Asperger syndrome

The extent of the overlap between Asperger syndrome and other forms of autism, particularly what was sometimes called high-functioning autism is unclear. The ASD classification is to some extent an artifact of how autism was discovered, and it may not reflect the true nature of the spectrum; methodological problems have beset Asperger syndrome as a valid diagnosis from the outset. As noted above, in the 2010s, Asperger syndrome, as a separate diagnosis, was eliminated and folded into autism spectrum disorder in the DSM-5 and the ICD-11. Like the diagnosis of Asperger syndrome, the change was controversial. The World Health Organization (WHO) previously defined Asperger syndrome (AS) as one of the pervasive developmental disorders (PDD), which are a spectrum of psychological disorders that are characterized by abnormalities of social interaction and communication that pervade the individual's functioning, and by restricted and repetitive interests and behavior. Like other neurodevelopmental conditions, ASD begins in infancy or childhood, has a steady course without remission or relapse, and has impairments that result from maturation-related changes in various systems of the brain. == Characteristics ==

As a pervasive developmental disorder, Asperger syndrome is distinguished by a pattern of symptoms rather than a single symptom. It is characterized by qualitative impairment in social interaction, by stereotyped and restricted patterns of behavior, activities, and interests, and by no clinically significant delay in cognitive development or general delay in language. Intense preoccupation with a narrow subject, one-sided verbosity, restricted prosody, and physical clumsiness are typical of the condition, but are not required for diagnosis. Social interaction A lack of demonstrated empathy affects aspects of social relatability for persons with Asperger syndrome. Individuals with Asperger syndrome experience difficulties in basic elements of social interaction, which may include a failure to develop friendships or to seek shared enjoyments or achievements with others (e.g., showing others objects of interest); a lack of social or emotional reciprocity; and impaired nonverbal behaviors in areas such as eye contact, facial expression, posture, and gesture. The cognitive ability of children with Asperger syndrome often allows them to articulate social norms in a laboratory context, More evidence suggests that children diagnosed with Asperger syndrome are more likely to be victims, rather than offenders. A 2008 review found that about 80% of reported violent criminals with Asperger syndrome also had other coexisting psychotic psychiatric disorders such as schizoaffective disorder. The sample size of this review was small (n = 37). Empathy People with an Asperger profile might not be recognized for their empathetic qualities, due to variation in the ways empathy is felt and expressed. Some people feel deep empathy, but do not outwardly communicate these sentiments through facial expressions or language. Some people come to empathy through intellectual processes, using logic and reasoning to arrive at the feelings. People with Asperger profiles may be bullied or excluded by peers, and might as a result be guarded around people, which could appear as lack of empathy. People with Asperger profiles can still be caring individuals; indeed, it is particularly common for those with the profile to feel and exhibit deep concern for individual rights, human welfare, animal rights, environmental protection, and other global and humanitarian causes. Evidence suggests that in the "double empathy problem model, autistic people have a unique interaction style which is significantly more readable by other autistic people, compared to non-autistic people." Restricted and repetitive interests and behavior People with Asperger syndrome can display behavior, interests, and activities that are restricted and repetitive and are sometimes abnormally intense or focused. They may stick to inflexible routines, move in stereotyped and repetitive ways, preoccupy themselves with parts of objects, or engage in compulsive behaviors like lining objects up to form patterns. Stims are believed to be used for self-soothing and regulate sensory input. They include hand movements such as flapping or twisting, and complex whole-body movements. Stimming may have a connection with tics, and studies have reported a consistent comorbidity between AS and Tourette syndrome in the range of 8–20%, According to the Adult Asperger Assessment (AAA) diagnostic test, a lack of interest in fiction and a positive preference towards non-fiction is common among adults with AS. Three aspects of communication patterns are of clinical interest: poor prosody, tangential and circumstantial speech, and marked verbosity. Although inflection and intonation may be less rigid or monotonic than in classic autism, people with AS often have a limited range of intonation: speech may be unusually fast, jerky, or loud. Speech may convey a sense of incoherence; the conversational style often includes monologues about topics that bore the listener, fails to provide context for comments, or fails to suppress internal thoughts. Individuals with AS may fail to detect whether the listener is interested or engaged in the conversation. The speaker's conclusion or point may never be made, and attempts by the listener to elaborate on the speech's content or logic, or to shift to related topics, are often unsuccessful. but have difficulty understanding figurative language and tend to use language literally. Motor and sensory perception Individuals with Asperger syndrome may have signs or symptoms that are independent of the diagnosis but can affect the individual or the family. These include differences in perception and problems with motor skills, sleep, and emotions. Individuals with AS often have excellent auditory and visual perception. Children with ASD often demonstrate enhanced perception of small changes in patterns such as arrangements of objects or well-known images; typically this is domain-specific and involves processing of fine-grained features. Conversely, compared with individuals with high-functioning autism, individuals with AS have deficits in some tasks involving visual-spatial perception, auditory perception, or visual memory. these sensory responses are found in other developmental disorders and are not specific to AS or to ASD. There is little support for increased fight-or-flight response or failure of habituation in autism; there is more evidence of decreased responsiveness to sensory stimuli, although several studies show no differences. Hans Asperger's initial accounts include descriptions of physical clumsiness. Children with AS may be delayed in acquiring skills requiring dexterity, such as riding a bicycle or opening a jar, and may seem to move awkwardly or feel "uncomfortable in their own skin". They may be poorly coordinated or have an odd or bouncy gait or posture, poor handwriting, or problems with motor coordination. Although AS, lower sleep quality, and alexithymia are associated with each other, their causal relationship is unclear. == Causes ==

Hans Asperger described common traits among his patients' family members, especially fathers, and research supports this observation and suggests a genetic contribution to Asperger syndrome. Although no specific genetic factor has yet been identified, multiple factors are believed to play a role in the expression of autism, given the variability in symptoms seen in children. Evidence for a genetic link is that AS tends to run in families where more family members have limited behavioral symptoms similar to AS (for example, some problems with social interaction, or with language and reading skills). Many environmental factors have been hypothesized to act after birth, but none has been confirmed by scientific investigation. These environmental elements can act as independent and significant risk factors, or they can potentially influence pre-existing genetic factors in people who have a genetic predisposition. Although the specific underpinnings of AS or factors that distinguish it from other ASDs are unknown, and no clear pathology common to individuals with AS has emerged, Neuroanatomical studies and the associations with teratogens strongly suggest that the mechanism includes alteration of brain development soon after conception. Several theories of mechanism are available; none are likely to provide a complete explanation. General-processing theories One general-processing theory is weak central coherence theory, which hypothesizes that a limited ability to see the big picture underlies the central disturbance in ASD. A related theory—enhanced perceptual functioning—focuses more on the superiority of locally oriented and perceptual operations in autistic individuals. Mirror neuron system (MNS) theory The mirror neuron system (MNS) theory hypothesizes that alterations to the development of the MNS interfere with imitation and lead to Asperger syndrome's core feature of social impairment. One study found that activation is delayed in the core circuit for imitation in individuals with AS. This theory maps well to social cognition theories like the theory of mind, which hypothesizes that autistic behavior arises from impairments in ascribing mental states to oneself and others; or hyper-systemizing, which hypothesizes that autistic individuals can systematize internal operation to handle internal events but are less effective at empathizing when handling events generated by other agents. == Diagnosis ==

Standard diagnostic criteria require impairment in social interaction and repetitive and stereotyped patterns of behavior, activities, and interests, without significant delay in language or cognitive development. Unlike the international standard, and by Gillberg and Gillberg. Diagnosis of ASD (and previously AS) is most commonly made between the ages of four and eleven. Underdiagnosis and overdiagnosis may be problems. The cost and difficulty of screening and assessment can delay diagnosis. Conversely, the increasing popularity of drug treatment options and the expansion of benefits has motivated providers to overdiagnose ASD. There are indications AS has been diagnosed more frequently in recent years, partly as a residual diagnosis for children of normal intelligence who are not autistic but have social difficulties. different screening tools may render different diagnoses for the same person. Adult diagnosis requires painstaking clinical examination and thorough medical history gained from both the individual and other people who know the person, focusing on childhood behavior. Conditions that must be considered in a differential diagnosis along with ADHD include other ASDs, the schizophrenia spectrum, personality disorders, obsessive–compulsive disorder, major depressive disorder, semantic pragmatic disorder, nonverbal learning disorder, social anxiety disorder, Tourette syndrome, social-cognitive deficits due to brain damage from alcohol use disorder, and obsessive–compulsive personality disorder (OCPD). == Screening ==

Parents of children with Asperger syndrome can typically trace differences in their children's development to as early as 30 months of age. Different screening instruments are used to diagnose AS, Gilliam Asperger's disorder scale (GADS); Krug Asperger's Disorder Index (KADI); and the autism-spectrum quotient (AQ), with versions for children, adolescents, and adults. None have been shown to reliably differentiate between AS and other ASDs. == Management ==

Treatment attempts to manage distressing symptoms and to teach age-appropriate social, communication, and vocational skills that are not naturally acquired during development. Although progress has been made, data supporting the efficacy of particular interventions are limited. Therapies Managing ASD may involve multiple therapies that address core symptoms of the disorder. While many professionals agree that the earlier the professional support the better, there is no combination that is recommended above others. ABA has faced a great deal of criticism over the years. Recently, studies have shown that ABA may be abusive and can increase PTSD symptoms in patients. The Autistic Self Advocacy Network campaigns against the use of ABA in autism. In the case of CBT and talking therapies, the effectiveness varies, with many reporting that they appeared 'too self-aware' to gain significant benefit, as the therapy was designed with neurotypical people in mind. In autistic children, specifically, they also report that it is only mildly beneficial in aiding with their anxieties. A typical program of professional support generally includes: The Autistic Self Advocacy Network campaigns against the use of ABA in autism; and to help reduce obsessive interests (although this may produce negative impact by demonising special interests) and repetitive routines; • Medication for coexisting conditions such as major depressive disorder and anxiety disorders; Of the many studies on behavior-based early intervention programs, most are case reports of up to five participants and typically examine a few problem behaviors such as self-injury, aggression, noncompliance, stereotypies, or spontaneous language; unintended side effects are largely ignored. Despite the popularity of social skills training, its effectiveness is not firmly established. A randomized controlled study of a model for training parents in problem behaviors in their children with AS showed that parents attending a one-day workshop or six individual lessons reported fewer behavioral problems, while parents receiving the individual lessons reported less intense behavioral problems in their AS children. Vocational training may be important to teach job interview etiquette and workplace behavior to older children and adults with AS, and organization software and personal data assistants can improve the work and life management of people with AS. Although research into the efficacy of pharmaceutical intervention for AS is limited, risperidone can reduce repetitive and self-injurious behaviors, aggressive outbursts, and impulsivity, and improve stereotypical patterns of behavior and social relatedness. The selective serotonin reuptake inhibitors (SSRIs) fluoxetine, fluvoxamine, and sertraline have been effective in treating restricted and repetitive interests and behaviors, In addition, scientists have made a noteworthy finding that oxytocin, a hormone, plays a significant role in shaping human social behavior and the formation of interpersonal connections. along with serious long-term neurological side effects. Sedation and weight gain are more common with olanzapine, have ramifications for classroom learning. Individuals with AS may be unable to identify and communicate their internal moods and emotions or to tolerate side effects that for most people would not be problematic. == Prognosis ==

There is some evidence that children with AS may see a lessening of symptoms; up to 20% of children may no longer meet the diagnostic criteria as adults, although social and communication difficulties may persist. Most students with AS and forms of autism sometimes seen as "high functioning" have average mathematical ability and test slightly worse in mathematics than in general intelligence. However, mathematicians are at least three times more likely to have autism-spectrum traits than the general population, and are more likely to have family members with autism. Although many attend regular education classes, some children with AS may attend special education classes such as separate classroom and resource room because of their social and behavioral difficulties. Anxiety may stem from preoccupation over possible violations of routines and rituals, from being placed in a situation without a clear schedule or expectations, or from concern with failing in social encounters; Education of families is critical in developing strategies for understanding strengths and weaknesses; helping the family to cope improves outcomes in children. Prognosis may be improved by diagnosis at a younger age that allows for early interventions, while interventions in adulthood are valuable but less beneficial. There are legal implications for individuals with AS as they run the risk of exploitation by others and may be unable to comprehend the societal implications of their actions. == Epidemiology ==

Frequency estimates vary enormously. In 2015, it was estimated that 37.2 million people globally are affected. combining the geometric mean ratio of 5:1 with a conservative prevalence estimate for autism of 1.3 per 1,000 suggests indirectly that the prevalence of AS might be around 0.26 per 1,000. Part of the variance in estimates arises from differences in diagnostic criteria. For example, a relatively small 2007 study of 5,484 eight-year-old children in Finland found 2.9 children per 1,000 met the ICD-10 criteria for an AS diagnosis, 2.7 per 1,000 for Gillberg and Gillberg criteria, 2.5 for DSM-IV, 1.6 for Szatmari et al., and 4.3 per 1,000 for the union of the four criteria. Boys seem to be more likely to have AS than girls; estimates of the sex ratio range from 1.6:1 to 4:1, using the Gillberg and Gillberg criteria. Comorbidities Anxiety disorders and major depressive disorder are the most common conditions seen at the same time; comorbidity of these in persons with AS is estimated at 65%. AS is associated with tics, Tourette syndrome and bipolar disorder. The repetitive behaviors of AS have many similarities with the symptoms of obsessive–compulsive disorder and obsessive–compulsive personality disorder, However many of these studies are based on clinical samples or lack standardized measures; nonetheless, comorbid conditions are relatively common. They are also significantly more likely to be non-theistic. == History ==

Asperger syndrome was named after the Austrian pediatrician Hans Asperger (1906–1980), but not coined by him. Asperger syndrome was a relatively new diagnosis in the field of autism, though a syndrome like it was described as early as 1925 by Soviet child psychiatrist Grunya Sukhareva (1891–1981). In 1944, Asperger gave detailed descriptions of four representative children in his practice Unlike what became known as AS, Asperger believed autistic psychopathy could be found in people of all levels of intelligence, including those with intellectual disability: as such, Asperger's understanding of autistic pathology was more akin to what is known as the autism spectrum today. Asperger defended the value of so-called "high-functioning" autistic individuals, writing: "We are convinced, then, that autistic people have their place in the organism of the social community. They fulfill their role well, perhaps better than anyone else could, and we are talking of people who as children had the greatest difficulties and caused untold worries to their care-givers." and popularized it to the English-speaking medical community in her February 1981 publication of case studies of children showing the symptoms described by Asperger, AS became a standard diagnosis when it was included in the tenth edition of the World Health Organization's diagnostic manual, International Classification of Diseases (ICD-10), published in 1990 and coming into effect in 1993; and in the fourth edition of the American Psychiatric Association's diagnostic reference, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), published in 1994. The ICD-11 characterizes ASD with qualifiers describing the presence of disorders of intellectual development and the degree of functional language impairment; the former diagnosis of Asperger syndrome is characterized as autism spectrum disorder without disorder of intellectual development and with mild or no impairment of functional language. == Society and culture ==

People identifying with Asperger syndrome may refer to themselves in casual conversation as aspies (a term first used in print in the Boston Globe in 1998). Some autistic people have advocated a shift in perception of autism spectrum disorders as complex syndromes, neurodivergences, and/or neurominority cognitive styles rather than diseases that must be cured. Proponents of this neurodiversity paradigm reject the notion that there is an "ideal" brain configuration and that any deviation from the norm is pathological; they promote tolerance of neurodiversity. These views are the basis for the autistic rights and autistic pride movements, within the broader neurodiversity movement. There is a contrast between the attitude of people with AS, who typically do not want to be cured and are proud of their identity; and parents of children with AS, who more often seek a "cure" of their children's autism. Some researchers have argued that AS and other autism can be viewed as a different cognitive style, not a disorder, and that it should be removed from psychiatric and medical manuals classifying diseases (ICD) or mental disorders (DSM), much as homosexuality was removed. Even some people typically associated with a pathology paradigm for autism are willing to consider AS a neutral difference. For example, in 2002, Simon Baron-Cohen wrote of those with AS: "In the social world, there is no great benefit to a precise eye for detail, but in the worlds of maths, computing, cataloging, music, linguistics, engineering, and science, such an eye for detail can lead to success rather than failure." Baron-Cohen cited two reasons why it might still be useful to consider AS to be a disability: to ensure provision for legally required special support, and to recognize emotional difficulties from reduced empathy, which was commonly associated with autism during that time but has since lost support. Baron-Cohen argues that the genes for ASD's combination of abilities have operated throughout recent human evolution and have made remarkable contributions to human history. By contrast, Pier Jaarsma and Welin wrote in 2011 that the "broad version of the neurodiversity claim, covering low-functioning as well as high-functioning autism, is problematic. Only a narrow conception of neurodiversity, referring exclusively to high-functioning autists, is reasonable." They say that "higher functioning" individuals with autism may "not [be] benefited with such a psychiatric defect-based diagnosis ... some of them are being harmed by it, because of the disrespect the diagnosis displays for their natural way of being", but "think that it is still reasonable to include other categories of autism in the psychiatric diagnostics. The narrow conception of the neurodiversity claim should be accepted but the broader claim should not." == References ==