The Complete Guide to Asperger's Syndrome

by Anthony Attwood

According to DSM-5, the essential features of ASD are persistent deficits in reciprocal social communication and social interaction, and restricted, repetitive patterns of behaviour, interests or activities.

The underlying assumption in the diagnostic criteria is that someone who has an ASD has difficulty ‘reading’ social situations. From my clinical experience, there are three adaptations to this characteristic. The most conspicuous is a tendency to be withdrawn, shy and introspective in social situations, avoiding or minimizing participation or conversations; or, conversely, actively seeking social engagement and being conspicuously intrusive and intense, dominating the interaction and being unaware of social conventions such as acknowledging personal space. In each example, there is an imbalance in social reciprocity. However, I have identified a third strategy for coping with difficulties with ‘reading’ social situations, and that is to avidly observe and intellectually analyze social behaviour and to achieve reciprocal social interaction by imitation and using an observed and practised social ‘script’ based on intellectual analysis rather than intuition. This is a compensatory mechanism often (but not exclusively) used by girls with Asperger’s syndrome, who are thus able to express superficial social abilities that can be confusing to the diagnostician.

Asperger’s syndrome also has a ‘signature’ language profile. This can include impaired pragmatic language abilities (i.e. the ‘art’ of conversation) such as attentive listening, with a tendency to engage in monologues and a failure to follow conversational rules. There may be literal interpretations, with a tendency for the person to become greatly confused by idioms, figures of speech and sarcasm. There may also be unusual prosody: for example, a child may consistently use an accent based on the voice of a television character, or an adult may speak with an unusual tone, pitch and rhythm. All these characteristics affect the reciprocity and quality of conversation.

The accompanying text to the diagnostic criteria of DSM-5 suggests there is a desire to establish friendships without a complete or realistic idea of what friendship entails.

The special interests all have a ‘use by date’, ranging from hours to decades, and have many functions, such as being a ‘thought blocker’ for anxiety, an energy restorative after the exhaustion of socializing, or an extremely enjoyable activity that is an antidote to depression. The interest may involve the creation of an intricate alternative world that may be more accommodating of the characteristics of Asperger’s syndrome. The special interest can also create a sense of identity and achievement, as well as provide an opportunity for making like-minded friends who share the same interests. The sense of well-being associated with the interest can become almost addictive, sometimes leading to concern that it is dominating the person’s time at home to such an extent that it is preventing engagement in other activities.

The children’s use of language was pedantic, and some children had an unusual prosody that affected the tone, pitch and rhythm of speech. The grammar and vocabulary may have been relatively advanced but, at the end of the conversation, one had the impression that there was something unusual about their ability to have the typical conversation that would be expected with children of that age.

Asperger also observed and described conspicuous impairments in the communication and control of emotions, and a tendency to intellectualize feelings.

Many adults who are diagnosed in their mature years say that the first time they felt different to others was when they started school. They describe being able to understand and relate to family members, including playing socially with brothers and sisters, but when they were expected to play with their peers at school and relate to a teacher, they recognized themselves as being very different from children their age. When I ask these adults to describe those differences, the replies usually refer to not being interested in the social activities of their peers, not wanting to include others in their own activities, and not understanding the social conventions in the playground or classroom.

The teacher may also notice that the child becomes extremely anxious if routines are changed or he or she cannot solve a problem.

Clinicians have recognized for some time that children with Asperger’s syndrome can also have signs of ADHD, which has been confirmed by several research studies and case descriptions (Ehlers and Gillberg 1993; Fein et al. 2005; Ghaziuddin, Weider-Mikhail and Ghaziuddin 1998; Klin and Volkmar 1997; Perry 1998; Tani et al. 2006). The two diagnoses are not mutually exclusive and a child may benefit from the medical treatment and strategies used for both disorders.

One of the problems faced by children with Asperger’s syndrome who use their intellect rather than intuition to succeed in some social situations is that they may be in an almost constant state of alertness and anxiety, leading to a risk of mental and physical exhaustion. The child may have developed compensatory mechanisms to avoid anxiety- provoking situations such as school, by refusing to go to school or being mute at school (Kopp and Gillberg 1997). There may be intense anxiety or a phobic reaction to certain social situations, or to sensory experiences such as a dog barking, or to a change in expectations such as an alteration to the daily school routine.

Eating disorders can include refusal to eat foods of a specified texture, smell or taste due to a sensory hypersensitivity (Ahearn et al. 2001). There can also be unusual food preferences, and routines regarding meals and food presentation (Nieminen-von Wendt 2004).

During adolescence, a teenager with Asperger’s syndrome is likely to have increasingly conspicuous difficulties with planning and organizational skills, and completing assignments on time.

A group of students may be expected to submit a science project and the teenager with Asperger’s syndrome is not easily assimilated into a working group of students.

I have noted that the signs of Asperger’s syndrome are more conspicuous at times of stress and change, and during the teenage years there are major changes in expectations and circumstances.

Sometimes children with Asperger’s syndrome perceive themselves as more adult than child. Indeed, such children may act in the classroom as an assistant to the teacher, correcting and disciplining the other children.

Those children who have exceptionally high IQs may compensate by becoming arrogant and egocentric, and have considerable difficulty acknowledging that they have made a mistake. Such children can be hypersensitive to any suggestion of criticism, yet overly critical of others, including teachers, parents or authority figures.

Those children who tend to internalize thoughts and feelings may develop signs of self-blame and depression, or alternatively use imagination and a fantasy life to create another world in which they are more successful.

Social ability and friendship skills are highly valued by peers and adults and not being successful in these areas can lead some children with Asperger’s syndrome to internalize their thoughts and feelings by being overly apologetic, self-critical and increasingly socially withdrawn.

A more constructive internalization of thoughts and feelings of being socially defective can be to escape into imagination. Children with Asperger’s syndrome can develop vivid and complex imaginary worlds, sometimes with make-believe friends.

When adults with Asperger’s syndrome have used imitation and acting to achieve superficial social competence, they can have considerable difficulty convincing people that they have a real problem with social understanding and empathy; they have become too plausible in their role to be believed.

The clinician perceives someone who appears able to develop a reciprocal conversation and use appropriate affect and gestures during the interaction. However, further investigation and observation at school may determine that the child adopts a social role and script, basing her persona on the characteristics of someone who would be reasonably socially skilled in the situation, and using intellectual abilities rather than intuition to determine what to say or do.

The motor coordination problems of girls may not be so conspicuous in the playground,

Being alone can be a very effective way of calming down and is also enjoyable, especially if engaged in a special interest, one of the greatest pleasures in life for someone with Asperger’s syndrome.

When alone, especially in a bedroom, the hypersensitivity for some sensory experiences is reduced as the environment can be relatively quiet, particularly in comparison to a school playground or classroom. The child with Asperger’s syndrome may also be sensitive to change and be anxious if things are not where they have been or should be. Furniture and objects in the bedroom will be a known configuration, and family members will have learned not to move anything. The child’s bedroom is a refuge that is sacrosanct.

For the child with Asperger’s syndrome, being alone has many advantages; problems only occur when someone enters the room, or when he or she has to leave the bedroom and interact with other people. I have noted that people with Asperger’s syndrome may function reasonably well in one-to-one interactions, using their intellectual capacity to process social cues and non-verbal communication, and using memory of similar social situations to determine what to say and do.

A child or adult with Asperger’s syndrome can mistake friendliness for friendship and conceptualize friends as though they should be reliable machines. Jamie, a young child with Asperger’s syndrome, said of the child he used to play with, ‘He can’t play with me one day and then other friends another day, he wouldn’t be a true friend.’ A child with Asperger’s syndrome may conceptualize friendship to be about possession, and is intolerant of anyone who breaks his or her personal rules about friendship.

The child with Asperger’s syndrome can be on the periphery of the playground, sometimes socially isolated by choice, or actively among the other children and seeking inclusion but being perceived by peers as intrusive and irritating. Such behaviour is often described by teachers as silly, immature, rude and uncooperative (Church et al. 2000).

When adolescents are included in the activities and conversations of their peers, there can still be feelings of not being included or popular. This is illustrated by two comments from adults with Asperger’s syndrome describing their teenage years: ‘I wasn’t rejected but did not feel completely included,’ and ‘I was supported and tolerated but not liked.’ A lack of genuine social acceptance by peers will obviously adversely affect the development of self-esteem.

Very young children with Asperger’s syndrome have a clear end-product in mind when playing with toys; however, they may fail to communicate this effectively to a playmate, or tolerate or incorporate the other child’s suggestions, as this would produce an unanticipated outcome. For example, the child with Asperger’s syndrome may have in mind while playing with construction equipment the mental image of the completed structure, and be extremely agitated when another child places a brick where, according to the mental image, there shouldn’t be a brick. The typical child, meanwhile, does not understand why his or her act of cooperation is rejected. The young child with Asperger’s syndrome often seeks predictability and control in play activities while typical peers seek spontaneity and collaboration.

When other children are included, the child with Asperger’s syndrome may be dictatorial, tending not to play by conventional rules and considering the other child as subordinate.

Children with Asperger’s syndrome can be very rule-bound and need to learn that, when playing with a friend, it is possible sometimes to change the rules and be inventive, yet still have an enjoyable experience, and that this is not necessarily a cause for anxiety.

‘It is not a sense of humour we lack, but rather the social skills to recognize when others are joking, signal that we ourselves are joking, or appreciate jokes which rely on an understanding of social conventions’ (Sainsbury 2000, p.80).

For example, the person with Asperger’s syndrome may not look at the other person as much as would be expected in a conversation, and especially when answering a question. Rather than undertake a program to know when to look at someone and read facial expressions, I recommend explaining the avoidance of eye contact: for example, ‘I need to look away to help me concentrate on answering your question. I am not being rude, dishonest or disrespectful.’ When talking about a special interest that is likely to be perceived as boring, the person with Asperger’s syndrome may say, before starting the monologue, ‘Sometimes I talk too much about my interests. If I am boring you, please ask me to stop. I will not think you are being rude.’ The person creates a spoken Social StoryTM for typical people to explain what appears to be eccentric or rude behaviour.

We each have a limited capacity for the duration of social contact. I use the metaphor of filling a ‘social bucket’. Some typical individuals have a large social bucket that can take some time to fill, while the person with Asperger’s syndrome has a small bucket, or cup, that reaches capacity relatively quickly. Conventional social occasions can last too long for someone with Asperger’s syndrome, especially as social success is achieved by intellectual effort rather than natural intuition. Socializing is exhausting.

The psychological term Theory of Mind (ToM) means the ability to recognize and understand thoughts, beliefs, desires and intentions of other people in order to make sense of their behaviour and predict what they are going to do next. It has also been described as ‘mind reading’ or ‘mind blindness’ (Baron-Cohen 1995) or, colloquially, a difficulty in ‘putting oneself in another person’s shoes’.

The child or adult with Asperger’s syndrome does not recognize or understand the cues that indicate the thoughts or feelings of the other person at a level expected for someone of that age.

It has been suggested that impaired ToM also affects self-consciousness and introspection (Frith and Happé 1999). I was talking to Corey, a teenager with Asperger’s syndrome, about the ability to ‘mind read’. He said, ‘I’m not good at working out what other people are thinking. I’m not sure what I’m thinking now.’ Thus there may be a pervasive difficulty in thinking about thoughts and feelings, whether they are the thoughts and feelings of another person or oneself.

To imply an absence of empathy would be a terrible insult to people with Asperger’s syndrome, with the implication that the person does not recognize or care about the feelings of others. The person does care, very deeply, but may not be able to recognize the more subtle signals of emotional states or ‘read’ complex mental states.

How do we know what a person may be thinking or feeling? One way is our ability to read a face, in particular the region around the eyes. We have known for some time that children and adults with an autism spectrum disorder, including Asperger’s syndrome, appear to engage in less eye contact than anticipated, tending to look at a person’s face less often, and therefore missing changes of expression.

recent research has indicated that adults with Asperger’s syndrome tend to look less at the eyes and more at the mouth, body and objects than do control subjects (Klin et al. 2002a, 2002b).

Children or adults with Asperger’s syndrome can be confused by sarcasm, and prone to teasing by others, as they are remarkably gullible and assume that people say exactly what they mean.

Stephen Shore sent me the following comment. ‘When I am asked what I would like to eat or drink when at another person’s home as a guest, it is impossible for me to answer. My response is to ask ‘What is available?’ Once the options are laid out for me it is easy to make a choice. Otherwise the question just feels too big.’

When presented with a problem, seeking guidance from someone who probably knows what to do is usually not a first or even a second thought. The child may be sitting or standing next to someone who could obviously help but appears ‘blinkered’ and determined to solve the problem by him- or herself.

Observations and experience of conflict situations suggest that children with Asperger’s syndrome are relatively immature, lack variety in negotiating tools and tend to be confrontational. They may resort to ‘primitive’ conflict management strategies, such as emotional blackmail or an inflexible adherence to their own point of view. They may fail to understand that they would be more likely to achieve what they want by being nice to the other person. When an argument or altercation is over, the person with Asperger’s syndrome may also show less remorse, or appreciation of repair mechanisms for other people’s feelings, such as an apology.

The children with Asperger’s syndrome tended to rate some situations as embarrassing whereas typical children did not, and they had some difficulty justifying why someone would be embarrassed.

Being unsure of what someone may be thinking or feeling can be a contributory factor to general feelings of uncertainty and anxiety. Marc Fleisher is a talented mathematician with Asperger’s syndrome and, like most people with Asperger’s syndrome, is a very kind person who does not want to cause someone to be confused or distressed. In his autobiography he wrote: Because of my lack of confidence, I am terribly afraid of upsetting others without realising it or meaning to, by saying or doing the wrong thing.

Typical people are very quick and efficient in using ToM abilities when engaged in social situations. Research has shown that while some children and adults with Asperger’s syndrome can demonstrate quite advanced ToM skills, they can take longer with the cognitive processing of the relevant cues and responses than one would expect, and require more encouragement and prompts. Their answers to questions that rely on ToM abilities can be less spontaneous and intuitive and more literal, idiosyncratic and irrelevant (Bauminger and Kasari 1999; Kaland et al. 2002).

I have also noted that ToM abilities in children and adults with Asperger’s syndrome can be influenced by the complexity of the situation, the speed of the interaction and the degree of stress. In large social gatherings the amount of social information can be overwhelming for someone with Asperger’s syndrome. The person may have reasonable ToM abilities but have difficulty determining which signals are relevant and which are redundant, especially when inundated with social cues. The time taken to process social information is similar to the time it takes for someone who is learning a second language to process the speech of someone fluent in that language. If the native speaker of the language talks too quickly, the other person can only understand a few fragments of what has been said. I have learned to adjust my interaction with a person with Asperger’s syndrome to be within the person’s processing capacity for social reasoning. When relaxed, the person with Asperger’s syndrome can more easily process mental states, but when stressed, as with any skill, performance declines.

Using cognitive mechanisms to compensate for impaired ToM skills leads to mental exhaustion. Limited social success, low self-esteem and exhaustion can contribute to the development of a clinical depression.