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DeWulf Workshop

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									Asperger’s Disorder

         Michael J. DeWulf, Ph.D.
                 Clinical Director
         Keystone Human Services
          of Central Pennsylvania
Asperger’s Disorder

• Described as a “social learning disorder”
• Dr. Hans Asperger, Austria, 1944
• Initially referred to as “autistic psychopathy” and
  later changed to “Asperger’s syndrome”
• Research on autism as a “separate and distinct type
  of developmental disability” was being conducted by
  Dr. Leo Kanner at about the same time in the U.S.
• Only an official diagnosis since 1994
• Is Asperger’s disorder “high functioning autism?”
DSM-4 Diagnostic Criteria
Impairment in social functioning with at least two of the
following:

   •   Impairment in the use of multiple nonverbal behaviors
       (eye contact, facial expressions, postures, and gestures)
       used in social interaction
   •   Failure to develop peer relationships appropriate to
       developmental level
   •   Failure to share enjoyment, interests, and achievements
       with others
   •   Lack of social or emotional reciprocity
DSM-4 Diagnostic Criteria (continued)
Restricted, repetitive, and stereotyped patterns of
behavior, interests, and activities with one or more of the
following:

   •   Encompassing preoccupation with one or more
       stereotyped interests considered abnormal either in
       intensity or focus
   •   Inflexible adherence to specific, repetitive routines
   •   Stereotyped and repetitive motor mannerisms (hand or
       finger flapping, twisting, complex whole-body movements)
   •   Preoccupation with parts of objects
DSM-4 Diagnostic Criteria (continued)


• Causes clinically significant impairment of social,
  occupational, or other important areas of functioning
• No significant delays in language development
• No delays in intellectual development, self-help
  skills, adaptive behavior, or curiosity about the
  environment as children
• Criteria are not met for schizophrenia or another
  Pervasive developmental disorder
ICD-10 Diagnostic Criteria (WHO)


Summary

•   No significant delays in language development
•   Impaired social interactions (eye-to-eye gaze, lack of seeking
    out of spontaneous enjoyment, etc.)
•   Circumscribed interests
•   Not due to another disorder (see differential diagnosis)
Gillberg’s Criteria
Summary

•   Impairment in reciprocal social interaction
•   Limited interests, preoccupations
•   Repetitive routines or rituals
•   Speech and language peculiarities
•   Non-verbal communication problems
•   Motor clumsiness


    *All six criteria must be met for confirmation of the diagnosis
Incidence/Cause of Asperger’s
Disorder


•   Incidence
•   Biological factors
•   Genetic contributions
•   Neurochemical differences
•   Neurological impairments
•   Do people with Asperger’s disorder have specific
    medical needs?
Areas of Assessment

• Behavioral or psychiatric, if needs are evident
• Pragmatic language (tone, volume, nuance,
  metaphors or other figures of speech) and
  perspective-taking
• Academic (e.g., organizational skills, school
  curriculum, reading comprehension)
• Non-verbal communication (body posture, nods,
  “looks”)
• Social and emotional
• Gross and fine motor skill
Assessment: Rating Scales

 •   Australian Scale for Asperger’s Syndrome (ASAS)
 •   Autism Diagnostic Interview (ADI)
 •   Autism Diagnostic Observation Scale (ADOS)
 •   Social/Communication Questionnaire
 •   Childhood Autism Rating Scale (CARS)
 •   Asperger’s Syndrome Diagnostic Scale (ASDS)
 •   Gilliam Asperger’s Disorder Scale (GADS)
 •   Krug Asperger’s Disorder Index (KADI)
 •   Psychoeducational Profile (PEP-R)
Differential Diagnosis

 • Obsessive Compulsive and OC Personality Disorder
   (aka “anankastic personality disorder”)
 • Schizophrenia spectrum disorders (schizophrenia,
   schizotypal or schizoid personality disorder)
 • Oppositional-defiant or disruptive behavior disorder
 • AD/HD or mania associated with bipolar disorder
 • Any other pervasive developmental disorder
 • Social Phobia
 • Reactive Attachment Disorder of Childhood
Characteristic Features


•   Good auditory and visual perception
•   Motor clumsiness
•   Facial grimaces
•   Odd hand gestures
•   Gait abnormalities
•   Pronoun substitution
•   Overly precise speech
•   Use of invented words
Characteristic Features

 •   All or nothing thinking
 •   Catastrophizing
 •   Literal interpretation of information
 •   Rigid and inflexible thinking
 •   Difficulty adjusting to physical proximity
 •   Nonspecific neurological deficits
 •   Circumscribed interests
 •   “Tunnel” vision
Associated Features and Disorders
• Higher incidence of anxiety disorders (e.g., OCD,
  phobias, and PTSD)
• Higher incidence of mood disorders (e.g., depression,
  dysthymia, and bipolar)
• By DSM-4 diagnostic criteria, cannot be diagnosed
  with developmental delay?
• Has a later onset than autism, fewer communication
  and language problems, and more motor skill deficits
• Difficulty showing empathy, “tunnel vision”, and
  engaging in adequate social interaction
Communication

Three Areas of Interest

1.   Inflection and intonation
2.   Tangential, circumstantial speech
3.   Verbosity
Teaching Communication
•   Interpret speech literally. Be careful with nuance/metaphor
•   Model sympathetic comments
•   Avoid “essay” responses
•   Responding (when called by name, when making requests,
    when receiving instructions)
•   Tone of voice, volume of speech
•   Initiating and terminating social interactions, appropriate
    conversational topics, changing topics, and taking turns when
    speaking to others
•   Responding to non-verbal cues (smiles, raised eyebrows)
•   Use of visual aids when teaching abstract concepts
•   Write things down
Social Skills
 •   Not well established as an effective “therapeutic technique”,
     but popular nonetheless
 •   People with AD are aware of the presence of others and want
     to have social relationships, but may not know how to
     establish or maintain them
 •   Seem to have difficulty acting on known information in a
     spontaneous or intuitive way, so the person may resort to
     formalistic rules of behavior and social convention
 •   PRACTICE in simulated conditions (for example, counseling,
     video modeling and e-learning)
 •   Do not stand too close or too far
Teaching Social Skills
 •   Teach to initiate peer interactions as a first step toward the
     goal of helping the person make friends.
 •   The person may need help learning certain aspects of body
     posture, eye contact, proximity to others, and responding to
     social cues. Do not “rush through” the teaching
 •   Teach and encourage sharing and turn taking (under the
     general heading of “reciprocal” social interactions or
     “perspective-taking”
 •   Responding to social praise and criticism
 •   Know what the person likes and dislikes socially and use
     this knowledge when planning activities
 •   Provide the person with adequate “alone” time
Behavior Development

•   Identify and avoid known antecedents (triggers). Stress often
    precedes difficult behavior and can typically be avoided with
    proper planning
•   Consistent, clear, predictable routines can help the person
    organize their time and place
•   Be clear with regard to behavioral expectations
•   Introduce change gradually and help explain changes with
    visual cues
•   If the person becomes agitated, understand that the usual
    strategies for calming a person down may have the opposite
    effect and lead to further agitation
Behavior Development

 • Teach and encourage self-calming techniques
   (allow some level of self-stimulation)
 • Flexibility with routines and changes in the
   environment, when necessary
 • Modeling, role playing, practice, and feedback
   in dealing with stressful events BEFORE they
   occur
 • Avoid sensory overload
 • Use interests as reinforcers for other behaviors
   that need development
Take Home Messages
 •   For children, address academic and school needs
 •   Address motor deficits with OT and PT referrals
 •   Focus teaching on developing social skills, to a lesser extent,
     communication skills
 •   Provide teaching in stress management
 •   Never leave out steps of a task analysis. The person needs the
     details, and only the details
 •   Teaching is often best accomplished in a repetitious, rote
     fashion (sequential rather than simultaneous presentation of
     the materials)
 •   Treat a “meltdown” like a seizure. Every person is different,
     what works for one person may or may not work for another
Take Home Messages

• Self-stimulation = self-regulation. Help people burn off extra
  adrenaline by exercising or engaging in other physical activities
• A cluttered, ever changing, unpredictable environment may be
  confusing and cause anxiety
• Write short, concise behavior support plans when indicated and
  focus on prevention (antecedent strategies)
• Do not force the person to “fit in” places that may cause stress or
  make them uncomfortable
• People with AD have very sensitive tongues. Food taste/texture
  may have a more pronounced effect
• The person may be sensitive to bright light. Use hats and glasses
  if needed
• No surprise parties
• Never use restraint unless absolutely necessary
                                        References


Baron-Cohen, S., Wheelwright, S., Robinson, J. & Woodbury-Smith (2005). The Adult Asperger
      Assessment (AAA): A Diagnostic Method. Journal of Autism and Developmental Disorders,
      35, 807-819.
Bauer, S. (2004). Asperger’s Syndrome. Online Asperger Syndrome Information and Support.
      Retrieved May 26, 2004 from http://www.udel.edu/bkirby/asperger /as_thru_years.html.
Bishop, D.V.M. (1989). Autism, Asperger’s syndrome, and semantic-pragmatic disorder: Where
      are the Boundaries (Electronic Version]? British Journal of Disorders of Communication, 24,
      107-121.
Cumine, V. Leach, J. & Stevenson, G. (1998). Asperger Syndrome: A Practical Guide for Teachers.
      Fulton: London
DeWulf, M.J. & Fedezko, J.A. (2003). Asperger’s Disorder. Harrisburg, PA: Keystone Human
      Services.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
      (4th ed.)Washington, DC: Author.
Faherty, C. (2004). Asperger’s Syndrome in Women: A Different Set of Challenges? Autism Today.
      Retrieved May 26, 2004 from http://www.autismtoday.com/articles/ Asperger’s_in_Women.
      htm
Gillberg, C. (1991). Outcome in autism and autistic-like conditions. Journal of the American
      Academy of Child Adolescent Psychiatry, 30, 375-382.
Gilliam, J. (2001). The Gilliam Asperger’s Disorder Scale. Austin, TX: Pro-Ed.
                                      References (cont.)



Klin, A. & Volkmar, F.R. (1995). Asperger’s Syndrome: Guidelines for Assessment and Diagnosis.
      Retrieved September 14, 2004 from, http://info.med.yale.edu/chldstdy/
      autism/astreatments.html
Klin, A. & Volkmar, F.R. (1995). Asperger’s Syndrome: Guidelines for Treatment and Intervention.
      Retrieved May 26, 2004, from http://info.med.yale.edu/chldstdy/autism/ asdiagnosis.html
Kowalski, T. (2005). Asperger’s Syndrome. Harrisburg, PA: Cross Country Education.
Lipsitz, L. (2003). Portraits of Asperger’s Syndrome: Identification and Intervention Alternatives.
      National Association for Dual Diagnosis Bulletin, 6, 116-119
Luiselli, J.K., Taras, M. & Lennon, L. (1998). Behavioral Support for Persons with Asperger’s
      Disorder. Mental Health Aspects of Developmental Disabilities, 1, 1-9.
Myles, B.S. & Simpson, R.L. (1998). Asperger Syndrome: A Guide for Educators and Parents (2nd
      Ed.). Austin: Pro-ED.
Myles, B.S., Jones-Bock, S., & Simpson, R.L. (2000). Asperger Syndrome Diagnostic Scale. Austin:
      Pro ED.
Simpson, R.L. (2001, May). Children and youth with Asperger syndrome: The search for effective
      practices. Paper presented at the Association for Behavior Analysis Convention, New Orleans,
      LA.
Szalavitz, M. (2009). Asperger’s Theory Does about Face. Retrieved May 27, 2009 from
      http://www.thestar.com/article/633688
Williams, K. (1995, June). Understanding the Student with Asperger’s Syndrome: Guidelines for
      Teachers [Electronic version]. Focus on Autistic Behavior, 10, 1-8.

								
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