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Asperger's Disorder Review

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Asperger’s Disorder - Review of Recent Articles

Simret Nanda

Penn State College of Medicine

DSM-IV Diagnostic Criteria

Qualitative impairment in social interaction, as manifested by at least TWO of the following:

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.
Failure to develop peer relationships appropriate to developmental level
A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (lack of showing, bringing, or pointing out objects of interest to other people)
Lack of social or emotional reciprocity

Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least ONE of the following:

encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
apparently inflexible adherence to specific, non-functional routines or rituals
stereotyped and repetitive motor mannerisms (hand or finger flapping or twisting or complex whole-body movements)
persistent preoccupation with parts of objects

The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.

There is no clinically significant general delay in language (single words used by age 2 years, communicative phrases used by age years)

There is no clinically significant delay in cognitive development or in the development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction) and curiosity about the environment in childhood.

Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.

Aspergers’s Disorder

· This disorder falls under the category of Pervasive Developmental Disorders in which Autistic Disorder, Rett’s Disorder, Childhood Disintegrative Disorder and PDD NOS fall under.

· This syndrome was originally described by Hans Asperger in 1944 who provided an account of a number of cases whose clinical features resembled Kanner’s description of autism but it differed in that speech was less commonly delayed, motor deficits were common, onset was later, and all the initial cases were in boys.

· Patients with AD usually engage in a one-sided conversation with long-winded, pedantic speech about a favorite/narrow topic. This symptom may not be easily recognized in childhood but may become more salient later on.

· This behavior may become peculiar in that it often involves extraordinary amounts of factual information about very circumscribed topics (snakes, names of stars, maps, TV guides, or railway schedules)

· AD individuals are usually described as “loners”, but they express a great interest in making friendships and meeting people.

· Chronically frustrated by their repeated failures to engage others and make friendships, some of these individuals develop symptoms of depression that may require treatment, including medication.

The American Journal of Psychiatry: Asperger’s Disorder (Clinical Case Conference)

· This journal was a case presentation of a patient by the name of “Robert” who was 11 years and 8 months old and diagnosed with AD. Robert was interested in and quite knowledgeable about astronomy. His interest was quite intense and he pursued this interest at any opportunity- it intruded on all aspects of his life.

· A drawing was represented as a figure in this article which depicted his interest in astronomy and his more recent interest in time. He engaged in a long monologue describing the history of the universe and the various epochs illustrated in the drawing.

· The drawing illustrates the history of the universe from the moment of its creation (12:00 midnight) through geologic time, example- the appearance of bacteria (6:30 am). It illustrates the patient’s profound interest and knowledge regarding this topic which tended to be all-encompassing as well as his less-developed fine motor abilities.

Journal of Abnormal Child Psychology: Does DSM-IV Asperger’s Disorder Exist?

· One question raised in this article was- Is Asperger’s Disorder separate and distinct from high-functioning autism?

· Asperger’s original paper entitled: “Autistic Psychopathy in Childhood” by Hans Asperger in 1944 described 4 separate areas:

1. 1.Impairment in social interaction- such as social isolation and poor eye contact

2. 2.Impairment in communication- such as idiosyncratic/unusual use of speech and problems with conversational speech

3. 3.Restricted/Repetitive Behavior and Interests- such as special interests, abnormal fixations, and “stereotypical” play and movements (rocking, ritualized behaviors)

4. Intelligence- included all levels from genius to -à MR

1997- Miller and Ozonoff published a study that analyzed Hans Asperger’s original 4 cases and demonstrated that ALL met criteria for autism and none for Asperger’s D/O

1996- Eisenmajer et al. All 69 children fulfilled DSM-IV criteria for autism

1995- Study by Szatmari- 68 pre-school children with PDD only 1 met criteria for Asperger’s disorder

· This together with failure of some children to meet the DSM-IV social impairment criteria for Asperger’s D/O led authors to believe that it was “virtually impossible” to make a DSM-IV diagnosis of Asperger’s D/O

· Criteria were applied to 157 children with clinical diagnoses of autism or Asperger’s and ALL children met the DSM-IV criteria for autism and none met the criteria for Asperger’s D/O b/c all children had social impairment and restricted/repetitive behavior and interests and all had a DSM-IV communication impairment which then qualified them for a diagnosis of Autistic D/O and not Asperger’s D/O. These findings are consistent with those of 5 other studies and indicates that DSM-IV diagnosis of Asperger’s D/O is unlikely.

Journal of the American Academy of Child Adolescent Psychiatry: Peer Victimization with Asperger’s Spectrum Disorders

· Sample of patients obtained by sending a survey to interested families (known by internet website) with children diagnosed with Asperger’s d/o. The overall response rate was 70%- 411 surveys were analyzed (Ages 4-17 mean age=10.5).

A Juvenile Victimization Questionnaire was utilized and 3 questions were used to measure peer shunning:

1. Invitation to birthday parties- 33%

2. Eating alone at lunch- 11%

3. Picked last or almost last for teams- 31%

Yearly Prevalence rate of peer victimization = 94%

73% of respondent’s children were hit by peers/siblings

75% was bullied

10% were attacked by a gang

15% had non-sexual genital assaults

· Children who were older, male or had a diagnosis of Asperger’s syndrome were more likely to be shunned by peers

· Victimization rates may reflect underestimates b/c children from family of lower socioeconomic status were not well represented

Developmental Medicine and Child Neurology: Head circumference in autism, Asperger’s syndrome and ADHD- a comparative study

· Asperger’s syndrome is conceptualized as a high-functioning variant of autism and is usually associated with marked intellectual impairment

· Methods- This study included 150 child psych patients with Asperger’s syndrome, Autistic D/O and ADHD. All had occipitofrontal circumference (OFC) measured at birth and for 88% of the sample at or after 16 months of age. There were 50 of each type of patient all matched for birth year and sex. There are sex and age normative values for wt. and ht. from birth-à 15 years for Swedish children. Swedish normative OFC values are available only for children aged 0-2 years.

Analysis

· Genuine macrocephalus- OFC surpassed norms by 2 SDs or more and ht and wt were both 1 SD or more UNDER that expected on the basis of OFC

· (genuine macrocephalus would not be an appropriate label for children with large heads proportional to overall body size)

· Relative macrocephalus- OFC surpassed the age and sex norms by 2SDs or more and ht OR wt but NOT BOTH was 1 SD or more UNDER that the expected on the basis of OFC

Results

· All 3 groups (Asperger’s, ADHD, and Autism) had mean OFCs at birth that were larger than normal values

· Asperger’s syndrome group was significantly greater than the autistic group

· After 16 months- all 3 groups had mean OFCs above the age/sex norms.

The Asperger’s syndrome group mean was significantly greater than the ADHD group

	Asperger’s Syndrome	Autistic Disorder	ADHD
Genuine macrocephalus at birth	22%	9.5%	14%
Genuine macrocephalus at 16 mo.	21%	9.5%	6%

· One other study demonstrated that ADHD and not just autistic spectrum D/O’s were associated with enlarged head size

· One problem with this study was that there was no control group without neuropsychiatric D/O was included in this study

· The finding that the group with Asperger’s syndrome differed significantly from the other groups suggests that this group with Asperger’s does have a high rate of macrocephalus- possibly 2 different types – one present at birth and 1 that emerges only after some years of development.

References:

1. 1.Mayes, S.D., Calhoun, S.L., and Crites D.L. (2001). Does DSM-IV Asperger’s Disorder Exist? Journal of Abnormal Child Psychology, 29:263-271.

2. Gillberg, C. and De Souza, L. (2002). Head Circumference in autism, Asperger syndrome, and ADHD: a comparative study. Developmental Medicine and Child Neurology, 44: 296-300.

3. 3.Volkmar, F.R., Klin, A., Schultz, R.T., Rubin, E., and Bronen, R. (2000) Asperger’s Disorder (Clinical Case Conference). The American Journal of Psychiatry, 157 (2): 262-267.

4. 4.Little, Liza (2001) Peer Victimization of Children with Asperger Spectrum Disorders. Journal of the American Academy of Child Adolescent Psychiatry, 40: 995-996.

(Volkmar, F.R. (2000) Asperger’s Disorder. The American Journal of Psychiatry, 157 (2): 262-267.)

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