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Fri 7th

Mental health and Asperger syndrome

Published by: Dean Rose on Friday 7th August 2009 07:08am

Introduction

People with autism or Asperger syndrome are particularly vulnerable to mental health problems such as anxiety and depression, especially in late adolescence and early adult life (Tantam & Prestwood, 1999). Ghaziuddin et al (1998) found that 65 per cent of their sample of patients with Asperger syndrome presented with symptoms of psychiatric disorder.

However, as mentioned by Howlin (1997), "the inability of people with autism to communicate feelings of disturbance, anxiety or distress can also mean that it is often very difficult to diagnose depressive or anxiety states, particularly for clinicians who have little knowledge or understanding of developmental disorders". Similarly, because of their impairment in non-verbal expression, they may not appear to be depressed (Tantam, 1991). This can mean that it is not until the illness is well developed that it is recognised, with possible consequences such as total withdrawal; increased obsessional behaviour; refusal to leave the home, go to work or college etc; and threatened, attempted or actual suicide. Aggression, paranoia or alcoholism may also occur.

In treating mental illness in the patient with autism or Asperger syndrome, it is important that the psychiatrist or other health professional has knowledge of the individual with autism being assessed. As Howlin (1997) says, "it is crucial that the physician involved is fully informed about the individuals usual style of communication, both verbal and non-verbal". In particular it is recommended, if possible, that they speak to the parents or carers to ensure that the information received is reliable, eg any recent changes from the normal pattern of behaviour, whilst at the same time respecting the right of the person with autism to be treated as an individual.

Wing (1996) asserts that psychiatrists should be aware of autism spectrum disorders as they appear in adolescents and adults, especially those who are more able, if diagnostic errors are to be avoided. Attwood (1998) also stresses the importance of the psychiatrist being knowledgeable in Asperger syndrome. Tantam and Prestwood (1999), however, state that treatments for anxiety and depression that are also effective for people without autism are effective for people with autism. They go on to say that practitioners and psychiatrists with no special knowledge of autism or Asperger syndrome can be of considerable assistance in treating these conditions. Typically, however, it is of great advantage if the psychiatrist has experience of autism/Asperger syndrome.

Here, we concentrate on mental health in people with high-functioning autism or Asperger syndrome although references will be made to autism per se where appropriate. Emphasis will be on depression, anxiety and obsessive compulsive disorder, but it is important to realise that people with Asperger syndrome also experience other problems, such as impulsive behaviour and mood swings. To date there has been little research in this area but, as Carpenter (2001) has found, these can sometimes be incapacitating. Treatment can include conventional mood stabilising drugs, but helping the person to improve their self-awareness is also important.

Depression

Depression is common in individuals with Asperger syndrome with about 1 in 15 people with Asperger syndrome experiencing such symptoms (Tantam, 1991). People with Asperger syndrome leaving home and going to college frequently report feelings of depression as demonstrated by the personal accounts that can be found at www.users.dircon.co.uk/~cns/index.html

As one young person says, "I also had to deal with anger, frustration, and depression that I had been keeping inside since high school". A study by Kim et al (2000) also found depression to be more common in children aged 10-12 years with high-functioning autism/Asperger syndrome than in the general population of children of the same age.

Depression in people with Asperger syndrome may be related to a growing awareness of their disability or a sense of being different from their peer group and/or an inability to form relationships or take part in social activities successfully. Personal accounts by young people with Asperger syndrome frequently refer to attempts to make friends but "I just did not know the rules of what you were or were not supposed to do" www.users.dircon.co.uk/~cns/jeanpaul.html

Indeed, some people have even been accused of harassment in their attempts to socialise, something that can only add to their depression and anxiety; "I also did not know how to approach girls and ask them to go out with me. I would just walk up and talk to them, whether they wanted to talk to me or not. Some accused me of harassment, but I thought that was the way everybody did that." www.users.dircon.co.uk/~cns/jeanpaul.html

The difficulties people with Asperger syndrome have with personal space can compound this sort of problem. For example, they may stand too close or too far from the person to whom they are speaking.

Other precipitating factors are also seen in many people without autism who are depressed and include loneliness, bereavement or other form of loss, sexual frustration, a constant feeling of failure, extreme anxiety levels etc.

Childhood experiences such as bullying or abuse may also result in depression, as can a history of misdiagnosis. Another possibility is that the person is biologically predisposed to depression (Attwood, 1998). However, there are, of course, many other factors that may trigger the depression and this list should not be taken as exhaustive.

Tantam and Prestwood (1999) describe the depression of someone with Asperger syndrome as taking the same form as in people without the condition, although the content of the illness may be different. For example, the depression might show itself through an individuals particular preoccupations and obsessions and care must be taken to ensure that the depression is not diagnosed as schizophrenia or some other psychotic disorder or just put down to autism. It is important to assess the individuals depression in the context of their autism, ie their social disabilities, and any gradual or sudden changes in behaviour, sleep patterns, anger or withdrawal should always be taken seriously.

Symptoms of depression can be psychological (poor concentration/memory, thoughts of death or suicide, tearfulness); physical (slowing down or agitation, tiredness/lack of energy, sleep problems, disturbed appetite (weight loss or gain)); or affects of mood and motivation (eg low mood, loss of interest or pleasure, hopelessness, helplessness, worthlessness, withdrawal or bizarre beliefs etc.) People with depression can also experience periods of mania.

Lainhart and Folstein (1994) cite three approaches that need to be made in diagnosing depression in a person with autism. The first concerns a deterioration in cognition, language, behaviour or activity. The complaint is rarely couched in terms of mood. Secondly, it is important to take the patients history to establish their baseline, patterns of activity and interests. It is this pattern with which the presenting patterns can be compared. Thirdly, an attempt should be made to assess the patients mental state, both directly and through the parent or carer, if present. Examples would include reports of crying, difficulties in separating from their parent/carer for an interview, increased/decreased activity, agitation or aggression. There may be evidence of new or increased self-injury or worsening autistic features, such as increased proportion of echolalia or the reappearance of hand-flapping.

Attwood (1998) also refers to the inability that some people with Asperger syndrome have in expressing appropriate and subtle emotions. They may, for example, laugh or giggle in circumstances where other people would show embarrassment, discomfort, pain or sadness. He stresses that this unusual reaction, for example after a bereavement, does not mean the person is being callous or is mentally ill. They need understanding and tolerance of their idiosyncratic way of expressing their grief.

In treating depression, medications used in general practice may be prescribed (Carpenter, 1999). It is important to realise, however, that such agents do not make an impact on the primary social impairments that underlie autism. See Gringras (2000) for a discussion on the use of psychopharmacological prescribing for children with autism or Santosh and Baird (1999) for a analysis of psychopharmacotherapy in children and adults with intellectual disability (including autism).

As with any treatment for depression, adjustments may have to be made to find the appropriate drug and dosage for that particular person. Side effects should also be monitored and effort made to ensure the benefits of the treatment outweigh the penalties (Carpenter, 1999). It is also important to identify the cause for the depression and this may involve counselling (see below), social skills training, or meeting up with people with similar interests and values.

Anxiety

Anxiety is a common problem in people with autism and Asperger syndrome. Grandin (2000) writes that, at puberty, fear was her main emotion. Any change in her school schedule caused intense anxiety and the fear of a panic attack. Anxiety attacks started shortly after her first menstrual period.

Muris et al (1998) found that 84.1% of children with pervasive developmental disorder met the full criteria of at least one anxiety disorder (phobia, panic disorder, separation anxiety disorder, avoidant disorder, overanxious disorder, obsessive compulsive disorder). This does not necessarily go away as the child grows older.

Attwood (1998) states that many young adults with Asperger syndrome report intense feelings of anxiety, an anxiety that may reach a level where treatment is required. For some people, it is the treatment of their anxiety disorder that leads to a diagnosis of Asperger syndrome.

People with Asperger syndrome are particularly prone to anxiety disorders as a consequence of the social demands made upon them. As Attwood (1998) explains, any social contact can generate anxiety as to how to start, maintain and end the activity and conversation. Changes to daily routine can exacerbate the anxiety, as can certain sensory experiences.

One way of coping with their anxiety levels is for persons with Asperger syndrome to retreat into their particular interest. Their level of preoccupation can be used a measure of their degree of anxiety. The more anxious the person, the more intense the interest (Attwood, 1998). Anxiety can also increase the rigidity in thought processes and insistence upon routines. Thus, the more anxious the person, the greater the expression of Asperger syndrome. When happy and relaxed, it may not be anything like as apparent.

One potentially good way of managing anxiety is to use behavioural techniques. For children, this may involve teachers or parents looking out for recognised symptoms, such as rocking or hand-flapping, as an indication that the child is anxious. Adults and older children can be taught to recognise these symptoms themselves, although some might need prompting. Specific events may also be known to trigger anxiety eg a stranger entering the room. When certain events (internal or external) are recognised as a sign of imminent or increasing anxiety, action can be taken for example, relaxation, distraction or physical activity.

The choice of relaxation method depends very much on the individual and many of the relaxation products available commercially can be adapted for use for people with autism/Asperger syndrome. Young children may respond to watching their favourite video. Older children and adults may prefer to listen to calming music. There is much music on the market, both from specialist outfits and regular music stores, that is written specifically to bring about a feeling of tranquillity. It is important the person does not have social demands, however slight, made upon them if they are to benefit. It is also important that they have access to a quiet room.

Other techniques include massage (this should be administered carefully to avoid sensory defensiveness), aromatherapy, deep breathing and using positive thoughts. Howlin (1997) suggests the use of photographs, postcards or pictures of a pleasant or familiar scene. These need to be small enough to be carried about and should be laminated in order to protect them. Howlin also stresses the need to practice whichever method of relaxation is chosen at frequent and regular intervals in order for it to be of any practical use when anxieties actually arise.

An alternative option, particularly if the person is very agitated, is to undertake a physical activity (Attwood, 1998). Activities may include using the swing or trampoline, going for a long walk perhaps with the dog, or doing physical chores around the home.

Drug treatment may be effective for anxiety. Individuals may respond to buspirone, propranilol or clonazepam (Santosh and Baird, 1999) although Carpenter (2001) finds St. Johns Wort, benzodiazepines and selective serotonin reuptake inhibitors (SSRI) antidepressants to be more effective. As with all drug treatments it may take time to find the correct drug and dosage for any particular person. Such treatment must only be conducted through a qualified medical practitioner.

Whatever method is chosen to reduce anxiety, it is crucial to identify the cause of the anxiety. This should be done by careful monitoring of the precedents to an increase in anxiety and the source of the anxiety tackled.

Obsessive compulsive disorder

Obsessive compulsive disorder (OCD) is described as a condition characterised by recurring, obsessive thoughts (obsessions) or compulsive actions (compulsions) (Thomsen, 1999). Thomsen goes on to say that obsessive thoughts are ideas, pictures of thoughts or impulses, which repeatedly enter the mind, whereas compulsive actions and rituals are behaviours which are repeated over and over again.

Baron-Cohen (1989) argues that the stereotypic obsessive action seen in children with autism differs from the child with OCD. As Thomsen (1999) explains, the child with autism does not have the ability to put things into perspective. Although terminology implies that certain behaviours in autism are similar to those seen in OCD, these behaviours fail to meet the definition of either obsessions or compulsions. They are not invasive, undesired or annoying, a prerequisite for a diagnosis of OCD. The reason for this is that people with (severe) autism are unable to contemplate or talk about their own mental states. However, OCD does appear often to coincide with Asperger syndrome, although there is very little literature examining the relationship between the two (Thomsen, 1999).

Szatmari et al (1989) studied a group of 24 children. He discovered that 8% of the children with Asperger syndrome and 10% of the children with high-functioning autism were diagnosed with OCD. This compared to 5 per cent of the control group of children without autism but with social problems. Thomsen el at (1994) found that in the children he studied, the OCD continued into adulthood.

People with Asperger syndrome can sometimes respond to conventional behavioural treatment to help reduce the symptoms of OCD. However, as with anyone, this will only be effective if the person wants to stop their obsessions. An alternative is use medication to reduce the anxiety around the obsessions, thus enabling the person to tolerate the frustration of not carrying out their obsession (Carpenter, 2001).

Schizophrenia

There is no evidence that people with autism spectrum conditions are any more likely than anyone else to develop schizophrenia (Wing, 1996).

It is also important to realise that people have been diagnosed as having schizophrenia when, in fact, they have Asperger syndrome. This is because their 'odd' behaviour or speech pattern, or the person's strange accounts or interpretations of life, are seen as a sign of mental illness, such as schizophrenia. Obsessional thoughts can become quite bizarre during mood swings and these can be seen as evidence of schizophrenia rather than the mood disorder that actually are. However, should someone with Asperger syndrome experience hallucinations or delusions that they find distressing, conventional antipsychotic medications can be prescribed. However, it is recommended that only the newer atypical antipsychotics are used, as people with Asperger syndrome often have mild movement disorders (Carpenter, 2001). Cognitive behaviour therapy and other psychological management methods may be effective.

Psychological treatments

A primary psychological treatment for mood disorders is cognitive behavioural therapy as it is effective in changing the way a person thinks and responds to feelings such as anxiety, sadness and anger, addressing any deficits and distortions in thinking (Attwood, 1999).

Hare and Paine (1997) list ways in which the therapy can be adapted for use with people with Asperger syndrome: having a clear structure eg protocols of turn-taking; adapting the length of sessions therapy might have to be very brief eg 10-15 minutes long; the therapy must be non-interpretative; the therapy must not be anxiety provoking as any arousal of emotion during therapy may be very counterproductive; group therapy should not be used. It is also important that the therapist has a working knowledge and understanding of Asperger syndrome in a counselling setting ie the difficulty people have dealing things emotionally, finding it best to deal with things intellectually. The therapist and client can work towards explicit operational goals, the focus being on concrete and specific symptoms.

Attwood (1999) gives a succinct overview of the components of the counselling process. Hare and Paine (1997) stress that such therapy is not a treatment or even an amelioration of the characteristics of Asperger syndrome itself. It merely opens the psychotherapeutic door for people with such a diagnosis.

Catatonia

Catatonia is a complex disorder covering a range of abnormalities of posture, movement, speech and behaviour associated with over- as well as under-activity (Rogers, 1992; Bush et al, 1996; Lishman, 1998).

There is increasing research and clinical evidence that some individuals with autism spectrum disorders, including Asperger syndrome, develop a complication characterised by catatonic and Parkinsonian features (Shah and Wing, 2006; Wing and Shah, 2000; Realmuto and August, 1991).

In individuals with autism spectrum disorders, catatonia is shown by the onset of any of the following features:

increased slowness affecting movements and/or verbal responses;
difficulty in initiating completing and inhibiting actions;
increased reliance on physical or verbal prompting by others;
increased passivity and apparent lack of motivation.

Other manifestations and associated behaviours include Parkinsonian features including freezing, excitement and agitation, and a marked increase in repetitive and ritualistic behaviour.

Behavioural and functional deterioration in adolescence is common among individuals with autism spectrum disorders (Gillberg and Steffenburg, 1987). When there is deterioration or an onset of new behaviours, it is important to consider the possibility of catatonia as an underlying cause. Early recognition of problems and accurate diagnosis are important as it is easiest to manage and reverse the condition in the early stages. The condition of catatonia is distressing for the individual concerned and likely to exacerbate the difficulties with voluntary movement and cause additional behavioural disturbances.

There is little information on the cause or effective treatment of catatonia. In a study of referrals to Elliot House who had autism spectrum disorders, it was found that 17% of all those aged 15 and over, when seen, had catatonic and Parkinsonian features of sufficient degree to severely limit their mobility, use of speech and carrying out daily activities. It was more common in those with mild or severe learning disabilities (mental retardation), but did occur in some who were high functioning. The development of catatonia, in some cases, seemed to relate to stresses arising from inappropriate environments and methods of care and management. The majority of the cases had also been on various psychotropic drugs.

There is very little evidence about effective treatment and management of catatonia. No medical treatment was found to help those seen at Elliot House (Wing and Shah, 2000). There are isolated reports of individuals treated with anti-depressive medication and electro-convulsive therapy (ECT) (Realmuto and August, 1991; Zaw et al, 1999).

Given the scarcity of information in the literature and possible adverse side effects of medical treatments, it is important to recognise and diagnose catatonia as early as possible and apply environmental, cognitive and behavioural methods of the management of symptoms and underlying causes. Detailed psychological assessment of the individuals, their environment, lifestyle, circumstances, pattern of deterioration and catatonia are needed to design an individual programme of management. General management methods on which to base an individual treatment programme are discussed in Shah and Wing (2001).

Conclusion

People with Asperger syndrome can experience a variety of mental heath problems, notably anxiety and depression, but also impulsiveness and mood swings. They may be misdiagnosed as having a psychotic disorder and it is therefore important psychiatrists treating them are knowledgeable about autism and Asperger syndrome. Conventional drug treatment can be used to treat depression, anxiety and other disorders. Behavioural treatments and therapies can also be effective. However, any treatment must be careful tailored to suit an individual and overseen by a qualified practitioner. However, any psychotropic medicine should be used with extreme caution and strictly monitored with people with autism due to their susceptibility to movement disorders, including catatonia.

References

Attwood, T. (1998). Aspergers syndrome: a guide for parents and professionals. London: Jessica Kingsley. 1853025771.
Available from the NAS Publications Department

Attwood, T. (1999). Modifications to cognitive behaviour therapy to accommodate the unusual cognitive profile of people with Aspergers syndrome. Paper presented at autism99 internet conference.
Available from the NAS Information Centre.

Baron-Cohen, S. (1989). 'Do autistic children have obsessions and compulsions?' in British Journal of Clinical Psychology, 28(99), pp193-200.

Bush, G. et al (1996). 'Catatonia. I. Rating scale and standardising examination'. Acta Psychiatrica Scandinavica, 93, pp. 129-136.

Carpenter, P. (1999). The use of medication to treat mental illness in adults with autism spectrum disorders. Paper presented at autism99 internet conference.
Available from the NAS Information Centre.

Carpenter, P. (2001). Personal correspondence.

Ghaziuddin, E., Weidmer-Mikhail, E. and Ghaziuddin, N. (1998). 'Comorbidity of Asperger syndrome: a preliminary report' in Journal of Intellectual Disability Research, 42(4), pp. 279-283.

Gillberg, C. and Steffenburg, S. (1987). 'Outcome and prognostic factors in infantile autism and similar conditions: a population based study of 46 cases followed through puberty' in Journal of Autism and Developmental Disorders, 17(2), pp. 273-287.
Available from the NAS Information Centre.

Hare, D.J. and Paine, C. (1997). 'Developing cognitive behavioural treatments for people with Aspergers syndrome' in Clinical Psychology Forum, 110, pp. 5-8.

Howlin, P. (1997). Autism: preparing for adulthood. London: Routledge.
Available from the NAS Publications Department.

Kim, J. et al (2000). 'The prevalence of anxiety and mood problems amongst children with autism and Asperger syndrome' in Autism, 4(2), pp. 117-132.
Available from the NAS Information Centre.

Lainhart, J.E. and Folstein, S.E. (1994). 'Affective disorders in people with autism: a review of published cases' in Journal of Autism and Developmental Disorders, 24(5), pp. 587-601.
Available from the NAS Information Centre.

Lishman, W. A. (1998). Organic psychiatry: the psychological consequences of cerebral disorder, pp. 349-356. Oxford: Blackwell.

Muris, P. et al. (1998). 'Comorbid anxiety symptoms in children with pervasive developmental disorders' in Journal of Anxiety Disorders, 12(4), pp. 387-393.

Realmuto, G. and August, G. (1991). 'Catatonia in autistic disorder; a sign of comorbidity or variable expressions?' in Journal of Autism and Developmental Disorders, 21(4), pp. 517-528.
Available from the NAS Information Centre.

Rogers, D. (1992). Motor disorder in psychiatry: towards a neurological psychiatry. Chichester: Wiley.

Santosh, P.J. and Baird, G. (1999). 'Psychopharmacotherapy in children and adults with intellectual disability' in The Lancet, Vol 354, July 17, pp.233-242.

Szatmari, P., Bartoluci, G. and Bremner, R. (1989). 'Aspergers syndrome and autism: comparison of early history and outcome' in Developmental Medicine and Child Neurology, 31, pp. 709-720.

Tantam, D. (1991). 'Asperger syndrome in adulthood' In U. Frith (ed.) Autism and Asperger Syndrome, Cambridge University Press, pp. 147-183.
Available from the NAS Information Centre.

Tantam, D. and Prestwood, S. (1999). A mind of one's own: a guide to the special difficulties and needs of the more able person with autism or Asperger syndrome. 3rd ed. London: National Autistic Society.
Available from the NAS Publications Department.

Thomsen, P.H. (1994). 'Obsessive-compulsive disorder in children and adolescents. A 6-22 year follow-up study. Clinical descriptions of the course and continuity of obsessive-compulsive symptomatology' in European Child and Adolescent Psychiatry, 3, pp. 82-86.

Thomsen, P.H. (1999). From thoughts to obsessions: obsessive compulsive disorder in children and adolescents. London: Jessica Kingsley. 1853027219.

Wing, L. (2002). The autistic spectrum: a guide for parents and professionals. London: Constable and Robinson. 1841196746.
Available from the NAS Publications Department.

Wing, L. and Shah, A. (2000). 'Catatonia in autistic spectrum disorders' in British Journal of Psychiatry, 176, pp. 357-362.

Zaw, F. K. et al (1999). 'Catatonia, autism and ECT' in Developmental Medicine and Child Neurology, 41, pp. 843-845.

NAS angry and disappointed at Gary McKinnon outcome

Published by: Dean Rose on Thursday 6th August 2009 08:08pm

Journalists: download our latest media release about Gary McKinnon's case in 'Related resources' at the bottom of this page.

Today, the National Autistic Society expressed great disappointment at the High Court decision that Gary McKinnon, a man with Asperger syndrome accused of hacking into US Government computer systems, should be extradited to the US. The ruling follows two judicial reviews where it was argued that his Asperger syndrome had not been given due consideration by those deciding on his case.

Mark Lever, chief executive of the NAS said:

"We are so disappointed for Gary and his family and so angry he is still in this position. The threat of extradition has been hanging over him for seven long years and sadly the nightmare continues. The NAS has campaigned hard for his extradition to be reconsidered in the light of his diagnosis of Asperger syndrome. We will continue to do whatever we can to keep him here in the UK and will support him in his appeal to the Supreme Court.

"People with Asperger syndrome are often far more vulnerable than initial appearances would suggest, frequently isolated, often bullied and sadly many experience severe mental health problems if they do not get the right support. We are extremely disappointed that the High Court has decided to continue with Gary's extradition despite these concerns."

The ruling today comes after two Judicial Review hearings examined whether the Home Secretary had been right in deciding to extradite Gary following his diagnosis with Asperger syndrome, and whether the Director for Public Prosecutions should have allowed him to stand trial in the UK. The NAS supplied evidence about Asperger syndrome during the judicial review process, urging that his condition be taken into consideration.

The National Autistic Society has been campaigning to stop Gary's extradition since his diagnosis and has written to both the Home Secretary and the Attorney General. Thousands of NAS supporters have also voiced their support, writing to their MPs and signing a petition which was delivered to Downing Street by Garys mother earlier this month.

Gary now has the opportunity to appeal to the UK Supreme Court. The NAS will continue to campaign for his extradition to be stopped.

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Background to Gary McKinnon's case

Gary McKinnon was diagnosed with Asperger syndrome in August 2008 and stands accused of allegedly hacking into US Defense computer systems. As a result of Gary's late diagnosis, his Asperger syndrome was not taken into account in any legal proceedings prior to August 2008.

We have continued to express our concern that Gary's diagnosis be taken into consideration and took action by writing to both the Home Secretary when his diagnosis first came to light last year, and the Attorney General.

Asperger syndrome is a form of autism, a condition that affects the way a person communicates with and relates to others and the world around them. It is not uncommon for people with Asperger syndrome to develop single-minded, obsessional interests, and to be unaware of the effect their actions have on others.

The decision on Friday 31 July follows two judicial reviews of Gary's case. The first, heard on 9th June 2009, looked at the Home Secretary's decision to extradite Gary following his diagnosis. We submitted evidence during this judicial review explaining the nature of Asperger syndrome and the fact that diagnosis in adults is often late, as in Mr. McKinnon's case. This included information explaining that people with Asperger syndrome may be particularly vulnerable because of their difficulties with social awareness and communication, and may be susceptible to additional mental health problems as a result of their disability.

Earlier this year, over 4,000 supporters took part in our campaigner action to email the Attorney General asking that Gary be allowed to stand trial in the UK. His appeal to the Crown Prosecution Service was turned down in February 2009 and this decision was the subject of a second judicial review, heard on 14th July 2009.

You can read more about Asperger syndrome, and access information for criminal justice professionals on our website:

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Thu 6th

Criminal justice system and ASDs

Published by: Dean Rose on Thursday 6th August 2009 08:08pm

A number of people with autism spectrum disorders (ASDs) are involved in the Criminal Justice System (CJS) as either victims, witnesses or offenders.

There is no evidence of an association between ASD and criminal offending. In fact, due to the rigid way many people with ASD keep to rules and regulations, they are usually more law-abiding than the general population. People with an ASD are more at risk as victims of crime rather than as offenders.

Here. we give an overview of the possible reasons why people with ASD may come into contact with the CJS, the procedures involved and the sources of support that are available. The term ASD will be used throughout the information sheet to refer to people across the autism spectrum including those with a diagnosis of autism or Asperger syndrome. Many people with ASD who come into contact with the CJS may be undiagnosed or misdiagnosed.

Prevention

There are various ways to ensure that the response of the police and other criminal justice professionals is appropriate if a person with ASD comes into contact with them. Preferably, these preparations should start from childhood. The following are some general tips:

Ensure that the child or adult with ASD carries an identity card stating their personal details, emergency contacts and an explanation of their condition. It may also be worth mentioning on this card that the person has the right to an appropriate adult (for more information on appropriate adults see the section 'At the police station' below). Autism alert cards containing all this information are available from The National Autistic Society. (See the 'Useful reading and resources' section at the end of this information sheet).
If possible, teach the child or adult to inform any police officers that they come into contact with that they have autism.
Remember that unusual behaviour that seems cute or endearing in a child with ASD may be interpreted as odd or threatening in an adult. It is therefore important to make clear rules about appropriate behaviour from a young age, particularly around obsessional interests. Rules can have their drawbacks for people with ASD as they may be adhered to rigidly and sometimes inappropriately. However, Howlin (1997) suggests it is generally better to establish strict rules during childhood that can be relaxed in adulthood rather than to implement stricter rules in adulthood which may then be resented.
Social stories can be used to teach children and adults with ASD about appropriate social behaviour and what to do in certain situations. For further information on this, please contact the Autism Helpline, or see the resources section at the end of this information sheet.
Investigate social skills training. Unfortunately, provision for this is patchy, but in some areas social skills training is offered through schools, colleges or local autism societies. There are also a number of resources available to use at home. For further information see the resources section at the end of this information sheet or contact the NAS Autism Helpline (see details below).
Keep all the written information you have about your child's condition, for example their diagnosis and any specialist reports ever written about them. These may be useful if they ever come into contact with the police.

The Home Office has produced a useful leaflet called 'Keep Safe: a guide to personal safety' which is aimed at adults with a learning disability. It offers tips on keeping safe in the home and out in the community. Copies can be downloaded from www.crimereduction.gov.uk/keepsafe.pdf

Why might people with ASD become involved in the CJS?

People with ASD experience difficulties with communication, social interaction and social imagination. In addition, they may have sensory difficulties and some coordination problems. Their odd behaviour can sometimes draw unnecessary attention, but in general ASD is a hidden disability and it may not be immediately obvious to the public or people in the CJS that someone with ASD has special needs.

People with ASD can find themselves in contact with the CJS for a variety of reasons. The following examples are the main types of offences people with ASD may commit:

Offences relating to social naivety. For example, the desire to have friends has led some people with ASD to be befriended by, and become unwitting accomplices of, criminals. People with ASD often do not understand the motives of other people.
Offences of an aggressive nature. These are often related to an unexpected change in routine or to the environment, which may cause great anxiety and distress. A typical example would be a delay in public transport.
Offences relating to a misunderstanding of social cues. For example, many people with ASD have difficulties with eye contact, which will often be avoided or may be fleeting. In some cases, eye contact may be prolonged or inappropriate and on occasion this has been interpreted as making unwanted sexual advances.
People with ASD often adhere rigidly to rules. They may become extremely agitated if other people break these rules. For example, one man with ASD was known to kick cars that were parked illegally.

People with ASD often do not understand the implications of their behaviour and due to their difficulties with social imagination they often do not learn from past experience. They may repeatedly offend if not offered the correct support and intervention.

In addition, the methods used by the police may exacerbate a situation for someone with ASD. For example, the use of handcuffs and restraint may be extremely frightening for someone with ASD who does not understand what is happening and may not be able to communicate their fears in an appropriate way. This, coupled with the use of loud sirens, may cause an individual to experience sensory overload and try to escape a situation by running away or, in extreme circumstances, hitting out at people, including the police. The very presence of the police may cause great anxiety to a law-abiding person with ASD who has no comprehension of the crime they may have committed.

Criminal acts carried out by people with ASD can be due to a variety of factors, but there is rarely a deliberate intention to hurt others.

Police contact

Initial contact with the police can be very frightening for somebody with an ASD. Should you need to advise the police on how to approach someone with ASD the following would be sensible suggestions.

Switch off sirens and flashing lights.
Keep calm. People with ASD can often sense anxiety in other people, which in turn can make them more anxious.
People with ASD may not understand personal space. They may invade your personal space, or they may need more personal space than the average person.
Approach the person in a non threatening way and keep facial expressions and gestures to a minimum.
If you know the person's name, use it at the start of each sentence so that they know you are addressing them.
Give clear, slow and direct instructions. For example, "Jack, get out the car".
Allow the person time to process information and don't expect an immediate response to instructions.
Avoid using sarcasm, metaphors or irony. People with ASD may take things literally.
Do not shout at the person with ASD.
Make sure you explain clearly to the person what is happening. If you are taking them somewhere else, clearly explain where they are going to lessen their anxiety.
People with ASD often understand visual information better than spoken words. It may be useful to use visual supports to explain to the person with ASD what is happening or, if they can read, to put it in writing. More information on this is available from the Autism Helpline (see details below). If possible, avoid touching the person.
Do not attempt to stop the person from flapping or from other repetitive movements as this can sometimes be a self-calming strategy and may subside once things have clearly been explained to them.
Check the person for any injuries in as non-invasive way as possible. They may not be able to communicate if they are in pain.

Police powers

The police have the power to stop people in the street and may ask straightforward questions about a person's name, address and where they are heading. However, police must caution an individual before they can question them about a suspected offence.

The police can search a person, their bag or vehicle if they have reasonable grounds for suspecting that they may find:

stolen goods
a knife or other weapon
something that could be used to commit a crime; for example, someone else's credit card
drugs.

Strip and intimate searches can only take place if a person is reasonably suspected to be hiding drugs or articles that may cause physical harm. An officer of the same sex must carry out strip and intimate searches. An appropriate adult must be present if the individual is aged under 17 or deemed to be a vulnerable adult. A record of the search must be kept and a copy of this can be obtained from the police station if required.

If a person is arrested they must be informed of the reason. Reasonable force may only be used to detain someone if they attempt to resist or escape, which in the case of people with ASD is a possibility. For further information on this, see the Community Legal Service information leaflet called 'Dealing with the police'. www.clsdirect.org.uk/en/legalhelp/leaflet11_3.jsp

At the police station

Once a person has been detained, they become the responsibility of the custody officer. While detained at the station people have the following basic rights.

An interpreter if English is not their first language.
An appropriate adult; for example, a family member or someone from the appropriate adult scheme if the detainee is aged under 17 or is deemed to be a vulnerable adult by the Custody Officer. Appropriate adults are usually volunteers. Their role is to look after the welfare of the detainee. They are not able to offer legal advice, and usually do not have any training in ASD.
Notification of the arrest to a relative or friend.
The right to speak to a solicitor in private. If a person does not have their own solicitor they can speak to a duty solicitor. In many cases, people with ASD will refuse the services of a solicitor as they do not understand their role and become even more confused when another stranger becomes involved.
A notice explaining further rights, called Criminal defence services at the police station and in court will be given to the detainee. A full copy of this can be downloaded from the following website. www.legalservices.gov.uk

Custody officers have to ask everyone that comes into their custody whether they have a special need. Most people with ASD will reply no to this question, as it is not specific enough for them to understand. By the time the individual is at the police station it is absolutely essential that the person with ASD, or a relative, has informed the police that the person has ASD, as custody officers are rarely able to recognise the condition. However, if the custody officer does suspect the detainee may have a special need, the following process will be triggered.

The Force Medical Officer will be called (usually a local GP, often with limited knowledge of ASD) whose main role is to decide whether the individual is fit to be interviewed.
If the Force Medical Officer feels a psychiatric assessment is necessary, a duty social worker who is qualified to make an assessment under section 12 of the Mental Health Act will be called to make an assessment. Social workers often have only limited training in ASD and may not recognise if someone has the condition.
If the social worker identifies any difficulties, two signatures will be required from psychiatrists in order to take the person out of the CJS and into the mental health system. This does not necessarily mean that the individual will be sectioned.

Police interviews

The police may interview a person about suspected involvement in an offence before any charge is made. The interview will be taped and the interviewee is entitled to have a legal representative present during the interview.

Due to the difficulties people with ASD have with communication and social interaction, any police interview can be extremely difficult. The person may appear very able, with a good or even exceptional vocabulary, and there may be no reason for an interviewing police officer to suspect that the interviewee requires special help. However, the officer may later find they receive blunt answers, the subject is changed and the individual is reluctant to make direct eye contact. The literal way in which people with ASD interpret language can lead to them giving incorrect answers or becoming anxious. All these things contribute to an assumption of guilt. Indeed many of the key interrogation techniques used by interviewers could inadvertently elicit false confessions from a person with ASD.

The following are suggestions for interviewing people with ASD in a manner that they may understand, and which should help elicit the correct response.

Keep language that is clear, concise and simple.
Use short sentences.
Use the person's name at the start of each sentence so they know they are being addressed.
Avoid the use of any irony, sarcasm or metaphors, as these will be taken literally.
Ask specific questions that avoid ambiguity.
Be aware that the person with ASD may simply repeat back the question they were asked.
If asked a yes or no question, a person with ASD may repeat back the first or last word said with no understanding of the question. Dennis Debbaudt (2002) suggests asking a series of yes or no questions to determine the style and dependability of the response, and then following this up with the key yes or no questions you require an answer to.
Allow the individual extra thinking time to process the information.
Keep your facial expressions and hand gestures to a minimum.
The use of visual supports may be helpful.
The individual may need frequent breaks. Explain clearly that he or she is going to have a break for a specified amount of time and what will happen next. Signs that the person is becoming anxious and in need of a break may include repetitive speech, hand-flapping or other repetitive movements, self-injury such as hand biting, shouting or physical behaviour.
In all cases we would advise that a specialist in the field of autism, such as a clinical psychologist or psychiatrist, be contacted. The NAS Autism Helpline keeps a database of people who may be suitable to contact for this purpose.

Dennis Debbaudt (2002) has a useful chapter on the interview and interrogation of people with ASD in his book, which we would suggest police officers read before interviewing someone with ASD.

At the magistrates' court

In most cases, people with ASD are unfit to plead in court. If an individual does not have their own solicitor, duty solicitors are available at the Magistrates Court. If they recognise that their client has a mental health condition or ASD, a solicitor may ask the magistrate to delay the proceedings until a psychiatric report can be obtained. ASD is classified under the heading of 'Mental and behavioural disorders' under the International Classification of Diseases and is under the sub-group of 'Disorders of psychological development'. This classification offers the option for the magistrate to proceed under mental health rather than criminal legislation. Under the Mental Health Act 1983, section 37, providing the magistrate is satisfied the crime occurred and that the person with ASD is guilty, the following options are available.

A hospital order.
A guardianship order (where someone is appointed to act as a guardian for the individual).
An absolute discharge.

In the Crown Court

The Crown Court is reserved for the most serious of offences. The accused person with ASD should be assessed for their capacity to understand the proceedings. The judge or jury can decide on a person's fitness to plead and can draw on as many psychiatric reports as necessary in order to do this. It is essential by this stage to have a report from a specialist in the field of ASD. Details of a small number of specialists able to act in court cases are available from the NAS Autism Helpline. A solicitor may need to convince the Community Legal Service that paying for this assessment is worthwhile. Sometimes it is easier to obtain a specialist medical report after obtaining medical reports from the persons GP. In some cases, a court may make a hospital order for 28 days for assessment. This will usually be at the local psychiatric unit, where there may not necessarily be a specialist in ASD.

If the client is found unfit to plead the court has the following options.

A hospital order.
A guardianship order.

If the client is found fit to plead, the court proceedings will continue as usual.

The person with ASD as a witness or victim of crime

The suggestions for interviewing people with ASD mentioned previously will also be useful for interviewing someone with ASD who is witness to a crime. As a witness, a person with ASD is entitled to be accompanied by an appropriate adult during their interview.

All witnesses aged under 17 years, and people whose evidence is likely to be diminished because they have a mental disorder within the meaning of the mental health act 1983, or otherwise have significant impairment of intelligence or social functioning, or have a physical disability or physical disorder, are eligible to apply for special measures. These may include:

screens, to ensure that the witness cannot see the defendant in court
video-recorded evidence
live TV links, allowing the witness to give evidence from outside the court
clearing the public gallery of the court
removal of wigs and gowns in court
video-recorded pre-trial cross-examination
allowing the witness to use communication aids.

Further information on these special measures is available from the Crown Prosecution Service (see contacts section below).

A scheme that uses intermediaries to help vulnerable witnesses is being rolled out across England and Wales from April 2008. An intermediary can help a vulnerable witness understand the questions they are asked and can then communicate the witnesss response. Intermediaries can help witnesses at each stage of the criminal justice process.

People with ASD who are victims or witnesses of crime may require specialist counselling. Voice UK and Respond are able to offer this service to some people with the condition. For more information, see the Useful contacts section below.

Complaints against the police

If you need to make a complaint against the police you can directly contact the police force concerned or go to The Independent Police Complaints Commission. For further information, see the Useful contacts section below.

Useful contacts

1) Legal assistance

Community legal service
0845 608 1122
www.justask.org.uk
Able to locate local solicitors.

The Law Society
020 72421222
www.lawsociety.org.uk
Database of solicitors in England and Wales.

The Law Society of Scotland
0131 226 7411
www.lawscot.org.uk
Database of solicitors on Scotland.

Lawyers for people with a learning disability
020 72423332
Able to locate local solicitors with experience of representing clients with learning disabilities.

The National Autistic Societys Autism Helpline (see details below) has a very small list of solicitors specialising in criminal law with an understanding of ASD. Please note that the Helpline is unable to offer legal advice.

2) Specialist counselling

Respond
0845 8080700
www.respond.org.uk
Offers a telephone helpline and counselling service for adults with a learning disability who have been victims of abuse, or who have abused others.

Voice UK
0870 0133965
Offers a telephone helpline and counselling services for adults and children with learning disabilities who have been abused, and for their parents and carers.

The National Autistic Societys Autism Helpline (see details below) has a small database of counsellors with experience of counselling people with ASD and family members. Please note that the Helpline is unable to offer a counselling service.

3) Advocacy

Advocacy Resource Exchange
07967 622010
www.advocacyresource.net
Features a national database of advocacy organisations.

Action for advocacy
020 78207868
www.actionforadvocacy.org.uk
Details of advocacy organisations in the UK.

4) Appropriate adult schemes

National Appropriate Adult Network
www.appropriateadult.com

5) Support for victims and witnesses

Victim Support
0845 3030900
www.victimsupport.org.uk
Organisation for anyone affected by crime.

Crown Prosecution Service
www.cps.gov.uk
020 77968500
Produces a useful leaflet on special measures in the CJS for people with disabilities.

Intermediaries Registration Board
020 70358461
intermediaries@cjs.gsi.gov.uk

6) Complaints against the police

The Independent Police Complaints Commission
90 High Holborn
London
WC1V 6BH
0845 300 2002
www.ipcc.gov.uk
Website includes some useful easy to read leaflets on making a complaint.

Useful reading and resources

Debbaudt, D. (2002). Autism, advocates and law enforcement professionals. London: JKP

Hollins, S. et al. (1994). Going to Court. London: Books beyond words
(A very useful picture book about being a witness in the Crown Court. The pictures suit any crime and any verdict.)

Hollins, S. et al. (1996). You're on trial. London: Books beyond words

Hollins, S. et al. (1996). You're under arrest. London: Books beyond words

Howlin, P. (1997). Autism: Preparing for adulthood. London: Routledge*

The National Autistic Society. (2008). Autism: A guide for criminal justice professionals. London: The National Autistic Society
(Available through the NAS website at www.nas.org.uk/nas/jsp/polopoly.jsp?d=118&a=5632)

Autism alert cards
A mini-information pack for situations when communication may be difficult. The pack includes a key facts leaflet about autism and a credit-card style insert for emergency contacts. *

Police and autism
www.policeandautism.cjb.net
American site with some useful information about avoiding unfortunate situations.

Criminal Justice System Online
www.cjsonline.org
Useful website outlining the work of the Criminal Justice System.

Community Legal Advice
www.clsdirect.org.uk
Free confidential and independent legal advice for residents of England and Wales.

Yourrights.org.uk
www.yourrights.org.uk/your-rights/index.shtml
Useful website from Liberty outlining the rights of victims, witnesses, suspects, defendants and prisoners, amongst others.

NSPCC
0800 0560566
http://www.nspcc.org.uk
Website of The National Society for the Prevention of Cruelty to Children.

Resources for teaching social skills

Gray, C. (2002). My Social Stories Book. London: JKP*
Her website also has some useful information on social stories http://www.thegraycenter.org

Howlin, P. Baron-Cohen, S and Hadwin, J. (1998). Teaching Children with Autism to mind read: A Practical Guide. London: John Wiley & sons Ltd*

Welton, J. (2004). What did you say? What do you mean? An Illustrated Guide to Understanding Metaphors. London: JKP*

Related Information sheets available from the Autism Helpline

1) Autistic Spectrum Disorders and prison

If an item is marked as available from the NAS please contact:
NAS Publications
Central Books Ltd
99 Wallis Road
London E9 5LN
Tel: +44 (0)845 458 9911
Fax: +44 (0)845 458 9912
Email: nas@centralbooks.com
Online orders: www.autism.org.uk/pubs

If you require further information please contact the
NAS Autism Helpline
Tel: 0845 070 4004. autismhelpline@nas.org.uk

Last updated: March 2008
© The National Autistic Society 2008

The National Autistic Society is the UK's leading charity for people affected by autism

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Wed 17th

Asperger syndrome

Published by: Dean Rose on Wednesday 17th December 2008 02:12am

Asperger syndrome

From Wikipedia, the free encyclopedia

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Asperger syndrome Classification and external resources
ICD-10	F 84.5
ICD-9	299.80
OMIM	608638
DiseasesDB	31268
MedlinePlus	001549
eMedicine	ped/147
MeSH	F03.550.325.10

Asperger syndrome (also called Asperger's syndrome, Asperger's disorder, Asperger's or AS) is the autism spectrum disorder (ASD) in which there is no general delay in language or cognitive development. Like other ASDs, it is characterized by difficulties in social interaction and restricted, stereotyped patterns of behavior and interests. Although not mentioned in standard diagnostic criteria for AS, physical clumsiness and atypical use of language are frequently reported.^[1]^[2]

Asperger syndrome is named after Austrian pediatrician Hans Asperger who, in 1944, described children in his practice who lacked nonverbal communication skills, demonstrated limited empathy with their peers, and were physically clumsy.^[3] Fifty years later, AS was standardized as a diagnosis, but questions about many aspects of AS remain.^[4] For example, there is lingering doubt about the distinction between AS and high-functioning autism (HFA);^[5] partly due to this, the prevalence of AS is not firmly established. The exact cause of AS is unknown, although research supports the likelihood of a genetic basis; brain imaging techniques have not identified a clear common pathology.^[1]

There is no single treatment for Asperger syndrome, and the effectiveness of particular interventions is supported by only limited data.^[1] Intervention is aimed at improving symptoms and function. The mainstay of management is behavioral therapy, focusing on specific deficits to address poor communication skills, obsessive or repetitive routines, and physical clumsiness.^[6] Most individuals with AS can improve over time, but difficulties with communication, social adjustment and independent living continue into adulthood.^[4] Some researchers and people with AS have advocated a shift in attitudes toward the view that AS is a difference, rather than a disability that must be treated or cured.^[7]

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Classification

Hans Asperger described his young patients as "little professors".

Asperger syndrome is one of the autism spectrum disorders (ASD) or pervasive developmental disorders (PDD), which are a spectrum of psychological conditions 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 psychological development disorders, 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.^[8] ASD, in turn, is a subset of the broader autism phenotype (BAP), which describes individuals who may not have ASD but do have autistic-like traits, such as social deficits.^[9] Of the other four ASD forms, autism is the most similar to AS in signs and likely causes but its diagnosis requires impaired communication and allows delay in cognitive development, Rett syndrome and childhood disintegrative disorder share several signs with autism, but may have unrelated causes, and pervasive developmental disorder not otherwise specified (PDD-NOS) is diagnosed when the criteria for a more specific disorder are unmet.^[10] The extent of the overlap between AS and high-functioning autism (HFA—autism unaccompanied by mental retardation) is unclear.^[5]^[11]^[12] The current ASD classification may not reflect the true nature of the conditions.^[13] A panel session at a 2008 diagnosis-related autism research planning conference noted problems with the classification of AS as a distinct subgroup of ASD, and two of three breakout groups recommended eliminating AS as a separate diagnosis.^[14]

Characteristics

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.^[15] 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.^[5]

Social interaction

Further information: Asperger syndrome and interpersonal relationships

The lack of demonstrated empathy is possibly the most dysfunctional aspect of Asperger syndrome.^[2] Individuals with AS 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 (for example, 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.^[1]

Unlike those with autism, people with AS are not usually withdrawn around others; they approach others, even if awkwardly, for example by engaging in a one-sided, long-winded speech about a favorite topic while misunderstanding or not recognizing the listener's feelings or reactions, such as need for privacy or haste to leave.^[5] This social awkwardness has been called "active but odd".^[1] This failure to react appropriately to social interaction may appear as disregard for other people's feelings, and may come across as insensitive.^[5] The cognitive ability of children with AS often lets them articulate social norms in a laboratory context,^[1] where they may be able to show a theoretical understanding of other people’s emotions; they typically have difficulty acting on this knowledge in fluid, real-life situations, however.^[5] People with AS may analyze and distill their observation of social interaction into rigid behavioral guidelines and apply these rules in awkward ways—such as forced eye contact—resulting in demeanor that appears rigid or socially naive. Childhood desires for companionship can be numbed through a history of failed social encounters.^[1]

The hypothesis that individuals with AS are predisposed to violent or criminal behavior has been investigated but is not supported by data.^[1]^[16] More evidence suggests children with AS are victims rather than victimizers.^[17] A 2008 review found that an overwhelming number of reported violent criminals with AS had coexisting psychiatric disorders such as schizoaffective disorder.^[18]

Restricted and repetitive interests and behavior

People with AS often display intense interests, such as this boy's fascination with molecular structure.

People with Asperger syndrome often 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, or preoccupy themselves with parts of objects.^[15]

Pursuit of specific and narrow areas of interest is one of the most striking features of AS.^[1] Individuals with AS may collect volumes of detailed information on a relatively narrow topic such as dinosaurs or deep fat fryers, without necessarily having genuine understanding of the broader topic.^[1]^[5] For example, a child might memorize camera model numbers while caring little about photography.^[1] This behavior is usually apparent by grade school, typically age 5 or 6 in the United States.^[1] Although these special interests may change from time to time, they typically become more unusual and narrowly focused, and often dominate social interaction so much that the entire family may become immersed. Because topics such as dinosaurs often capture the interest of children, this symptom may go unrecognized.^[5]

Stereotyped and repetitive motor behaviors are a core part of the diagnosis of AS and other ASDs.^[19] They include hand movements such as flapping or twisting, and complex whole-body movements.^[15] These are typically repeated in longer bursts and look more voluntary or ritualistic than tics, which are usually faster, less rhythmical and less often symmetrical.^[20] Speech and language

Although individuals with Asperger syndrome acquire language skills without significant general delay and their speech typically lacks significant abnormalities, language acquisition and use is often atypical.^[5] Abnormalities include verbosity, abrupt transitions, literal interpretations and miscomprehension of nuance, use of metaphor meaningful only to the speaker, auditory perception deficits, unusually pedantic, formal or idiosyncratic speech, and oddities in loudness, pitch, intonation, prosody, and rhythm.^[1]

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 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 monitor 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.^[5]

Children with AS may have an unusually sophisticated vocabulary at a young age and have been colloquially called "little professors", but have difficulty understanding figurative language and tend to use language literally.^[1] Children with AS appear to have particular weaknesses in areas of nonliteral language that include humor, irony, and teasing. Although individuals with AS usually understand the cognitive basis of humor they seem to lack understanding of the intent of humor to share enjoyment with others.^[12] Despite strong evidence of impaired humor appreciation, there are anecdotal reports of humor in individuals with AS, which challenge theories of humor in AS.^[21]

Other

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.^[22] 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.^[23] Conversely, compared to individuals with HFA, individuals with AS have deficits in some tasks involving visual-spatial perception, auditory perception, or visual memory.^[1] Many accounts of individuals with AS and ASD report other unusual sensory and perceptual skills and experiences. They may be unusually sensitive or insensitive to sound, light, touch, texture, taste, smell, pain, temperature, and other stimuli, and they may exhibit synesthesia;^[24] 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.^[25]

Hans Asperger’s initial accounts^[1] and other diagnostic schemes^[26] include descriptions of physical clumsiness. Children with AS may be delayed in acquiring skills requiring motor 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 visual-motor integration.^[1]^[5] They may show problems with proprioception (sensation of body position) on measures of apraxia (motor planning disorder), balance, tandem gait, and finger-thumb apposition. There is no evidence that these motor skills problems differentiate AS from other high-functioning ASDs.^[1]

Children with AS are more likely to have sleep problems, including difficulty in falling asleep, frequent nocturnal awakenings, and early morning awakenings.^[27]^[28] AS is also associated with high levels of alexithymia, which is difficulty in identifying and describing one's emotions.^[29] Although AS, lower sleep quality, and alexithymia are associated, their causative relationship is unclear.^[28]

Causes

Further information: Causes of autism

Hans Asperger described common symptoms among his patients' family members, especially fathers, and research supports this observation and suggests a genetic contribution to Asperger syndrome. Although no specific gene has yet been identified, multiple factors are believed to play a role in the expression of autism, given the phenotypic variability seen in this group of children.^[1]^[30] Evidence for a genetic link is the tendency for AS to run in families and an observed higher incidence of family members who have behavioral symptoms similar to AS but in a more limited form (for example, slight difficulties with social interaction, language, or reading).^[6] Most research suggests that all autism spectrum disorders have shared genetic mechanisms, but AS may have a stronger genetic component than autism.^[1] There is probably a common group of genes where particular alleles render an individual vulnerable to developing AS; if this is the case, the particular combination of alleles would determine the severity and symptoms for each individual with AS.^[6]

A few ASD cases have been linked to exposure to teratogens (agents that cause birth defects) during the first eight weeks from conception. Although this does not exclude the possibility that ASD can be initiated or affected later, it is strong evidence that it arises very early in development.^[31] Many environmental factors have been hypothesized to act after birth, but none has been confirmed by scientific investigation.^[32]

Mechanism

Further information: Mechanism of autism

Asperger syndrome appears to result from developmental factors that affect many or all functional brain systems, as opposed to localized effects.^[33] 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,^[1] it is still possible that AS's mechanism is separate from other ASD.^[34] Neuroanatomical studies and the associations with teratogens strongly suggest that the mechanism includes alteration of brain development soon after conception.^[31] Abnormal migration of embryonic cells during fetal development may affect the final structure and connectivity of the brain, resulting in alterations in the neural circuits that control thought and behavior.^[35] Several theories of mechanism are available; none is likely to provide a complete explanation.^[36]

Functional magnetic resonance imaging provides some evidence for both underconnectivity and mirror neuron theories.^[37]^[38]

The underconnectivity theory hypothesizes underfunctioning high-level neural connections and synchronization, along with an excess of low-level processes.^[37] It maps well to general-processing theories such as weak central coherence theory, which hypothesizes that a limited ability to see the big picture underlies the central disturbance in ASD.^[39] A related theory—enhanced perceptual functioning—focuses more on the superiority of locally oriented and perceptual operations in autistic individuals.^[40]

The mirror neuron system (MNS) theory hypothesizes that alterations to the development of the MNS interfere with imitation and lead to Asperger's core feature of social impairment.^[38]^[41] For example, one study found that activation is delayed in the core circuit for imitation in individuals with AS.^[42] 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,^[43] or hyper-systemizing, which hypothesizes that autistic individuals can systematize internal operation to handle internal events but are less effective at empathizing by handling events generated by other agents.^[44]

Other possible mechanisms include serotonin dysfunction^[45] and cerebellar dysfunction.^[46]

Screening

Parents of children with Asperger syndrome can typically trace differences in their children's development to as early as 30 months of age.^[30] Developmental screening during a routine check-up by a general practitioner or pediatrician may identify signs that warrant further investigation.^[1]^[6] The diagnosis of AS is complicated by the use of several different screening instruments,^[6]^[26] including the Asperger Syndrome Diagnostic Scale (ASDS), Autism Spectrum Screening Questionnaire (ASSQ), Childhood Asperger Syndrome Test (CAST), Gilliam Asperger’s Disorder Scale (GADS), Krug Asperger’s Disorder Index (KADI),^[47] and the Autism Spectrum Quotient (AQ).^[48] None have been shown to reliably differentiate between AS and other ASDs.^[1]

Diagnosis

Main article: Diagnosis of Asperger syndrome

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,^[8] U.S. criteria also require significant impairment in day-to-day functioning.^[15] Other sets of diagnostic criteria have been proposed by Szatmari et al.^[49] and by Gillberg and Gillberg.^[50]

Diagnosis is most commonly made between the ages of four and eleven.^[1] A comprehensive assessment involves a multidisciplinary team^[2]^[6]^[51] that observes across multiple settings,^[1] and includes neurological and genetic assessment as well as tests for cognition, psychomotor function, verbal and nonverbal strengths and weaknesses, style of learning, and skills for independent living.^[6] The current "gold standard" in diagnosing ASDs combines clinical judgment with the Autism Diagnostic Interview-Revised (ADI-R)—a semistructured parent interview—and the Autism Diagnostic Observation Schedule (ADOS)—a conversation and play-based interview with the child.^[4] Delayed or mistaken diagnosis can be traumatic for individuals and families; for example, misdiagnosis can lead to medications that worsen behavior.^[51] Many children with AS are initially misdiagnosed with attention-deficit hyperactivity disorder (ADHD).^[1] Diagnosing adults is more challenging, as standard diagnostic criteria are designed for children and the expression of AS changes with age.^[52] Conditions that must be considered in a differential diagnosis include other ASDs, the schizophrenia spectrum, ADHD, obsessive compulsive disorder, depression, semantic pragmatic disorder, nonverbal learning disorder,^[51] Tourette syndrome,^[20] stereotypic movement disorder and bipolar disorder.^[30]

Underdiagnosis and overdiagnosis are problems in marginal cases. The cost of screening and diagnosis and the challenge of obtaining payment can inhibit or delay diagnosis. Conversely, the increasing popularity of drug treatment options and the expansion of benefits has motivated providers to overdiagnose ASD.^[53] There are indications AS has been diagnosed more frequently in recent years, partly as a residual diagnosis for children of normal intelligence who do not have autism but have social difficulties. There are questions about the external validity of the AS diagnosis, that is, it is unclear whether there is a practical benefit in distinguishing AS from HFA and from PDD-NOS;^[54] the same child can receive different diagnoses depending on the screening tool.^[6]

Management

Further information: Autism therapies

Asperger syndrome treatment attempts to manage distressing symptoms and to teach age-appropriate social, communication and vocational skills that are not naturally acquired during development,^[1] with intervention tailored to the needs of the individual child, based on multidisciplinary assessment.^[55] Although progress has been made, data supporting the efficacy of particular interventions are limited.^[1]^[56]

The ideal treatment for AS coordinates therapies that address core symptoms of the disorder, including poor communication skills and obsessive or repetitive routines. While most professionals agree that the earlier the intervention, the better, there is no single best treatment package.^[6] AS treatment resembles that of other high-functioning ASDs, except that it takes into account the linguistic capabilities, verbal strengths, and nonverbal vulnerabilities of individuals with AS.^[1] A typical program generally includes:^[6]

the training of social skills for more effective interpersonal interactions,^[57]
cognitive behavioral therapy to improve stress management relating to anxiety or explosive emotions,^[58] and to cut back on obsessive interests and repetitive routines,
medication, for coexisting conditions such as depression and anxiety,^[59]
occupational or physical therapy to assist with poor sensory integration and motor coordination,
social communication intervention, which is specialized speech therapy to help with the pragmatics of the give and take of normal conversation,^[60]
the training and support of parents, particularly in behavioral techniques to use in the home.

Of the many studies on behavior-based early intervention programs, most are case studies 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.^[61] Despite the popularity of social skills training, its effectiveness is not firmly established.^[62] 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.^[63] Vocational training is important to teach job interview etiquette and workplace behavior to older children and adults with AS, and organization software and personal data assistants to improve the work and life management of people with AS are useful.^[1]

No medications directly treat the core symptoms of AS.^[59] Although research into the efficacy of pharmaceutical intervention for AS is limited,^[1] it is essential to diagnose and treat comorbid conditions.^[2] Deficits in self-identifying emotions or in observing effects of one's behavior on others can make it difficult for individuals with AS to see why medication may be appropriate.^[59] Medication can be effective in combination with behavioral interventions and environmental accommodations in treating comorbid symptoms such as anxiety, depression, inattention and aggression.^[1] The atypical neuroleptic medications risperidone and olanzapine have been shown to reduce the associated symptoms of AS;^[1] 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.^[1]^[2]^[30]

Care must be taken with medications; abnormalities in metabolism, cardiac conduction times, and an increased risk of type 2 diabetes have been raised as concerns with these medications,^[64]^[65] along with serious long-term neurological side effects.^[61] SSRIs can lead to manifestations of behavioral activation such as increased impulsivity, aggression and sleep disturbance.^[30] Weight gain and fatigue are commonly reported side effects of risperidone, which may also lead to increased risk for extrapyramidal symptoms such as restlessness and dystonia^[30] and increased serum prolactin levels.^[66] Sedation and weight gain are more common with olanzapine,^[65] which has also been linked with diabetes.^[64] Sedative side-effects in school-age children^[67] 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.^[68]

Prognosis

There is some evidence that as many as 20% of children with AS "grow out" of it, and fail to meet the diagnostic criteria as adults.^[4] As of 2006, no studies addressing the long-term outcome of individuals with Asperger syndrome are available and there are no systematic long-term follow-up studies of children with AS.^[5] Individuals with AS appear to have normal life expectancy but have an increased prevalence of comorbid psychiatric conditions such as depression and anxiety that may significantly affect prognosis. Although social impairment is lifelong, outcome is generally more positive than with individuals with lower functioning autism spectrum disorders;^[1] for example, ASD symptoms are more likely to diminish with time in children with AS or HFA.^[69] Although most students with AS/HFA have average mathematical ability and test slightly worse in mathematics than in general intelligence, some are gifted in mathematics^[70] and AS has not prevented some adults from major accomplishments such as winning the Nobel Prize.^[71]

Children with AS may require special education services because of their social and behavioral difficulties although many attend regular education classes.^[5] Adolescents with AS may exhibit ongoing difficulty with self-care, organization and disturbances in social and romantic relationships; despite high cognitive potential, most young adults with AS remain at home, although some do marry and work independently.^[1] The "different-ness" adolescents experience can be traumatic.^[72] 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;^[1] the resulting stress may manifest as inattention, withdrawal, reliance on obsessions, hyperactivity, or aggressive or oppositional behavior.^[58] Depression is often the result of chronic frustration from repeated failure to engage others socially, and mood disorders requiring treatment may develop.^[1] Clinical experience suggests the rate of suicide may be higher among those with AS, but this has not been confirmed by systematic empirical studies.^[73]

Education of families is critical in developing strategies for understanding strengths and weaknesses;^[2] helping the family to cope improves outcome in children.^[17] Prognosis may be improved by diagnosis at a younger age that allows for early interventions, while interventions in adulthood are valuable but less beneficial.^[2] 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.^[2]

Epidemiology

Further information: Conditions comorbid to autism spectrum disorders

Prevalence estimates vary enormously. A 2003 review of epidemiological studies of children found prevalence rates ranging from 0.03 to 4.84 per 1,000, with the ratio of autism to Asperger syndrome ranging from 1.5:1 to 16:1;^[74] combining the average 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.^[75] 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.^[76]

Anxiety and depression are the most common other conditions seen at the same time; comorbidity of these in persons with AS is estimated at 65%.^[1] Depression is common in adolescents and adults; children are likely to present with ADHD.^[77] Reports have associated AS with medical conditions such as aminoaciduria and ligamentous laxity, but these have been case reports or small studies and no factors have been associated with AS across studies.^[1] One study of males with AS found an increased rate of epilepsy and a high rate (51%) of nonverbal learning disorder.^[78] AS is associated with tics, Tourette syndrome, and bipolar disorder, and the repetitive behaviors of AS have many similarities with the symptoms of obsessive-compulsive disorder and obsessive-compulsive personality disorder.^[79] Although many of these studies are based on psychiatric clinic samples without using standardized measures, it seems reasonable to conclude that comorbid conditions are relatively common.^[4]

History

Main article: History of Asperger syndrome

Named after the Austrian pediatrician Hans Asperger (1906–80), Asperger syndrome is a relatively new diagnosis in the field of autism.^[80] In 1944, Asperger described four children in his practice^[2] who had difficulty in integrating themselves socially. The children lacked nonverbal communication skills, failed to demonstrate empathy with their peers, and were physically clumsy. Asperger called the condition "autistic psychopathy" and described it as primarily marked by social isolation.^[6] Unlike today's AS, autistic psychopathy could be found in people of all levels of intelligence, including those with mental retardation.^[81] He called his young patients "little professors",^[3] and believed some would be capable of exceptional achievement and original thought later in life.^[2] His paper was published during wartime and in German, so it was not widely read elsewhere.

Lorna Wing popularized the term Asperger syndrome in the English-speaking medical community in her 1981 publication^[82] of a series of case studies of children showing similar symptoms,^[80] and Uta Frith translated Asperger's paper to English in 1991.^[3] Sets of diagnostic criteria were outlined by Gillberg and Gillberg in 1989 and by Szatmari et al. in the same year.^[76] AS became a standard diagnosis in 1992, when it was included in the tenth edition of the World Health Organization’s diagnostic manual, International Classification of Diseases (ICD-10); in 1994, it was added to the fourth edition of the American Psychiatric Association's diagnostic reference, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).^[6]

Hundreds of books, articles and websites now describe AS, and prevalence estimates have increased dramatically for ASD, with AS recognized as an important subgroup.^[80] Whether it should be seen as distinct from high-functioning autism is a fundamental issue requiring further study.^[2] There is little consensus among clinical researchers about the use of the terms Asperger's syndrome or Asperger's disorder, and there are questions about the empirical validation of the DSM-IV and ICD-10 criteria.^[5]

Cultural aspects

Further information: Sociological and cultural aspects of autism

People with Asperger syndrome may refer to themselves in casual conversation as aspies, coined by Liane Holliday Willey in 1999.^[83] The word neurotypical (abbreviated NT) describes a person whose neurological development and state are typical, and is often used to refer to non-autistic people. The Internet has allowed individuals with AS to communicate and celebrate with each other in a way that was not previously possible due to their rarity and geographic dispersal. A subculture of aspies has formed. Internet sites like Wrong Planet have made it easier for individuals to connect.^[7]

Autistic people have contributed to a shift in perception of autism spectrum disorders as complex syndromes rather than diseases that must be cured. Proponents of this view reject the notion that there is an "ideal" brain configuration and that any deviation from the norm is pathological; they promote tolerance for what they call neurodiversity.^[84] These views are the basis for the autistic rights and autistic pride movements.^[85] There is a contrast between the attitude of adults with self-identified AS, who typically do not want to be cured and are proud of their identity, and parents of children with AS, who typically seek assistance and a cure for their children.^[86]

Some researchers have argued that AS can be viewed as a different cognitive style, not a disorder or a disability.^[7]^[87] In a 2002 paper, 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 math, computing, cataloguing, 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.^[88] It has been argued that the genes for Asperger's combination of abilities have operated throughout recent human evolution and have made remarkable contributions to human history.^[

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Asperger's Syndrome

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Mental health and Asperger syndrome

Introduction

Depression

Anxiety

Obsessive compulsive disorder

Schizophrenia

Psychological treatments

Catatonia

Conclusion

References

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Criminal justice system and ASDs

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Why might people with ASD become involved in the CJS?

Police contact

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At the police station

Police interviews

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In the Crown Court

The person with ASD as a witness or victim of crime

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Asperger syndrome

Asperger syndrome

From Wikipedia, the free encyclopedia

Contents

Classification

Characteristics

Social interaction

Restricted and repetitive interests and behavior

Other

Causes

Mechanism

Screening

Diagnosis

Management

Prognosis

Epidemiology

History

Cultural aspects

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