You might think that you could recognize autism in someone without much trouble, but neurologists and mental health specialists are now realizing that many people with high-functioning autism disorders often fly under the radar.
Like classical autism, Asperger syndrome and high-functioning autism are neurological conditions that cause impairments in communication and socialization. So people with these conditions might have trouble having a back-and-forth conversation or picking up on body language. Unlike people with classical autism, people with these disorders always have average or above-average intellectual abilities. In fact, it's thought that a number of historic figures, such as Albert Einstein, may have had Asperger syndrome and been aided by their ability to zero in a given issue. But until recently, these disorders were not widely recognized, which is why more and more adults are being diagnosed.
Healthology talked with Marjorie Solomon, PhD, an assistant professor in the Department of Psychiatry and Behavioral Sciences at the University of California Davis Medical Center and a psychiatrist at the Medical Investigation of Neurodevelopmental Disorders (M.I.N.D.) Institute, about how children and adults with Asperger syndrome and high-functioning autism can learn to manage living in a social world.
What are Asperger syndrome and high-functioning autism?
Asperger syndrome and high-functioning autism are types of autism spectrum disorders. Autism spectrum disorders range from classical autism to milder forms like high-functioning autism and Asperger syndrome. Symptoms occur in three areas: language or communication, reciprocal social interaction—like being able to have a friend or to engage in interactive conversations—and rigid or repetitive patterns of behavior and interest.
To have a diagnosis of high-functioning autism or Asperger syndrome, you also need to have an IQ in the average or above average range. The difference between Asperger syndrome and high-functioning autism is that individuals with Asperger syndrome don't have a language delay. In autism, single words aren't acquired before two years of age.
What causes autism–spectrum disorders?
Autism–spectrum disorders, in general, have a large genetic component. There are some studies going on now taking a look at environmental factors. I think, in five years, we'll know more about environmental factors that might be responsible for what's being called a big rise in autism. Some people say mercury in fish, vaccines or living under high power lines or any number of things are responsible for the increase.
Are autism-spectrum disorders more common in boys than girls?
So far, that's what we think. The estimates range that boys outnumber girls from 9 to 1 to 4 to 1. Girls can be harder to spot, though, because girls tend to be socialized in our culture to fit in more and not misbehave. For example, some girls with autism spectrum disorders become very good at "pretending to be normal" and appear to function well, but they really lack a complete understanding of social interaction. So are we underdiagnosing girls? It's actually an interesting research question.
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When are people usually diagnosed?
With autism, there is the language delay, so that's going to start to raise questions earlier. Asperger syndrome can show up later, because some of the kids are extremely bright and they just seem kind of quirky. They almost seem like little geniuses. We certainly see a lot of cases where it's not picked up until third grade or fourth grade. At that time, the demands of being someone's friend increase, and kids with Asperger syndrome have trouble adjusting and fall behind socially. Some kids with Asperger syndrome are really good at rote learning, so when reading becomes more inferential and math more complicated, the deficits become more pronounced.
Because Asperger syndrome wasn't recognized as a disorder until the early 90s, and because many health professionals are not trained to recognize it, Asperger syndrome is now being diagnosed in adults who weren't picked up as children.
What are the symptoms?
Autism spectrum disorders involve problems engaging in nonverbal behaviors like eye contact, facial expressions and body postures. People with autism spectrum disorders may not use them properly and don't read them well in other people.
They don't develop peer relationships that you would expect. I always ask, "Has this child ever had a friend?" That, to me, is always a red flag. By the time you get to third grade, you have to be able to have a conversation and share interests and show some reciprocity.
There is generally a lack of seeking out others to share enjoyment. But this isn't always the case. Many kids with Asperger syndrome actually approach others too much.
These children may also have a lack of emotional reciprocity, or empathy. So we ask, "Does the child not get stuff? When somebody gets hurt, do they laugh? Do they really just not get why somebody's upset?" That can look like defiance but it's really a lack of understanding.
What other kinds of behaviors might a child have?
They may have deep fascinations. Although young kids tend to have preoccupations with topics like trucks and trains, in kids with Asperger syndrome, it doesn't go away. I've worked with some kids who are 12, and they still are very much convinced that [the children's TV show] Thomas the Tank Engine is a very important thing. Other children are deeply fascinated with topics like astronomy, cosmology or Japanese animation. They tend to memorize many facts about these interests.
They also might have rigid patterns of behavior. One boy would get upset if there was going to be an assembly at 10 o'clock instead of math. Or some kids need to drive to school a certain way or they get extremely upset. Another child we were working with was upset because his mother dropped him off at preschool in the morning and his father picked him up.
What are some coexisting problems?
Problems including depression and anxiety may occur with autism spectrum disorders. It's hard to know whether they are due to related brain abnormalities or some of the problems and consequences associated with autism spectrum disorders. Children with autism sometimes get diagnosed with attention deficit-hyperactivity disorder (ADHD) before receiving an autism spectrum disorder diagnosis.
How do problems change in adolescence and adulthood?
I don't think we have great studies on individuals with Asperger syndrome and high-functioning autism in later life, though we are hearing more about people with Asperger syndrome in college. Some of these kids are very good at school. If you get the hang of school, the expectations are a lot clearer than they are in the work world.
I chatted recently with one mother about her son with Asperger syndrome. He did fine at a good university undergrad. But then he had several jobs where he could not understand the social expectations. At his firm, he had to work in teams. He did not realize the politics among his team members, so he would step on other people's toes without realizing it. His reviews repeatedly said, "You are arrogant and act as if you're the only who knows anything," but he really didn't get what was going on.
It's also complicated to maintain long-term intimate relationships. You have to be able to read somebody's nonverbal cues.
How is a diagnosis made?
Diagnosis has to involve collecting information from several sources, such as parents and teachers. The doctor should do a psychosocial history, finding out when language developed, what other kinds of symptoms were present, what kind of social issues were present, if there were any academic issues. A clinician should then sit with the patient and evaluate them with a standardized evaluation tool. The best advice is to go to somebody that has a recognized reputation in autism spectrum disorders in your community.
How is Asperger syndrome or high-functioning autism treated?
To help people reach their potential, I advise at least assessment and some form of treatment in the vast majority of cases. One of the recommendations is a type of speech therapy called pragmatic language work, or knowing how to use language appropriately. In social skills groups, a form of therapy that often includes language pragmatics, kids get together and learn skills in the context of a group setting. For example if we're working on conversation, we're going to model a conversation by passing a tennis ball back and forth. We're teaching them to ask someone else about themselves, and not just talk about their own interests.
Cognitive-behavior therapy is a treatment that is being adapted to deal with the anxiety and depression. We are also experimenting with a therapy called parent-child interactive therapy to help children with behavioral problems and inflexibility. Sometimes we recommend others kinds of psychotherapy to deal with thinking issues, such as learning how to become better at learning how to broaden their perspective. Some people are experimenting with neural retraining literatures, such as recognition of facial expression of emotion done on computers.
Are medications helpful?
Medications can be helpful to deal with some of the symptoms. For instance, attention medications are frequently given to help kids to focus better and do better in school and not be so distractible. Sometimes, a class of medications called SSRIs is used to help with inflexibility, anxiety, depression or obsessiveness. Sometimes atypical antipsychotics are used, if kids are having a lot of behavioral issues. So medications can be helpful, but there's no medication that cures autism.
What is your overall advice to parents?
You want to seek professionals who have experience dealing with this disorder. They can follow your child as different issues appear in development. We can help kids with social skills that are appropriate to an 8-year-old but, when they're 14, the rules of the game change, and they usually need more help.
There's not a cure, but we are optimistic that with proper help and guidance, people with Asperger syndrome and high-functioning autism can have really good lives. And we hope that as we understand more about social cognition, more tools and medications will be developed that might be more specific for social interaction. This research has attracted a lot of attention, because neural scientists and geneticists really want to understand what makes us social beings; there are a lot of broader implications.
