Asperger syndrome

Asperger syndrome
Other names	Asperger's syndrome, Asperger disorder (AD), Asperger's, Sukhareva's syndrome,[1] schizoid disorder of childhood,[2] autistic psychopathy[2]
Restricted interests or repetitive behavior may be features of Asperger syndrome; this boy is playing with a magnetic construction toy.
Pronunciation	/ˈæspɜːrɡərz/,[3] /-dʒərz/[4]
Specialty	Clinical psychology, psychiatry, pediatrics, occupational medicine
Symptoms	Problems with social interaction, verbal and nonverbal communication, and the presence of repetitive behavior and restricted interests[5]
Complications	Social isolation, employment problems, family stress, bullying, self-harm[6]
Usual onset	Before two years old[5]
Duration	Lifelong[5]
Causes	Inconclusive[5]
Diagnostic method	Based on the symptoms[7]
Medication	For associated conditions[8]
Frequency	37.2 million globally (0.5%) (2015)[9]
Named after	Hans Asperger

Asperger syndrome (AS), also known as Asperger's syndrome or Asperger's, is a diagnostic label that has historically been used to describe a

The syndrome was named in 1976 by English psychiatrist Lorna Wing after the Austrian pediatrician Hans Asperger, who, in 1944, described children in his care who struggled to form friendships, did not understand others' gestures or feelings, engaged in one-sided conversations about their favorite interests, and were clumsy.^[15] In 1990 (coming into effect in 1993), the diagnosis of Asperger syndrome was included in the tenth edition (ICD-10) of the World Health Organization's International Classification of Diseases, and in 1994, it was also included in the fourth edition (DSM-4) of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. However, with the publication of DSM-5 in 2013 the syndrome was removed, and the symptoms are now included within autism spectrum disorder along with classic autism and pervasive developmental disorder not otherwise specified (PDD-NOS).^[5][16] It was similarly merged into autism spectrum disorder in the International Classification of Diseases (ICD-11) in 2018 (published, coming into effect in 2022).^[17][18]

The exact cause of autism, including what was formerly known as Asperger syndrome, is not well understood.^[5] While it has high heritability, the underlying genetics have not been determined conclusively.^[19][20] Environmental factors are also believed to play a role.^[5] Brain imaging has not identified a common underlying condition.^[19] There is no single treatment, and the UK's National Health Service (NHS) guidelines suggest that "treatment" of any form of autism should not be a goal, since autism is not "a disease that can be removed or cured".^[21] According to the Royal College of Psychiatrists,^[22] while co-occurring conditions might require treatment, "management of autism itself is chiefly about the provision of the education, training, and social support/care required to improve the person's ability to function in the everyday world". The effectiveness of particular interventions for autism is supported by only limited data.^[19] Interventions may include social skills training, cognitive behavioral therapy, physical therapy, speech therapy, parent training, and medications for associated problems, such as mood or anxiety.^[8] Autistic characteristics tend to become less obvious in adulthood,^[22] but social and communication difficulties usually persist.^[23]

In 2015, Asperger syndrome was estimated to affect 37.2 million people globally, or about 0.5% of the population.^[9] The exact percentage of people affected has still not been firmly established.^[19] Autism spectrum disorder is diagnosed in males more often than females,^[24] and females are typically diagnosed at a later age.^[25][26] The modern conception of Asperger syndrome came into existence in 1981 and went through a period of popularization.^[27][28][29] It became a standardized diagnosis in the 1990s^[30] and was merged into ASD in 2013.^[12] Many questions and controversies about the condition remain.^[23]

The extent of the overlap between Asperger syndrome and other forms of autism, particularly what was sometimes called high-functioning autism is unclear.^[31][32][33] The ASD classification is to some extent an artifact of how autism was discovered,^[34] and it may not reflect the true nature of the spectrum;^[35] methodological problems have beset Asperger syndrome as a valid diagnosis from the outset.^[36][37] As noted above, in the 2010s, Asperger syndrome, as a separate diagnosis, was eliminated and folded into autism spectrum disorder in the DSM-5 and the ICD-11. Like the diagnosis of Asperger syndrome,^[38] the change was controversial.^[38][39]

The

As a pervasive developmental disorder, Asperger syndrome is distinguished by a pattern of symptoms rather than a single symptom. It is characterized by qualitative impairment in social interaction, by stereotyped and restricted patterns of behavior, activities, and interests, and by no clinically significant delay in cognitive development or general delay in language.^[41] Intense preoccupation with a narrow subject, one-sided verbosity, restricted prosody, and physical clumsiness are typical of the condition, but are not required for diagnosis.^[31]

Suicidal thoughts and behaviors are a serious concern within the autistic population. One study found that adults with Asperger syndrome exhibited suicidal thoughts at 9 times the rate of the general population. Of autistic study participants, 66% had experienced suicidal ideation, while 35% had planned or attempted suicide.^[42][43]

A lack of demonstrated empathy affects aspects of social relatability for persons with Asperger syndrome.^[44] Individuals with Asperger syndrome experience difficulties in basic elements of social interaction, which may include a failure to develop friendships or to seek shared enjoyments or achievements with others (e.g., showing others objects of interest); a lack of social or emotional reciprocity; and impaired nonverbal behaviors in areas such as eye contact, facial expression, posture, and gesture.^[19]

People with Asperger syndrome may not be as withdrawn around others, compared with those with other forms of autism; they approach others, even if awkwardly. For example, a person with Asperger syndrome may engage in a one-sided, long-winded speech about a favorite topic, while misunderstanding or not recognizing the listener's feelings or reactions, such as a wish to change the topic of talk or end the interaction.^[31] This social awkwardness has been called "active but odd".^[19] Such failures to react appropriately to social interaction may appear as disregard for other people's feelings and may come across as rude or insensitive.^[31] However, not all individuals with Asperger syndrome will approach others. Some may even display selective mutism, not speaking at all to most people and excessively to specific others.^[45]

The cognitive ability of children with Asperger syndrome often allows them to articulate

The hypothesis that individuals with Asperger syndrome are predisposed to violent or criminal behavior has been investigated but is unsupported by data.^[46][47] More evidence suggests that children diagnosed with Asperger syndrome are more likely to be victims, rather than offenders.^[48]

A 2008 review found that about 80% of reported violent criminals with Asperger syndrome also had other coexisting psychotic

People with an Asperger profile might not be recognized for their empathetic qualities, due to variation in the ways empathy is felt and expressed. Some people feel deep empathy, but do not outwardly communicate these sentiments through facial expressions or language. Some people come to empathy through intellectual processes, using logic and reasoning to arrive at the feelings. People with Asperger profiles may be bullied or excluded by peers, and might as a result be guarded around people, which could appear as lack of empathy. People with Asperger profiles can still be caring individuals; indeed, it is particularly common for those with the profile to feel and exhibit deep concern for individual rights, human welfare, animal rights, environmental protection, and other global and humanitarian causes.^[50]

Evidence suggests that in the "double empathy problem model, autistic people have a unique interaction style which is significantly more readable by other autistic people, compared to non-autistic people."^{[51][52][53][54]}

People with Asperger syndrome can display behavior, interests, and activities that are restricted and repetitive and are sometimes abnormally intense or focused. They may stick to inflexible routines, move in stereotyped and repetitive ways, preoccupy themselves with parts of objects, or engage in compulsive behaviors like lining objects up to form patterns.^[41]

The pursuit of specific and narrow areas of interest is one of the most striking among possible features of AS.^[19] Individuals with AS may collect volumes of detailed information on a relatively narrow topic such as weather data or star names without necessarily having a genuine understanding of the broader topic.^[19][31] For example, a child might memorize camera model numbers while caring little about photography.^[19] This behavior is usually apparent by age five or six.^[19] Although these special interests may change from time to time, they typically become more unusual and narrowly focused and often dominate social interaction so much that the entire family may become immersed. Because narrow topics often capture the interest of children, this symptom may go unrecognized.^[31]

Stereotyped and repetitive motor behaviors, called

According to the Adult Asperger Assessment (AAA) diagnostic test, a lack of interest in fiction and a positive preference towards non-fiction is common among adults with AS.[62]

Although individuals with Asperger syndrome acquire language skills without significant general delay and their speech typically lacks significant abnormalities,

Individuals with Asperger syndrome may have signs or symptoms that are independent of the diagnosis but can affect the individual or the family.[66] These include differences in perception and problems with motor skills, sleep, and emotions.

Individuals with AS often have excellent

Children with AS are more likely to have sleep problems, including difficulty in falling asleep, frequent nocturnal awakenings, and early morning awakenings.^[72][73] AS is also associated with high levels of alexithymia, which is difficulty in identifying and describing one's emotions.^[74] Although AS, lower sleep quality, and alexithymia are associated with each other, their causal relationship is unclear.^[73]

Hans Asperger described common traits among his patients' family members, especially fathers, and research supports this observation and suggests a genetic contribution to Asperger syndrome. Although no specific genetic factor has yet been identified, multiple factors are believed to play a role in the

A few ASD cases have been linked to exposure to teratogens (agents that cause birth defects) during the first eight weeks from conception. Although this does not exclude the possibility that ASD can be initiated or affected later, it is strong evidence that ASD arises very early in development.^[77] Many environmental factors have been hypothesized to act after birth, but none has been confirmed by scientific investigation.^[78] These environmental elements can act as independent and significant risk factors, or they can potentially influence pre-existing genetic factors in people who have a genetic predisposition.^[76]

Asperger syndrome appears to result from developmental factors that affect many or all functional brain systems, as opposed to localized effects.^[80]

Although the specific underpinnings of AS or factors that distinguish it from other ASDs are unknown, and no clear pathology common to individuals with AS has emerged,^[19] it is still possible that AS's mechanism is separate from other ASDs.^[81]

Mirror neuron system (MNS) theory

This section's factual accuracy may be compromised due to out-of-date information. The reason given is: There have been almost 4 decades since some of the material cited here was published, and current consensus in ASD is less straightforward than depicted here. Please help update this article to reflect recent events or newly available information. (January 2022)

The

Underdiagnosis and overdiagnosis may be problems. The cost and difficulty of screening and assessment can delay diagnosis. Conversely, the increasing popularity of drug treatment options and the expansion of benefits has motivated providers to overdiagnose ASD.^[94] There are indications AS has been diagnosed more frequently in recent years, partly as a residual diagnosis for children of normal intelligence who are not autistic but have social difficulties.^[95]

There are questions about the external validity of the AS diagnosis. That is, it is unclear whether there is a practical benefit in distinguishing AS from autism or PDD-NOS;^[95] different screening tools may render different diagnoses for the same person.^[8]

Many children with AS are initially misdiagnosed with attention deficit hyperactivity disorder (ADHD).^[19] Diagnosing adults is more challenging, as standard diagnostic criteria are designed for children and the expression of AS changes with age.^[96][97] Adult diagnosis requires painstaking clinical examination and thorough medical history gained from both the individual and other people who know the person, focusing on childhood behavior.^[62]

Conditions that must be considered in a

Different screening instruments are used to diagnose AS,[8]^[71] including the Asperger Syndrome Diagnostic Scale (ASDS); Autism Spectrum Screening Questionnaire (ASSQ); Childhood Autism Spectrum Test (CAST), previously called the Childhood Asperger Syndrome Test;^[101] Gilliam Asperger's disorder scale (GADS); Krug Asperger's Disorder Index (KADI);^[102] and the autism-spectrum quotient (AQ), with versions for children,^[103] adolescents,^[104] and adults.^[105] None have been shown to reliably differentiate between AS and other ASDs.^[19]

Treatment attempts to manage distressing symptoms and to teach age-appropriate social, communication, and vocational skills that are not naturally acquired during development.^[19] Intervention is tailored to the needs of the individual based on multidisciplinary assessment.^[106] Although progress has been made, data supporting the efficacy of particular interventions are limited.^[19][107]

Managing ASD may involve multiple therapies that address core symptoms of the disorder. While many professionals agree that the earlier the professional support the better, there is no combination that is recommended above others.^[8] Professional support for ASD varies depending on the individual; it takes into account the linguistic capabilities, verbal strengths, and nonverbal vulnerabilities of individuals.^[19]

Many of those diagnosed with ASD or similar disorders advocate against behavioral therapies, like Applied behavior analysis (ABA) and Cognitive behavioral therapy (CBT), often as part of the

In the case of CBT and talking therapies, the effectiveness varies, with many reporting that they appeared 'too self-aware' to gain significant benefit, as the therapy was designed with neurotypical people in mind.[119]^[120] In autistic children, specifically, they also report that it is only mildly beneficial in aiding with their anxieties.^[121]

A typical program of professional support generally includes:^[8]

• Applied behavior analysis (ABA) procedures, including positive behavior support (PBS)—or training and support of parents and school faculty in behavior management strategies to use in the home and school, and social skills training for more effective interpersonal interactions.^[122] The Autistic Self Advocacy Network campaigns against the use of ABA in autism;^[117][118]
• Cognitive behavioral therapy to improve stress management relating to anxiety or explosive emotions^[123] and to help reduce obsessive interests (although this may produce negative impact by demonising special interests) and repetitive routines;
• Medication for coexisting conditions such as major depressive disorder and anxiety disorders;^[124]
• Occupational or physical therapy to assist with poor sensory processing and motor coordination; and,
• speech therapy to help with the pragmatics and give-and-take of normal conversation.^[125]

Fecal Microbiota Transplantation (FMT) is an innovative therapy for AS that aims to restore microbial balance in the patient's gastrointestinal tract by introducing healthy fecal microbiota acquired from people with a diverse microbial composition. This approach attempts to reconstruct the patient's gut microbiota by taking into account the intricate interactions between the human gut and the central nervous system via the gut-brain axis (GBA). Any disruption in gut health has been linked to an increased susceptibility to diverse neurodevelopmental disorders.^[76]

It is vital to remember that research of AS specifically operates upon the out-dated classification of this syndrome as external to ASD (Autism Spectrum Disorder). Similarly, we should also note that ASD is a spectrum and support varies dramatically depending on the individual.

No medications directly treat the core symptoms of AS.

Education of families is critical in developing strategies for understanding strengths and weaknesses;[44] helping the family to cope improves outcomes in children.^[48] Prognosis may be improved by diagnosis at a younger age that allows for early interventions, while interventions in adulthood are valuable but less beneficial.^[44] There are legal implications for individuals with AS as they run the risk of exploitation by others and may be unable to comprehend the societal implications of their actions.^[44]

Frequency estimates vary enormously. In 2015, it was estimated that 37.2 million people globally are affected.

Asperger syndrome was named after the Austrian pediatrician Hans Asperger (1906–1980), but not coined by him. Asperger syndrome was a relatively new diagnosis in the field of autism,^[152] though a syndrome like it was described as early as 1925 by Soviet child psychiatrist Grunya Sukhareva (1891–1981),^[153][1] As a child, Asperger appears to have exhibited some features of the very condition named after him, such as remoteness and talent in language.^[154][155] In 1944, Asperger gave detailed descriptions of four representative children in his practice^[44] who had difficulty in integrating themselves socially and showing empathy towards peers. They also lacked nonverbal communication skills and were physically clumsy. Asperger described this "autistic psychopathy" as social isolation.^[8] Fifty years later, several standardizations of AS as a medical diagnosis were tentatively proposed, many of which diverge significantly from Asperger's original work.^[156]

Unlike what became known as AS, Asperger believed autistic psychopathy could be found in people of all levels of intelligence, including those with intellectual disability: as such, Asperger's understanding of autistic pathology was more akin to what is known as the

People identifying with Asperger syndrome may refer to themselves in casual conversation as aspies (a term first used in print in the

Some researchers have argued that AS and other autism can be viewed as a different cognitive style, not a disorder,[170] and that it should be removed from psychiatric and medical manuals classifying diseases (ICD) or mental disorders (DSM), much as homosexuality was removed.^[171]

Even some people typically associated with a

pathology paradigm for autism are willing to consider AS a neutral difference. For example, in 2002, Simon Baron-Cohen wrote of those with AS: "In the social world, there is no great benefit to a precise eye for detail, but in the worlds of maths, computing, cataloging, music, linguistics, engineering, and science, such an eye for detail can lead to success rather than failure." Baron-Cohen cited two reasons why it might still be useful to consider AS to be a disability: to ensure provision for legally required special support, and to recognize emotional difficulties from reduced empathy, which was commonly associated with autism during that time but has since lost support.^[172] Baron-Cohen argues that the genes for ASD's combination of abilities have operated throughout recent human evolution and have made remarkable contributions to human history.^[173]

By contrast, Pier Jaarsma and Welin wrote in 2011 that the "broad version of the neurodiversity claim, covering low-functioning as well as high-functioning autism, is problematic. Only a narrow conception of neurodiversity, referring exclusively to high-functioning autists, is reasonable."[174] They say that "higher functioning" individuals with autism may "not [be] benefited with such a psychiatric defect-based diagnosis ... some of them are being harmed by it, because of the disrespect the diagnosis displays for their natural way of being", but "think that it is still reasonable to include other categories of autism in the psychiatric diagnostics. The narrow conception of the neurodiversity claim should be accepted but the broader claim should not."^[174]

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Further reading

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• Autistic Empire, Are you Autistic? Take the test – an online version of the Adult Asperger's Assessment developed by Cohen, S. et al. (2005) (see Woodbury-Smith MR, "Screening adults for Asperger Syndrome using the AQ: a preliminary study of its diagnostic validity in clinical practice", in §References).
• Hus V, Lord C (August 2014). "The autism diagnostic observation schedule, module 4: revised algorithm and standardized severity scores". Journal of Autism and Developmental Disorders. 44 (8): 1996–2012.
  PMID 24590409. A public paper re-calibrating the Autism Diagnostic Observation Schedule
  for appropriate assessment of autistic adults, who typically score lower on measures of impairment than autistic children due to compensatory strategies.
• Royal College of Psychiatrists (2017), Interview Guide for the Diagnostic Assessment of Able Adults with Autistic Spectrum Disorder – based on the Autism Diagnostic Interview-Revised (ADI-R)