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Current Clinical Practice in Asperger Disorder: Page 2 of 4

Current Clinical Practice in Asperger Disorder: Page 2 of 4

Clinical features

Significant social disability is the primary feature of AD. This disability extends from basic elements of social behavior—such as eye contact, gesture, and facial expression—to more sophisticated aspects, such as empathy and perspective taking.12 The social deficits may be more subtle than in persons with autism; this may reflect intact cognition better enabling individuals with AD to compensate through analysis of social situations and distillation of guiding rules for behavior.13 This analytical, rather than intuitive, approach to social interaction frequently results in a rigid social style or awkward patterns of eye contact and gesture.14

Intense areas of preoccupation are a second salient clinical feature. In contrast to typical topical infatuations of childhood, the circumscribed interests in children with AD tend to be obsessive, intrusive, exclusive of other activities, and factually driven—often without comprehension of broader relevant contexts. These often stand out during psychiatric evaluations as intrusive conversation topics foisted on the interviewer.

Despite the absence of diagnostic criteria specifying language impairment, individuals with AD tend to display difficulties with the social use of language. Children with AD may develop a precocious vocabulary and pedantic speech patterns, orating at length on their preferred topics with insufficient regard for the contributions or interest level of a conversational partner. Speech volume may be poorly modulated, with nasal tone, limited prosody, and dysfluent rhythm or pace.15 Individuals with AD generally experience difficulty in using and comprehending figurative language.16 Loose associations may be evident but usually reflect poor perspective of the listener’s need (eg, inadequate expository information, inclusion of extraneous details) rather than disorganized thought processes.

Strong language skills and a concrete cognitive style make individuals with AD receptive to strategies aimed at establishing straightforward rules to guide behavior and memorization of verbal social scripts.

Additional clinical characteristics focus on motor control and learning profile. Clumsiness and motor difficulties were observed in Asperger’s initial report, and unusual gait patterns, odd posture, poor handwriting, problems with visuomotor integration, and difficulties with activities that require motor dexterity have been noted in subsequent accounts.17,18 Individuals with AD may also display proprioceptive difficulties, such as problems with apraxia, balance, tandem gait, and finger-thumb apposition.19 Some research suggests that individuals with AD possess a distinct neuropsychological profile, featuring deficits in fine and gross motor skills, visuomotor integration, visuospatial perception, nonverbal concept formation, and visual memory with preserved articulation, verbal output, auditory perception, vocabulary, and verbal memory.20,21 This pattern of stronger verbal abilities relative to performance abilities, with a particular weakness in visuospatial organization and graphomotor skills, resembles, and may overlap with, nonverbal learning disability.22

AD is often comorbid with several other psychiatric disorders. The boundaries between symptoms and syndromes can be difficult to determine, and limited data (mainly from case reports and a few large, epidemiologically drawn studies) are available to inform such decisions.23,24 Depression and anxiety frequently coexist with AD; estimates of comorbidity are as high as 65% and increased rates of anxiety and depression have been reported in family members.23,25,26 Anxiety often stems from behavioral rigidity and divergence from predicted or routine events; it may resemble social anxiety. Depressive symptoms often emerge in adolescence secondary to social failings. Hyperactivity and inattention are common among children with AD, which has also been associated with Tourette syndrome, obsessive-compulsive disorder, and psychotic conditions—particularly schizophrenia.27-30

Epidemiology

Data on the epidemiology of AD are more limited than those for autism, which reflects the continuing disagreement about best diagnostic approaches and the fact that official recognition of AD is relatively recent. Fombonne31 estimated that prevalence of AD is approximately 2.6 per 10,000, about one-fifth as common as autism. The disorder occurs at a much higher rate in boys than in girls. In Asperger’s original report, all cases were male1; in reanalysis of his subsequent cases, approximately 5% were girls.4

As with autism, more research is needed on cultural and ethnic factors. Cases have been reported from many different countries, although most are from the developed regions of the world.32

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