Current Clinical Practice in Asperger Disorder

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Educational Objectives

After reading this article, you will be familiar with:

• How Asperger disorder (AD) differs from other autism spectrum disorders
• Clinical features and assessment of AD
• Pathophysiology associated with AD
• Treatment modalities appropriate for AD

Who will benefit from reading this article?
Psychiatrists, child and adolescent psychiatrists, psychologists, primary care physicians, nurse practitioners, and other health care professionals. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing and certification boards.

In 1944, Hans Asperger published a description of 4 boys who had major social problems despite adequate cognitive and verbal skills.¹ His original term for the condition was Autistischen Psychopathen im Kindesalter, usually translated as autistic psychopathy or autistic personality disorder in childhood. His use of the term “autistic” occurred a year after Leo Kanner’s classic description of the syndrome of early infantile autism but, because of the war, Asperger was likely unaware of Kanner’s paper.²

Asperger considered the disorder a personality factor rather than a developmental issue. He emphasized the centrality of social deficits in the face of relatively intact intellectual and linguistic abilities along with unusual circumscribed interests, motor difficulties, and a history of similar problems in fathers.^3,4 The condition received scant attention in North America until Lorna Wing’s influential review and case series appeared nearly 40 years later.⁵ In her review, Wing termed the condition “Asperger syndrome,” which shaped the current term “Asperger disorder” (AD). She suggested some modifications to Asperger’s original description, such as the inclusion of females. Contrary to Asperger’s belief that diagnosis would be unlikely until children were of preschool age, Wing observed that some features, such as lack of pleasure in socialization and play, might emerge earlier. Wing suggested that the disorder might best be regarded as a variant of autism.

Distinguishing features of AD

Once introduced into English-speaking psychiatry, multiple conceptualizations and diagnostic approaches arose. Differences in diagnostic approaches, predominantly small sample sizes, and confusion with other disorders complicate the interpretation of clinical and research reports from this era. As part of the field trial for DSM-IV and ICD-10 criteria for pervasive developmental disorders, international clinical reports of persons with AD were used to evaluate potential differences from other pervasive developmental disorders.⁶ Findings from the field trial suggested that children with a clinical diagnosis of AD:

• Are more likely to exhibit strength in verbal IQ than are those with autism

• Are more likely to show more severe social deficits than those with pervasive developmental disorder—not otherwise specified

• Tend to exhibit circumscribed interests

As a result of the trial, AD was incorporated into both DSM-IV and ICD-10 as an official diagnostic category. The diagnostic criteria reflect these observed distinctions. DSM-IV-TR criteria for AD are provided in the Table. This Table also displays diagnostic criteria for the other autism spectrum disorders (ASDs) to facilitate differential diagnostic comparison. Although the diagnostic criteria for AD in DSM-IV-TR are identical to those published in DSM-IV, the DSM-IV-TR includes detailed accompanying text that is particularly useful for illustrating the differences between AD and other high-functioning (ie, intact cognitive ability) ASDs.

In AD, restricted repetitive and stereotyped interests tend to manifest as the consuming and intrusive pursuit of a particular body of knowledge, also known as a “circumscribed interest,” rather than other behaviors that are more common in autism (atypical motor mannerisms or inappropriate object use). Individuals with AD are also more likely to be socially motivated despite poor social agility (ie “active but odd”) rather than being frankly disinterested in social interactions.⁷

AD is commonly detected in children 4 years or older, although the diagnosis often may not be made until the child is 10 or 11. As such, a diagnosis of AD is typically made later than a diagnosis of autism.^8-10 This delay probably reflects the relative subtlety of developmental effects and the absence of language-based red flags rather than a different pattern of onset. Indeed, retrospective reports indicate social and behavioral anomalies as early as 20 months of age.¹¹ Despite efforts to better operationalize the distinction between AD and other ASDs—especially high-functioning autism—the distinction remains controversial.