Definition, Frequency
Asperger’s Disorder or Asperger’s Syndrome, which is examined under the heading of Pervasive Developmental Disorders according to the Anglo-Saxon school and under the heading of Autistic Disorders Spectrum according to the European school; It is a neuropsychiatric problem observed in children with normal or above-normal intelligence, where autistic features are relatively background or mild, the most basic problem is incompetence in social communication.
Its frequency is not known exactly, but a study conducted in Sweden in 1993 determined a rate of 3.6 per thousand for children. It has also been suggested that this rate may rise to 7.1 percent with suspicious cases. It is thought to be four times more common in boys than girls. An estimated rate of two out of ten thousand has also been suggested by some experts doing field research.
by Austrian pediatrician Hans Asperger in 1944; Four typical children with normal intelligence but poor non-verbal communication, lack of empathy, focus on fixed interests, coordination problems, strange speech patterns, and social isolation were defined by the term “autistic neuropathy”. .
In 1981, a British doctor named Lorna Wing; The same clinical picture came to the fore after many years, after revealing the existence of a certain group of children who “deprived of empathy, motor coordination problems, communication problems” and was named Asperger’s Syndrome after the physician who discovered it. It has taken its place in 4.
Causes
Studies could not reveal the exact causes of Asperger’s Syndrome, but genetic and brain imaging studies; This suggests that there is a neuropsychiatric disorder that starts with birth, comes with genes and is reinforced by environmental factors. It has been thought that abnormalities in the migration (transport) of embryonic cells during the development of the fetus may cause disruptions in brain development.
Clinical Features
Asperger’s Syndrome usually manifests itself with behavioral disorders in social relations.
The most important problem in these children is their inadequacy in social communication skills. They have difficulty in understanding and following complex rules in bilateral relations and group environment. It is also described as “mind blindness” by some sources. Because they are too egocentric, they are usually preoccupied with themselves even in the group environment, they are not in the central position in the group, but at the periphery, that is, they are followers. The weak social and emotional reciprocity in bilateral relations makes it difficult for them to have healthy communication. They may deviate from the common thread. They have problems with non-verbal communication. They do not understand body language, do not understand clues in looks and attitudes, gestures and facial expressions, and they cannot use these abilities efficiently. There are boundary issues in their relationship. They may be incapable of initiating, maintaining, or discussing a topic within the group. In the level of obsession in group activities, excessive prescriptiveness, detail, sense of control, fuss, performance anxiety, and repetition cause problems. Due to their inflexibility in human relations, they may experience conflicts and mental tensions.
The motor development of the language is good, they speak in a timely manner, but there are problems in the practical use of what we call pragmatic skills. On certain topics; it is easier to speak of intellectual knowledge rather than interpretations and feelings. There may also be problems in the semantic, meaning-oriented use of the language. They comprehend words with their plain and plain meanings, not with their abstract meanings. There are problems with clear comprehension of expressions such as metaphors, aphorisms, etc. In speech, emphasis, intonation, rhythm, etc. are weak, it may sound monotonous. They have problems with language processing, that is, analyzing and processing the information that comes with the language, they cannot grasp the abstract meanings behind the words, that is, they cannot read the “subtexts”. For all these reasons, children with Asperger’s have difficulties in mutual dialogue on certain issues.
In these children; ritualistic behavior, rigid principles, or unchanging obsessions can be observed. The reason for this is what we can call “persistence in sameness”. Changes and surprises can disturb and create uneasiness. Strictly faithful to daily routines and rituals, prescriptive, insistent, and detailed to the degree of perfectionism.
The persistence of children with Asperger’s Disorder in sameness leads them to concentrate on specialized activities or interests, which may change at intervals, for example from year to year.
Inadequacies in motor coordination can cause problems. Depending on the problems in gross motor skills, balance problems, clumsiness, inadequacies in children’s games that require body language, problems in actions that require muscle coordination such as tying shoes and riding a bicycle can be observed. Due to fine motor skill problems, problems may be observed in activities such as hand-writing, painting, cutting and opening the cover.
Attention and concentration problems are common in children with Asperger’s Disorder. Their minds can be easily distracted, and due to their strong intuitive side, they can become distracted and return to their own complex thought patterns, even in groups.
In addition to all these features, children and adolescents with Asperger’s Disorder; They also attract attention with their high intelligence, special abilities, talkativeness and youthful appearance.
Diagnostic Process
Asperger’s Syndrome is a disease that is difficult to diagnose. Since the most basic features are seen in advanced ages, they are often better recognized at school age, but some problems at a young age may also indicate the diagnosis.
First of all, it is evaluated by child psychiatrists, and the diagnosis is tried to be made through a comprehensive history taking and developmental evaluation process. Neuropsychological evaluations supporting the diagnosis or distinguishing other accompanying diagnoses can also be performed.
The child’s intelligence level, psychomotor functionality, verbal and non-verbal communication skills, learning styles, independent living and social communication skills, language ability, motor coordination and in-group interaction should be investigated, and the diagnosis should be strengthened with a comprehensive genetic and neurological evaluation. .
Diagnostic criteria for Asperger’s Disorder according to DSM-4, the most valid psychiatric diagnosis system today, are as follows:
A. Qualitative deterioration in social interaction manifested by the presence of at least two of the following:
1. There is a significant deterioration in many nonverbal behaviors such as gestures made to provide social interaction, body position taken, facial expression made, eye eye contact.
2. Inability to develop relationships with peers appropriate to their developmental level.
3. Doesn’t seek to have fun with other people and spontaneously share interests or achievements (eg, failing to show, bring, or indicate objects of interest)
4. No social or emotional responses
B. Limited, stereotyped and repetitive patterns of behavior in behaviors, interests, and activities, as manifested by at least one of the following:
1. One or more stereotypes and closure in a pattern of limited attention
2. Inflexible adherence to specific, dysfunctional routines or rituals
3. Stereotypical and repetitive motor mannerisms (e.g. finger snapping, hand clapping) or twisting or complex whole-body movements)
4. Preoccupation with parts of things
C This disorder causes clinically significant distress in social, occupational, or other important areas of functioning.
D. There is no clinically significant general delay in language development (eg, single words are used by age 2, communicative sentences are used by age 3).
E. There is no clinically significant delay in cognitive development or the development of age-appropriate self-efficacy skills, adaptive behavior (except for social interaction), and involvement with the environment in childhood.
F. Criteria not met for another specific Pervasive Developmental Disorder or Schizophrenia.
Differential Diagnosis
Asperger’s disorder; Due to its clinical features, it can be confused with many psychiatric diseases and should be considered in the differential diagnosis.
These include Autistic Disorder, Reactive Attachment Disorder, Some Personality Disorders (schizoidal or schizotypal, narcissistic, obsessive-compulsive, avoidant), Social Phobia, Adjustment Disorder, Borderline Intelligence, Developmental Coordination Disorder, Post Traumatic Stress Disorder, Special Learning Disability, Excessive Self-Confidence, etc. situations can be counted.
Autistic disorder; It is a developmental disorder that is evaluated in the same group as Asperger’s and has many common points. In particular, there is a group called “high-functioning autistic people” whose intelligence levels are normal or higher than other autistics. Incompatibility with their peers, clumsiness in the pragmatic use of language and motor development are also observed in high-functioning autistics. high-functioning autistics; They can live in the same environment as their peers, such as those with Asperger’s. When comparing children with healthy development, the following is said: Autistic people do not live in our world, they live in their own world, whereas people with Asperger’s live in our world, as they know how, but by trying to adapt (Van Krevelen, 1991)
In children; There is a picture that is very similar to autism, which we call Reactive Attachment Disorder, which can be confused with Asperger’s disorder. The attachment relationship between the mother and the child does not develop in a healthy way in children born as a result of unintended pregnancies, experiencing significant psychological traumas in the family environment or infancy, orphaned and under institutional care, born to mothers who are poorly cared for, experiencing postpartum depression, and who have a physical illness that may hinder the love relationship with the environment. In such children; They may show discomfort from not making eye contact, developmental delay, restlessness in the social environment, touching, etc. approaches of love. When they grow up, they may appear as overly controlling, cold, low-talk, and avoidant children who have difficulty in one-to-one relationships. All these features are also seen in children with Asperger’s. However; Language development of children with Reactive Attachment Disorder is normal (if they have not spoken late), they are more skillful in social relations, they respond better to treatment.
The definition of personality disorder is not often used for children, but children may exhibit behavioral problems specific to some personality disorders, which may increase their problems in adolescence.
For example; Children who are candidates for schizotypal personality disorder may experience extreme discomfort in the presence of strangers and avoid one-to-one relationships, they may have more advanced and strangely fantastic attitudes, skepticism and irritability compared to their peers, non-verbal communication skills, that is, using gestures, facial expressions, and body language are very weak, anxiety under stress, fussiness increases, there may be quirks in speech content. Children with schizotypal features are aware of the outside world, but they have poor insight into their own inadequacies and avoid communication.
Adolescents who are candidates for Narcissistic Personality Disorder may also have aspects that are confused with Asperger’s. Narcissistic individuals are also very self-centered or preoccupied with themselves, which may result in very limited and inconsistent social and professional relationships. Narcissistic individuals may also not use their body language much due to excessive self-control, and even their verbal communication may be limited. Because narcissistic individuals are overly selective in their relationships and do not care about individuals they deem inferior, they may seem cold and maladaptive, whereas children with Asperger’s have a general social inadequacy towards everyone. The narcissistic individual will appear overly social when he feels good or has high self-esteem, whereas children with Asperger’s are more likely to experience anxiety in such situations. narcissistic child; In order to maintain their self-esteem, they devalue and ignore others, whereas the child with Asperger’s withdraws himself and limits his environment. The narcissistic individual’s language ability is usually well developed, and may even be a weapon of superiority, whereas the verbal communication of the child with Asperger’s is weak.
Certain personality traits of those with obsessive-compulsive personality disorder may overlap with some of the personality traits of children with asperger’s. Their common points are that they are detailed and prescriptive, inflexible, relatively controlled and cold, indecisive, and ritualistic obsessions.
Avoidant Personality Disorder; It is a diagnosis usually made in adults. Children who show such characteristics at an early age cannot establish close relationships, or even avoid them. They are extremely sensitive to criticism and humiliation. Children with Asperger’s do not avoid social contact, are inadequate, or stay away from being abused.
There are many similarities between Social Phobia and Asperger’s Disorder. From a very early age, children with social phobia may display a shy, avoidant, over-controlled and cold social environment, and show an obscure appearance. However, motor coordination problems that can be seen in children with Asperger’s do not occur in social phobia, and language development is also normal. The child with social phobia knows “how to do it” but is inept at social interaction due to fear of making mistakes, whereas the child with Asperger’s hardly knows how to do it.
Apart from these; There are also conditions that have some features similar to Asperger’s disorder and may mislead the clinician in the diagnosis process. For example; The main characteristics of children with anxiety-based adjustment disorder, borderline intelligence, developmental coordination problems, trauma history, special learning difficulties, and extreme insecurity can be confused with children with Asperger’s and should not be ignored in the differential diagnosis.
Comorbidity (Common Diseases)
Children with Asperger’s disorder have anxiety disorder, depression, obsessive compulsive disorder, attention deficit and hyperactivity disorder, bipolar disorder, adjustment disorder, social phobia higher than the general average seen too much.
Treatment
When it comes to the treatment of Asperger’s Disorder; Increasing the quality of life of the child and the treatment of accompanying mental problems should be understood.
The earlier the treatment is started, the higher the chance of success. Treatment is aimed at basic difficulties, ie supportive and reconstructive psychotherapy, which puts social communication skills, pragmatic use of language, motor clumsiness, and rigid ritualistic behavior at the center, is the most important treatment approach.
If we summarize the content of the treatment configuration under headings:
-Peer harmony is studied with social skills training in the group.
-Cognitive behavioral therapy techniques and appropriate behavior models are taught.
-Drug treatments can be given when the mental state requires it.
– With occupational therapy, the child’s subjective interests are made more refined and productive.
-Intermittent physiotherapy can also be applied against motor clumsiness.
-Speech and communication therapy is the most important part of treatment.
-Parents should be informed about the child’s current difficulties and future course through family counseling.
-School and classroom auxiliary arrangements should be made to support the social adaptation of the child.
-Peer support system should be used; The child should be prevented from playing the role of scapegoat or mascot, and should be protected from peer abuse.
-It should highlight positive features; He should benefit from his strong memory, talkativeness and special abilities.
-Social behavior repertoire should be supported and enriched at positive points, and two-way communication techniques should be taught.
-In learning, instead of their emotions or intuitions, their intellectual features and intelligence should be used more.
– It may be considered to benefit from the guidance of a close friend or group of friends.
The need to be isolated from time to time should be respected without exaggeration, but often encouraged to participate in group activities.
-A predictable, routine and reliable environment should be provided.
-It should be prepared in advance for vital changes and supported against unexpected surprises.
-Special interests and abilities; It should be used in a way that will not bore the environment and even include it in social environments, but it should not cover the entire living area.
– Considering their inflexibility; a semi-structured lifestyle should be established.
-In the responsibilities to be given; motor coordination problems and concentration problems should be taken into account.
-Academic program; It should be personalized and simple.
-Because the child’s awareness will increase during adolescence and he will complain more about his own weaknesses, more attention should be paid to possible mental problems.
Prognosis (Long-Term Course)
Children with Asperger’s Disorder can also be difficult into adulthood. Because; The above-mentioned problems will continue in advanced ages, and secondary mental problems of adolescents or adults whose awareness increases as they get older will be added to the table. However, supportive and restructuring psychotherapy practice, which will start in childhood and continue into adulthood, will increase the quality of life of all children with Asperger’s and enable them to lead a normal life like their peers.
Exp. Dr Ahmet ÇEVİKASLAN
Child and Adolescent Psychiatrist
