The Complete Guide to Asperger's Syndrome

by Anthony Attwood

•delay in the development of the art of persuasion, compromise and conflict resolution

If a parent has a mood disorder, a child with Asperger’s syndrome could have a genetic predisposition to strong emotions. This may be one of the factors that explain problems with the intensity and management of emotions that are characteristics of Asperger’s syndrome.

Research on executive function and Asperger’s syndrome suggests characteristics of being disinhibited and impulsive, with a relative lack of insight that affects general functioning (Eisenmajer et al. 1996; Nyden et al. 1999; Ozonoff et al. 2000; Pennington and Ozonoff 1996). Impaired executive function can also affect the cognitive control of emotions. Clinical experience indicates there is a tendency to react to emotional cues without thinking.

The child may express anger and affection at a level expected of a much younger child. There can be a limited vocabulary to describe emotions and a lack of subtlety and variety in emotional expression. When other children would be sad, confused, embarrassed, anxious or jealous, the child may have only one response, and that is to feel angry. The degree of expression of negative emotions such as anger, anxiety and sadness can be extreme, and described by parents as an on/off switch set at maximum volume.

Conversations with parents can examine whether the child suppresses feelings of confusion and frustration at school but releases such feelings at home. I describe some children with Asperger’s syndrome as being a ‘Dr Jekyll and Mr Hyde’ – an angel at school but a devil at home.

Some children and adolescents with Asperger’s syndrome can feel responsible for another person’s agitation or distress and apologize or appease when they did not cause the other person’s feelings. Wendy Lawson explained: Until recently I always believed that if someone close to me was ‘angry’ then it must be because of me. Now I am beginning to realise that people can be unhappy or even angry, for many different reasons. In fact it may have nothing to do with me at all!

The child may have a history of being overly attached to a parent, or detached; or having an intense emotional reaction to changes in routines or expectations, or when experiencing frustration and failure. The child may rapidly switch from one emotion to another.

Despite their being notorious for becoming irritable over relatively trivial matters, I have noted that some adults with Asperger’s syndrome are renowned for remaining calm in a crisis when some typical adults would panic.

As much as there can be problems with the understanding, expression, regulation and repair of emotions, there can also be problems regarding the confidence to respond appropriately.

The sensory sensitivity will create a feeling of anxiety, but unfortunately feeling anxious also heightens sensory perception, and the combination of sensory sensitivity and anxiety thus has a profound effect on the person’s quality of life.

Social phobia, or social anxiety disorder, would be expected to be relatively common for those with Asperger’s syndrome, especially in the teenage and adult years when they are more acutely aware of their confusion in social situations, of making social mistakes, and possibly suffering ridicule. A typical person who develops social phobia is very concerned as to what others will think of him or her, with a fear of being embarrassed. I have noted that young people with Asperger’s syndrome who develop signs of social phobia are more avoidant of self-criticism than the criticism of others, and have a pathological fear of making a social mistake.

People with Asperger’s syndrome are often perfectionists, tend to be exceptionally good at noticing mistakes, and have a conspicuous fear of failure.

Touch, and especially attempts at physical restraint, can increase the feelings of anger and energy levels. Sometimes asking the person ‘What’s the matter?’ can also inflame the situation, because when experiencing severe emotional distress, the person’s ability to articulate the cause of the anger can be significantly diminished and create further frustration.

However, the reverse can occur for some children and adults with Asperger’s syndrome, with the person needing frequent expressions of affection (sometimes for reassurance) and often expressing affection that can be overbearing for others.

I have observed that the degree of motivation and duration of time spent on the interest is proportional to the degree of stress, anxiety or agitation. The more the person experiences worries, confusion and agitation, the more the interest becomes obtrusive in thinking or dominant in the person’s daily life.

One of the issues during the practice stage of CBT will be generalization. People with Asperger’s syndrome tend to be quite rigid in terms of recognizing when the new strategies are applicable in a situation that does not obviously resemble the practice sessions. It will be necessary to ensure that strategies are used in a wide range of circumstances and no assumption made that once an appropriate emotion management strategy has proved successful, it will continue to be used in all settings.

One of the distinguishing characteristics between a hobby and a special interest that is of clinical significance is an abnormality in the intensity or focus of the interest. The clinician makes a subjective judgement regarding the intensity, based on the amount of time typical children or adults would engage in the same activity:

Reality to an autistic person is a confusing, interacting mass of events, people, places, sounds and sights. There seems to be no clear boundaries, order or meaning to anything. A large part of my life is spent trying to work out the pattern behind everything. Set routines, times, particular routes and rituals all help to get order into an unbearably chaotic life. Trying to keep everything the same reduces some of the terrible fear. (Jolliffe et al. 1992)

We know that the amount of time and resources dedicated to the special interest can cause considerable disruption to the daily life of the person with Asperger’s syndrome and his or her family, and that this characteristic is also remarkably stable over time (Piven et al.1996; South et al. 2005). However, the special interest can also provide a valuable source of intellectual enjoyment and can be used constructively to facilitate friendships and employment.

In an e-mail I received from Jennifer McIlwee Myers, an adult who has Asperger’s syndrome, she explained that: Morbid and gruesome topics become a way to deal with one’s own otherness, as well as with the constant well-founded fear of pain and rejection. Examples: An interest in ‘freaks’ provides a forum for mentally dealing with one’s own otherness; the works of Edgar Allen Poe and H.P. Lovecraft provide an outlet for both feelings of paranoia and otherness; identifying with inevitability and dangerously misunderstood monsters (such as Frankenstein, the Wolf man, and the Phantom of the Opera) allows one to deal with the very difficult and painful feelings of being an outsider. If an interest serves a legitimate purpose, it should be tolerated even when it is strange or distasteful.

The special interest is also important in helping to create a sense of personal identity in adults. In conversation, adults with Asperger’s syndrome often describe themselves in terms of their interests rather than personality. The collection of objects provides a sense of both security and identity.

Some aspects of the special interest can be indicative of impaired executive function (see Chapter 9). One of the roles of the ‘executive’ or frontal lobes of the brain is the cognitive or thoughtful control of what you do or say, especially the ability to change and inhibit thoughts and actions. When a person with Asperger’s syndrome engages in or talks about the special interest, there may be evidence of perseveration and being ‘stuck in set’, with considerable difficulty changing thinking or conversational focus to another topic (Turner 1997). The person seems to have a ‘one-track’ mind, with an irresistible determination to complete the activity or monologue. Children and adults with Asperger’s syndrome often say how the special interest dominates their thinking and how difficult it is to stop part-way through the thought or activity and to do something else. It is almost as if once the person has started there is a compulsion for completion. The person cannot be interrupted or distracted, or close the thought before the natural conclusion.

While the motivation for the child with Asperger’s syndrome is to increase his or her time engaged in the interest, the motivation for parents and teachers is to reduce the duration and frequency of access to the interest. This is to enable the child to engage in a wider range of activities, which is particularly important when the time devoted to the interest appears to virtually exclude social interaction with family members at home and peers at school and affects the completion of homework assignments.

The accompanying text to the diagnostic criteria in the DSM-IV refers to the way in which the language may be abnormal in terms of the individual’s preoccupation with certain topics, verbosity and failure to appreciate and utilize conventional rules of conversation, and the fact that the child may have a vocabulary that would be typical of an adult.

problems with receptive language abilities, especially specific aspects of language comprehension such as understanding figures of speech and the interpretation, recall and execution of increasingly complex oral directions (Koning and Magill-Evans 2001).

There is often a significant difference between language knowledge and practice. The child may demonstrate linguistic ability in a formal testing situation with a speech pathologist but have considerable difficulties with the speed of language processing needed in real-life situations such as when playing with peers, and with hearing and understanding someone’s speech when there are other distractions and background noise.

The prosody and especially the vocal tone of speech can be unusual, with some children and adults with Asperger’s syndrome having a ‘flat’ vocal tone that is perceived as monotonous. The speech characteristics can include problems with volume, being too loud or too quiet for the context. Speech that is too loud can be extremely irritating for family members and especially difficult for teachers who are trying to encourage less noise in the classroom. The person’s speech may also be unusually high-pitched or have a ‘nasal’ quality that is quite distinct and distracting for the listener. The fluency or delivery of speech can sometimes be too rapid, particularly when the person is excited or talking about a special interest. In contrast, speech may be unusually ponderous when the person has to think what to say, especially if the reply requires understanding what someone is thinking or feeling during a social conversation.

While someone with Asperger’s syndrome can dislike being interrupted, that same person may be notorious for interrupting or talking over the speech of other people.

During a conversation, the person with Asperger’s syndrome may frequently change topics, unaware that the logical link between the topics is not obvious to the listener. Such conversations or monologues appear to be without structure and are perceived as a stream of thoughts and experience that lack coherence or relevance to the context. The person fails to acknowledge the perspective of the listener, who is trying to follow the logic and wondering what the ultimate point will be and also whether he or she will have an opportunity to contribute to the conversation. There can be a conspicuous lack of inclusive comments such as ‘What do you think of that suggestion?’ or ‘Have you had a similar experience?’

It is important to find out why the person talks to him- or herself. It could simply be developmental delay, or a means of organizing his or her thoughts, improving comprehension and providing comfort.

I have noticed that when some adults with Asperger’s syndrome are deep in thought, their lips can move as though the person has difficulty disengaging mind and mouth.

When in doubt as to what to say, the person with Asperger’s syndrome can lack the confidence to admit ‘I don’t know’ or ‘I’m confused’ and, rather than saying ‘I’m not sure what you mean by that,’ ‘This is not easy to talk about,’ or ‘I’m lost for words,’ can take a considerable length of time to think of his or her reply, or may suddenly change the conversation to a topic he or she is familiar with. The conversation can lack flexibility of themes and thought and there may be problems generating relevant ideas (Bishop and Frazier Norbury 2005). Thus, the conversation can include abrupt changes of topic and tangential responses (Adams et al. 2002; Fine et al. 1994). An unfortunate characteristic of some conversations with a person with Asperger’s syndrome is that the conversation eventually reverts to the person’s special interest, or is characterized by ‘and now for something completely different.’

When a child with Asperger’s syndrome is asked a question or is expected to reply to a comment, there can be a tendency to avoid responding or offering new or relevant information (Capps, Kehres and Sigman 1998). This is not necessarily indifference or insolence but another example of a genuine difficulty repairing and maintaining a conversation.

(that is, provide a ‘narrative discourse’), the child with Asperger’s syndrome may have significant difficulty providing an organized and coherent framework for the story (Abele and Grenier 2005).

The child (and some adults) with Asperger’s syndrome can have significant developmental delay in the narrative discourse aspects of a conversation. There may be no clear beginning to the story, too much or too little information provided for the listener, an absence of key information, and a tendency to be side-tracked with irrelevant information. There can also be a difficulty summarizing and getting to the point, which can be boring or irritating to the listener who expects a shorter and more coherent story. The facts may be there, but logical structure and the thoughts and feelings of the participants are often missing. The errors in the pragmatic aspects of language can cause other people to assume that the person with Asperger’s syndrome is being deliberately obtuse and uncooperative, and thus there may be a reluctance to engage in subsequent conversations.

An adult may be able to engage in a conversation about practical matters but have considerable difficulty with social chit chat or the language of courtship.

Affective prosody functions as a means of communicating feelings and attitudes. For example, the simple request ‘Come here’ could be said with a tone of voice that would indicate the person has found something interesting and is happy; is anxious and needs reassurance; or is perhaps angry and about to administer an expected consequence (Pyles 2002). Research has confirmed the impressions of parents and clinicians, that the prosody of children and adults with Asperger’s syndrome can be unusual, especially with regard to pragmatic and affective prosody (Shriberg et al. 2001). The person’s speech may not convey the amount of social and emotional information that one would expect.

The speech of children and adults with Asperger’s syndrome can be perceived as being pedantic, overly formal and pretentious (Ghaziuddin and Gerstein 1996; Ghaziuddin et al. 2000; Kerbeshian et al. 1990). The characteristics include providing too much information, an emphasis on rules and minor details, a tendency to correct errors in the previous utterance of the other person, the use of overly formal sentence structures, and making a rigid interpretation of what someone says that could be perceived as being argumentative rather than corrective. The person with Asperger’s syndrome is often characterized as being a pedant, a comment which is not intended as a compliment.

Another characteristic of being pedantic is that during a conversation with someone with Asperger’s syndrome, the conversational partner soon recognizes that abstractions and a lack of precision are rarely tolerated. Family members have learned to avoid comments or replies using words such as ‘maybe’, ‘perhaps’, ‘sometimes’ or ‘later’.

We now have research evidence to confirm significant problems for children and adults with Asperger’s syndrome in their ability to understand what someone says when there is background speech or noise (Alcantara et al. 2004) and perceive, discriminate and process auditory information (Jansson Verkasalo et al. 2005).

Psychologists divide attention into four components: the ability to sustain attention, to pay attention to relevant information, to shift attention when needed, and to encode attention – that is, to remember what was attended to. Children with Asperger’s syndrome appear to have problems with all four aspects of attention (Nyden et al. 1999).

The child with Asperger’s syndrome can be capable of thoughtful deliberation before responding, but under conditions of stress, or if feeling overwhelmed or confused, can be impulsive.

The child with Asperger’s syndrome may have an exceptional long-term memory, and is perhaps able to recite the credits or dialogue of his or her favourite film, but has difficulty with the mental recall and manipulation of information relevant to an academic task. The child’s working memory capacity may be less than that of his or her peers.

Another problem with working memory is a tendency to forget a thought quickly. One of the reasons children with Asperger’s syndrome are notorious for interrupting others was explained by one child who said he had to say what was on his mind because if he waited he would forget what he was going to say. Impaired executive function can include a difficulty considering alternative problem-solving strategies.

I have observed that children with Asperger’s syndrome can be the last to know if they are on the wrong track, or to recognize that there may be other tracks to the destination. Thus, there may be a problem with flexible thinking, one of the characteristics of impaired executive function.

Research has indicated that children with Asperger’s syndrome tend to continue using incorrect strategies and are less likely to learn from their mistakes, even when they know their strategy isn’t working (Shu et al. 2001).

Adolescents with impaired executive function have problems with the organizing and planning aspects of class work, assignments and homework.

Some adolescents with Asperger’s syndrome can also have difficulty with abstract reasoning, prioritizing which task to concentrate on first, and time management, especially how long to spend on a designated activity.

The child with Asperger’s syndrome may prefer to use his or her own idiosyncratic approach to problem solving, which I describe as the ‘Frank Sinatra Syndrome’ or ‘My Way’. Adults with Asperger’s syndrome may be famous (or notorious) for being an iconoclast and rejecting popular beliefs and conventional wisdom.

The learning profile of children and adults with Asperger’s syndrome can include a tendency to focus on errors, a need to fix an irregularity and a desire to be a perfectionist. This can lead to a fear of making a mistake and the child’s refusal to commence an activity unless he or she can complete it perfectly. The avoidance of errors can mean that children with Asperger’s syndrome prefer accuracy rather than speed, which can affect performance in timed tests and lead to their thinking being described as pedantic. Creative adults with Asperger’s syndrome, such as composers, engineers and architects, often cannot cope with any deviation from their original design.