Asperger Disorder ( Social Communication Disorder)
Running head: ASPERGER DISORDER ( Social Communication Disorder or SCD)
Note: The Diagnostic Statistical Manual Addition 5 updated the Autism Diagnosis and replaced Asperger’s with Social Communication Disorder.
Asperger Disorder: Understanding a Complex Condition
Brian R. Grandjean
Texas Woman’s University
Abstract
Asperger Disorder (SCD) is a complex and often misunderstood diagnosis. This article addresses the hypothesis that Asperger Disorder is a combination of a social skills delay and an altered thinking process. A review of current research data concerning Asperger’s and high functioning Autism was conducted to test the hypothesis. Data suggest that a social skills deficit is one of the primary challenges of individuals who exhibit Asperger’s and that a significant degree of the deficit concerning social skills can by diminished through the use of appropriate therapy forms. Findings also show that individuals with Asperger Disorder (SCD) and high functioning Autism tend to exhibit difficulties in cognitive processing.
Theoretical formulations in regard to the study of disorders that fall within the Autism Spectrum suggest the possibility of an altered or diminished cognitive processing sequence.
Asperger Disorder (SCD): Understanding a Complex Condition
The last ten years has seen a significant increase in the number of children who are diagnosed with disorders that fall within the autism spectrum. Bertrand et al. (2001) and Yeargin-Allsopp et al. (2003) stipulate that as many as 1 out of every 150 children will be diagnosed as having an autism spectrum disorder (Harrington, Patrick, Edwards, & Brand, 2006). With the numbers of children with Autism Spectrum Disorders this high, it is not surprising that the level of research and treatment techniques has increased at a rapid rate over the past several years. Despite the increased awareness and scientific research there is still considerable confusion concerning the identification and treatment of children who have Autism Spectrum Disorders, particularly in the diagnosis of Asperger’s (AS/ SCD) and high functioning Autism Disorder (HFA). In an attempt to analyze the existing data concerning both Asperger’s and high functioning Autism, a hypothesis concerning the overall construction of the disorder was constructed. The author theorizes that Asperger’s Disorder is a combination of a social skills delay, and an altered thinking process.
The Diagnostic and Statistical Manual of Mental Disorders (IV) developed by the American Psychiatric Association (2000), defines Asperger’s as consisting of two mandates: “a qualitative impairment in social interaction and restricted repetitive and stereotypical patterns of behaviors, interests and activities” (p. 77). Classified as one of the least severe forms of developmental delays within the Autism Spectrum ( Cuccaro, 2007; Hill, 2006; Macintoash, 2006), the DSM-IV (2000) lists only one significant
qualification distinguishing HFA from Asperger’s, that of impairment in communication (American Psychiatric Association, 2000). However, even this distinction is questionable. At the point at which one is able to diagnose a child or an adult with Asperger’s or HFA, much of the deficit in communication that may be present in the early stages of high functioning Autism, is often diminished or no longer present (Ambery, Russell, Perry, Morris, & Murphy, 2006; Grandjean, 2007). Just as importantly, research concerning Asperger’s and HFA has found no reliable distinction between the two disorders (Manjiviona, 1999; Stokes, 2005; Wing 2001). With Asperger’s and HFA so intertwined, it may be more advisable to see them not as distinct disorders but as one in the same or as classifications of the lightest form of Autism (Wing, 1997; Javaloyes, 2006).
Distinguishing Traits
If Asperger’s (SCD) and high functioning Autism are so similar and can be classified as different names of a single high functioning disorder, then it becomes imperative to determine the primary features of the disorder in order to develop and hone effective therapy techniques that can counter the existing deficits seen in children and adults who have Asperger’s or high functioning Autism. In expressing the primary traits of Asperger’s (SCD) or HFA, the following two categorizations will be used: social interaction and cognitive processes.
Social Interaction
One of the difficulties concerning social interaction of children who have Autism is the ability to read facial expressions (White, Hill, Winston, & Frith, 2006). In a
study done by White, Hill, Winston, & Frith (2006), individuals who were diagnosed with Asperger’s were shown to have poor facial recognition. Interestingly, the people
with Asperger’s while showing poor facial recognition did very well in terms of making social judgments from photographs shown in the study. Hirschfeld (as cited in White, Hill, Winston, & Frith, 2006) suggests that despite the difficulty of Asperger’s individuals to identify facial expressions, they may have preserved the ability to connect social stereotypes to photographs. Taken one step further, one may hypothesize that people with Asperger’s (SCD) or HFA have an easier time grasping larger conceptual social norms then they do the numerous rules and nuances that are different for each person. The hyper-systemizing, assortative mating theory of autism discussed by Baron-Cohen (2006), gives a level of support for this form of thought. His theory suggests that individuals with autism are prone to use behaviors that tend to be lawful. By this, Baron-Cohen (2006) contends that many individuals with Autism are prone to attempt to predict and control events or systemize within their environment. However, systemizing only works when one is able to deal with one item at a time and is able to keep everything else constant. Thus, using Baron-Cohen’s theory of hyper-systemizing, and assortative mating, one may stipulate that an individual with Asperger’s (SCD) would easily be able to connect social stereotypes to photographs. Reasons for this ability would stem from the fact that the individual only has to deal with the single picture and the overall behavior expressed by the photo tends to be lawful, operating off of predictable social norms expressed by the overriding society. In the case of facial expressions of everyday people, individuals who have Asperger’s (SCD) will have difficulty in accurately reading a facial expression because the meaning and expressions are not as predictable nor can all other variables be kept constant. This difficulty in reading facial expressions has also gained biological support. In a study conducted by Deeley et al. (2006), it was found that the fusiform and extrastriate cortices of the brain were hypersensitive in adults with Asperger’s. This supports the hypothesis that people who exhibit Asperger’s have a decreased level activity in the amygdale and as a result have difficulty in analyzing facial expressions (Deeley et al., 2006).
Social Interaction deficits in individuals who have Asperger’s (SCD) and HFA also include the failure to develop appropriate peer relations, a lack of emotional or social reciprocity, and a limited development of self initiated and or parallel play (Elder, Caterino, Chao, Shacknai, & Simone, 2006; Howard, Cohn, & Orsmond, 2006; Lopata, Thomeer, Volker, & Nida, 2006). Lack of the before mention social interaction skills may have a profound effect on children who fall within the autism spectrum diagnoses as the existing deficits may make developing friendships much more difficult (Howard, Cohn, & Orsmond, 2006).
Compounding the difficulty of interacting with others is the tendency for children who have Asperger’s (SCD) to develop very restricted interests, often to the exclusion of most other topics or items that children of their chronological age usually play with (American Psychiatric Association, 2000; Lopata, Thomeer, Volker, & Nida, 2006; Sansosti & Powell-Smith, 2006). This restriction of interests may act as a defense mechanism for children with Asperger’s. (SCD) Many children who have Asperger’s or high functioning Autism express a limited ability to transition from one environment to another. Their ability to interact with the surrounding environment may be directed by a level of systemization. Returning to Baron-Cohen’s theory of hyper-systemizing, and assortative mating of autism, one may speculate that the tendency to formulate and work with very lawful behavior induces very black and white rules of survival (Baron-Cohen, 2006). An Asperger’s (SCD) tendency to hyper focuses on a few items and know everything about the expressed objects may be seen as an extreme form of systemization. The very act of systemization that is so often used by individuals who express Social Communication Disorder may in itself be a side effect of cognitive deficits, some of which are explained through the executive function hypothesis, the theory of mind and the weak coherence theory.
Cognitive Processing
Cognitive Processing involves the thought processes and biological predisposition that allow for problem solving, and adaptation to the surrounding environment. Current research concerning disorders that fall within the Autism Spectrum have revealed a range of new theories that attempt to explain the mental deficits that are so prevalent within both Social Communication Disorder and HFA. The three theories discussed here are: the weak coherence theory, the theory of mind, and the executive function hypothesis.
The weak coherence theory discussed by Happe (as cited in Beaumont & Newcombe, 2006) as well as South, Ozonoff, and Mcmahon (2007) hypothesizes that the cognitive deficits expressed by individuals who have Asperger’s are the result of an inability to take in the factors inherent in the environment when they make a decision (South, Ozonoff, & Mcmahon, 2007). Support for the weak coherence theory comes from a study conducted by Bock (2007). The research emphasized the use of social skills treatment that used the abbreviation of SODA standing for stop, observe, deliberate and act. Focusing on the cognitive deficits implied by the weak coherence theory, Bock (2007) used the social skills training to teach Asperger’s children how to remove
irrelevant responses, change behavior in relation to environmental factors, use personal experience to develop common since rules of action and differentiate between important information and non-important information. By improving these cognitive processes the social skills training was able to minimize social deficits and increase the amount of time that the Asperger’s children spent in cooperative learning activities such as sports and P.E..
The executive function hypothesis reviewed by Joseph (1999), suggests that individuals who fall within the Autism Spectrum exhibit diminished executive functioning. The mental operations concerning planning, shifting of mental set, and flexible thinking do not operate at full efficiency. Side effects of deficiencies in executive function include but are not limited to: difficulties in inductive logic and inflexible behavior (Nyden, Gillberg, Hjelmquist, & Heiman, 1999). Support for the executive functioning hypothesis has been wide spread in the research, particularly in supporting the theory in regards to adults, adolescents and older children who have autism (Pennington & Ozonoff, 1996; Rumsey, 1985). An important finding by Griffith, Pennington, Wehner, & Rogers (1999) in relation to the executive functioning hypothesis concerns the age at which individuals that fall within the Autism Spectrum Diagnosis may exhibit difficulties in executive functioning. Griffith, Pennington, Wehner, and Rogers (1999) found that children with autism between the ages of 40 to 60 months did just as well as individuals within the control group on executive functioning tasks. This suggests that executive functioning, while it may be a problem is not the overriding cause of Autism Spectrum Disorders (Griffith, Pennington, Wehner, & Rogers, 1999).
A third cognitive theory is the theory of the mind. It attributes cognitive deficits expressed by individuals who have Social Communication Disorder as being a result of difficulty in ascribing mental states both to themselves and others (Baron-Cohen, 2001). A good example of this theory in regards to individuals who have Asperger’s or high functioning Autism is the difficulty they express in terms of understanding how a family member may feel emotionally or how to describe their own feelings or thoughts to others (Vincente, Antoranz, & Moreo, 2003). One would hypothesize, that in order to diminish the difficulty in ascribing mental states to oneself and others, a highly interactive therapy procedure that focused on effective communication between peers would be beneficial. It would also be advisable to have strong visual and tactile components to the therapy as most Asperger’s and high functioning Autism children learn more readily when these forms of teaching are used. A study done by Legoff and Sherman (2006) used a social skills intervention based on interactive Lego play. Extremely hands on and visual, the Lego play group consisted of three positions to be held by the children: director (explaining how to build a Lego item), supplier (supplying the Lego parts), and builder (building the Lego item). The primary emphasis during the therapy group focused around verbal and non-verbal communication, joint attention and task focus, collaborative problem solving, as well as sharing and turn taking (Legoff & Sherman, 2006). Long term results of the study exhibited improved social adaptation and social competence in natural settings. As social adaptation involves the ability to not only express ones own thoughts or feelings to others as well as reading and understanding thoughts and
expressions exhibited by peers, it is suggestive that the Lego group play had significant long term results in helping Asperger’s and HFA children express and understand their own mental states as well as those of their peers.
Extending the theory of mind is a study conducted by Badenes, Estevan, and Bracete (2000). While not directly addressing Social Communication Disorder or HFA, it does connect the theory of mind with peer rejection. The overriding premise is that an inability to discern the interests of others and express ones own thoughts may instigate peer rejection (Badenes, Estavan, & Bracete, 2000). Such peer rejection which looks to be common with children who have Social Communication Disorder or HFA, may instigate a level of depression (Hedley & Young 2006; Elder, Caterino, Chao, Shacknai, & Simone, 2006). Despite its prevalence, there has not been much research on the subject. One reason for this lack may be due to the fact that impairment in verbal and non-verbal communication may mask the symptoms (Stewart, Bernard, Pearson, Hasan, & O’Brien, 2006). It is suggested by Stewart, Barnard, Pearson, Hasan, and O’Brien (2006) that if we are to develop effective treatment for children who exhibit Asperger’s or high functioning Autism, we need to develop tools that would allow for measurement of depression despite the communication gap that exists in many of the children who fall within the Autism Spectrum Diagnosis.
Conclusions
In order to discern the traits of Social Communication Disorder and high functioning Autism, we theorized that Asperger’s / Social Communication Disorder. Disorder is a combination of a social skills delay, and an altered thinking process. A collection of research concerning the disorder revealed deficits of Asperger’s and HFA as both insufficient social skills development and limitations in
cognitive processes, supporting both aspects of the given hypothesis. In the case of social skills, Asperger’s children have shown difficulty in facial recognition (White, Hill, Winston, & Frith, 2006), discerning the interests of others, as well as a lack of emotional and social reciprocity (Elder, Caterino, Chao, Shacknai, & Simone, 2006; Howard, Cohn, & Orsmond, 2006; Lopata, Thomeer, Volker, & Nida, 2006). In the case of cognitive processing, current research using the theory of executive function, suggests individuals with Asperger’s have a deficiency in flexible thinking and adaptation (Joseph,1999). The theory of mind proposes that people who have HFA may have difficulty in discerning mental states such as emotions or feelings (Baron-Cohen, 2001). Finely, the theory of weak coherence suggests that those who have Asperger’s express deficiencies in considering external factors when making decisions (Beaumont & Newcombe, 2006). Taken together, the before mentioned theories suggest that the thought processes used by individuals who have Asperger’s or HFA are altered in comparison to people who do not express any disorders that fall within the Autism Spectrum Diagnosis.
Furthermore, I propose that while executive functioning deficits are not the cause of Asperger’s/ Social Communication Disorder or HFA (Griffith, Pennington, Wehner, & Rogers, 1999), they do predispose individuals with the disorder to use systemization as a way to cope with the surrounding environment (Baron-Cohen, 2006).This systemization then leads to defects expressed in the theory of mind (Baron-Cohen, 2001) and encourages a very narrow and limited understanding of the surrounding environment in which those with Asperger’s or HFA live. Taken one step further, and incorporating systems theory (von Forester, 1984), if reality is subjective and the Asperger’s child’s definition of that reality is confined to a
limited number of external factors then his or her ability to adapt to the surrounding world will also be limited (Vincente, Antoranz, & Moreo, 2003). It becomes the job of therapist and parents to expand that perspective of reality and help the individuals with Asperger’s/ Social Communication Disorder or HFA develop a new narrative or a new way of seeing the world in which they live.
To develop this new narrative requires innovative therapeutic techniques that incorporate a child’s thirst for play as well as hands on activities that will expand the social skills of the young adults who have Social Communication Disorder. Studies that incorporate this perspective are currently lacking in the literature, with one notable exception. Legoff and Sherman (2006) developed a phenomenal social skills intervention technique using Legos. Not traditional in its conception, it does follow the theory of mind loosely and shows positive results in terms of identification of mental states. It is also notable that the Lego study was longitudinal and lasted a total of three years. As many of our current research studies using therapy techniques last only months, and Asperger’s is a long term disorder, is arguable that support for theories of the various developmental delays as well as effective treatment will bear fruit only if we plan for long term treatment lasting at least several months.
References
Ambery, F. Z., Russell, A. J., Perry, K., Morris, R., & Murphy, D. G. (2006).
Neuropsychological functioning in adults with asperger syndrome. Autism, 10(6), 551-564.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text rev.). Washington, DC: Author.
Badenes, L. V., Estevan, R. A., & Bracete, F. J. (2000). Theory of mind and peer
rejection at school. Social Development, 9(3), 271-283.
Baron-Cohen, S. (2006). The hyper-systemizing, assortative mating theory of autism.
Progress In Neuro-Psychopathology & Biology Psychiatry, 30, 865-872.
Baron-Cohen, S. (2001). Theory of mind and autism: A review. International Review of
Research in Mental Retardation: Autism, 23, 169-184.
Beaumont, R., Newcombe, P. (2006). Theory of mind and central coherence in adults
with high-functioning autism or asperger syndrome. Autism, 10(4), 365-382.
Bertrand, J., Mars, A., Boyle, C., Bove, F., Yeargin-Allsopp, M. & Decoufle, P. (2001).
Prevalence of autism in a United States population: The brick township, New Jersey investigation. Pediatrics, 108(5), 1155-61.
Bock, M. A. (2007). The impact of social-behavioral learning strategy training on the
social interaction skills of four students with asperger syndrome. Focus on Autism and Other Developmental Disabilities, 22(2), 88-95.
Cuccaro, M. L., Nations, L., Brinkley, J., Abramson, R. K., Wright, H. H., Hall, A.,
Bilbert, J., & Pericak-Vance, M. A. (2007). A comparison of repetitive behaviors in aspergers disorder and high functioning autism. Child Psychiatry Human Development, 37, 347-360.
Deeley, Q., Daly, E. M., Surguladze, S., Page, L., Toal, F., Robertson, D., et al. (2007).
An event related functional magnetic resonance imaging study of facial emotion processing in asperger syndrome. Biological Psychiatry, 62, 207-217.
Grandjean, B. R. (2007, October). Autism rocks: An autism guide. Paper presented at the
meeting of the United Methodist Church Community Outreach, Sherman, TX.
Griffith, E. M., Pennington, B. F., Wehner, E. A., & Rogers, S. J. (1999). Executive
functioning in young children with autism. Child Development, 70(4), 817-832.
Elder, L. M., Caterino, L. C., Chao, J., Shacknai, D., & Simone G. D. (2006). The
efficacy of social skills treatment for children with asperger syndrome. Education and Treatment of Children, 29(4), 635-663.
Harrington, J. W., Patrick, P. A., Edwards, K. S., & Brand, D. A. (2006). Parental Beliefs
about autism. Autism, 10(5), 4Harrington, J. W., Patrick, P. A., Edwards, K. S., & Brand, D. A. (2006). Parental Beliefs about autism. Autism, 10(5), 452-462.
Hedley, D., & Young, R. (2006). Social comparison processes and depressive symptoms
in children and adolescents with asperger syndrome. Autism, 10(2), 139-153.
Hill, E. L., & Bird, C. M. (2006). Executive processes in asperger syndrome: Patterns of
performance in a multiple case series. Neuropsychologia, 44, 2822-2835.
Howard, B., Cohn, E., & Orsmond, G. I. (2006). Understanding and negotiating
friendships. Autism, 10(6), 619-627.
Javaloyes, M. A. (2006). The need for reviewing international diagnostic categories in
pervasive developmental disorders. Autism, 10(5), 525-526.
Joseph, R. M. (1999). Neuropsychological frameworks for understanding autism.
International Review of Psychiatry, 11, 309-325.
Legoff, D. B., & Sherman, M. (2006). Long-term outcome of social skills intervention
based on interactive lego play. Autism, 10(4), 317-329.
Lopata, C., Thomeer, M. L., Volker, M. A., & Nida, R. E. (2006). Effectiveness of
cognitive-behavioral treatment on the social behaviors of children with asperger disorder. Focus on Autism and Other Developmental Disabilities, 21(4), 237-244.
Macintosh, K., & Dissanayake, C. (2006). A comparative study of the spontaneous social
interactions of children with high-functioning autism and children with Asperger’s disorder. Autism, 10(2), 199-220.
Manjiviona, J., & Prior, M. (1999). Neuropsychological profiles of children with asperger
syndrome and autism. Autism, 3(4), 327-356.
Nyden, A., Gillberg, C., Hjelmquist, E., & Heimann, M. (1999). Executive function/
attention deficits in boys with asperger syndrome, attention disorder and reading/ writing disorder. Autism, 3 (3), 213-339.
Pennington, B. F., & Ozzonoff, S. (1996). Executivev functions and developmental
psychopathology. Journal of Child Psychology and Psychiatry, 37(1), 51-87.
Rumsey, J. (1985). Conceptual problem-solving in highly verbal, non-retarded autistic
men. Journal of Autism and Developmental Disorders, 15(1), 23-36).
Sansosti, F. J., & Powell-Smith, K. A. (2006). Using social stories to improve the social
behavior of children with asperger syndrome. Journal of Positive Behavior Interventions, 8(1), 43-57.
South, M., Ozonoff, S., & Mcmahon, W. M. (2007). The relationship between executive
functioning, central coherence, and repetitive behaviors in the high-functioning autism spectrum. Autism, 11(5), 437-451.
Stewart, M. E., Barnard, L., Pearson, J., hasan, R., & O’Brien, G. (2006). Presentation of
depression in autism and asperger syndrome. Autism, 10(1), 103-116.
Stokes, M. A. & Kaur, A. (2005). High-functioning autism and sexuality. Autism, 9 (3),
266-289.
Vincente, M. P., Antoranz, A. V., & Moreo, L. G. (2003). Review on the study of the
theory of the mind in pervasive developmental disorders and schizophrenia. Actas Esp Psiquiatr, 31(6), 339-346.
von Forester, H. (1984). On constructing a reality. In Observing systems (pp. 288-309).
Seaside, CA: Entersystems Publications.
White, S., Hill, E., Winston, J., & Frith, U. (2006). An islet of social ability in asperger
syndrome: Judging social attributes from faces. Brain and Cognition, 61, 69-77.
Wing, L. (2001). The autistic spectrum. Great Britain: Constable and Company.
Wing, L. (1997). The history of ideas on autism. Autism, 1 (1), 13-23.
Yeargin-Allsopp, M., Rice, C., Karapurkart, P., Doernberg, N., Boyle, C. & Murphy, C.
(2003). Prevalence of autism in a US metropolitan area. Journal of the American Medical Association, 289(1), 49-55.