Current Clinical Practice in Asperger Disorder: Page 4 of 4
Current Clinical Practice in Asperger Disorder: Page 4 of 4
Numerous self-report, parent/teacher report, and direct observation measures have been developed to screen for and diagnose AD.58,59 To date, these instruments have not been empirically demonstrated to reliably distinguish AD from other high-functioning ASDs.58,60 Gold standard diagnostic procedures for ASDs include a parent interview; the Autism Diagnostic Interview–Revised; and a semi-structured conversation/play-based interview, the Autism Diagnostic Observation Schedule.61,62 The last 2 instruments are publicly available but require training to administer and score. Neither instrument offers an algorithm to distinguish AD from other ASDs, although the information they provide is useful in this regard. Differential diagnosis, therefore, relies primarily on clinical judgment.
Because ASDs, including AD, entail impairment across domains of function, it is advisable to refer children with suspected AD for a multidisciplinary assessment by a team with expertise in this area. Such an assessment should entail a developmental and health history, psychological assessment (cognitive ability, psychomotor control, adaptive function), communication assessment (receptive/expressive language, nonverbal communication, nonliteral language, pragmatics, prosody, and content), and a formal diagnostic evaluation using standardized diagnostic assessments. When necessary, consultation regarding behavioral management, motor disabilities, neurological concerns, psychopharmacology, college-readiness, or vocational training may be indicated. The aim of such an assessment is to determine a profile of strengths and weaknesses to inform intervention.
Psychosocial treatment of AD focuses on teaching appropriate social and communication behaviors. The guiding principle is the explicit inculcation of information that is not learned through natural, implicit methods. Treatment guidelines and strategies are akin to those for other ASDs and should take into account the verbal strengths that characterize AD.63 Broadly speaking, recommended interventions use strengths (eg, cognitive or memory skills) to compensate for areas of weakness while establishing environmental supports to facilitate learning and socialization. Intervention programs must be developed according to the individualized needs of each person with AD, based on a nuanced assessment.64 Intervention programs should address basic social and communication skills (with focus on pragmatic communication), adaptive functioning, and academic or vocational skills, while ensuring that learned skills generalize to naturalistic environments.65
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. These rules and scripts can be learned and practiced, first in therapeutic settings and then in more naturalistic settings. Social skills groups are a recommended treatment modality for children with AD because they provide a forum for both teaching and applying social lessons.
Challenging behaviors, such as aggression, should be addressed through functional behavior analysis and positive behavior management. For older children and adults with AD, vocational training should teach appropriate etiquette for job interviews and workplace behavior. Assistive technology, such as organizational software and personal data assistants, is often appropriate for supporting organization and work and life management in persons with AD.66
The core social vulnerability of AD has not proved responsive to drug treatment. However, associated psychiatric problems are often responsive to pharmacological as well as behavioral and psychotherapeutic interventions. Medications can help with comorbid mood disorders, which are common during adolescence and young adulthood.67 As noted, adolescents and adults with AD are particularly prone to anxiety and depression; as such, SSRIs are frequently prescribed for this group. Children often exhibit attentional problems and sometimes receive a concurrent diagnosis of attention-deficit/hyperactivity disorder. Mental health professionals should be knowledgeable about the potential for comorbidity but must try to avoid the temptation to “chase symptoms” and to employ polypharmacy.
Dr Asperger1 was optimistic about outcome in the patients he identified, given the presence of similar problems in fathers and his conceptualization of the condition as a personality characteristic rather than a developmental disorder. His view tempered over time, although he maintained that the outcome was more favorable than in persons with autism, probably because at the time autism was conceptualized as primarily associated with intellectual deficiency.3,68
Considering the enduring debate about diagnostic conceptualization, discussion about differences in outcome of AD versus higher-functioning ASDs remains controversial. The limited data suggest that, in contrast to autism, more individuals with AD are self-sufficient and married, but this has not held true in all samples.69-72 Extrication of symptom severity and adaptive capacity is needed to better understand differences in outcome among persons with ASDs.8
In the 65 years that have elapsed since the publication of Asperger’s original manuscript, much progress has been made in understanding the disorder and, more important, in developing methods to detect and treat AD. Despite considerable research, however, psychiatry is yet to elucidate the genetic or brain bases of the disorder and parsimoniously and robustly distinguish AD from similar ASDs. This ongoing topic of debate promises to enter a new chapter with the publication of DSM-V.
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