Consultation with the Specialist : Asperger Syndrome

Louis Pellegrino and Gregory S. Liptak

Pediatrics in Review 2011;32;481
DOI: 10.1542/pir.32-11-481

The online version of this article, along with updated information and services, is
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[Link]

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 consultation with the specialist

Asperger Syndrome
Louis Pellegrino, MD,* Gregory S. Liptak, MD†

Objectives After completing this article, readers should be able to:

1. Define Asperger syndrome and review the history and prevalence of the
condition.
2. Describe the clinical characteristics of Asperger syndrome and comorbid
conditions.
3. Review the major elements in the management of Asperger syndrome.
4. Describe the role of the primary care physician or practitioner (PCP) and
medical home in the lives of children who have Asperger syndrome.
5. Describe current controversies relevant to the diagnosis and treatment of
Asperger syndrome.
What is Asperger Syndrome? these children showed a tendency to
Asperger syndrome (AS) is one of a engage in long-winded recitations of
group of conditions referred to as their favorite subjects, leading
Author Disclosure
autism spectrum disorders (ASDs). Asperger to describe them as “little
Drs Pellegrino and Liptak have Children on the autism spectrum professors.” Unaware of Kanner’s
disclosed no financial relationships demonstrate impairments in social- previous work, Asperger referred to
relevant to this article. This ization and communication (espe- this condition as “autistic psychopa-
commentary does contain a cially social and nonverbal aspects of thy” and conceptualized the condi-
discussion of an unapproved/ communication) and have atypical tion as a personality disorder with a
and repetitive behaviors and inter- strong genetic basis. In 1981, Lorna
investigative use of a commercial
ests. However, individuals on the Wing published a case series and
product/device. spectrum vary widely in the manifes- coined the term “Asperger’s syn-
tations of these impairments. drome” to characterize the features
Kanner first described “early in- that Asperger had described.
fantile autism” in 1943. He de- The diagnosis was officially recog-
Abbreviations scribed a group of children who had a nized (as Asperger disorder) for the
profound disturbance in social re- first time in the International Classi-
AD: autistic disorder
sponsiveness and pronounced lan- fication of Diseases, 10th Edition, and
ADHD: attention deficit
guage deficits associated with evi- subsequently in the Diagnostic and
hyperactivity disorder
dence of intellectual disability. A year Statistical Manual of Mental Dis-
AS: Asperger syndrome
later, Hans Asperger, an Austrian pe- orders, Fourth Edition (DSM-IV; see
ASD: autism spectrum disorder
diatrician, described four children Table 1). The DSM-IV currently
EI: early intervention
who had intact intellectual ability but recognizes five “pervasive develop-
HFA: high-functioning autism
nonetheless showed marked impair- mental disorders,” including autistic
NVLD: nonverbal learning
ments in socialization, notable diffi- disorder (AD), AS, pervasive devel-
disability
culties with nonverbal and social opmental disorder—not otherwise
OCD: obsessive-compulsive
communication (despite intact gen- specified (PDD-NOS), Rett syn-
disorder
eral language ability), and unusual, drome, and childhood disintegrative
PCP: primary care physician
all-consuming interests. Some of disorder. ASD, as currently con-
or practitioner
PDD-NOS: pervasive developmental ceived, is thought to include AD, AS,
*Assistant Professor of Pediatrics, Upstate Medical and PDD-NOS. Rett syndrome and
disorder—not otherwise University, Syracuse, NY.
specified †
Professor of Pediatrics., Upstate Medical University, childhood disintegrative disorder are
Syracuse, NY. specific, rare conditions that include

Pediatrics in Review Vol.32 No.11 November 2011 481

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consultation with the specialist

autistic traits but do not typically en- Comparison of Autistic Disorder and
Table 1.
ter into discussions of the “autism
spectrum.” Although AS is currently Asperger Disorder Using DSM-IV Criteria
recognized as a distinct ASD, a pro-
Autistic Asperger
posal under consideration for the Disorder Disorder
fifth edition of the DSM suggests in-
cluding AS along with the other dis- Social interaction
Impaired nonverbal behavior (eg, eye contact); ⴙ ⴙ
tinct forms of ASD under the lack of appropriate peer relationships; lack of
broader ASD heading (see discussion spontaneous sharing of experience; lack of
below). social/emotional reciprocity
The most recent study by the Restrictive/repetitive behaviors and interests
Centers for Disease Control and Pre- Restricted/obsessive play interests; rigid ⴙ ⴙ
adherence to nonfunctional routines;
vention (CDC) estimates the preva- repetitive/stereotyped movements (eg, hand
lence of all ASDs to be 1 in 110. flapping); preoccupation with parts of objects
A few studies have determined the Communication
specific prevalence of ASD subtypes; Delayed speech without compensatory ⴙ ⴚ
however, comparisons among these nonverbal communication; inability to initiate
or sustain conversation; idiosyncratic language
studies are difficult because of differ- (eg, echolalia); lack of imaginary/imitative play
ences in definitions and ascertain- Onset
ment. As a general statement, indi- Delays or abnormal functioning before 3 y with ⴙ ⴚ
viduals who have AD represent about social, communication, or play
one third to one half of those on the DSM-IV⫽Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
autism spectrum, whereas individuals
who have AS, high-functioning au-
tism (HFA; referring to individuals treme form of “maleness,” noting the Recognizing the
having less severe social and cogni- predisposition of males to deal with the Characteristics of
tive deficits who still meet criteria for world as a problem or puzzle to be Asperger Syndrome
autism), and PDD-NOS represent solved, rather than a place populated Jeremy is a 10-year-old boy who is do-
about one half to two thirds of those by people who have relationships that ing well academically in fifth grade
on the spectrum. In one Swedish can be understood through social con- but struggling socially. He complains
study, the prevalence of AS was nection and intuition. often that no one wants to be his friend
1/250 (1); prevalence estimates have The long-term prognosis for indi- but has very little idea of how to ap-
varied greatly among studies, but viduals who have ASD correlates proach other children. At recess, he in-
generally have increased over the past with cognitive ability; so those who terrupts games and tries to impose his
two decades. have AS and HFA theoretically own wishes and rules; he is bewildered
Although the specific causes of should have better outcomes than when his classmates react negatively.
ASD and AS are not well defined, a those who have AD, and generally Sometimes he is not even aware of their
strong genetic component to these they do. The effect of the social dis- negative reactions. At the lunch table,
disorders is apparent. Children who ability associated with AS may be un- he often makes inappropriate com-
have AS frequently have a family his- derestimated, however. For exam- ments, insults others without realizing
tory of relatives who have AS or “AS ple, although individuals who have it, or dominates the conversation by
traits,” such as social awkwardness or AS are more likely to complete col- lecturing about his favorite topic, pro-
obsessive compulsive tendencies. lege than others who have high- fessional wrestling, regaling anyone
Children who have AS have a higher functioning or milder forms of ASD, who is within earshot on the subject in
than expected frequency of parents they are not necessarily more likely to encyclopedic detail. In the classroom,
and grandparents in engineering or hold a job as a consequence of having his teacher has to remind him to use
the natural sciences. The male to fe- a college degree. Likewise, individu- his “indoor voice” because he speaks
male ratio among individuals who als who have AS may have significant loudly at all times; he tends to speak
have ASD, including AS, is 4:1; sev- challenges with establishing and in a mechanical or robotic fashion
eral authors suggest that ASD and AS maintaining long-term, intimate re- that other students mock. He has poor
in particular may represent an ex- lationships such as marriage. eye contact and often has to be re-

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 consultation with the specialist

minded to look at others when speak- Typically they say what they think nounced need for predictability and
ing. Until second grade Jeremy’s class- and do what they want without ref- sameness. For children who have
mates seemed to enjoy his interests and erencing the responses of those severe autism, this often manifests as
precocious verbal expositions, but more around them. Lacking the ability to a need for ritualistic behavior focus-
recently have found reasons to avoid “read” the social environment, they ing on primitive forms of repetition
him. He has become the target of teas- tend to rely heavily on knowing and (such as turning things on and off, or
ing and bullying, is increasingly dis- applying rules, and often are heavy- opening and closing things repeti-
enchanted with school, and comes home handed in their application of these tively). For children who have AS, this
sullen and irritable. His parents are rules to others. Although they are need for predictability and sameness
at a loss as to how to help him. aware of explicit rules, such as “no manifests in a more sophisticated ef-
This example illustrates several talking in class,” they often are un- fort to classify and systematize the
characteristics typical of children who aware of unwritten rules, such as world. Because the world of social
have AS. Although many children “students do not tell on their class- interactions eludes simple classifica-
who have AS are gifted academically mates.” Poor eye contact and other tion and systemization, children who
and intellectually, they struggle deficits in nonverbal communication have AS gravitate towards subjects
with social skills. In contrast to chil- further complicate their ability to en- that are more amendable to this styl-
dren afflicted with AD, who often are gage in reciprocal social responses. ized treatment, and, to the chagrin of
socially aloof and uninterested in so- Although many children who their parents, siblings, and peers, it is
cial contact, most children who have have AS have well-developed and one of their greatest joys to share the
AS are interested in having friends even precocious general language fruits of their efforts with anyone
and being accepted but are severely skills, their ability to interact in con- who will listen.
limited in their ability to form and versation is severely limited. This im- This facility for organizing and
maintain relationships. These chil- pairment in the social aspect of lan- understanding the world in terms
dren demonstrate impairments both guage use is referred to as pragmatic of detail often extends into other as-
in their social perceptions and re- language dysfunction. They have dif- pects of interaction and cognition.
sponses. Many are lacking in what is ficulty with greeting and requesting Children who have AS tend to in-
referred to in autism research as “the- skills. They have difficulty taking terpret things very literally, seeing
ory of mind.” This concept refers to a turns and are particularly known for everything as “black or white.” They
lack of understanding that others engaging in pedantic diatribes on are concrete thinkers, and often mis-
have ideas and perceptions that differ preferred topics. They are poor at understand expressions, idioms, and
from one’s own, resulting in an in- recognizing the rules and nuances of jokes. This tendency may extend
ability to see things from another conversation, and have trouble going into academics: the early elementary
person’s point of view. Children who beyond the literal meaning of sen- grades often go very well, but as
have AS are particularly known for tences; they struggle with humor, the curriculum shifts from basic aca-
their lack of social empathy; they may sarcasm, and irony. They may have demics and rote learning to more
be able to recognize the more obvi- difficulty regulating the volume and abstract materials, many children
ous aspects of emotional response (if inflection of speech, resulting in who have AS begin to show signs of
someone is yelling or crying), but voice quality that is described often difficulty (especially beginning in
completely miss the more nuanced as robotic or “sing-song,” and which third or fourth grade).
manifestations of emotion. Research comes across to the listener as artifi- Although sensory processing dys-
suggests that individuals who have cial and incongruent with what is function is not a specific criterion for
AS have a specific impairment in the being said (impaired speech prosody). the diagnosis of AS, many children
ability to read facial expressions and Children who have AS especially who have AS have pronounced dif-
must rely on other cues to sort out are known for their all-encompassing, ferences in how they perceive and
the meaning of a specific social situa- obsessive interests. These interests react to sensory stimuli. Oversen-
tion. This inability to read and inter- often involve a scientific or historical sitivity to loud noises, ambient light,
pret the rapid flux of social interac- topic but can relate to anything that tactile sensations, smells, and tastes
tion leads to mishandling of social lends itself to in-depth, systematic are described commonly. At the
reactions and responses. Children analysis of details, such as baseball same time, some children exhibit
who have AS act as though their view statistics. Children who have ASD as undersensitivity to pain, whereas
of the world is shared by everyone. a group are known to have a pro- others exhibit “sensory seeking be-

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consultation with the specialist

havior” (a desire for movement, con- control affect classroom function- ventions are less effective, and chil-
tact, pressure, or repetitive action). ing and academic progress and often dren who have AS are more prone
Although the sensory processing dif- complicate social interactions in to adverse effects, such as increased
ferences can be associated with many children who already are severely irritability or anxiety.
different developmental disorders, challenged in their efforts to relate Nonverbal learning disability
they may be particularly pronounced to peers. Standard treatments for (NVLD) has been associated with
in children who have AS. ADHD are appropriate to consider, AS. Children who have NVLD typi-
including the use of stimulant medi- cally have strong verbal cognitive
cations, but pharmacologic inter- abilities but show pronounced weak-
Conditions Associated With
Asperger Syndrome and
High-Functioning Autism Characteristics of Asperger Syndrome
Table 2.
AS is associated with an increased and Interventions Often Utilized
prevalence of a number of develop-
mental, behavioral, and emotional Findings Interventions
disorders (Table 2). Developmental Primary Characteristics
issues encountered include difficul- Impaired communication Speech and language therapy*
ties with motor control, attention, Social competence groups†
and impulse control; specific learning Impaired social interactions Social competence groups†
Individual behavioral counseling†
problems are common. Although
Restricted interests Social competence groups§
most children who have AS begin Individual behavioral counseling§
walking at about the expected time Family communication§
(around 1 y of age), many are de- Secondary Conditions
scribed as being awkward or Anxiety/OCD Physical activity*
Relaxation/Meditation/Massage†
“clumsy.” These coordination diffi-
Cognitive behavioral therapy*
culties are associated with a mild SSRIs†
degree of muscular hypotonia, but ADHD Environmental modifications§
focal neurologic abnormalities rarely Medications, including stimulants*
are found; special neurologic testing Auditory processing disorder Speech and language therapy*
Headset with FM radio amplification system
usually is not indicated. Difficulties
for classroom†
with motor planning and sequenc- Depression Individual counseling†
ing of motor actions associated with SSRIs†
judging body position in space are Physical activity§
the hallmarks of developmental co- Developmental coordination Physical therapy*
disorder Occupational therapy†
ordination disorder, a diagnosis
Omega-3 oils*
frequently applied to children who Disruptive/Explosive Individual behavioral counseling†
have AS. A significant number of behavior Family counseling†
children who have AS experience dis- Medications, including alpha-2 agonists,
ordered sleep, including difficulty antipsychotics, and mood stabilizers†
Learning disabilities Specialized educational interventions*
falling asleep as well as maintaining
Oppositional defiant Individual behavioral counseling†
sleep. This problem typically is man- disorder Family counseling†
aged by insuring sleep hygiene and Medications, including alpha-2 agonists†
treating anxiety if it is present. Sensory differences Sensory (integration) therapy§
Rarely, a formal sleep study is indi- Sleep disorders Sleep hygiene†
Treatment for anxiety, if present§
cated. Occasionally medications such
Medications, including melatonin§ or
as melatonin or clonidine may be clonidine†
helpful.
ADHD⫽attention deficit hyperactivity disorder; OCD⫽obsessive compulsive disorder;
Many children who have AS also SSRI⫽selective serotonin reuptake inhibitor.
show evidence of attention deficit hy- *Based on strong evidence of efficacy; approved use.
†
Based on moderate evidence of efficacy; approved and off-label uses.
peractivity disorder (ADHD). Prob- §
Based on weak or anecdotal evidence; off-label use.
lems with attention and poor impulse

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 consultation with the specialist

ness with visual spatial tasks and cer- Overall Care of Children Who to learn and practice social skills in a
tain nonverbal problem-solving skills. Have Asperger Syndrome controlled and safe environment. (2)
This characteristic is reflected in a Helping children who have AS to Psychopharmacologic interven-
marked discrepancy between verbal develop to their fullest potential in- tions may be indicated in some in-
intelligence quotient scores, which volves a collaborative effort of many stances. These therapies typically
are average or above, and nonverbal individuals, systems, and agencies. will target specific difficulties such
or performance intelligence quotient Chief among these are educational as attention and impulse control
scores, which are below average. Ba- and related services. Early interven- problems, anxiety with or without
sic reading skills are well developed, tion (EI) can be a critically important obsessive-compulsive traits, or emo-
but math may be difficult. Children starting point for these interventions. tional lability and explosive out-
However, many children are not bursts. Commonly used agents in-
who have NVLD (with or without
given a diagnosis of AS until after clude stimulant medications for
AS) often exhibit “cognitive rigid-
they start school. Some children who attention and impulse control diffi-
ity.” They tend to excel at rote-
have AS may not be eligible for EI culties, selective serotonin reuptake
learning tasks and memorization but
services because they may not be suf- inhibitors for anxiety, OCD, and
are challenged by abstract thinking
ficiently delayed. Similar difficulties depression, alpha-2 agonists (cloni-
that requires cognitive flexibility. dine and guanfacine) for impulsivity
Other learning and information may be encountered in getting the
school system to provide extra ser- and explosive outbursts, and, in
processing problems have been de- some instances, antipsychotic drugs
scribed in association with AS. Cen- vices, especially if a particular child
who has AS excels academically. and anticonvulsant mood stabilizers
tral auditory processing dysfunction for severe emotional lability, out-
Early recognition of the diagnosis of
in particular is invoked frequently bursts, and aggression. These medi-
AS or high-functioning autism can
for children who have difficulties lis- cations, which often are used “off-
be critical to ensure that these chil-
tening and processing auditory in- label,” should be used cautiously and
dren receive the educational support,
formation, especially in a challeng- conservatively, under the direction of
classroom accommodations, and re-
ing acoustic environment, such as a a trained professional, and in the
lated services necessary for them to
noisy classroom. It may be difficult context of ongoing counseling, both
succeed. A major emphasis for the
to separate attentional weaknesses, with the child and the family.
special education team will be on
learning disability, and specific audi-
helping the child who has AS learn to
tory processing deficits in a child who The Medical Home
cope with the complexities of school The PCP engages in an integrated
has AS.
life, which will necessarily include process to promote early identifica-
Behavioral and emotional diffi-
support for the development of adap- tion of children who have AS and to
culties commonly occur in associa- tive and social skills. School-based
tion with AS. Anxiety disorders, in- expedite referral to community ser-
counseling, speech-language therapy vices. The first step is to establish a
cluding obsessive-compulsive disorder to support the development of social diagnosis of AS, which rarely can
(OCD) and depression, are more communication skills, and participa- be made before entry into kinder-
common in children who have AS. tion in social-skills groups are impor- garten, and may not be made until
Problems with impulse control, be- tant facets of such a program. the child is in middle school. The
havioral rigidity, and anxiety lead to Many children who have AS ben- second step is to evaluate the child
problems with explosive outbursts, efit from activities, programs, and and family to determine the inter-
disruptive behavior, and defiance; interventions outside the educational ventions that are most likely to opti-
oppositional defiant disorder may domain. For children who have spe- mize the health and well being of
be diagnosed in these children. Be- cific difficulties related to emotional both child and family. AS may be
havioral and social difficulties con- regulation, anxiety, or behavior, ac- suspected by the child’s family,
spire to increase the likelihood that cess to mental health services and teacher, PCP, or another provider
children who have AS will become counseling often is critically impor- (eg, occupational therapist). The
the targets of bullying, although some tant. In many communities, social PCP obtains a history, reviews any
children who have AS, in their desire skills (competence) groups have documents (eg, school records, for-
to control the behavior of others, been developed to provide targeted mal testing), observes the child, and
may become bullies themselves. interventions for school-age children performs a physical examination.

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consultation with the specialist

Screening Instruments Used to Help

Table 3. and related services, and social com-
petence groups; the family may
Identify Children Who Have Asperger benefit from family training or sup-
Syndrome port services. The child may benefit
from formal evaluations (Table 4)
Ages Completed Number Free to identify his or her strengths and
Screening Instrument (y) by of items online
needs. These services may be ob-
Asperger Syndrome Diagnostic Scale 5–18 Clinician 50 No tained through EI programs, school
Australian Scale for Asperger 6–12 Clinician 24 Yes districts, or private practitioners.
Syndrome
Family goals, structure, and resources
Autism Spectrum Screening 6–17 Parent 27 No
Questionnaire should be considered when develop-
Childhood Asperger Syndrome Test 4–11 Parent 38 Yes ing treatment plans that may include
Gilliam Asperger Disorder Scale 3–22 Clinician 32 No clinical consultations, community-
Krug Asperger Disorder Index 6–22 Clinician 32 No based programs, and educational
Social Communication 4–22 Parent 40 No
Questionnaire services. Although EI is known to
improve adjustment and there is evi-
dence of the effectiveness of psycho-
Once AS is suspected, a screening AD; they may be considered also for education and cognitive behavioral
test may be administered either by children who have AS, although the therapy in managing AS, there is lim-
the PCP or by a consultant. Table 3 yield of positive findings for individ- ited research on some of the other
lists some screening tests that have uals who have AS is low. medical, behavioral, educational, and
been studied. Each of these screen- In addition to determining the family interventions listed in Table 2.
ing tests has its strengths and weak- diagnosis, the PCP should assess the After diagnosis and assessment for
nesses but a positive screening test, child for intervention planning. This intervention planning are complete,
clinical history, and observations evaluation includes characterizing the PCP starts ongoing care and
may be sufficient to make a diag- the severity of the AS and determin- monitoring of the child. This respon-
nosis of AS. If uncertainty exists, the ing the occurrence of associated con- sibility includes ongoing review with
child may be referred to diagnostic ditions, such as anxiety or ADHD the family of the child’s current test
and assessment services, for exam- (see Table 2), which helps to identify results and progress, input from the
ple, a developmental pediatrician. the needs of the child and family. family regarding therapeutic deci-
Etiologic testing, focusing on ge- Similarly, the strengths of the child sions, care coordination, and advo-
netic tests such as a karyotype, DNA and family should be ascertained. cacy, especially with education (or
testing for fragile-X syndrome, and The child may need to be referred for EI) services. This task requires the
chromosome microarray often are specialized medical care, behavioral PCP to be knowledgeable about
considered for children who have programs and therapies, educational available community resources as

Formal Assessments That May Be Part of the Evaluation of a

Table 4.

Child Who Has Asperger Syndrome and Examples of Instruments That

Can Be Used
Component Instrument
Cognitive functioning Wechsler Intelligence Scale for Children–Fourth Edition
Academic abilities Wechsler Individual Achievement Test–Second Edition
Adaptive behavior Vineland-II Adaptive Behavior Scales
Communication—speech and language Clinical Evaluation of Language Fundamentals–Fourth Edition
Fine motor skills Bruininks–Oseretsky Test of Motor Proficiency
Gross motor skills Peabody Developmental Motor Scales–Second Edition
Social, emotional, and behavioral functioning Behavioral Assessment System for Children–Second Edition
Sensory differences Sensory Profile
Family functioning Parenting Stress Index

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 consultation with the specialist

well as the child’s current care. The who have AS, the PCP should deter- social awareness and empathy inter-
PCP can help explain the rights of mine the extent of this problem, find feres with their ability to socialize
the family with regard to educational out the policies in force in the child’s and to participate in commonly per-
services, including obtaining a func- school, provide insights to the family formed activities. As noted above,
tional behavior analysis and behavior on this issue, and advocate for the children who have AS are more
support plan from the school district. child within the school system if nec- likely to have associated conditions
High-quality care for the child who essary. Issues related to the transition such as anxiety with OCD, depres-
has AS depends on collaborations from adolescence to adulthood are sion, ADHD, and problems with
among parents, health-care provid- similar to those for other teens who sleep. All of these factors suggest that
ers, and community agencies (eg, ed- have a chronic condition. The teen AS is a disability. To some extent, the
ucational services, recreation pro- who has AS may be sexually naive difference between disability and dif-
grams, and parent groups), with and require specific and repeated ference is academic; however, many
ongoing monitoring of the child’s instructions and guidance to avoid have argued that AS should continue
health and function. becoming victimized or performing to be viewed as a disability to enable
The person primarily responsible inappropriate activities in public. Iso- children to continue getting the spe-
for treating specific conditions will lation accompanied by sadness and cial services that they need.
depend on the expertise of the indi- depression needs to be identified and
viduals as well as the resources avail- addressed. Should Asperger Syndrome
able in the community. For example, Remain a Separate Condition?
a child’s anxiety and depression may Controversies A new version of the DSM is being
be managed by a psychologist or psy- Disability or Difference? planned. One change that has been
chiatrist, whereas the PCP manages When Tony Atwood, an interna- discussed is the elimination of the
the child’s sleep disorder and moni- tional expert on AS, gives a diagnosis diagnosis of AS, including it under
tors the educational interventions. to a child who has the condition, he the “Autism Spectrum Disorder”
Whatever specific aspects of care the tells them, “Congratulations, you heading. The diagnosis of AS is clin-
PCP manages, the child’s physical have Asperger’s syndrome!” He then ical and is not based on biologic
fitness, nutrition, health maintenance, explains that this means that the markers or changes in cranial imag-
and overall well being should be child is “not mad, bad, or defective, ing. Differentiation from HFA often
addressed by the PCP. Because many but has a different way of thinking.” is difficult. For example, in one study
children who have AS have difficulty Children who have AS clearly do 57% of children given a diagnosis of
with team sports because of the com- have differences: they are more inter- AS also qualified for a diagnosis of
plexity of social interactions and ested in objects and concepts (like AD (3); some experts use the terms
rules, alternate ways to maintain fit- math) than they are in people; they AS and HFA synonymously. Geneti-
ness, such as bicycling, skate board- pay attention to detail and can re- cally related individuals can show
ing, swimming, and sports such as member rote information very well; different manifestations of autism
tennis or badminton, should be they follow their own interests rather spectrum, with one person having
identified. Medications such as stim- than being distracted by the interests AS and the other AD. In addition,
ulants used for ADHD may decrease of others; they systematize, ie, they some preschool-age children who
appetite (and interfere with sleep), are interested in categories of objects are given a diagnosis of AD meet crite-
whereas those used for behavior or information; and they have a ria for AS by the time they are in ele-
problems, such as the atypical anti- strong desire to be in control. These mentary school. Thus far, no biologic
psychotics may increase appetite, characteristics can be adaptive, as in or genetic markers have been found
thus heightening the need for moni- certain work situations such as com- that differentiate between AS and
toring nutrition and growth. puter programming. In addition, no HFA. These findings suggest that AS
Children who have AS and their specific defect in body structure has and HFA are not separate entities.
families also may benefit from refer- been identified, just differences, for Others have argued that children
rals to parent support and advo- instance, in connectivity and cell who have AS are different from those
cacy groups, respite programs, and number in certain parts of the brain. having HFA. They have a different
community programs of recreational In this regard, AS would be a differ- quality of social impairment, tending
sports. Because teasing and bullying ence and not a disability. to be active and odd rather than pas-
at school are common with children On the other hand their lack of sive and aloof. Their special interests

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consultation with the specialist

often are sophisticated and intellec- mentary and alternative therapies for
tual rather than simple. They com- children who have autism have been Summary
municate in a pedantic, verbose, tan- published. (4) However, most of • Based on strong research
gential style (like little professors) these studies included children who evidence, children who have AS
rather than in stilted phrases and typ- had AD and not AS; thus, generaliz- have a high occurrence of
ically had developed spontaneous ing the findings to AS may not be ADHD, learning problems,
phrases before age 3 years. Many have warranted. clumsiness, emotional and
behavior disorders, sensory
a later age of onset of symptoms (7 The safety and cost of any inter- differences, and disordered
to 8 y) than those who have HFA. vention should be balanced against sleep.
These specialists have argued that its efficacy. Thus, although omega-3 • Based on strong research
the diagnosis of AS should remain, oils have not specifically been studied evidence, children who have AS
but be modified to reflect these dif- in children who have AS, generally are teased and bullied more
often than other children
ferences. they are safe and inexpensive. On • Based on some research
AS is not just a medical diagnosis the other hand, intravenous chela- evidence as well as consensus,
but a social phenomenon. Some in- tion has been linked with several counseling, group interventions,
dividuals given a diagnosis of AS deaths and should never be recom- environmental modifications,
call themselves “Aspies” and have mended. In some instances, such as and medications can improve
emotional and behavioral
formed groups, embracing their dif- the use of oxytocin to promote so- disorders.
ferences. AS has become a household cialization, neither efficacy nor safety • Based primarily on consensus
word; it is a fairly neutral term and has been established. Sensory inte- due to lack of relevant clinical
suggests high intelligence, unlike gration therapy to help children who studies, the medical home can
HFA, which is more stigmatizing. have AS deal with sensory differences increase the rate of early
diagnosis and coordinate
Use of the category has increased remains controversial because studies comprehensive management of
general understanding of the con- to evaluate this intervention are lim- children who have AS.
cept of autism and has been helpful ited by small sample sizes and lack
for teachers and others to gain in- of standardized interventions and
sight into the behavior of many chil- outcomes. Novel treatments also are trum disorders. Pediatrics. 2007;120:
dren. Some individuals worry that available for secondary conditions 1183–1215
Leekam S, Libby S, Wing L, Gould J, Gill-
if the AS category is eliminated, ado- such as ADHD and anxiety. How-
berg C. Comparison of ICD-10 and
lescents and adults who have symp- ever, most of these have not been Gillberg’s criteria for Asperger syn-
toms will not be assessed for autism. well studied either. In summary, very drome. Autism. 2000;11–28
It is not clear what would happen to few novel treatments have been stud-
individuals already given a diagnosis ied specifically in children who have References
of AS; the change likely would cause AS. The PCP needs to stay up to date 1. Kadesjo B, Gillberg C, Hagberg B. Brief
them some distress. Others have ar- with scientific publications and to report: Autism and Asperger syndrome in
gued the category should remain be- help families who are interested in seven-year-old children: a total population
study. J Autism Dev Disord. 1999;29:
cause we have not had enough time these treatments by providing them
327–331
to determine whether a biologic or with information on evidence-based 2. Stichter JP, Herzog MJ, Visovsky K, et
genetic difference really exists be- methods and current knowledge al. Social competence intervention for youth
tween AS and classic autism. about those specific interventions. with Asperger Syndrome and high-
functioning autism: an initial investigation.
J Autism Dev Disord. 2010;40:1067–1079
Controversial Therapies
3. Mahoney WJ, Szatmari P, MacLean JE,
Because children who have AS have Suggested Reading et al. Reliability and accuracy of differentiat-
multiple symptoms for which no cu- Attwood T. The Complete Guide to Asperg- ing pervasive developmental disorder sub-
rative treatment exists, their families er’s Syndrome. London: Jessica Kingsley types. J Am Acad Child Adolesc Psychiatry.
seek therapies from many sources. Publishers; 2007 1998;37:278 –285
Many treatments touted as being Baron-Cohen S. What’s so special about 4. Levy SE, Hyman SL. Complementary
Asperger Syndrome. Brain Behav. 2006; and alternative medicine treatments for chil-
helpful for children who have AS 61:1– 4 dren with autism spectrum disorders. Child
are not based on scientific evidence. Johnson CP, Myers SM. Identification and Adolesc Psychiatr Clin N Am. 2008;17:
Several excellent reviews of comple- evaluation of children with autism spec- 803– 820

488 Pediatrics in Review Vol.32 No.11 November 2011

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 consultation with the specialist

PIR Quiz
Quiz also available online at [Link]
NOTE: Beginning in January 2012, learners will only be able to take Pediatrics in Review quizzes and claim credit
online. No paper answer form will be printed in the journal.

11. Children on the autism spectrum demonstrate, with variation, impairments in:
A. Anxiety, communication impairment, and aggressive behaviors
B. Sensory integration disorder, communication impairment, and obsessive compulsive behaviors
C. Sensory integration disorder, learning disability, and atypical and repetitive behaviors and interests
D. Social impairment, learning disability, and obsessive compulsive behaviors
E. Socialization and communication impairments, atypical and repetitive behaviors and interests

12. A 10-year-old boy who has Asperger syndrome has had prominent difficulties with distractibility, off-task
behavior, and impulsiveness at school that are affecting his school work and peer interactions. He has had
similar difficulties throughout his academic career and has similar problems at home. Which of the
following statements regarding diagnosis and treatment is correct:
A. A diagnosis of Asperger syndrome excludes a diagnosis of ADHD by definition.
B. Treatment of distractibility and impulsivity with psychostimulant medications is contraindicated in
children with Asperger syndrome and other autism spectrum disorders.
C. Nonstimulant ADHD medications are the first choice for children with Asperger syndrome.
D. A trial period of a psychostimulant medication is warranted, but the response to the medication is less
predictable than for a child with ADHD alone.
E. Children with Asperger syndrome who present with ADHD usually have bipolar disorder and should be
treated as such.

13. The earliest age at which most children with Asperger syndrome are identified as meeting criteria for the
condition is:
A. early grade school
B. kindergarten
C. middle school
D. preschool
E. toddlerhood

14. A 10-year-old boy has been identified as having Asperger syndrome. He is academically gifted, but over
the past year, he has become more resistant to completing his math homework. He is a good reader and
excels at memorizing historical facts. He is delayed in math. His teacher notes that he more frequently
displays outbursts in the classroom, but he has no significant behavior concerns at recess. His teacher
maintains a structured classroom, and the boy is allowed to leave the classroom for breaks as needed. You
are most likely to recommend evaluation of:
A. attention, impulsivity, and anxiety
B. auditory processing skills
C. cognitive abilities
D. sensory integration concerns
E. social skills

Pediatrics in Review Vol.32 No.11 November 2011 489

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 Consultation with the Specialist : Asperger Syndrome
Louis Pellegrino and Gregory S. Liptak
Pediatrics in Review 2011;32;481
DOI: 10.1542/pir.32-11-481

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