eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Asperger's Syndrome: Follow-up

Author: James Robert Brasic, MD, MPH, Research Associate, Division of Nuclear Medicine, Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine
Contributor Information and Disclosures

Updated: Mar 17, 2009

Follow-up

Complications

  • Depression and hypomania are common among adolescents and adults with Asperger disorder, particularly those with a family history of these conditions.
  • An increased risk of suicide is observed, with risks possibly rising in proportion to the number and severity of comorbid maladies. Asperger disorder is probably undiagnosed in many suicide cases because of the dearth of awareness of the condition's existence and the ineffective and unreliable tools used to identify it. Therefore, people with Asperger disorder who commit suicide are probably reported as having other or undiagnosed psychiatric problems. In cases of unexpected suicide, Asperger disorder is a strong possibility.
  • The American Psychiatric Association reports that a quarter of the American population is likely to experience a major depression at some time. Thus, depression is a serious public health problem demanding attention. People with Asperger syndrome and their caregivers may be prone to develop depression.
    • Every person who interacts with people with Asperger syndrome can benefit from developing an awareness of the symptoms of depression. When these symptoms occur in people with Asperger syndrome, family, friends, and others, the afflicted person can be guided to receive the needed help.
    • Several criteria have been identified to diagnose depression. A major depression is characterized by the presence of the symptoms on a sustained basis for at least 2 weeks. In other words, transient sadness lasting a few hours does not qualify as major depression. In order to meet the criteria for a symptom of depression, the symptom must interfere with the person’s life, possibly in educational, occupational, or social settings.
    • The key hallmarks include depression and anhedonia. Anhedonia is characterized by the inability to experience pleasure. Anhedonia is a symptom of depression. Either depression or anhedonia must be present to diagnose major depression. The presence of depression can be elicited by asking the person, “Do you feel low, blue, sad, down in the dumps?” The presence of anhedonia can be elicited by asking if the person experiences pleasure from activities that usually produce pleasure.
    • In addition to depression and anhedonia, 7 other symptoms of depression are noted as follows:
      1. Disturbances of eating are typical in depression. The person may lose weight when not dieting or may gain weight. A change of 5% of the body weight in one month qualifies as a symptom of depression. Alternatively, the person may experience a marked decrease or increase in appetite.
      2. Sleep disturbances are common in depression. The person may experience insomnia. Difficulty falling asleep may be reported. Ask the person, “Do you wake up in the middle of sleeping? Do you wake up earlier in the morning than usual?” Alternatively, the person may sleep more than usual.
      3. Disturbances of activity levels often occur in depression. The person may move much more frequently or much less frequently than usual. This may lead others to comment that the activity level has changed.
      4. The person may have a loss of energy and a persistent feeling of tiredness.
      5. The person may have difficulty concentrating.
      6. The person may experience feelings of guilt, helplessness, and hopelessness. Ask the person, “Do you feel worthless?”
      7. The person may have thoughts that life is not worth living. The person may consider, plan, attempt, or commit suicide. This symptom requires immediate evaluation by a mental health professional. Involuntary psychiatric hospitalization is indicated if the person is acutely suicidal.
    • Throughout the process of interacting with a person who has depression, the person needs to be informed that the depression will pass. Unlike other progressive mental disorders, depression is a remitting illness. In other words, the depression resolves entirely without treatment. However, treatment likely hastens the onset of recovery. Still, a person with depression may be convinced that recovery is not possible. This may be a result of the temporary feeling of hopelessness common in depression. The belief that the person will never recover may lead to suicide. For this reason, people with depression must be told that the depression will completely resolve. Inform the person that sometimes people’s minds play tricks on them and that they will completely recover.
    • People who are depressed may need assistance to obtain help from mental health professionals. If a person is suicidal, call 911 to ask for an ambulance for a person with a mental disorder. People who are dangers to themselves merit commitment to mental hospitals for treatment to protect them from hurting themselves.
  • People with Asperger disorder can have other neuropsychiatric disorders, including Tourette disorder, anorexia nervosa, and schizophrenia; treating such comorbid disorders may be beneficial.
  • 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).
  • Changes to a child's environment may exacerbate symptoms. Therefore, minimize separations if the child is fond of family members, teachers, and others.

Prognosis

  • Comorbid psychiatric disorders, when present, significantly affect the patient's prognosis.
  • Individuals tend to have a better prognosis when they have supportive families who are knowledgeable about Asperger disorder.
  • Individuals with Asperger disorder may be taught specific social guidelines, but the underlying social impairment is believed to be lifelong.

Patient Education

  • Activities: Individuals with Asperger disorder can often concentrate on activities for hours without interruption and can continue this concentration daily for years. With proper instruction, their talents can be developed enormously; therefore, identifying and nurturing their interests and abilities (eg, music, mathematics) at an early age is beneficial. Although many children might refuse to practice a musical instrument for even a few minutes a day, a child with Asperger disorder may enjoy hours of daily practice. Skilled instruction is necessary to fully develop these talents. Parents and teachers should creatively uncover skills, abilities, and talents; these talents may also help the child earn respect from classmates.
  • Social behaviors in school settings
    • Teachers have many opportunities to help children develop appropriate social behaviors.
    • Children can learn to watch other children for social cues and for behaviors to imitate.
    • Teachers can model socially appropriate behavior and encourage cooperative games in the classroom.
    • Teachers can explain appropriate means of seeking help when the child demonstrates problematic social behaviors in the classroom. Videotapes may facilitate self-monitoring of adherence to classroom rules.29
    • Teachers may identify suitable friends for children and encourage prospective friendships.
    • Teachers may help children in challenging social situations by supervising breaks between classes and lunchroom and playground activities.
    • Children may benefit from a full-time, trained, 1-on-1 teacher aide to shadow them in the classroom and to coach appropriate behavior.
    • Because changes in schools, classrooms, and teachers may exacerbate symptoms, attempt to minimize alterations to the patient's schedule and educational environment
    • Children, adolescents, and adults with Asperger disorder typically benefit from a weekly, therapist-guided, social skills group with peers
    • Auditory integration training helps some children with social interactions.
  • Interaction with other children
    • Children may benefit from an organized club, chaperoned by adult leaders who provide advance preparation and a discussion forum.
    • Parents can help children learn appropriate play by modeling and rehearsing such skills as flexibility, cooperation, and sharing.
    • Parents should encourage an affected child to invite a friend to their home.
  • Communication and language strategies
    • Children can be taught to memorize phrases for specific purposes (eg, to open conversations).
    • Children can learn to seek clarification by asking people to rephrase confusing expressions. Encourage children to ask that confusing instructions be repeated, simplified, clarified, and written down.
    • Encourage children, when appropriate, to admit that they do not know an answer.
    • Caregivers, through modeling, can teach affected children how to interpret the conversational cues of others to reply, to interrupt, or to change topics.
    • Because interpretation of metaphors and figures of speech is often difficult, caregivers should explain these language subtleties when they arise.
    • Children can be taught to refrain from vocalizing every thought.
    • When communicating a series of instructions to a child with this disorder, pause between each separate statement.
    • Role-playing may help a child learn to understand the perspectives and thoughts of other people. Encourage the child to stop and think how another person will feel before the child acts and speaks.
    • Some children with Asperger disorder may have good visual thinking abilities; they may be encouraged to visualize using diagrams and visual analogues.
  • Career counseling and orientation
    • Career choice is crucial for persons with Asperger disorder because social impairment limits their success in many occupations.
    • Career choices using technology, especially the Internet, are often particularly suitable for people with Asperger disorder. Computer science, engineering, and natural sciences are common career choices for individuals with this disorder. Other special interests may be developed into careers.
    • Individuals may need special help to prepare for job interviews and to maintain an appropriate demeanor in a work environment.
  • Resources

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider comorbid movement disorders: Various rating scales, when used regularly, help identify and differentiate among various movement disorders. These rating scales include the following:
  • Prescription of drugs without indication: Regular administration of the Psychoactive Medication Quality Assurance Rating Survey (see Figure 5 in Tardive Dyskinesia) helps ascertain the need for psychoactive medication use.
  • Failure to identify toxicity of medications: For example, regular administration of the Serotonin Syndrome Checklist (see Media file 1) helps identify early evidence of adverse effects of SSRIs.

    Autism screening checklist.

    Autism screening checklist.

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    Autism screening checklist.

    Autism screening checklist.

Special Concerns

  • Individuals with Asperger disorder (and related conditions), their families, teachers, and communities benefit from the experiences of other individuals with this disorder and from the experiences of their advocates. The following organizations provide information and advice to persons with Asperger disorder and related conditions:
    • Asperger Syndrome Coalition of the United States (ASC-U. C.), Inc.
      PO Box 49267
      Jacksonville, FL 32240-9267
      Telephone: 904-745-6741
      email: info@asc-us.org
    • ASPEN
      Asperger Syndrome Education Network, Inc.
      9 Aspen Circle
      Edison, NJ 08820
      Telephone: 732-321-0880
      email: info@aspennj.org
    • Asperger Norfolk
      Old Lion Cottage
      Thurne, Great Yarmouth
      NR29 3AP
      United Kingdom
      Telephone: 01 692 670 864
  • Individuals with Asperger disorder and their families benefit from intensive assessments and treatment interventions. Contact the above resources for information about assessment and treatment facilities located near the patient.
  • Several other resources have been recorded in a recent manual for parents of young people with Asperger syndrome.30 This excellent guide for lay people who encounter people with Asperger syndrome provides practical suggestions for day-to-day life.
  • The social deficits exhibited by many people with Asperger syndrome and related conditions remain major obstacles to their functioning in family, educational, occupational, and community settings. Research is needed to develop programs to train individuals in the nuances of social interaction.
  • The ability to communicate with groups with people can be developed. Toastmasters International is an organization of clubs that promote the communication and leadership skills of members. Some individuals with Asperger syndrome may develop special skills, such as interpretive reading and storytelling, by participation in the activities of Toastmasters. Toastmasters has local clubs around the world to help members become better speakers in public.
 
Acknowledgments

This research is supported by the Essel Foundation, the National Alliance for Research on Schizophrenia and Depression (NARSAD), the Tourette Syndrome Association, the National Institutes of Health, the Department of Psychiatry of Bellevue Hospital Center, and the New York University School of Medicine. The cooperation of the Health and Hospitals Corporation of the City of New York is gratefully acknowledged.



More on Asperger's Syndrome

Overview: Asperger's Syndrome
Differential Diagnoses & Workup: Asperger's Syndrome
Treatment & Medication: Asperger's Syndrome
Follow-up: Asperger's Syndrome
Multimedia: Asperger's Syndrome
References
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Further Reading

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Keywords

Asperger syndrome, Asperger disorder, autistic psychopathy, high-functioning autism, HFA, hyperlexia, nonverbal learning disorder, NLD, personality disorder, pervasive developmental disorder- not otherwise specified, PDD-NOS, pragmatic language disorder

right hemisphere dysfunction, schizoid personality, semantic pragmatic disorder, sensory integration disorder, persistent impairment in social interactions, repetitive behavior patterns, restricted interests, pedantic speech, early childhood motor delays, clumsiness, fine motor difficulty, gait anomalies, odd movements, social insensitivity, severe social impairment, depression, mood disorders, obsessive-compulsive disorder, Tourette disorder, socially inappropriate behavior

abnormalities in speech, abnormalities in language, oddities in pitch, abnormalities in intonation, abnormalities in prosody, abnormalities in rhythm, selective mutism, lax joints, anomalies of locomotion, anomalies of balance, anomalies of manual dexterity, anomalies of handwriting, anomalies of rapid movements, anomalies of rhythm, anomalies of imitation of movements, impaired ball-playing skills, doll-play paradigm, miscomprehension of language nuance, inability to use language in social contexts, lack of sensitivity about interrupting others, irrelevant commentary, absent facial expressions, inappropriate facial expressions, peer relation difficulties

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Contributor Information and Disclosures

Author

James Robert Brasic, MD, MPH, Research Associate, Division of Nuclear Medicine, Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine
James Robert Brasic, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Neurology, and Movement Disorders Society
Disclosure: Taylor and Francis Royalty Independent contractor; Wolters Kluver/Lippincott Williams & Wilkins Royalty Independent contractor

Medical Editor

Carol Diane Berkowitz, MD, Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center
Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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