 2005)
Gilliam Aspergers Disorder
Scale (GADS; Gilliam, 2001)
Screening Questionnaire
for Asperger Syndrome
and other high Functioning
Autism Spectrum Disorders
in school age children
(ASSQ; Ehlers et al., 1999)
Measures of multiple conditions on the autism spectrum
Autism Spectrum
Disorders-DC
(Matson & Gonzalez, 2007)
Behavior Flexibility Rating
Scale (BFRS;
Green et al., 2006)
Pervasive Developmental
Disorders Questionnaire
(PDD-Q; Baron-Cohen
et al., 1996)
Diagnostic Systems
DSM-IV (APA, 1994)
ICD-10 (WHO, 1992)

consulted. The sheer number of measures used to diagnose core symptoms is daunting and
requires a bit of organizing. A list of the scales found in the published literature to diagnose core
symptoms of AS are presented in Table 1. Furthermore, nowhere is the problem underscored
more than by the absence of direct comparisons of various Aspergers scales to determine their
accuracy and overall utility in differential diagnosis relative to each other.
The reader will note that 5 tests used in studies to diagnose AS are measures of autism only, 5
scales have been published that are specifically designed for the diagnosis of AS, only 3 instruments
measure more than one disorder under the spectrum, and two major diagnostic systems are used, in

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241

effect, as scaling methods, DSM-IVand ICD-10. Thus, scales to date appear to be designed largely
on the dichotomy model; they measure one ASD versus the spectrum model where multiple ASD
could be evaluated along a continuum. The reasons for these general approaches to the diagnosis of
AS appear to have strong historical roots which have produced a considerable, and apparently, a
difficult to change momentum in the current use patterns of scales for differential diagnosis.
1.2.1. General comments on scaling methods
A number of the major autism diagnostic methods have been applied to diagnosing AS. This
model parallels the approach taken to diagnose PDD-NOS. Thus, the AS diagnosis is made based
on the fact that the child does not meet criteria for autism. After this first step, clinical
judgement and additional modified symptoms which are deemed characteristic of AS are added
to arrive at the relevant diagnosis. This approach not only reflects limits in scale development but
also dissatisfaction with DSM-IV and ICD-10 criteria as written. Scales used in this manner have
included the Autism Diagnostic Interview, Autism Diagnostic Interview- Revised, the Autism
Diagnostic Observation Schedule-Generic, and the CARS-TV. The premise of working from the
most reliable, valid, and most heavily researched scales in the ASD spectrum, measures of
autism, helps establish that the identified AS cases are not in fact autistic and is a diagnostic
model previously used with PDD-NOS as well (Matson & Boisjoli, 2007). However, not
specifically measuring AS also presents its own set of challenges.
A second set of measures has been designed to specifically measure AS. However, they were
not designed to allow for the differentiation of AS from other ASD which is particularly
interesting since there is so much debate in the literature about differentiating between AS and
HFA. These scales are of considerable value because they allow for opportunities to more
precisely measure AS symptoms, how they vary between cases, and what symptoms appear to be
most salient for diagnosis. Scales that fit this description include the Adult Asperger Assessment,
Asperger Syndrome Diagnostic Interview, Australian Scale for Asperger Syndrome, and
Childhood Asperger Syndrome Test. The biggest issue at this point with respect to all of these
measures is that initial development has not been followed by continued research to expand and
refine the various scales applicability. Furthermore, no direct comparisons between the various
scales has been made to determine if they are measuring the same construct, nor have they been
used in conjunction with other tests of ASD. For example, one interesting approach would be to
use established autism and AS scales in the same study with persons diagnosed with both
conditions included as participants to determine if these scales could accurately differentiate a
person in the AS and autism cohorts. Studies of this type are urgently needed.
A third approach to the diagnostic questions surrounding AS has been approached with three
scales that are designed specifically to measure multiple ASD, and to allow for the differentiation of
these various subcategories or disorders. This approach may prove to be particularly useful for
differentiating between the various ASD, since symptom presentation is developed on a continuum,
allowing the researcher to identify demarcating points between groups based on symptom
presentation. The Autism Spectrum Disorders-Diagnosis for Children (ASD-DC) is one such
instrument. A second measure which has considerable promise is the Behavior Flexibility Rating
Scale (BFRS) which was tested on 968 persons with autism, AS, or Down Syndrome (Pituch et al.,
2007). This scale fills a large gap in the literature with respect to core features of resistance to change
and insistence on sameness. They found distinct differences between the autism and AS groups with
the latter scoring particularly high relative to autism on interpersonal mishaps.
To date, several avenues for objectively diagnosing AS have been developed. This trend is
encouraging, and at present reasonably reliable parameters for ASD versus no ASD have been

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established. However, considerably more research is needed to establish the parameters of the
various disorders within ASD. Particularly, emphasis on distinguishing between PDD-NOS, AS,
and autism would seem to be a potential priority topic, given that these are the high frequency
ASD, and are the particular categories with the greatest potential for existing on a continuum.
1.3. Measures of intelligence and academic performance
Several researchers have reported on the use of individually administered I.Q. tests in the
diagnosis of AS. Thus, it has been reported in a few papers that AS can occur in persons with
borderline or mild intellectual disability (Strum, Fernell, & Gillberg, 2004), but the unspoken
rule for most researchers appears to be that below normal I.Q. is a rule out (e.g. Klin, Pauls,
Schultz, & Volkmar, 2005; Ozonoff, South, & Miller, 2000). In fact, the primary use of I.Q.
measures has been as a method of including or excluding people from Aspergers groups in
nosological and treatment studies. However, intelligence tests have been used in some few
instances to help further describe symptom patterns of those who evince the disorder. For
example, looking at subdomains of intellectual functioning appears to be useful in sorting out
people who have an ASD versus those who do not. However, these data do not seem to show
differential patterns of responding between AS and other ASD. The flip side of the coin is that
these common features help build an argument for the notion of a spectrum of differing disorders,
which nonetheless have many overlapping features.
1.4. Social and neuropsychological problems
In the research literature, alternating terms are used to describe a group of tests that address
language, social interaction, and perspective taking which are common core deficits in ASD
(Lee, David, Rusyniak, Landa, & Newschaffer, 2007; Matson & Wilkins, 2007). Social and
neuropsychological tend to be among the most common labels, thus the reason for the current
heading. Sanders, Johnson, Garavan, Gill, and Gallager (2007) provide a critical review of
neuropsychological and neuroimaging research as it applies to attention, inhibition, and
cognitive flexibility in the ASD population. Their review notes that ASD does have some striking
differences from the regularly developing population.
One example of these tests is described by Ponnet, Roeyers, Burysse, De Clercq, and Van der
Heyden (2004). They discuss a task labelled emphatic accuracy as a method of differentiating
between an AS group and typically developing individuals. This test was designed as a form of
perspective taking, where the individual tested attempted to discern thoughts and feelings of
another in a particular context. Another interesting study designed to differentiate AS and HFA
was by Lewis, Murdoch, and Woodyatt (2007). They looked at linguistic performance on the
Clinical Evaluation of Language Fundamentals-Fourth Edition (CELF-4; Semel, Wiig, &
Second, 2003) and the Test of Nonverbal Intelligence-Second Edition (Toni-2; Brown,
Sherbenou, & Johnson, 1990). They found that the children with ASD could be distinguished
from their normally developing peers, but not between AS and HFA. However, grouping was
done using DSM-IV criteria, which as we have noted, has been problematic and could have
effected accurate grouping. The 2 measures used in their study covered core linguistic issues, but
certainly not all potential language problems. Having stated this, it would seem only natural that
some skills will differentiate AS and HFA from each other, while other behaviors will not, even
assuming a true diagnostic distinction exists between AS and HFA. An alternate interpretation is

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243

that the data support a dimensional versus dichotomous view of ASD; a point made by a number
of researchers (e.g., Howlin, 2003; Howlin & Asgharian, 1999).
1.5. Measures of comorbid psychopathology and challenging behaviors
While a bit sparse at this point, some research has been conducted on the potential for comorbid
psychopathology and challenging behaviors in persons with ASD in general and Aspergers
syndrome in particular (LaMalfa et al., 2007; MacDonald et al., 2007; Matson & Minshawi, 2007;
Matson & Nebel-Schwalm, 2007). Green, Gilchrist, Burton, and Cox (2000), for example studied
20 boys with Asperger syndrome ages 1119 and compared them to 20 children and adolescents
with conduct disorder. High levels of anxiety and obsessive compulsive behavior relative to the
conduct disorder group were reported, and they noted that both groups had high rates of depression
and suicidal ideation. These data appear to support the notion that AS is a risk factor for mental
heath conditions. However, this area has received almost no empirical study to this point and no
scales of comorbid psychopathology for AS, or AS norms on existing childhood psychopathology
scales have been published to date. The recent recognition of AS for research attention and the
observation that comorbid psychopathologies can be present in ASD versus being part of the ASD
core symptoms are likely major reasons for this state of affairs. Nonetheless, it would appear that the
time has come for the introduction of comorbid psychopathology research with AS. Most likely,
researchers will show that particular forms of psychopathology are likely to be present in this group.
Such knowledge would be of considerable value in better pairing assessment and treatment and may
prove valuable in giving insights as to the causes of ASD.
1.5.1. Autism scales and diagnostic systems
Table 2 presents some eye opening diagnostic practices for AS, from our perspective at least.
We say this because there is an almost total disconnect between scale development for AS and the
Table 2
Assessment methods used in selected studies of Aspergers syndrome
Gilchrist et al. (2001)
Green et al. (2000)
Herrinton et al. (2007)
Klin, Volkmar, Sparrow, Cicchetti, and Rourke (1995)
Klin et al. (2005)

Koyama, Tachimori, Osada, Takeda, and Kurita (2007)

Lewis et al. (2007)
Ozonoff et al. (2000)

Ozonoff, Rogers, & Pennington (1991)

Rondan and Deruelle (2007)
Strum et al. (2004)
Szatmari, Archer, Fisman, Streiner, & Wilson (1995)

Szatmari et al. (2000)

WISC-R or WAIS-R, ICD-10 criteria

ICD-10, WISC, WAIS, IOWI, IOWS
ICD-10 and DSM-IV criteria
I.Q. test, 2 independent clinicians, ICD-10 criteria
WISC-III or WAIS-III, ADI-R, ADOS, K-SADS,
SCID, DSM-IV, Klin et al., criteria, Speech
Delays System
WISC-III, DSM-IV and ICD-10, CARS-TV
DSM-IV
WISC-III, ADI-R, ADOS-G. CELF-III, CANTAB,
SSRS, Repetitive Behavior Questionnaire, School
Intervention Checklist
Modified ICD-10
WISC-III, DSM-IV, ASSQ
WISC-III, CHAT Review with ICD-10
Leiter or Stanford-Binet, ADI, ICD-10 and DSM-IV
criteria, VABS, Reynell Developmental Language
Scales, Test of Language Development-2, Grammatical
Completion Test, Beery Visual-Motor Integration Test,
Symbolic Play Test-Second-Edition
Leiter or Stanford Binet- 4th ed., ADI

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measures researchers use to diagnose Aspergers for treatment and nosology studies. Ironically,
autism scales and the ICD-10 and DSM-IV have been and continue to be the preferred method of
differential diagnosis of AS in the research literature. This finding is particularly interesting in
light of the frequent comments that the symptoms presented in these manuals are inadequate to
reliably differentiate AS and HFA in particular while at the same time multiple additional
symptoms that distinguish the groups are being reported in the literature (Matson et al., 2007b).
The reader will note that most of these papers we have cited were published after the AS scales
were introduced and the bulk of the nosology papers presenting differences on AS and HFA were
published. Thus, the introduction of scales specific to AS and related nosological studies have
had little impact to date on the diagnosis of AS; in studies on the topic. It would be interesting to
know if these AS scales have had an impact on the actual diagnosis of AS in clinical practice. At
present the answer to this question is unknown. However, if clinical practice mirrors the research
literature, then scale development in AS has a long way to go to win over what apparently is a
sceptical audience.
2. General discussion
While debate continues, a summary statement for AS might be that most researchers consider
the disorder distinct from HFA despite the fact that the general core areas of dysfunction such as
perception, stereotypies, affect, and social skills are present in both (Balconi & Carrera, 2007;
Chung et al., 2007; Hilton, Graver, & La Vesser, 2007; Ingersoll & Gergans, 2007). Additionally,
however, the majority view also seems to be that DSM-IV and ICD-10 do not provide sufficient
detail and clarity to make reliable and valid distinctions between these two ASD on a consistent
basis, although researchers continue to use these symptoms as the primary method for
differentially diagnosing AS. This problem is compounded by the fact that measures used to
distinguish HFA from AS typically measure only autism or AS thus clinicians and researchers
must wing it to a certain extent when diagnosing AS from HFA. Scales would seem to be
needed that measure both ASD as a means of adding standardization and objectivity in diagnosis.
This approach would allow for the distinction to be better made between symptoms that represent
AS and those which characterize HFA. It appears at present that the literature has outpaced
thinking about scaling methods. Tests are generally designed to distinguish autism or AS from
the general population of individuals. However, a primary need relative to HFA and AS is scales
that differentiate between these two ASD. Thus, the literature appears to support the notion that
ASD can be reliably identified from the general population with existing measures but HFA and
AS are still hard to differentiate from each other.
The development of scaling methods that make the HFA and AS distinction requires more
fine-grained symptom descriptions, since as noted the same general core deficit areas are
present in both groups. A number of nosology papers appear to be providing some of this detail
with a substantial number of papers providing a large number of discrete symptoms where the
two groups do differ (Matson et al., 2007b). The refrain that more research is needed is common
in the ASD field in general, but nowhere is this point more relevant than for scale development as
a means of differential diagnosis of AS from HFA. However, we are very positive regarding
developing trends in differential diagnosis of ASD. Scales are proliferating which signifies the
important point that researchers in the field accept the notion that objective scaling methods
versus clinical interviews alone, projective tests or other less than reliable methods should be
paramount. In areas of mental health diagnosis, those latter views still hold sway to a large
degree. Thus, the ASD diagnostic literature is cutting edge relative to most other areas of

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differential diagnosis. Having a large number of measures is welcome since this demonstrates
that a considerable number of research teams are in the hunt to develop reliable and valid
diagnostic instruments which can also be used to help define types of ASD along the way. Time
and persistence will result in a shaking out of those testing methods which will have staying
power versus scales or symptoms which fall by the wayside. Traditionally, this factor is decided
by which research teams continue to publish and in the process further refine diagnostic methods
as the field of knowledge advances.
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