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Asperger's Disorder

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Asperger’s Disorder vs. Autism - The Great Debate

Sara Kennedy

Penn State College of Medicine

July 2002

I. Pervasive Developmental Disorders (PDDs) (Volkmar, Lord, Klin, and Cook, 2000).

A. Definition: Neuropsychiatric disorders characterized by specific delays and deviance in social, communicative, and cognitive development, with an onset typically in the first years of life.

B. Examples:

1. Autistic Disorder

2. Asperger’s Disorder

3. Childhood Disintegrative Disorder

4. Rett’s Disorder

5. Pervasive Developmental Disorder NOS

II. The origin of Asperger’s Disorder (Mayes, Calhoun, and Crites, 2001).

A. “Autistic Psychopathy in Childhood” by Hans Asperger in 1941 described a “pedantic group of little professors” who displayed:

1. Impairment in social interaction

2. Impairments in communication

3. Restricted, repetitive, and stereotyped patterns of behaviors, interests, and activities

B. Pre-DSM-IV addendums to the definition of Asberger’s Disorder

1. Usually normal IQs and speech milestones

2. Frequcnt gross motor clumsiness

C. DSM-IV Diagnostic Criteria for Asperger’s Disorder

III. Diagnostic Controversy

A. Many clincians disregard the DSM-IV criteria and use definitions of Asperger’s that are influenced by literature or popular beliefs. Various clinical uses of Asperger’s Diagnosis include higher-functioning autism, subthreshold pervasive developmental disorder not otherwise specified, and right-hemisphere learning problems (Mayes, Calhoun, and Crites, 2001).

B. With the DSM-IV, Autism takes precedence over Asperger’s Disorder (Volkmar, Klin, Schultz, Rubin, and Bronen, 2000). Many studies demonstrate that the majority of children with the clinical diagnosis of Asperger’s Disorder also meet the DSM-IV criteria for Autism

C. The DSM-IV includes overlapping diagnostic criteria for Asperger’s Disorder and Autism: DSM-IV criteria for Asperger’s Disorder includes a “lack of social…reciprocity” and “encompassing preoccupation with one or more…restricted interests”. Children with these symptoms will obviously use repetitive language due to their restricted interests and have difficulty maintaining a conversation. If the child also demonstrates social impairment and restricted interests, the child would qualify for a diagnosis of Autism and not Asperger’s (Mayes, Calhoun, and Crites, 2001).

IV. Differences between Asperger’s Disorder, Autism, and PDD NOS: Literature Reviews

A. Conclusions following a clinical case conference at Yale University School of Medicine (Volkmar, Klin, Schultz, Rubin, and Bronen, 2000)

1. Patients with Asperger’s Disorder had higher verbal performance IQs than those with autism and greater social impairment than those with PDD NOS

2. In Asperger’s Disorder, verbal skills are greater than nonverbal skills. In Autism, nonverbal skills are usually greater than verbal skills

3. Though both Asperger’s Disorder and Autism have strong genetic associations, in Asperger’s Disorder, there is a significantly greater incidence of the Disorder in first-degree relatives

4. Different patterns of comorbidity have been suggested: higher levels of psychosis, violent behavior, depression, and bipolar disorder have been implicated with Asperger’s Disorder vs. Autism

5. Because of their excellent verbal skills, a patient with Asperger’s Disorder may be overlooked and their poor social skills and performance on nonverbal tasks attributed to negativism. Increased risk for individuals with Asperger’s Disorder to be labeled as “socially maladjusted” and placed in classes for children with conduct Disorder and other behavioral problems.

6. Treatment for Asperger’s Disorder is best structured using verbally mediated treatment programs, problem-oriented psychotherapy, and counseling, which are usually not indicated in autism

B. Conclusions from “Two-Year Outcome of Preschool Children with Autism or Asperger’s Syndrome” (Szatmari, Bryson, Streiner, Wilson, Archer, and Ryerse, 2000)

1. Objective: To compare the outcomes of groups of children with Asperger’s Disorder and Autism over a period of 2 years and to identify variables that might account for the differences

2. Method: The children (all had IQs in the nonretarded range) were given a battery of cognitive, language, and behavioral tests. Families were contacted 2 years later and many of the tests were readministered.

3. Results:

a. Children with Asperger’s Disorder and children with Autism identified at 4-6 years of age demonstrate differences in social competence and autistic symptoms 2 years later (differences in nonverbal IQ, expressive language, and verbal reasoning were controlled for)

b. Variation in outcome seen in autistic children and those with Asperger’s Disorder are best explained by language fluency, measured by the oral vocabulary test.

c. Large differences existed between the groups with Asperger’s Disorder and Autism on oral vocabulary at both the beginning of the study and at follow-up. Once children with Autism develop a certain level of language fluency, they resemble children with Asperger’s Disorder but at an earlier stage of development

d. OVERALL CONCLUSION: Both Autism and Asperger’s Disorder follow parallel developmental pathways but Autistic children are behind. As defined in DSM-IV, Asperger’s Disorder is so rare as to be virtually useless clinically

C. Conclusions from “Does DSM-IV Asperger’s Disorder Exist?” (Mayes, Calhoun, and Crites, 2001).

1. Objective: To analyze a large sample of children with diagnoses of Autism or Asperger’s Disorder to determine if any of the children met the DSM-IV criteria for Asperger’s Disorder

2. Method: The children were independently evaluated by both a psychologist and a child psychiatrist who were previously unfamiliar with the children’s diagnoses

3. Results:

a. 100% diagnostic agreement between the psychologist and the child psychiatrist that all 157 children met the DSM-IV criteria for Autism and none met the criteria for Asperger’s Disorder

b. All the children had delays or abnormal functioning before age 3 in social interaction, social communication, or imaginative play and all children exhibited six or more of the DSM-IV symptoms required for the diagnosis of Autism.

c. 47 of the 157 children had IQs of 80 or above. Of these, 75% had the DSM-IV criterion of “impairment in the ability to initiate or sustain a conversation” and 96% had the DSM-IV criterion of “stereotyped and repetitive…or idiosyncratic language.” Both symptoms were present in 71% of the children, and either or both present in 100%. The results were the same for the children with IQs below 80

d. OVERALL CONCLUSION: There is no clinically meaningful distinction between Asperger’s Disorder and high-functioning Autism.

D. Summary from Clinical Case Conference at Harvard Medical School (Frazier, Doyle, Chiu, and Coyle, 2002)

1. Asperger’s Disorder is a pervasive developmental disorder on a diagnostic continuum with Autism

2. Asperger’s Disorder is characterized by a lack of empathy, na�ve and inappropriate interactions, a limited ability to form friendships with peers, pedantic and poorly intonated speech, egocentrism, poor nonverbal communication, intense absorption in circumscribed topics, and in some patients, ill-coordinated movements

3. Distinguishing features in Asperger’s Disorder from Autism is the relatively normal speech development, less frequent stereotyped behaviors, and normal intelligence. Average age of diagnosis for patients with Asperger’s is 11 years, compared to 5.5 years in Autism. Asperger’s Disorder occurs in 8.4-10 of 10,0000 children, compared to 2 of 10,0000 children being Autistic.

4. Long-term outcome for patients with Asperger’s Disorder is more favorable than for patients with Autism

5. Comorbidity of Autism Spectrum Disorder and Bipolar Disorder:

a. Children with developmental disabilities have a 2-6 times greater risk of experiencing comorbid psychiatric conditions than their developmentally normal peers.

b. Several studies reveal an association between Asperger’s Disorder and Bipolar Disorder. Greater risk of bipolar Disorder in family members of individuals with Asperger’s Disorder: Relatives of probands with PDDs have a 4.2% prevalence of bipolar disorder (almost 5 times greater than the general population) and the prevalence is highest among relatives of probands with Asperger’s Disorder (6.1% vs. 3.3% for relatives of probands with Autism). Other studies show conflicting evidence with rates of affective disorder in the Autistic Spectrum Disorder similar to the general population

c. Children with Asperger’s Disorder may suffer from mood disorder for years before being recognized because the symptoms of the mood disorder may be masked by the behaviors associated with Asperger’s Disorder (behaviors characteristic of the Autistic Spectrum Disorder such as obsessiveness, hyperactivity, inattention, social intrusiveness, social withdrawal, aggression, and self-injurious behavior may become more pronounced during manic or depressive phases). These changes are usually episodic and occur within the context of the shifting mood state, and are thus responsive to effective treatment of the mood disorder.

Conclusions of this review:

The majority of the research has concluded that the DSM-IV provides inadequate criteria for the clinical diagnosis of Asperger’s Disorder. As it stands currently, there is little clinical usefulness to the Asperger’s Disorder diagnosis. Until the criteria for Autism and Asperger’s Disorder are better delineated, clinicians should focus on the level of language development of children with PDDs in order to best estimate prognosis and treatment.

Table 1. DSM-IV Diagnostic Criteria

Asperger’s Disorder	Autistic Disorder
A. Qualitative impairment in social interaction, as manifested by at least two of the following: 1. marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction 2. failure to develop peer relationships appropriate to developmental level 3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people 4. lack of social or emotional reciprocity	A total of six (or more) items from A, B, and C, with at least two from A, and one each from B and C: A. Qualitative impairment in social interaction, as manifested by at least two of the following: 1. marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction 2. failure to develop peer relationships appropriate to developmental level 3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people 4. lack of social or emotional reciprocity
B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: 1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus 2. apparently inflexible adherence to specific, nonfunctional routines or rituals 3. stereotyped and repetitive motor mannerisms 4. persistent preoccupation with parts of objects	B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: 1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus 2. apparently inflexible adherence to specific, nonfunctional routines or rituals 3. stereotyped and repetitive motor mannerisms 4. persistent preoccupation with parts of objects
C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning	C. Qualitative impairments in communication as manifested by at least one of the following: 1. delay in, or total lack of, the development of spoken language 2. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others 3. stereotyped and repetitive use of language or idiosyncratic language 4. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
	D. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play
	E. The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder

References

1. Volkmar FR, Klin A, Schultz RT, Rubin E, Bronen R: Asperger’s Disorder. American Journal of Psychiatry 2000; 157(2): 262-267.

2. Szatman P, Bryson SE, Striner DL, Wilson F, Archer L, Ryerse C: Two-year Outcome of Preschool Children with Autism or Asperger’s Syndrome. American Journal of Psychiatry 2000; 157(12): 1980-1987.

3. Mayes SD, Calhoun SL, Crites DL: Does DSM-IV Asperger’s Disorder Exist? Journal of Abnormal Child Psychiatry 2001; 29(3): 263-271.

4. Frazier JA, Doyle R, Chiu S, Coyle JT: Treating a Child with Asperger’s Disorder and Comorbid Bipolar Disorder. American Journal of Child Psychiatry 2002; 159(1): 13-21.

5. Volkmar FR, Lord C, Klin A, Cook E: Autism and the Pervasive Developmental Disorders, in Child and Adolescent Psychiatry. Edited by Lewis M. Philadelphia, Lippincott Williams & Wilkins, 2002, pp. 587-595.

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