Diagnostic Assessment for Asperger’s Syndrome The Continuum of Autism



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Diagnostic Assessment for Asperger’s Syndrome

  • The Continuum of Autism:

  • From the work of Tony Atwood


What is Asperger’s Syndrome?



Symptoms of Asperger’s Syndrome



Aloof

  • Avoid interactions

  • Mute

  • Behavior the main means of communication

  • Fascination with sensory experience



Passive



Active but Odd

  • Often initiates interactions of short duration

  • Repetitive questions (social echolalia, script, alternative meaning, reassurance)

  • Lack of social play with others

  • Fascination with a specific topic or person.



Six Pathways to a Diagnosis of Asperger’s Syndrome

  • Diagnosis of autism in early childhood

  • Significant natural progress between 4 and 6 years of age

  • Effective early intervention programs

  • Progression along the continuum of autism



Recognition of Characteristics When First Enrolled at School

  • No clear signs of autism in early childhood

  • Teacher notices conspicuous features

  • Avoids social play with peers

  • Unaware of the codes of social conduct

  • Unusual qualities in conversation and imaginative play

  • Intense interest in a specific interest

  • Clumsiness when running, writing and catching

  • Teacher completes a developmental checklist for Asperger’s syndrome (ASAS)



Diagnosis of a Relative with Autism or Asperger’s Syndrome



Dual Diagnosis

  • Attention deficit disorder

  • Language disorder

  • Cerebral palsy

  • Tourette’s disorder



Secondary Psychiatric Disorder

  • Depression

  • Anxiety disorder such as Obsessive Compulsive Disorder

  • Anger management

  • Schizophrenia



Residual Asperger’s Syndrome in an Adult

  • Self referral due to a relative having the diagnosis or information from the media

  • Agency referral from psychiatric services, forensic psychology and employment agencies



Diagnostic Assessment



Social Impairment

  • Reciprocity (the balance between participants)

  • Inclusion (welcome, cooperation and control)



Pretending to be Normal

  • “…the fun came from setting up and arranging things. Maybe this desire to organize things rather than play with things, is the reason I never had a great interest in my peers. They always wanted to use the things I had so carefully arranged. They would want to rearrange and redo. They did not let me control the environment.”



Social Impairment

  • Level of maturity in deceit

  • Limited ability with team skills

  • Limited range of facial expressions and body language

  • Difficulty reading the facial expressions and body language of others

  • Limited ability to conceptualize the thoughts and feelings of others



Speech and Language Characteristics



Pragmatic Aspects

  • The art of conversation

  • Reciprocity

  • Repairing a conversation

  • Knowing when and how to interrupt

  • Inappropriate comments

  • Keeping on track

  • Primarily interested in an exchange of information

  • Appropriate topics

  • Monologues or scripts

  • Recognizing and accepting different points of view

  • Literal interpretation



Prosody or the Melody of Speech

  • Lack of change of vocal tone and volume to indicate emotion and key words

  • Lack of variation in pitch, stress and rhythm

  • Accent not consistent with that of the local children

  • Difficulty understanding the relevance of the change in tone, inflection or emphasis on certain words when listening to the speech of others



Pedantic Speech

  • Overly Formal

  • Excessive technical details

  • “Adult” quality, sophisticated grammar or phrases

  • Must correct errors

  • Precise intonation



Unusual Qualities of Speech



Special Interests

  • Dominate the person’s time and conversation

  • Statistics, cataloguing and symmetry

  • Idiosyncratic



Motor Clumsiness



Cognition

  • Problems with advanced Theory of Mind Skills

  • Weak Central Coherence

  • Impaired Executive Function

  • Profile on an Intelligence Test

  • Visualisers or verbalisers

  • Enclopedic memory

  • Solitary and idiosyncratic play

  • Preference for routines

  • Limited flexibility in thinking

  • Originality in problem solving



Sensory Sensitivity

  • Sound sensitivity

  • Tactile sensitivity

  • Sensitivity to the taste or texture of food

  • Stoic in response to pain or temperature

  • Synaesthesia



Relevant Information

  • Family history of similar individuals

  • Reports from teachers and therapists

  • Medical investigations and medicine

  • Developmental history

  • Prior diagnosis

  • Presence of a psychiatric disorder

  • Observation at school and home



Issues Relevant to the Diagnostic Assessment



Alternative Terms

  • HFA and AS at the behavioral and treatment level, are more the same than different

  • Lack of expertise, experience and confidence in the diagnosis of AS



Developing Social Skills and Understanding Emotions



Social Play

  • Observe and make notes of the social “play” of the child’s peers

  • Note the “script” and “acts”

  • Rehearse with an adult acting as a friend

  • Turn taking and help

  • “Rent a friend” as a “dress rehearsal”

  • Practice with same age peers

  • Social Sandwich

  • Sharing experiences



Strategies for Social Integration



Inclusion with Ordinary Children

  • Observation of appropriate social/emotional behavior

  • Peer group who know how to modify their behavior to accommodate and support the child



Knowledge of the Nature of Asperger’s Syndrome



Teach Theory of Mind Skills

  • Photographs, text, drawings, games

  • Metaphor

  • Social Stories

  • Comic Strip Conversations

  • Social Skills Groups



Encourage Friendship Skills

  • Behavioral strategies of task analysis, shaping, prompting and rewards

  • Cognitive strategies to learn the theory and script using Social Stories



Four Levels in the Development of Friendship



Level 1: Approximately 3 to 6 Years

  • Recognition of turn taking

  • Egocentric conceptualization

  • One way assistance

  • Proximity and physical attributes

  • Why is….your friend?

  • “Because I like him”

  • “He lives next door”



Level 2: Approximately 6 to 9 Years



Level 3: Approximately 9 to 13 Years

  • Aware of other’s opinion of them and how their words and actions affect the feelings of others

  • Shared experiences and interests

  • Greater selectivity and durability

  • Gender split

  • Trust, loyalty and keeping promises



Level 4: Adolescence to Adult

  • Peer group acceptance more important than the opinion of parents

  • Greater depth and breadth of self disclosure

  • Desire to be understood by friends

  • Different types of friendships

  • “He/She accepts me for who I am”

  • “We think the same way about things”



Characteristics Associated with Asperger’s Syndrome

  • Motivation for friendship

  • Immaturity

  • Control the activity

  • Describe what a friend should not do

  • Negative experiences



Checklist of Social Behaviors Used as an Index of Friendship Skills

  • Entry Skills

    • Recognizing when and how to join in
    • The “welcome” provided for children who approach them
  • Assistance

    • When and how to provide assistance
    • Seeking assistance from others
  • Criticism

  • Compliments

    • Compliments at appropriate times
    • Responding to a friend’s compliment
  • Accepting Suggestions

    • Incorporating the ideas of others in the activity
    • Indicating agreement
  • Reciprocity and Sharing

    • An equitable distribution of conversation, direction and resources


Checklist of Social Behaviors Used as an Index of Friendship Skills - Con’t

  • Conflict Resolution

    • Managing disagreement with compromise
    • Accepting the opinions of others
    • Not responding with aggression or immature resolution mechanisms
  • Monitoring and Listening

    • Regularly observing the other person to monitor their contribution and body language
    • Their own body language indicating an interest in the other person
  • Empathy

    • Recognizing when appropriate comments and actions are required in response to the other person’s circumstances and positive and negative feelings
  • Avoiding and Ending

    • Appropriate behavior and comments to maintain solitude
    • Appropriate behavior and comments to end the interaction


Encouraging Friendship Skills

  • Assess which skills are observed or absent

  • Assess the quality and range of expression

  • Use behavior and cognitive strategies to acquire and develop specific skills

  • Task analysis, prompting, shaping and reward

  • Reward all participants

  • Teach the theory as well as the practices

  • Social stories



Additional Strategies



Characterization Skills

  • Unusual in their perception and description of the personality characteristics of others and themselves

  • Limited lexicon to describe the different types of character

  • Immaturity and predominance of physical attributes

  • One dimensional approach

  • Difficulty reading a person’s character and adapting their behavior accordingly



Teaching Characterization Skills

  • The Mr. Men and Little Miss books

  • Examples are Mr. Grumpy, Little Miss Chatterbox and Mr. Nosey

  • Choosing an animal to represent someone’s personality

  • Reading dictionary definitions of character and identifying someone who has those characteristics

  • Identifying the description of their own character



Social Skills Groups



The Understanding and Expression of Emotions

  • A project on a specific emotion

  • Create a scrap book that illustrates the emotion

  • Compare and contrast other children’s scrap books

  • Identify the facial elements that express the emotion

  • A “thermometer” to measure the degree of intensity

  • Place photographs and words at the appropriate point on the “thermometer”

  • Point to the “degree” of expression in a particular situation



The Understanding and Expression of Emotions – Con’t

  • Appropriate tone of voice

  • Drama games for appropriate body language

  • Mirror and video recordings

  • Story books

  • Sentence completion exercises

  • Alternate positive and negative emotions



Imitation

  • Identify individuals skilled in a specific ability

  • Observe their actions and script

  • Copy or mimic their style

  • Speech and drama training



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