Asperger Syndrome Clinical Presentation

Developmental history

Interview parents about prenatal history and maternal health factors that may have affected the pregnancy.

Include a thorough evaluation of social behaviors, language, interests, routines, physical coordination, and sensory sensitivity, starting from birth.

Social problems

Children with Asperger syndrome may have difficulties with peer relations and may be rejected by other children. Depression and loneliness may occur in adolescents with Asperger syndrome.^[6]

Outside the realm of immediate family members, the affected child may exhibit inappropriate attempts to initiate social interaction and to make friends. Within the immediate family, the child is often loving and affectionate.

Alternatively, an affected child may not display affection to parents or other family members. A lack of bonding and warmth with parents and other guardians may seem apparent, typically resulting from the child's lack of social skills.

Separations from parents because of work and divorce may be particularly stressful for these children. Changing homes, communities, and neighborhoods may also exacerbate symptoms.

Individuals with Asperger syndrome may have particular difficulty in dating and marriage. Boys and men with Asperger syndrome may decide to marry suddenly without the dating and courtship that typically precede a union. They may also be unaware that friendship often precedes courtship and engagement. Individuals with Asperger syndrome may want to marry despite the lack of awareness of the many social interactions that usually lead up to matrimony. Such problems may continue into adulthood.

Socially inappropriate behavior and failure to understand social cues may be reported.

Patients may lose employment because their impaired comprehension of social norms may lead to poor judgment in work site behavior (eg, speaking inappropriately to colleagues, bosses, or administrators).

The child may not understand why people become upset when he or she breaks social rules.

Communication abnormalities

Use of gestures is frequently limited, and body language or nonverbal communication may be awkward and inappropriate.

Facial expressions may be absent or inappropriate.

Pragmatic errors are commonly produced by children with Asperger syndrome in response to questions. Children with Asperger syndrome often produce irrelevant responses.^[12]

Speech and hearing

Affected children demonstrate several abnormalities in speech and language, including pedantic speech and oddities in pitch, intonation, prosody, and rhythm.

Miscomprehension of language nuance (eg, literal interpretations of figures of speech) is common.

Individuals often exhibit practical speech problems, including an inability to use language in social contexts, a lack of sensitivity about interrupting others, and irrelevant commentary.

Speech may be unusually formal or used in idiosyncratic ways that others do not understand.

Individuals may vocalize their thoughts without censoring. Personal remarks inappropriate to most social environments may be uttered routinely.

The amount of speech may also widely vary and reflect the individual's current emotional state more than the communication requirements of the social setting. Some individuals may be verbose and others taciturn. Furthermore, the same individual may demonstrate excesses and paucity of speech intermittently.

Some individuals may display selective mutism, speaking not at all to most people and excessively to specific people. Some may choose to talk only to people they like. Thus, speech may reflect idiosyncratic interests and preferences of the individual.

The form of language chosen may include metaphors that are meaningful only to the speaker. The message meant by the speaker may not be understood by those who hear it, or the message may be meaningful only to a few people who understand the private language of the speaker.

Children often exhibit auditory discrimination and distortion, particularly when the child encounters 2 or more people speaking simultaneously.

Activities

Children exhibit peculiar and narrow interests, excluding other activities.

These interests may be so important that the children do not develop typical relationships with their family, school, and community.

Sensory sensitivity

Children may show sensitivity to sound, touch, taste, sight, smell, pain, and temperature. For example, a child may demonstrate either extreme or diminished sensitivity to pain.

Children may be particularly sensitive to the texture of foods.

Children may exhibit synesthesia, including a sensory response to an environmental stimulus in a different sensory modality.

Typical physical findings in children with Asperger syndrome include the following:

• Lax joints are often observed (eg, an immature or unusual grasp for handwriting and other fine hand movements)
• Clumsiness is common
• Affected children may exhibit anomalies of locomotion, balance, manual dexterity, handwriting, rapid movements, rhythm, and imitation of movements
• Individuals exhibit impaired ball-playing skills

Screening for a theory of mind

Key features of the deficit manifested in people with Asperger syndrome pertain to their inability to understand the thoughts of other people and themselves. A typical child can recognize the thoughts of other children and those that he or she have himself or herself and can hypothesize how other people are likely to respond to life occurrences. The lack of this comprehension in a person with Asperger syndrome is termed a deficiency in the formation of a theory of the mind.^{[13, 14, 15, 16, 17]}

A theory of the mind can be thought of as a form of intuition in which young children learn how other children respond to common situations. Children usually develop the skill to predict other children's responses to common occurrences before they begin school. Some people with Asperger syndrome appear never to develop a theory of mind.^[18]

Because most children have the ability to understand the mental processes of themselves and others since early childhood, pediatricians and other clinicians need to recognize that children with Asperger syndrome often lack abilities to intuit the thoughts of others and themselves. Pediatricians and other clinicians may be shocked to recognize that otherwise intelligent children with Asperger syndrome lack simple mental abilities to grasp situations that appear obvious to even typical preschool children. Therefore, screening for a theory of mind is an important process a pediatrician can use to identify some of the core behavioral symptoms of Asperger syndrome.

Clinicians can screen for a theory of mind in a few minutes in offices, homes, and other everyday settings with minimal props. Screening for a theory of mind involves a doll-play paradigm and an imagination task.^[19]

The 2 components of the doll-play paradigm constitute a fundamental procedure to demonstrate the presence of a theory of mind. The clinician and the patient are seated at opposite ends of a table. The clinician shows the patient 2 dolls and names them by saying, "This is Sally. This is Anne."^[20]

For the first procedure in the doll-play paradigm, the clinician tells and shows Sally placing a marble in a basket. The clinician then removes Sally from the room and closes the door, leaving her outside. The clinician then tells and shows Anne removing the marble from the basket and placing it in a box. The clinician then brings Sally back into the room. The clinician asks the patient, "Where will Sally look for the marble?"

Typical children, adolescents, and adults with a theory of mind indicate that Sally will look for the marble in the basket where she placed it before leaving the room. If this response is elicited, the child passes the doll-play paradigm and the subsequent sections, and the clinician may then proceed to the imagination task.

If the patient does not indicate that Sally will look for the marble in the basket, the clinician proceeds with questions to clarify the patient's understanding of the situation. The clinician asks the patient, "Where is the marble really?" Typical and atypical children, adolescents, and adults usually state that the marble is in the box. The clinician then asks the patient, "Where was the marble in the beginning?" Typical and atypical children, adolescents, and adults usually state that the marble was originally in the basket.

The first procedure of the doll-play paradigm identifies the absence of a theory of mind when an affected child, adolescent, or adult indicates that Sally will look for the marble in the box. The patient thereby indicates an assumption that Sally, like the patient, will look for the marble in the box because the patient knows that the marble is in the box. The ability to recognize that Sally, unlike the patient, was absent and does not know that the marble was moved from the basket into the box is an example of a theory of mind of Sally as distinct from that of the patient.

For the second procedure of the doll-play paradigm, the clinician tells and shows Sally placing a marble in a basket. The clinician then removes Sally from the room and closes the door, leaving Sally outside. The clinician then tells and shows Anne removing the marble from the basket and placing it in the clinician's pocket. The clinician then brings Sally back into the room. The clinician then asks the patient, "Where will Sally look for the marble?"

Typical children, adolescents, and adults with a theory of mind respond that Sally will look in the basket, because Sally last placed the marble in the basket. If this response is elicited, then the patient passes the doll-play paradigm. The clinician may proceed to the imagination task. Otherwise, the clinician then asks the patient, "Where is the marble really?"

Typical and atypical children, adolescents, and adults respond that the marble is in the clinician's pocket. The clinician next asks the patient, "Where was the marble in the beginning?" Typical and atypical children, adolescents, and adults respond that the marble was in the basket originally.

As for the first step in the doll-play paradigm, an absence of a theory of mind is identified when an affected child, adolescent, or adult indicates that Sally will look for the marble in the clinician's pocket. Affected children, adolescents, and adults repeatedly incorrectly think that Sally will know the location of the marble because they do. Affected individuals do not recognize that Sally's understanding of the placement of the marble is different from theirs because she was absent when it was moved. This is evidence of deficits in the ability to formulate a theory of mind in the affected person.

The final activity in the screen for a theory of mind is the imagination task. In this procedure, the clinician tells the patient, "Now, I want you to close your eyes and think about a big white teddy bear. Make a picture in your head of a big white teddy bear. Can you see the white teddy?" Typical children, adolescents, and adults report the visualization of a big white teddy bear. If the patient does not report the image of a big white teddy bear, then the clinician asks, "What can you see when you close your eyes?" If the patient reports any mental image, then the clinician asks, "What are you thinking of?" Typical children, adolescents, and adults readily report the visualization of a big white teddy bear with these stimuli.^[21]

The next activity of the imagination task is a repetition of the first part, with the substitution of a big red balloon for the white teddy bear. Typical children, adolescents, and adults readily report the visualization of a big red balloon.

For the final activity of the imagination task, the clinician asks the patient to identify the first picture of the task. Typical children, adolescents, and adults readily report that they first imagined a big white teddy bear. The ability to remember an earlier mental image is evidence of a theory of mind. The inability to recognize one's own prior mental images suggests the lack of a theory of mind; therefore, the report that a big red balloon was first item imagined is evidence of the absence of a theory of mind.

Typical children show evidence of having a theory of the mind before beginning school. Thus, inability to correctly perform any of the theory of mind screening procedures in a school-aged child suggests the need to refer the child for additional evaluation.