Asperger Syndrome Asperger\'s Disorder --

Asperger Syndrome

Asperger's Disorder -- also referred to as Asperger syndrome (AS) -- is essentially a "…chronic neurodevelopmental disorder" that limits the afflicted person's ability to have normal social interaction and communication, according to an article in the journal, European Child & Adolescent Psychiatry (Woodbury-Smith, et al., 2009, p. 2). While AS is not associated with the problems resulting from intellectual disability, Woodbury-Smith emphasizes that AS is viewed as a "severe social disability" and in some cases there are "associated mental health and other medical problems" that can (and do) persist throughout life (p. 2).

The authors of this article point to some of the difficulties that result from AS, including the fact that diagnosis of AS is frequently delayed and that causes additional problems because there are now "…a range of interventions available" (Woodbury-Smith, 2009, p. 2). But because those interventions are best applied in early childhood, when a person is not found to have AS until later in life the healthcare professionals have a late start and solutions are not always effective.

Reciprocal Communication Issues

Writing in the Journal of Abnormal Child Psychology, Margaret Semrud-Clikeman and colleagues conclude -- as other researchers and scholars have -- that individuals with AS have difficulty with "reciprocal communication" and the AS person has "difficulty with sharing enjoyment of activities or objects" (Semrud-Clikeman, 2010, p. 509). In addition, the AS person often demonstrates an "…inflexible adherence to routines or rituals" and moreover that person has problems understanding social "intent" (what did that person mean by his statement or his body language?) and this leads to misunderstandings and "subsequent withdrawal particularly in novel and unexpected social interactions" (Semrud-Clikeman, 2010, p. 509).

Getting the proper diagnosis is very important because AS has certain similarities with "nonverbal learning disabilities" (NLD) and with Attention Deficit Hyperactivity Disorder (ADHD), Semrud-Clikeman writes (p. 510). Indeed AS and NLD have been categorized as related disorders, albeit AS is generally considered more severe and children with AS "…generally need to stick to strict routines, have stereotyped interests, and often succeed academically" while children with NLD often experience difficulty "with visual-spatial skills" and struggle to differentiate between right and left and "frequently get lost" (Semrud-Clikeman, 2010, p. 510).

AS children are not known for getting lost and unlike children with NLD AS children "stick to strict routines, have stereotyped interests, and often succeed academically" (Semrud-Clikeman, 2010, p. 510). The authors conclude this research paper -- in which they utilized several empirical testing strategies to differentiate between NLD, ADHD and AS -- by asserting that both AS and NLD children have trouble "…understanding emotional and nonverbal cues in social interactions" (Semrud-Clikeman, 2010, p. 518). Qualitative clinical research into the behaviors of AS and NLD and ADHD children revealed that these individuals "…experience significant feelings of loneliness and social isolation that are painful to them" (Semrud-Clikeman, 2010, p. 518).

Why is a study of AS important? Why is this topic worth investigating?

First of all, because autism is the most widely recognized pervasive development disorder (PDD), other health issues that are somewhat similar to autism -- including AS -- have been "…less intensively studied, and their validity, apart from autism, is more controversial" (Yale Child Studies Center). Indeed, more, much more research and attention should go into all aspects and manifestations of Asperger's syndrome.

Secondly, because the complexity of AS conditions -- juxtaposed with the importance of knowing the developmental history of AS sufferers -- and the "common difficulties in securing adequate services for children and individuals with AS," parents, teachers and friends must be encouraged to "observe and participate in the evaluation" of those with AS (Yale Child Studies Center). And yet, notwithstanding the need spelled out in the previous sentence, how can intervention for individuals with AS be successful if there are still of host of mysteries yet to be solved vis-a-vis AS?

Thirdly, even though AS is not fully understood, ironically AS is becoming a "well-known diagnostic label…a fashionable concept used in an often unwarranted fashion by practitioners," the Yale Center report explains. Indeed, at the risk of generalizing, the Yale Center asserts that some practitioners -- who don't really fully grasp AS -- intend to convey that their client is "…currently experiencing difficulties in social interaction and in peer relationships" and so they latch on to the AS label, which seems appropriate but may be totally wrong-headed.

Finally, it is important to continue research into AS because there is a common thread found in much of the research, and that is that many people who are likely to have AS go undetected. More research is certainly needed, and more information should be made available to the general public. As Lars Perner, Ph.D., assistant professor in the Marshall School of Business at the University of Southern California writes:

"I have always known that I was 'different' in some sense. The facts that I am a bit on the clumsy side, do not like confronting people, have difficulty recognizing faces, and have problems with non-verbal communication were not news to me.

Nevertheless, my diagnosis with Asperger's, a condition I had never heard of when it was revealed to me at age 32. When trying to pronounce new sounds, I must be shown explicitly how to produce them… [and] one of the areas where I continue to experience difficulty is in spontaneity and social coordination…I have learned not to force myself to go to cocktail parties and receptions despite the value of networking. Ironically, it's not so much the social experience I can't handle, but rather the problem is that the words of my conversant simply drown in the sea of background talk…I have to lean uncomfortably close and concentrate intensely on the other person's words to get anything…"

(Perner, 2002, www.aspergerssyndrome.org).

Understanding what AS really is -- and what it isn't

Gena P. Barnhill, along with many other scholars and clinicians, asserts that not enough research has been conducted on adults with AS. The author notes that unlike adults with autism, adults with AS generally have "…intellectual ability and syntactical speech that is considered to fall within normal limits" (Barnhill, 2007, p. 116). But, Barnhill continues, AS individuals have great difficulty with "pragmatic language" and as a result it is difficult for the AS individual to "provide the right information at the right time" -- and social niceties are not to be expected from individuals with AS. Also, nonverbal cues are not easy for the person with AS (p. 116). All that having been said, Barnhill makes it clear that while persons with AS "share the same set of core symptoms," those symptoms are not predictable, they manifest themselves in various ways depending on the particular individual, and hence, diagnosis is "challenging" (p. 116).

On page 117 Barnhill discusses the problems adults with AS have in finding a niche for their chosen vocation, in securing employment that matches up with their abilities, in staying on the job, and in "negotiating social relationships." When a job ends suddenly for an adult with AS, it can lead to depression and low self-esteem, Barnhill reports, adding that the job interview itself becomes problematic because while the adult individual may have the technical skills that the job requires, engaging in "reciprocal conversation" or being able to quickly respond to questions is beyond their abilities -- hence, they miss out on the job opportunity (p. 119). Without the ability to be gainfully employed, stress and isolation can creep up on the AS adult in ways that non-AS people will never understand.

Woodbury-Smith reports (p. 3) that the early descriptions of AS were not always on target. Researchers believed at one time that AS was actually: a) some milder form of autism; b) a "manifestation of autism in people with normal intellectual ability"; c) a form of autism that allowed a higher verbal functioning in the patient; or d) a form of autism that was "socially motivated." One of the differences between autism and AS, Woodbury-Smith explains (p. 3), is that people who have AS are "typically motivated to interact with others," however they discover in time that they are "socially isolated because of their odd communication style." That communication style is "overly formal" and may be manifested as a kind of monologue, which may bore the person trying to listen but to the AS speaker it is a topic of special interest, Woodbury-Smith continues on page 3.

In autism, the author points out (p. 3), speech is generally delayed and speech is not a great source of good communication in most cases. In AS, however, speech is often a bit too much, often over the top, so to speak. "Often" AS speech is "verbose and tangential," and moreover, an AS speaker may be given to odd peculiarities in that he or she may not have a normal rhythm or volume when speaking, drawing undue attention to the weirdness (Woodbury-Smith, 2009, p. 3). What the AS person is most interested in talking about is something he or she has focused on in a repetitive way, and in social situations that subject the AS person is fixated on may -- in most cases -- not be what another person listening to the AS person wishes to relate to, Woodbury-Smith continues.

The AS person has often spent an inordinate amount of time fixated on one particular (often peculiar) topic, and when that person is in a social environment, he or she tends to ramble on about the topic and that one-sided rambling is more important to that AS person than any other activity in a social setting, Woodbury-Smith writes on page 4. According to Woodbury-Smith, as the AS person gets older, the tendency to focus obsessively on one particular topic is increased, "…and they can be debilitating in terms of frequency of engagement as well as degree of distress that they cause the person and their family" (Woodbury-Smith, 2009, p. 4).

The "gold standard" as far as a diagnostic approach to determining autism vs. AS is through use of ADI-R (based on autism interviews) and of ADOS ("autism diagnostic observation scale"). The ADI-R amounts to a "semi-structured interview" between a person believed to be autistic and that person's caregiver. The ADOS, like the ADI-R requires specific training for the person conducting the research. The ADOS is also "semi-structured" and it is an interactive session rather than just an interview, and play is usually part of the session.

Evaluating young children -- as to whether they have AS or autism -- "can be tricky," according to Dr. Leon Hoffman, writing in the "Letters to the Editor" section of the American Journal of Psychiatry. Hoffman, writing in response to an earlier published article on Asperger's syndrome in the same journal, asserted that when assessing children the clinician should not focus on the "exact categorization" of the child, seeking the ideal niche or grouping he or she might be placed in (Hoffman, 2009, p. 235). Rather, Hoffman goes on, the clinician should "…evaluate the nature of the child's social interactions with parents, siblings, relatives, and other children and significant adults as well as how others interact with the child" (p. 235).

In other words, it is sometimes "tricky" to tell the difference between a child with autism and one with AS, but the clinician / researcher needs to understand "the nature of the child's responses" to sensory stimuli (Hoffman, 2009, p. 235). Also, the clinician should understand whether the child's responses are appropriate, under-reactive, or over-reactive, and evaluate those responses in the context of the child's language development, memory, fund of knowledge, and "ability to understand social situations" (Hoffman, 2009, p. 235). Moreover, Hoffman continues on page 235, the clinician should evaluate the degree to which the child feels "internal conflict in contrast to conflict with other people" -- and the degree to which the child can differential his or her fantasy life from true life experiences.

The Yale Child Studies Center spells out the specifics of AS in easy-to-understand language. The DSM-IV definition of Asperger's syndrome is: a) a qualitative impairment in social interaction, manifested by "at least two" of these issues: impairment in the use of eye-to-eye gaze, body language, facial expressions and gestures; poor peer group relationships; lack of spontaneous enjoyment with other people; and inability to reciprocate socially or emotionally; b) repetitive behaviors, interests, and activities, manifested by one or more of the following: abnormal preoccupation with a particular interest or focus; a seeming inflexible insistence on certain routines or rituals; repetitive "motor mannerisms" such as "finger flapping or twisting or complex whole-body movements"; or "persistent preoccupation with parts or objects"; c) significant "impairment" in several areas of functioning (social, occupational, et al.); d) there is no clinically significant delay in "cognitive development or in the development of age-appropriate self-help skills; e) there is no clinically significant delay in language development; and f) the criteria for Schizophrenia or PDD are not met with AS.

Chapter Two -- Literature Review

What is known about the kind of suffering AS individuals go through? What is known about the likes and the dislikes, and the day-to-day living challenges of people with AS? Gena Barnhill writes -- referencing a study of 12 men with AS (ages 18 to 21) -- about health dynamics in the following areas: they feel a general and near-constant fatigue; they experience "discomfort and pain"; they dislike their dependence on medication and medical treatment; their work capacity, mobility and lack of energy is a source of embarrassment (Barnhill, 2007, p. 120). Barnhill also alludes to sensory challenges that AS sufferers go through. First of all there is pain that individuals with AS suffer from but have a hard time explaining to doctors, "which makes it difficult for doctors to treat…" them, Barnhill continues (p. 120).

Moreover, as to sensory challenges, young people with AS contend with sensitivity to noise, "oversensitivity to touch, and difficulties with rhythm" -- all of which lad to "behavior problems" (Barnhill, 2007, p. 120). Some of the sounds that persons with AS have to endure "…can actually hurt a person's ears, and he or she may be fearful of anticipated noises and hum or make other noises to block them out," Barnhill continues on page 120. Beyond sensitivity to sound and touch, individuals with AS are also frequently described as "clumsy" and demonstrating "ill-coordinated gross-motor movements"; also they tend to have odd or poor posture and an awkward gait when they walk (Barnhill, 2007, p. 120).

Barnhill asserts that very little research has looked into whether neurological problems persist in AS individuals as they leave adolescence and reach adulthood, but at least one study referenced by Barnhill (p. 120) does indeed report that shortcomings in motor skills appeared to differentiate adults with AS from adults that do not have AS. Lack of sleep is another typical symptom for those who have AS. Barnhill's son, Brent, whom she mentions frequently because he has AS, has suffered from lack of restful sleep most of his life. Brent tries to find part time jobs that he can report to in the afternoon, because early in the morning he often has not had enough sleep.

"He told his boss many times that he would be at work the following day," Barnhill writes (p. 120). But due to "the fatigue and physical discomfort that he frequently experiences, he was unable to work as he had promised," Barnhill continues. But the good news was that Brent worked for an organization that offers services for people with developmental disabilities, and hence, they were supportive of him and did not fire him because of his inconsistency with reporting on time.

Another major hurdle for AS young people is "making friends and establishing intimate partners," Barnhill explains (p. 121). Of course those with AS wish to have friends, and romantic relationships, but they "tend either to approach others in an inappropriate physical or verbal manner," or they also may "…misread subtle social cues or body language," the author goes on (p. 121). Sometimes the blunt or awkward actions by AS individuals is misread as sexually-motivated overtures, when in fact that was not at all the intention, according to Barnhill. Since many of individuals with AS did not receive sex education, they tend not to know how to establish a romantic relationship and once in such a relationship they don't understand how to behave.

Barnhill's son Brent has met several potential female friends on the Internet, and often he meets people in person who are "savvier than him" and they try to take advantage of his naivete; also, when he actually meets a date face-to-face he "has misread their intentions and at times offended them with his comments without being aware that this was the case" (Barnhill, 2007, p. 121). Individuals with AS can quickly find themselves in situations that make them vulnerable, and they don't even know they are vulnerable because the world is passing them by from a social interaction point-of-view.

AS from an Individual's Perspective

An article in the journal Autism asserts that despite the considerable research done on the syndrome, "Only a handful of studies…" have been-based directly on "the perspectives of [AS] individuals themselves" (Muller, et al., 2008, p. 174). And so the authors conducted interviews with eighteen individuals with Asperger's syndrome. The participants had been formally diagnosed with AS ("…or other ASD or an informal diagnosis of Asperger syndrome based on DSM-IV criteria…"), were at lease 18 years of age, had self-reported difficulties with "social cognition" but had no diagnosed "mental retardation" (Muller, 2008, p. 174). Thirteen of the 18 were diagnosed "formally" with Asperger syndrome, two were "informally diagnosed" with Asperger syndrome, two were "formally diagnosed with high-functioning autism" and one was "formally diagnosed" with PDD (Muller, 2008, p. 175-76).

It should be mentioned that these 18 participants were recruited by telephone calls and personal contacts; parent support groups for "autism spectrum disabilities" had nominated the participants -- and the participants were paid a "small stipend" for their time.

The interviews were conducted in places that the participants chose -- some in homes, some in conference rooms at local universities -- and each interviewee sat for one to two hours in a "semi-structured" setting. They were told they could end the interviews at any time and any question that was uncomfortable for them they could ignore. The interviews were recorded on audiotape and played back verbatim. The tapes were played independently by each member of the 4-member research team and the results revealed two main categories of concern for the participants: one, social experiences; and two, recommendations for better strategies for social support (to alleviate social anxiety) (Muller, 2008, pp. 176-77).

Clearly, these participants had strong opinions about what their lives were like, and how they could be better served given their situations with AS and PDD. These are the kinds of research exercises -- with solid results -- that families, teachers, and friends of people with AS should read and understand. Under the social experiences category, the participants identified the following as major issues: a) intense isolation; b) difficult initiating social interactions; c) challenges "relating to communication"; d) desiring more social connectedness and intimacy; e) a strong desire to be able to "contribute to one's community"; and f) effort to develop "greater social / self-awareness" (Muller, 2008, p. 177).

Several of the 18 participants claimed they had no "real friendships" and one said he felt as though he was "…at the bottom of a remote abyss, removed from everything, and not developing the normal peer relationships I perceived everybody else as experiencing" (Muller, 2008, p. 179). The recommendations these participants offered included: a) better "external supports"; b) more "communication supports"; c) "self-initiated supports"; and d) supports for their attitudes (Muller, 2008, p. 177). As a way to launch more appropriate supports, several participants suggested they needed "structured social activities" in small groups.

Social Anxiety Experienced by Parents

Another study of AS and high-functioning autism (HFA) involved 52 children and adolescents between the ages of 8 and 15 years (having been evaluated with AS / HFA from patient records at Oulu University Hospital in Finland). This study was designed to measure "social anxiety" and parents of the children in the study were asked to complete questionnaires -- and they were given a week to a month to complete the questionnaires. The questions in the study were read aloud to the children who were 8 and 9 years old "…to avoid the possibility of misunderstanding items due to developing reading skills" (Kuusikko, et al., 2008, p. 1699-1700).

A control group of 353 students (ages 8 to 16 years) was selected from the city of Oulu, Finland using "randomized cluster sampling selection."

The questionnaires used for the participants were the SPAI-C (a 26-item inventory taken directly from the DSM-IV) and the Social Anxiety Scale for Children-revised (SASC-R). That SASC-R measured three dynamics: a) fear of "negative evaluation"; b) "social avoidance, behavioral inhibition and social discomfort"; and c) "generalized social avoidance, behavioral inhibition and social discomfort" (Kuusikko, 2008, p. 1700). The authors of the study removed some of the questions in the SPAI-C in order to not use items based on "behavioral avoidance"; for example, "I try to avoid social situations"; "I leave social situations"; and "I usually do not speak to anyone until they speak to me" (Kuusikko, 2008, p. 1701). What they left in the SPAI-C were questions related to social anxiety, like "I feel scared when I have to join in social situation with a large group of boys and girls [more than 6]; When I am someplace [a party, school, soccer game or anyplace where I will be with others] my heart beats fast" (Kuusikko, 2008, p. 1701).

CBCL questionnaires that were given to the parents removed the following: "Complains of loneliness"; "Would rather be alone than with others"; "Refuses to talk"; "Stares blankly"; and "Feels or complains that no one loves him/her" (Kuusikko, 2008, p. 1701). Some of the items left in the CBCL include: "Clings to adults or too dependent"; "Cries a lot"; "Fears certain animals, situation, or places other than school"; "Nervous, high-strung, or tense"; and "Worries" (Kuusikko, 2008, p. 1701).

The data from this research -- and the point of this research -- boiled down to two aims. One was to examine self-reported symptoms of social from children and adolescents with HFA / AS. The results suggest that adolescents and children with HFA / AS are expected to report "more social anxiety symptoms" and their parents are expected to report "more internalizing symptoms than their typically developing peers" (Kuusikko, 2008, p. 1706). The second main aim of the study was to investigate the relationships between age, social anxiety and internalizing symptoms of children with HFA / AS. And the results showed that children with HFA / AS reported "an increase in social anxiety as they grew older" -- while the control group studied reported "…a decrease in social and evaluative anxiety as they grew older" (Kuusikko, 2008, p. 1706).

Another result of this research points to the fact that adolescents with HFA / AS reported "more behavioral avoidance and generalized social anxiety symptoms than did their control counterparts"; also the results indicate that social and evaluative anxiety problems found in HFA / AS youth may indicate a "…clinically significant and perhaps under-recognized problem," particularly as young people enter adolescence. Moreover, when children and adolescents who are diagnosed with HFA / AS begin to "…recognize their own impaired social skills," they may become "self-conscious, apprehensive or worried about their competency in social situations," Kuusikko writes on page 1707. This, in turn, could lead the HFA / AS adolescent to become withdrawn and avoid social situation, Kuusikko continues.

Meanwhile the parents of children with HFA / AS -- according to this research -- reported "significantly more internalizing problems" including "social anxiety symptoms," withdrawal and depression, than did the parents of those children in the control sample. This could be explained, Kuusikko writes (p. 1707) due to the fact that: a) adolescents tend to withdraw from parents during puberty and hence parents can't precisely observe their behavior in that window of time; b) parents of younger children with HFA / AS tend to spend more time with their children; c) parents of younger children with HFA / AS perhaps become "particularly sensitive to their children's behaviors" and may in fact "over-report" symptoms; and d) that very anxiety that parents of HFA / AS children are known to exhibit "may have influence" -- and bias -- over how parents score the questionnaires.

Inability of AS Individuals to Empathize

One of the characteristics of Asperger syndrome is reported to be the inability of individuals with AS to empathize with others, according to an article in the Journal of Autism and Developmental Disorder (Rogers, et al., 2007, p. 709). Of course empathy is important in the society, and in fact it is a revered characteristic, according to Rogers; that said, when there is a lack of empathy on the part of an individual, it is generally alluded to as "antisocial behavior" (p. 709). The authors of this research article note at the outset that cognitive empathy and theory of mind (ToM) are very similar concepts.

ToM relates to one person understanding the "feelings, intentions, and motivations of others" and cognitive empathy is "…understanding another person's perspective or feelings" -- hence, the interchangeable use of the two terms, Rogers writes on page 210. And hence, also, claims of AS impairments in empathy "based solely on assessments of ToM may be misleading" (Rogers, 2007, p. 710). That having been said, this study was designed to do two things; one, look into cognitive and affective empathy in AS; and two, to "attempt to clarify the relationship between ToM and empathy" (Rogers, 2007, p. 710).

Twenty-one individuals with AS (documented as having met the DSM-IV diagnostic criteria for AS) participated in the study, balanced with 21 control participants. The control and AS participants were matched in terms of age, gender, IQ and educational achievements. The clinical diagnostic interview with both groups was videotaped, and the Autism Diagnostic Interview -- Revised (a "semi-structured" interview) was used. The control group consisted of "healthy volunteers" from the New York University School of Medicine's Center for Brain Health. The AS adults were recruited from local AS support groups and were referred by clinicians, Rogers explained on page 711.

"Trained examiners" in a private and quiet room at the NYU School of Medicine conducted the testing of the 42 individuals. Eight ToM stories and two control stories of Happe's original Strange Stories test were given. In the ToM stories the participants were required to "infer a character's thoughts, feelings, or intentions" (for example, "Why did X say that?") (Rogers, 2007, p. 711). In those ToM stories, there were examples of "double bluff, persuasion, irony and white lies," Rogers explained on page 711. For the control group, they were asked about "physical causation instead of about the mental states of others," Rogers continued (p. 712). "As expected, the AS group did significantly worse than the control group on the Strange Stories test," Rogers explains (p. 712).

What was the bottom line as far as determining the degree to which individuals with AS are empathetic in a cognitive sense? First, a review of the two kinds of empathy: "cognitive empathy" refers to the "process of understanding another person's perspective"; and "affective empathy" is defined as "an observer's emotional response to the affective state of others" (Rogers, 2007, p. 709). On the PD scale (assessing self-oriented feelings of anxiety and discomfort that results from "tense interpersonal settings") the AS group scored higher than the control group.

But on the PT (the tendency to "spontaneously adopt the psychological point-of-view of others") scale and F (the tendency to identify with fictional characters in books) scale the AS group scored lower than the control group. What this suggests, Rogers relates on page 713, is that individuals with AS have difficulty relating to the perspective of fictional and real people.

As to the "affective empathy" results, the PD results, the AS group actually scored "significantly higher" than the control group. Rogers said (p. 713) this indicates a tendency to have "self-oriented feelings of anxiety and discomfort" when confronted with "tense interpersonal settings." The bottom line, according to Rogers, is that because individuals with AS don't react to human interaction situations as expected, they may have obtained the label of being uncaring or cold. However, the data from this research shows that when AS individuals are given full information about a situation, allowing them to "understand the point-of-view of others, they have as much concern and compassion as unaffected individuals" (Rogers, 2007, p. 713).

What about the relationship between ToM and empathy? The authors state that while cognitive empathy may to some degree overlap with ToM, affective empathy seems "partially independent." As to what that really means, the authors are vague. They do suggest that future studies must be carrier out to more definitively solve that puzzle.

Delay in AS Diagnosis

Brenda Smith Myles and Richard L. Simpson emphasize the fact that "many children and youth who exhibit characteristics" associated with Asperger syndrome are not diagnosed with AS until sometime later in their lives (Myles, et al., 2002, p. 132). This is an important issue because there are interventions -- to be detailed later in this paper -- that appear to be helpful, if implemented early in life. Calling AS a "social disorder," Myles explains that young people with AS typically are awkward and stiff in social situations and they are "emotionally blunted, self-centered, deficient at understanding nonverbal and social cues, and inflexible" (p. 133). In previous scholarship reviewed for this paper "inflexible" and "emotionally blunted" have not been used in connection with AS.

But it appears Myles is suggesting (p. 133) that "inflexible" alludes to the fact that children with AS are "deficient at understanding nonverbal social cues" and gestures. The failure of a person with AS to interpret facial expressions, voice tone, posture is what Myles refers to as "inflexible" albeit that may not be fair to people with AS because they are not deliberately being "inflexible." Myles takes another shot at AS persons on page 133 when she asserts that they "often lack common sense" as well as being unaware of "social standards" -- and both of these shortcomings lead to a "…range of socially unaccepted behaviors."

A far more fair and balanced analysis of the problems an AS person displays is also on page 133 as Myles explains: "Children with AS do not generally reveal stress through voice tone or posture" -- hence, others may not be aware at all that the AS person is on the cusp of a crisis. The discomfort an AS person feels, if it goes unnoticed, can be brutally harmful in time to the sensitive emotions of a person who really doesn't understand all that is going on around him or her. Moreover, Myles correctly points out (p. 133) that because an AS person is often unaware of the dynamics of social behaviors around her or him, and do not show others the stress they may feel inside, "It should be obvious…that children and youth with AS are relatively easy targets for bullying by others."

And given that they are vulnerable to bullying and other impolite behaviors, and in many instances unable to "predict outcomes," children and young people with AS are additionally open to hurtful behaviors by others because they "…find themselves more and more in conflict with prevailing social norms as they move through adolescence and young adulthood, when social growth is the norm" (Myles, 2002, p. 133).

On page 134 Myles presents a paradox as related to the educational issues of a person with AS. On the one hand, an AS student "…typically" has "average to above-average intellectual abilities," are blessed with "good rote memory skills" and have a motivating urge to join their peers in general education success. On the other hand, an AS student can be expected to struggle with "significant academic problems" which are related to "social and communication deficits," Myles continues on page 134. Moreover, the AS student suffers from what Myles refers to as "…obsessive and narrowly defined interests, concrete and literal thinking styles," and poor abilities when it come to solving problems and being organized.

The word "inflexibility" enters Myles' scholarly vocabulary again, this time in the sense that the AS student is often locked into the irrelevant rather than the relevant. The problem is that the AS student often cannot tell the difference between what is pertinent and what is not, and also, the AS student generally struggles with "abstract materials" like metaphors and idioms (Myles, 2002, p. 134). And when it comes to sensory issues, AS students are known to have difficulty, Myles goes on (p. 135). In a 2002 study referenced by Myles, "…over 75% of students with AS…demonstrated behavioral problems when sensory issues were violated" and that is due to the fact that they have sensory profiles "distinctive from that of neurotypical individuals" (p. 135).

Chapter Three -- Working With AS Students - Interventions

Woodbury-Smith offers nine approaches / interventions when working with AS students, all of which are used to: help the person develop social skills; encourage the development of strategies that help the AS person solve problems and "…reduce maladaptive patterns of behavior"; and also teach the AS person better ways to communicate (Woodbury-Smith, 2009, p. 6).

While Woodbury-Smith acknowledges that his list of approaches is not detailed ("…behavioral approaches [are] beyond the scope" of his review) there are certain pertinent themes among the nine: a) educational programs must meet each individual's pattern of "cognitive strengths and vulnerabilities"; b) the use of role-playing in order to learn social rules may not be as effective as "rote verbal learning"; c) verbal learning should be advanced step-by-step rather than as "a narrative gestalt"; d) small class sizes are more helpful and allow 1-on-1 supervision; e) children with AS should be integrated with peers who do not have AS; the social and communication skills the AS students witness between non-AS students can have a beneficial effect; f) curriculum should be specially structured for the AS student -- meaning, more time than with non-AS students will be required for things to sink in; g) the Vineland adaptive behavior scale (VABS) is useful in determining areas of "vulnerability" after adaptive skills have been taught through rehearsal and practice; h) organizational skills can be "targeted by…scheduling, scripts, rules or lists…"; i) the use of eye-contact training, and other small group dynamics, can be practiced using computer software ("Let's Fact It," and "Mind Reading: An Interactive Guide to Human Emotions" (Woodbury-Smith, 2009, p. 6).

Development of Social Skills

On the subject of the desirability of better social skills for persons with AS, a research piece in the Journal of Autism and Developmental Disorders describes a project involving 19 children with AS, 20 children with "high-functioning autism" and 17 children the authors describe as "typically developing" (Macintosh, et al., 2006, p. 1067). The children ranged in age from 4 years, 4 months, to 10 years, 10 months of age.

As to specific social skills (cooperation and self-control) -- based on teachers' and parents' reports -- the autism group showed "below average demonstration of each social skill"; the Asperger's group -- in some cases -- was classified as having "average" skills in cooperation and self-control. In other cases the AS group "showed deficits in the social skills of cooperation, assertion and self-control across a variety of real-life settings, relative to they typically developing peers" (Macintosh, 2006, p. 1073). And the "typically developing children" showed skills in social settings that are expected of children in that category.

The authors conclude, "…children with high-functioning autism and Asperger's Disorder are often troubled and frustrated by their poor social competence"; given that fact, the authors believe that "…inappropriate behaviors may be strategies the child has developed to achieve desired social response" (Macintosh, 2006, p. 1074).

Renae Beaumont and Kate Sofronoff present a social skills intervention for children in Australia with AS called "The Junior Detective Training Program" (Beaumont, 2008, p. 743). The 7-week program used a computer game, parent training sessions and teacher involvements for 26 children with AS (and 23 in a control group). The AS children were recruited with the help of internationally noted Asperger syndrome experts Dr. Tony Attwood and Dr. Tony Leslie, and the basic purpose of the intervention was to improve the social skills of the participants. According to Beaumont, the Junior Detective Program (JDTP) "appeared to be effective in enhancing the social skills and emotional understanding of children with AS" (p. 743).

There were four phases to the study: group social skills training; training of the parents of children with AS; handouts by teachers; and a computer game. It was hoped that: a) participants would learn to be more perceptive to the body language and facial expressions of others; b) children with AS would make gains in social competence; c) AS participants would show gains on how to handle anxiety and anger; and d) overall the AS group would show positive responses to predictive variables (age and IQ) when the control group also received the same intervention through JDTP (Beaumont, 2008, p. 744).

The method for carrying out the JDTP project first entailed an authenticated AS diagnosis by a pediatrician, ethical approval by the University of Queensland, and of course approval by parents. The AS participants had to have an IQ of 85 or above and needed to be between 7-1/2 and11 years of age (Beaumont, 2008, p. 744-45).

A junior detective computer game was invented that helped children learn how to recognize "complex emotions" such as embarrassment, teasing, suspicion and guilt. A strategy was developed for small groups with therapy materials in play; with this game children were taught "a generic formula for solving social problems" and were taught how to recognize and put into practice the social skills they were shown in the computer game. The small group materials were presented through "multiple modalities" and included posters, modeling, and role-playing. Parents were asked to complete a social skills questionnaire that rated the social competence of their children during and following the seven-week session (Beaumont, 2008, p. 745-46).

The bottom line results, according to Beaumont (p. 747), was that there was improvement in social functioning in both the AS children and the control group. Using MANOVA (multivariate analyses of variance), the researchers showed that both the control group and the intervention / treatment group showed gains in understanding facial expression changes. As to the anxiety and anger-management strategies, there was "a significant improvement" in the scores for the treatment group but not for the control group (Beaumont, 2008, p. 748).

At the six-week follow-up and the 5-month follow up, parents rated improvements in social skills in the home for both groups. However, teachers reported that the improvements in social skills "had eroded within six weeks of the program ending" (Beaumont, 2008, p. 749). There were limitations on the study, including "limited availability of training" in some of the measures and the fact that parents and teachers played the roles of "intervention agents and the primary evaluators of the intervention" (Beaumont, 2008, p. 750). Overall though, "…some improvements in social functioning" were realized.

Building Social Skills Confidence

Still on the subject of social skills training for adolescents with Asperger syndrome and high-functioning autism (HFA), a scholarly research article published in 2007 reported on the success of a program involving 46 adolescents and their parents coving a 12-week period of time. This particular study focused on improving the social competence and lessening problem behaviors that are generally associated with AS and HFA.

The study embraced adolescents ages 13-18 -- all referred by psychiatry and community clinics in and around McGill University in Montreal, Canada. Six separate groups of adolescents -- with 7 or 8 adolescents in each group -- were led by a psychologist and a social worker that had experience in psychiatry. The sessions lasted about an hour and a half and were conducted weekly for 12 weeks. At each session, group members were asked to review whether or not they practiced last week's skill and they were introduced to a new social skill. In each group members practiced the new social skill (one pair at a time) while the remainder of the group watched what was going on, and later provided feedback. Later, during a snack break, participants were "encouraged to interact with one another"; following the break group games like Charades were played and at the close of the sessions "…members are encouraged to say goodbye to each other" (Tse, et al., 2007, p. 1962).

Some of the exercises used in the session to teach new skills were drawn from the book Skillstreaming the Adolescent (Goldstein & McGinnis, 2000), a publication known to be useful in working with youths who have behavioral problems (but not necessarily noted for use with AS and HFA young people). In the end there were 44 participants that finished the training, and the authors (p. 1964) report the data and the questionnaire results showed "…a robust trend towards social competence gains." Moreover, "significant improvements were also found on measures of problem behaviors," Tse writes (p. 1965).

The authors claim that their project proves that "social skills groups" can indeed be an effective approach to helping AS and HFA youths to "develop comfort and confidence in social interactions" (Tse, 2007, p. 1965). Interestingly, the adolescents "perceived more improvement in their social skills than did their parents," and there were also improvements in "problem behaviors" ("irritability" and being "overly sensitive" were two that the authors named), according to Tse (p. 1966). This was a "simple, low-cost intervention" and as such the authors believe social deficits of young people with AS and HFA "…can be readily addressed" (Tse, 2007, p. 1967).

Helpful Services for College Students with AS

As an increasing number of college-age students are attending places of higher education, the author of this article, Caroline P. Smith, posits that there are strategies through which institutions can "better accommodate and serve this population" (Smith, 2007, p. 515). Smith suggests that when "…adjusting a student's schedules and appointments" advisors should use "caution" because those AS students might require "assistance in interpreting things a professor or another student might say" (p. 517). The author objects to the policy of one school (unnamed) that charges an extra $4,500 per semester for AS students who require extra help in understanding assignments (p. 517).

Meantime, Smith's survey was designed to be informative as to what services colleges and universities are offering in the way of special help for AS students. Smith's research consisted of an "electronic survey" (questionnaire by email) sent out to 102 educational institutions that are members of the Association on Higher Education and Disability (AHEAD). However, only 5 survey questionnaires out of the 102 sent to AHEAD schools were returned to Smith. But Smith writes that 66 fax numbers were available and working and so the same introductory letter, informed consent and survey were faxed and of those 36.3% were returned (Smith, 2007, p. 520). .

The results of this effort by Smith: for the most part accommodations for AS students are the same ones "provided…for other students with different disabilities"; this will "not always satisfy the students with AS needs" (Smith, 2007, p. 526). More will have to be done, Smith observes, including support groups that are there to provide help for AS students. Among all the institutions surveyed, no support groups were available albeit the number of students with AS "is significant" (Smith, 2007, p. 527). The author recommends that faculty receive training as regards the classroom needs of AS students, and moreover, support groups should be established.

"Social Thinking" Interventions

In another research project, six male children (between ages 9 -- 11) with either HFA or AS were recruited by the University of Arizona to participate in both structured and non-structured settings for the teaching of the "social cognitive (Social Thinking) approach" (Crooke, et al., 2008, p. 581). Sessions lasted 60 minutes and went on for eight consecutive weeks. "Social cognitive deficits" were addressed in these lessons that were intended to promote "Social Thinking" (Crooke, 2008, p. 586). More specifically, this approach does not use "tangible consequences" or "punishment" to eliminate undesirable behaviors but rather uses a strategy where children are taught to "…understand that others had 'thoughts' separate from their own and that 'social' is based on understanding and regulating others' thoughts via their own individual behaviors" (Crooke, 2008, p. 586).

This approach is different from a "strictly behavioral model of teaching," Crooke explains; indeed, the "Social Thinking" approach is based on: a) taking "abstract concepts" and making them "concrete"; b) "using visual structure support language abilities"; c) focusing on "self/peer awareness"; and d) emphasizing activities that "promote generalization to 'real world' interactions" (p. 586). What kind of result was recorded? The "most salient" result, according to Crooke, was that "significant changes occurred" in both the expected verbal and nonverbal behaviors and the unexpected verbal and nonverbal behaviors (p. 587). Boiled down, that means socially desirable behaviors increased because the six participants learned "about their own social behaviors and the impact on others' thoughts about them" (Crooke, 2008, p. 587).

Social thinking teaches children with AS to "think with your eyes" and "listen with your eyes" -- and that "looking equals thinking" -- hence, the AS child can learn to explore the intentions and emotions of others more proficiently in real time interactions with peers (Crooke, 2008, p. 588).

Improving Social Functioning

Meantime another approach to working with AS children is called the social-behavioral learning strategy intervention (SODA); Marjorie A. Bock explains that the SODA approach was applied in a study of the social interaction skills of 4 elementary school children with AS. For five months, the SODA strategy was utilized during cooperative learning activities, during organized sports games, and during visits with peers at lunchtime. A multiple-baseline-across-settings design was used in order to critique behavior with (intervention) and without (baseline) the use of SODA; a specific SODA story was written for each of the four boys and each story included "self-question and self-answer statements" and each story described the specific "social-behavioral difficulties that participants presented" (Bock, 2007, p. 90).

Without going into the step-by-step procedures and individual outcomes, it is pertinent to report that the four -- Bob, Joe, Alex, and Craig -- each "showed benefits" from the SODA intervention. They each demonstrated "long-term memory of the SODA strategy" and each indicated that they will continue to use SODA because "…it helped them make sense of what their peers did during social studies group, at noon recess, and at lunch" (Bock, 2007, p. 94).

How to improve social functioning for students with Asperger syndrome -- that is the crux of an article by E. Amanda Boutot in the journal Intervention in School and Clinic. Prior to describing her own intervention strategy, Boutot quickly reviews four interventions that have been found to be of some use in working with children who have AS and ASD. Those four are: a) social stories (a pictorial or written story that zeros in on a difficulty experienced by AS students); b) social scripts (providing "clear instructions" on how to properly behave in certain social situations); c) power card strategy (the card depicts a hero -- that the participant views as a hero -- solving a problem in a "socially appropriate manner"); d) cognitive behavior modification (having the participant "use self-talk out loud" that progresses to "internal speech" as a way of monitoring behavior and responding to environmental stimuli") (Boutot, 2009, p. 277).

Boutot's approach is the "I Will" card strategy; that strategy includes components of social stories, scripts, self-management (CBM) and power cards. The "I Will" cards teach social skills by relying on the student's strengths (memory and intelligence) and by taking into account the "deficit areas" (resistance to "corrective feedback" and generally preferring adults to peers). The bottom line, Boutot writes, is that "I Will" cards helps students "prompt their own appropriate behavior" rather than having a teacher or other person redirect them when they make an inappropriate statement (Boutot, 2009, p. 278). In any given situation, the "I Will" card instructs the student to tell himself or herself "silently or aloud what she or he needs to hear or think to respond appropriately" in any given situation (Boutot, 2009, p. 278).

Not unlike the power card strategy, the "I Will" card approach encourages the student to say aloud something like, "When I have something to say in class, I will raise my hand" or "When people look at me funny, I will look away, walk away, or say something nice" (Boutot, 2009, p. 278). In training students to use the "I Will" cards the instructor must insist on emphasizing the following: "Read it, think it, read it again," Boutot explains on page 278. The teacher actually needs to model the procedure in front of the student, then the teacher praises that student when he or she correctly imitates what the teacher just read.

Care must be taken, Boutot continues, so that the cards are not uniquely associated with problem situations; since meetings with AS students are an every-day occurrence, the coach's job is to make sure the student knows how to use the cards, how to take ownership of the cards, and how to apply them to real-life situations. One parent cited by Boutot actually put her son's "I Will" cards on a key ring and color-coded them (green cards are for peer interactions; blue cards are for "appropriate classroom behavior"; orange is for proper behavior out in the community) (Boutot, 2009, p. 280).