Asperger's Syndrome: Emotional and Social Implications

Lesson Six: Social or Emotional Difficulties Frequently Occurring with the Diagnosis

Hyperactivity

There has recently been considerable interest and research into the possible connection between autism spectrum disorders and Attention Deficit Hyperactivity Disorder (ADHD). This interest includes both the similarities in symptoms as well as genetics. According to Richard Perry¹⁹, hyperactivity, inattentiveness and impulsivity can be present in a number of childhood onset disorders, including ADHD as well as autism spectrum disorders. A recently published book on this subject is The ADHD Autism Connection by Diane M. Kennedy¹⁴. Tony Attwood has also written on the subject, noting, "Children with Attention Deficit Disorder (ADD) are often considered as having some characteristics indicative of Asperger's Syndrome. Although they are two distinct disorders, they are not mutually exclusive and a child could have both conditions"³.

One nine year old boy with Asperger’s, Jeremy, displayed severe symptoms of hyperactivity. He could barely contain himself when in his therapist's office, preferring to remove all the books from her bookshelf and trying to race down the hallways.

Another possibility is that of misdiagnosis. Richard Perry, in his article entitled "Misdiagnosed ADD/ADHD; Re-diagnosed PDD"¹⁹, notes that some children originally diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) have later been re-diagnosed with a diagnosis on the autistic spectrum.

Attwood summarizes the similarities and differences between the two diagnoses in the following way: "Perhaps the central feature of Asperger's Syndrome is the unusual profile of social and emotional behavior... with ADHD, the children tend to know how to play and want to play, but do so badly... children with ADD have a diverse range of linguistic skills and interests, while there is a distinct language and interests profile for those with Asperger's Syndrome. Their interests tend to be idiosyncratic and solitary, in contrast to those children with ADD whose interests are more likely to be conventional for children of that age. Children with both conditions prefer and respond well to routines and predictability, can experience sensory sensitivity and have problems with motor coordination... Both conditions can be associated with impulsivity but this feature tends to be less of an issue with Asperger's Syndrome... The child with ADD has a propensity to have problems with organization skills... With Asperger's Syndrome, the profile includes unusual aspects of organizational skills such as unconventional means of solving problems and inflexibility"².

Obsessive-Compulsive Traits

As noted in Lesson Four, inflexibility regarding routines and rituals is a very common characteristic of people with autism and Asperger's Syndrome. In Leo Kanner's writings about autism in 1943, he referred to the child with autism as having an "obsessive insistence on sameness"¹³.

While many individuals with autism spectrum disorder display inflexibility and rigidity, sometimes the symptoms are extreme and may warrant an additional diagnosis of Obsessive-compulsive disorder (OCD). According to Luke Tsai, "...it is conceivable that some higher-functioning autistic people's quasi-obsessive behaviors reflect true symptoms of a co-existing OCD"²⁵. He describes the case of a woman with Asperger’s who needed to check her doors and stove many times a day. Similarly, Tony Attwood describes a man with Asperger's who needed to wash his hands very frequently because he feared contamination by germs². In these two examples, the extreme nature of the symptomatology and the fact that the individuals involved were troubled by their rituals support the diagnosis of OCD.

A commonly asked question is how to make a distinction between obsessive-compulsive symptoms and the unusual preoccupations of many people with Asperger's. In general, people with OCD realize their behavior is odd and are upset by their inability to control their symptoms. Attwood states the special interests of people with Asperger's are "different from a compulsive disorder in that the person really enjoys their interest and does not try to resist it"². As Jane, an adult with Asperger's said, "It's fun!".

There is considerable controversy in the field about whether people with autism or Asperger’s who have milder ADHD or OCD symptoms should be diagnosed with multiple disorders. In other words, does the person have Asperger's Disorder with hyperactive traits or is it preferable to diagnose him with Asperger's as well as ADHD? Does he have Asperger's Syndrome with obsessive-compulsive characteristics or Asperger's plus OCD? Some clinicians feel that autism spectrum disorder, including Asperger's Syndrome, is a broad category encompassing a wide variety of symptoms, with some individuals displaying more of some symptoms than others. On the other hand, other clinicians worry that many symptoms which respond well to psychopharmacological treatment may go untreated if not specifically diagnosed.

Anxiety

Anxiety appears to be extremely common among people with autism and Asperger's Syndrome. As one might expect, there are certain situations that typically lead to anxiety in this population. These situations include such things as changes in routine, interference with rituals, things not happening in the expected way, failing at tasks, and sensory overload.

Interestingly, for some people on the spectrum, it is the "little" things which seem to cause the most distress, while more major changes may be experienced with less disruption. Evan, the boy who became overwhelmed with a change in television programming, looked forward with eager anticipation as his family prepared to move to a new house and, in fact, did quite well before, during and after the move.

If anxiety builds up to a critical level in any individual, a tantrum may be the end result. Unfortunately, for a child on the spectrum, a tantrum may be an overwhelming and prolonged event. Furthermore, the techniques often used with typically developing children may not work and may even prolong the difficulty. Trying to talk the child through the experience or reasoning with him are usually not effective. In addition, after the tantrum has subsided, trying to process with the child what happened and why may even contribute to the return of anxiety as well as the tantrum. Brenda Smith-Myles has referred to this phenomenon as "recycling"¹².

Clearly, it is preferable to be proactive in preventing tantrums whenever possible, rather than trying to stop them once they have begun. In a proactive approach, thought is given beforehand to the kinds of things likely to provoke a tantrum in any particular individual and either trying to avoid them or preparing for them. For example, for a person greatly upset by change, one approach is to try to keep things as consistent and predictable as possible. When changes are unavoidable, if they are known in advance, it is often helpful to prepare the individual for this fact. Another approach is to teach the individual in a gradual, but systematic way, techniques for dealing with the changes and disruptions in life.

In addition to trying to prevent tantrums whenever possible, it is useful to have a plan in place to deal with them should they occur. This approach has more likelihood of success if utilized early in the tantrum; circumventing a tantrum is usually much easier than trying to stop one in full swing. The plan needs to be tailor made to the individual; what works for one person may be quite different from what works for another. It is often useful for teachers to speak to parents about what approaches are helpful in dealing with their children. Undoubtedly, they have had many opportunities to try out different techniques! For some children, removing them from the scene and providing them with "settling"activities may be useful. For example, Frank was often helped by being led to a quiet place where he could look at his calendars and yearbooks. For some children, touch, especially firm pressure, can be a useful technique. On the other hand, for children who are sensory defensive, touch can be too overwhelming. The following example illustrates one approach to containing a tantrum.

Max had been eagerly looking forward to going on the Swan Boats in Boston. One day, his mother planned an outing in which they rode the subway into town, an experience Max loved, and then went on to the boats. Unfortunately, just as they were about to board, the skies opened up in a downpour and the attendant announced the Swan Boats were closing. Max began a full-fledged tantrum, complete with screaming, name-calling and flailing. His mother somehow managed to usher him into the subway station and onto the train, where, naturally, everyone else was also congregating because of the weather! Although the train was extremely crowded, the other passengers gave Max and his mother a wide berth. She sat him down on a seat and knelt before him, placing her face very close to his and cupping his face in her hands. In a soothing voice, she told him repeatedly to look at her and reassured him that he was okay. His sobbing and flailing soon ceased.

Depression

Like anxiety, depression is quite common in people with Asperger’s Syndrome. Many individuals develop problems with low self-esteem and depression during adolescence. It is at this time that many become acutely aware of their differences from their peers. Unfortunately, this is also the time in life when fitting in becomes so critical.

Some individuals with Asperger’s develop affective disorders, which include true clinical depression and bipolar disorder. There is some data to suggest the incidence of these disorders in Asperger’s Syndrome is higher than in the general population. ² When these disorders do occur, there may be changes in the person’s predominant mood or in his view of himself and the world. Vegetative symptoms, e.g., changes in sleep, eating, and activity level, may also occur. Of critical importance is the fact that some individuals with Asperger’s and autism display an increase in “autistic” behaviors, for example, stereotyped motor mannerisms, self-injurious behaviors, or aggressiveness, when they become depressed. This fact seems to contribute to the problem of mental illness not being accurately diagnosed in this population, because clinicians sometimes attribute the increased “autistic” symptoms to the autism or Asperger’s, rather than to the affective illness. Affective disorders are also more difficult to diagnose in this population because many people with autism spectrum disorders have difficulty communicating their feelings, both in words and in facial expressions. As a general rule of thumb, a significant change from the person’s baseline level of functioning should raise questions about the possibility of an additional diagnosis.

In "Emotional Disturbance and Mental Retardation: Diagnostic Overshadowing"²¹, Steven Reiss, Grant W. Levitan and Joseph Szyszko of the University of Illinois conducted an important study outlining difficulties similar to those described above. They conducted two experiments showing that people with mental retardation were less likely than controls to be diagnosed with emotional disturbances. They coined the term diagnostic overshadowing, meaning that the emotional problems seemed less significant, or were overshadowed in importance, by the presence of mental retardation. Although this study did not include people with autism or Asperger’s, it seems highly likely that similar results would occur. The following example illustrates this point.

Tommy, an 8 year old with high functioning autism, was a gentle, rather easy-going youngster and was included in a Montessori classroom. During the fall of 3rd grade, he seemed to become more and more depressed, with increasingly frequent episodes of weeping with no apparent precipitant. His condition continued to deteriorate throughout the fall and by Christmas he required psychiatric hospitalization. By this time, he was weeping almost constantly, had become assaultive, and was trying to escape from his family’s home, which was situated near a major highway. In addition, he kept repeating bizarre demands, such as insisting the names of the days of the week be changed to those of the names of the children in his class. After discharge from the hospital, he went to a residential school, where the psychiatrist viewed his symptoms as indicative of his autism. It was not until sometime later that another psychiatrist correctly concluded that Tommy carried the additional diagnosis of bipolar illness.

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