Asperger Syndrome Treatment & Management

Treatment of people with Asperger syndrome consists of instruction and counseling to ameliorate the social disabilities that are features of the disorder, along with encouragement of special skills that can take advantage of these individuals’ capacity for narrowly focused and sustained concentration. Teachers provide an important resource for school-age children with Asperger syndrome.

For children and youths, specific interventions that may be provided include communication and language strategies and social skills training. For youths and adults, interventions may include relaxation training and career counseling and orientation.

Depression is a common comorbidity, and depressed patients may benefit from specific treatment. People with Asperger syndrome can also have other neuropsychiatric disorders, including Tourette syndrome, anorexia nervosa, and schizophrenia; treating such comorbid disorders may be beneficial.

Drugs to treat the core characteristics of Asperger syndrome have not yet been identified. ^{[48, 49]} Pharmacologic interventions are used to treat comorbid disorders, including attention problems and mood disorders (eg, dysthymia and bipolar disorder), but should not be prescribed in the absence of an indication. Regularly assessing the patient by administering the Psychoactive Medication Quality Assurance Rating Survey ^{[50, 51, 52, 53, 54]} helps determine the need for psychoactive medications. Vigilance for drug toxicity must be maintained.

Teachers have many opportunities to help children develop appropriate social behaviors. For instance, they can model socially appropriate behavior and encourage cooperative games in the classroom. They can explain appropriate means of seeking help when the child demonstrates problematic social behaviors in the classroom. They may identify suitable friends for children and encourage prospective friendships. They may also 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’s aide. The aide can shadow the child in the classroom and coach appropriate behavior. Videotapes may facilitate self-monitoring of adherence to classroom rules. ^[55] Children can learn to watch other children for social cues and for behaviors to imitate. Because changes in schools, classrooms, and teachers may exacerbate symptoms, efforts should be made to minimize alterations to the patient’s schedule and educational environment.

There is some evidence that early intensive behavioral intervention benefits patients with austism spectrum disorders. ^[68] However, it has been specifically worked on due to positive prognosis. ^[69]

For complete information on these topics, see Pervasive Developmental Disorder and Autism Spectrum Disorder.

Children with Asperger syndrome can be taught to memorize phrases for specific purposes (eg, to open conversations). They can also learn to seek clarification by asking people to rephrase confusing expressions. They should be encouraged to ask that confusing instructions be repeated, simplified, clarified, and written down, as well as to admit, when appropriate, that they do not know an answer.

Caregivers, through modeling, can teach affected children how to interpret others’ conversational cues to reply, interrupt, or change topics. Because interpretation of metaphors and figures of speech is often difficult, caregivers should explain these language subtleties when they arise. When communicating a series of instructions to a child with Asperger syndrome, caregivers should pause between each separate statement.

Role-playing may help children with Asperger syndrome learn to understand the perspectives and thoughts of other people. Affected children should be encouraged to stop and think how another person will feel before acting or speaking. They can be taught to refrain from vocalizing every thought.

Some children with Asperger syndrome may have good visual thinking abilities. These children may be encouraged to visualize by using diagrams and visual analogues.

Additionally, participation in the activities of Toastmasters International may help individuals with asperger syndrome to develop outstanding abilities in communication and leadership.

Children with Asperger syndrome may benefit from participation in an organized club, chaperoned by adult leaders who provide advance preparation and a discussion forum. Children, adolescents, and adults with Asperger syndrome typically benefit from a weekly, therapist-guided, social skills group that includes peers. ^[68] Auditory integration training helps some children with social interactions.

Parents can help children to 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. Only 6 hours of parent training, including group sessions, would benefit the child's social communicative behavior. ^{[70, 71]}

To assist people with Asperger syndrome in social encounters, it may be helpful to provide social skills training, including role modeling and role playing. Attwood described techniques for parents to use with children with Asperger syndrome. ^[56]

The ability to communicate with groups of people can be developed. Toastmasters International is an organization of local clubs that promote communication and leadership skills (eg, public speaking); these clubs are found around the world. Some individuals with Asperger syndrome may develop special skills, such as interpretive reading and storytelling, by participating in the activities of Toastmasters.

Psychotherapy can often help people with Asperger syndrome recognize their deficits in social skills. Group psychotherapy may facilitate the development of appropriate social skills. Individual psychotherapy may help the person with Asperger syndrome identify and address particular personal issues.

Overall emotionl recognition skills can be improved in children with ASD by proper interventions. ^{[72, 73]}

People with Asperger syndrome are frequently misunderstood by family, friends, neighbors, and the general public. They may encounter harsh, unreasonable criticism from teachers, parents, supervisors, and others. Such experiences, together with their difficulties in understanding social situations, may result in anxiety, panic attacks, and other psychological disturbances. Chronic stress may cause hypertension.

For coping with stress, the practice of relaxation techniques is often beneficial. ^[57] Additional effects of relaxation training may include lowering blood pressure and maintaining and improving health.

Relaxation constitutes a major effect of yoga and meditation. For some people, practices such as these have a religious aspect; however, Benson and Klipper showed that the crucial parts of a relaxation session have a purely physiologic basis, and they developed a compendium of the essential aspects of relaxation that are suitable for practice by the general public. ^[57] According to Benson and Klipper, the necessary features of relaxation training include the following:

• Quiet environment

• Mental device

• Passive attitude

• Comfortable position

To establish the desired environment, the person sets aside periods of 10–20 minutes for relaxation sessions twice a day, before breakfast and before dinner. He or she sits in a comfortable chair with eyes closed or open; lying down is not recommended, because sleep may result. Pagers and cell phones should be shut off, and internal and external stimuli should be shut out.

The mental device is a focusing aid that consists of the silent or spoken repetition of a sound, word, or passage. A nonsense syllable or a neutral word is suitable. Benson and Klipper suggest the repetition of the word “one.” This is equivalent to a mantra, such as is used in some meditation techniques. Attending to the pattern of breathing is also a mental device. Alternatively, the person may focus on a picture, image, symbol, or other visual stimulus as the item of attention.

During the session, thoughts are allowed to come and go. Whatever thoughts come should be disregarded. Attention is paid to the chosen mental device. The thoughts are passively allowed to enter awareness and are then passed from awareness. Perceptions are allowed to pass. At the end of the 20 minutes, gradual movement of the hands, feet, and body allow the individual to return to full alertness.

Acute anxiety may take the form of rapid respirations, rapid heartbeat, and a sense of impending doom. Acute relaxation training may relieve the panic to facilitate the ability to continue in the situation. Guided imagery can be provided by clinicians as well as family members, friends, and neighbors.

Individuals with Asperger syndrome can often concentrate on activities for hours without interruption and continue this concentration daily for years. For example, although many children might refuse to practice a musical instrument for even a few minutes a day, a child with Asperger syndrome may enjoy hours of daily practice.

With proper instruction, the talents of people with Asperger syndrome can be developed enormously. Accordingly, it is beneficial to identify and nurture their particular interests and abilities (eg, music or mathematics) at an early age. These talents may also help the child to earn respect from classmates.

Parents and teachers should take creative approaches to uncovering the skills, abilities, and talents of children with Asperger syndrome. Skilled instruction is necessary to develop such talents fully.

Career choice is especially crucial for persons with Asperger syndrome, in that social impairment limits their success in many occupations. Careers in technology, especially the Internet, are often particularly suitable for people with this syndrome. Computer science, engineering, and natural sciences are common career choices. 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. Otherwise, their impaired comprehension of social norms may lead to poor judgment in worksite behavior.

Depression

Clinicians must be aware of the risk of depression associated with Asperger syndrome and institute prompt interventions when major depression occurs. Unlike other progressive mental disorders, depression typically resolves entirely without treatment; however, treatment likely hastens the onset of recovery.

Even with appropriate management, a person with depression may be convinced that he or she will never recover. This conviction may be a result of the temporary feeling of hopelessness common in depression. The belief that recovery is impossible may lead to suicide. Accordingly, the clinician must continually emphasize to the patient that the depression will probably resolve completely, explaining that sometimes people’s minds play tricks on them and that regardless of how things may seem, full recovery is the most likely outcome.

People who are depressed may need assistance with obtaining help from mental health professionals. If they are suicidal, their caregivers (or they themselves) can call emergency services (eg, 911) to ask for an ambulance for a person with a mental disorder. People who are a danger to themselves may be committed to a mental hospital for treatment to protect them from self-injury.

Behavioral disorders

Many pharmacologic agents (eg, antipsychotics, selective serotonin reuptake inhibitors [SSRIs], clonidine, and naltrexone) have been tried in attempts to improve some of the symptoms associated with Asperger syndrome and related conditions, such as stereotyped movements, self-injury, hyperactivity, and aggression.

Studies suggest that SSRIs help treat repetitive behaviors, impulsivity, irritability, and aggression. However, controlled clinical trials, based on well-diagnosed populations, are needed to confirm the impressions that SSRIs and atypical antipsychotic agents may alleviate core symptoms of Asperger syndrome and related conditions.

A randomized controlled trial found that the SSRI citalopram lacks efficacy in treating repetitive behavior in children diagnosed with autism spectrum disorder (ASD), including Asperger syndrome. ^[8] Specifically, citalopram did not significantly improve dimensional scores on repetitive behavior, scores on a parent-rated repetitive behavior scale, or the rate of positive global response in comparison with placebo.

Stimulants may be effective as adjunctive therapy for attention-deficit/hyperactivity disorder (ADHD) associated with Asperger syndrome. Patients with Asperger syndrome who have inattention and distractibility may respond to second-line agents for ADHD. Atomoxetine may be effective as adjunctive therapy for comorbid ADHD. Guanfacine has been used off label to reduce hyperactivity in children with Asperger syndrome. ^[22]

Patients should be observed walking and running. Adult patients may model appropriate motions to improve the coordination of their upper and lower extremities. Helping patients learn to catch and throw balls proficiently can facilitate their ability to participate in team sports and thereby enhance their social skills.

Wearing sunglasses and avoiding intense light may help children with Asperger syndrome who exhibit photosensitivity. Using earplugs may also help children who exhibit extreme intolerance or sensitivity to sound.

Remedial exercises may improve handwriting. Printing in block capital letters may also facilitate written communication. Alternatively, use of assistive technology (eg, a laptop computer) often helps.

A neurologist should be consulted for examination and neuropsychological testing. Consultation with an otolaryngologist, an audiologist, and a speech pathologist is appropriate for excluding treatable auditory and vocal system anomalies. Speech testing helps assess children with developmental disabilities, and speech therapy is often helpful.

Consultation with physical and occupational therapists may be helpful; such therapy often improves the handwriting and other fine motor activities of patients with lax joints and unusual grasps. Sensory integration therapy reportedly helps some individuals.

Mindfulness is a technique to relieve stress and to promote effective living. Mindfulness has been a component of martial arts and meditation.

Mindfulness in martial arts

Mindfulness has been a component of martial arts for centuries. Practitioners of martial arts learn to maintain a water face, a sense of calmness reflected in the unbroken surface of a pool. Practitioners of martial arts are also taught to develop a moon face, an awareness of every item surrounding the practitioner as if illuminated by the light of the moon. Awareness of surroundings are needed when walking outside in settings where assailants may appear from all sides. Practitioners of martial arts are also taught to develop mirror face, concentration on exactly the task at hand. Concentration is necessary to effectively and correctly execute the movements of martial arts.

Mindfulness-based stress reduction

People with Asperger syndrome can learn to apply this tool with beneficial results. Extensive training in mindfulness includes classes with regular homework. Individuals with Asperger syndrome may benefit from participating in organized classes, group meditations, and study of texts. ^[74] Mindfulness practice is based on seven principles as follows: non-judging, patience, beginner’s mind, trust, non-striving, acceptance, and letting go. ^[74] A key component to mindfulness is the regular practice of meditation and yoga exercises. A full discussion of mindfulness is beyond the scope of this article. Nevertheless, readers may benefit from practicing meditation for 20 minutes or so daily by performing simple breathing exercises. People with and without Asperger may benefit from practicing meditation with breathing for 20 minutes daily. If a person experiences pain or stress with the exercises, then by all means stop. The experience of meditation is not supposed to be harmful or upsetting.

With regular practice of meditation, individuals learn the techniques so that they can provide the cues for a meditation without the guidance of an instructor. While people are learning the techniques, listening to the instructions of a leader in person or on recording facilitates the performance of a meditation. For this reason we provide the text for the spoken instructions for a meditation to focus on the breathing. If the listener encounters increased anxiety or pain during the playing of the sound track, then the person should discontinue the practice with the tape. People who have negative experiences listening to the spoken meditation practice should seek consultation with an experienced teacher instead of practicing with the recorded meditation guidance.