Aspergers syndrome: definition, assessment, therapeutic intervention

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Introduction

This essay focuses on Aspergers syndrome. This special educational need was chosen because I have a personal interest in this condition. The essay looks in detail at how Asperger's syndrome is defined and how Asperger's syndrome is assessed and diagnosed. The essay then moves on to discuss the various therapeutic interventions for Asperger's syndrome and what teaching approaches are appropriate for children presenting with this condition. The different theoretical perspectives from which Asperger's syndrome can be understood are then discussed, namely the medical model, the social model and Bronfenbrenner's ecological model.

What is Asperger's syndrome?

According to Klin et al. (1995), Aserger's syndrome is "a severe developmental disorder characterized by major difficulties in social interaction and restricted and unusual patterns of interest and behaviour". There are many similarities with autism and there is still discussion as to whether Asperger's syndrome and autism are actually different conditions (Klin et al., 1995). As Klin et al. (1995) highlight, however, the APA made Asperger's syndrome officially a separate diagnosis following the results of a field trial, which revealed that Asperger's syndrome does have different diagnostic criteria to autism.

Other definitions of Asperger's syndrome differ from these definitions, with the American Psychiatric Association, via their Diagnostic Statistical Manual of Mental Disorders IV, defining a diagnosis of Asperger's syndrome as, "requiring four of five listed criteria be present, including at least two indicatros of a qualitative disability in social interaction (e.g., serious impairments in peer relationships, social reciprocity, nonverbal behaviours, empathy) and at least one in the category of restricted behaviours or rituals (e.g., rigid adherence to rules or routines, preoccupation with a narrow interest, parts or objects, repetitive motor movements)" (Safran, 2002). Medicine.Net defines Asperger's syndrome as "an autistic disorder most notable for the often great discrepancy between the intellectual and social abilities of those who have it" (Medicine.Net, 2010). The Autism Society of America defines Asperger's syndrome as, "…high functioning autism with no speech delay" (Autism Society of America, 2010). It is clear, therefore, that there are a variety of definitions of Asperger's syndrome, with this confusion arising as a result of the difficulty in diagnosing Asperger's syndrome, as will be discussed later in the essay.

In terms of the clinical features of Asperger's syndrome, a paucity of empathy is usually noted, as is naïve, inappropriate and one-sided social interactions with pedantic and monotonic speech (Klin et al., 1995). In addition, poor non-verbal communication and intense absorption in specific topics and clumsy and/or ill-coordinated movements all help to identify children with Asperger's syndrome (Klin et al., 1995). It is noted that the onset of the condition occurs later than the onset of autism with children living with Asperger's syndrome having a normal range of intelligence (Klin et al., 1995).

The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) provides the following, more detailed, diagnostic criteria, "qualitative impairment in social interactions…(and)…restricted repetitive and stereotyped patterns of behaviour, interests and activities manifested by either encompassing preoccupation, apparently inflexible adherence, stereotyped and repetitive mannerisms or persistent preoccupation with parts of objects" with these guidelines recommending that Asperger's syndrome be diagnosed where all other conditions have been excluded (Klin et al., 1995). It is noted that children living with Asperger's syndrome have no delay in their acquisition or use of language and that the disturbances the syndrome cause can cause major clinical impairments, such as socially, occupationally or in other areas of functioning (Klin et al., 1995).

Assessment of Asperger's syndrome

Assessment of Asperger's syndrome, particularly in children, is difficult as there is a paucity of diagnostic instruments and no standardization amongst the diagnostic tools that do exist (Howlin, 2000a). The problems of differentiating Asperger's syndrome from autism, particularly in the ICD-10 and DSM-IV systems, is also a complicating factor in the assessment of Asperger's syndrome: as Howlin (2000a) argues, attempting to develop diagnostic tools in the absence of any clear definition of Asperger's syndrome is "attempting to put the horse before the cart" (Howlin, 2000a).

As Klin et al. (1995) argue, the lack of awareness of professionals of the condition can also make diagnosis difficult, with a comprehensive assessment of children suspected of having Asperger's syndrome needing to include the "patient's medical history, a psychological assessment, communication and psychiatric assessments, parental conferences and further consultation, if necessary". The initial stage of any assessment is to take a careful medical history, including all information relating to the child's development, from pregnancy to the present; next, a psychological assessment would be undertaken which would aim at establishing the child's level of emotional functioning, their strengths and weaknesses and their preferred style of learning (Klin et al., 1995). Next, communication and psychiatric examinations would be taken, which would collect both quantitative and qualitative information about the child's willingness and ability to communicate and their psychiatric status.

One complication with diagnosing Asperger's syndrome is that many of the clinical manifestations of this condition are similar to those manifested by autistic children (Bishop, 1989). As argued by Wing (1988), because the diagnosis of autism is so difficult, as autism appears to present as a continuum of symptoms, with no clear boundaries, this has further complicated the diagnosis of Asperger's syndrome. As Wing (1988) discusses, the only clear diagnostic tool for diagnosing some form of autistic disorder is the presence of social impairment; the degree of social impairment, coupled with other symptoms, can then lead to the diagnosis of other forms of developmental disorder, such as Asperger's syndrome or semantic-pragmatic disorder (Bishop, 1989). Placing children along the autistic continuum, with autism being divided along two main axes of 'interests and social relationships' and 'meaningful verbal communication', can thus help to diagnose the three different conditions (Semantic-pragmatic disorder, Asperger's syndrome or autism), with children diagnosed with autism being classed as more 'abnormal' along these axes and children diagnosed with Asperger's syndrome being classed as 'abnormal' along the 'interests and social relationships' axis and 'normal' along the 'meaningful verbal communication' axis (Bishop, 1989).

Yet, this does not stop researchers attempting to produce an assessment tool for the clinical diagnosis of Asperger's syndrome. Scott et al. (2002), for example, report the development of the CAST (Childhood Asperger Syndrome Test), which they designed to be able to screen children for Asperger's syndrome. The test is suitable for 4-11 year old children and was tested on 37 children with 'typical development' and similar numbers of children with suspected Asperger's syndrome, with the finding that the tool detected significant differences between the sample means of 'normal' children and those children living with Asperger's syndrome (Scott et al., 2002). It was concluded, therefore, that the CAST is a useful tool for the clinical diagnosis of Asperger's syndrome or to identify those children at risk of Asperger's syndrome and related conditions. As has been argued, however, the validity of this test is questionable, given the lack of a clear definition for Asperger's syndrome.

Therapeutic interventions

As highlighted in Klin et al. (1995), the treatment of Asperger's syndrome is, essentially, to provide support to the child in the event of any distress. There have been suggestions that behavioural coaching and supportive psychotherapy, can have some degree of positive effect on children with this condition although this has yet to be tested rigorously (Klin et al., 1995). As Weiss (2005) argues, however, no therapeutic interventions have been shown to be completely successful in treating the negative manifestations of Asperger's syndrome. Jacobsen (2004), however, makes a case for the use of individual psychotherapy and case management for children with Asperger's syndrome, as the therapeutic relationship can become an important source of support and routine for these children.

As the mind of an individual with Asperger's syndrome is different to the mind of someone who does not live with this condition, it is important to consider theories of mind in the evaluation of the therapeutic needs of children living with this condition. Various tests, such as false belief tests, for example, have suggested that children with autism have an impaired theory of mind, with Baron-Cohen (2001) relating how theory of mind refers to the ability to reflect on one's own and others minds with children living with conditions along the autism spectrum having difficulty in understanding other people's minds. As Baron-Cohen (2001) argues, much of the basic research in this field, on functional brain neuroimaging, for example, "may have clinical applications in the areas of…early intervention or early diagnosis".

As Gevers et al. (2006) report, a social cognition programme based around this lack of a theory of mind had some success in dealing with children with pervasive development disorders including Asperger's syndrome, with this treatment intervention significantly raising consciousness of the feelings of others in those children who were assigned to this arm of the trial. This article gives hope to those parents of children with Asperger's syndrome, and to those adults living with Asperger's syndrome, that some therapeutic intervention may result from Baron-Cohen's work and allow them to live a full life, free of the problems that Asperger's syndrome brings to them.

Theoretical perspectives on Asperger's syndrome

This section will discuss three main theoretical perspectives that are used/can be used to define Asperger's syndrome, namely the social model, the medical model and Bronfenbrenner's ecological model. As Bricout et al. (2004) argues, children who live with disabilities, and also their families and social workers, face "complex social and institutional environments in their quest for developmental, educational and daily living supports". Models of disabilities can provide conceptual frameworks with which to understand their disability and can inform the decision-making processes of parents and social workers (Bricout et al., 2004). The medical model, for example, focuses on individual deficits whereas the social model focuses on disabling social environments (Bricout et al., 2004). These models will all affect how the disabled child is understood and treated, as such models dictate how society views people with disabilities.

The social model of disability, for example, views the disabled individual in terms of their differences, with 'disability' meaning that the individual is restricted somehow with the term 'disability' being a social construct that exists as a result of people's reactions to 'the disabled' and the shared meanings that surround this category of individuals within society (British Council of Disabled People, 1981). Society as a whole decides whether the impairments held by an individual leads them to be labeled 'disabled', with a label of 'disabled' meaning certain discrimination via the imposition of barriers which will limit the abilities of these individuals to participate in society. For individuals with Asperger's syndrome, which challenges their ability to concentrate and to interact 'normally' with other children, the social model of disability labels them as 'disabled' in terms of their ability to be educated, meaning that they will usually be placed in a special educational needs situation. This is intended to ensure that their special needs can be catered for, yet placing children in special educational needs contexts can often doom children to a life of poor educational achievement, as it is known that disabled children placed in special educational needs contexts do less well academically than disabled children placed within the setting of a 'normal' school (Reiser and Mason, 1990; Howlin, 2000b).

Molloy and Vasil (2002) discuss whether "Asperger's syndrome is a disorder or a neurological difference that has been socially constructed as a disorder", discussing how Asperger's syndrome is currently defined, in medical terms, as a developmental disorder. Yet, as Molloy and Vasil (2002) argue, the diagnostic criteria for Asperger's syndrome have been socially constructed, with 'Asperger's syndrome' being readily accepted as a diagnosis for the problems that the children diagnosed with this condition face, as a way of being able to deal with these children under the umbrella of special educational needs. As such, it is educators, argue Molloy and Vasil (2002) that are mainly responsible for this social construction of Asperger's syndrome, with schools viewing this condition as a social disability and, this, being able to categorize the children with the condition and to give credence to their treatment of these children as needing to 'rehabilitated' or 'normalized', something that is not, necessarily, in the child's best interests. As such, Molloy and Vasil (2002) argue, a shift really needs to be made towards an examination of the social implications of a diagnosis of Asperger's syndrome. Viewing children under the medical model, which labels children living with Asperger's syndrome as 'deficient' in something is also unhelpful, Molloy and Vasil (2002) argue, as the child comes to be viewed only with that label and therefore suffers a loss of individuality and consequent lowered expectations.

The medical model of disability does not, like the social model, implicate society in the understanding of a person's disability, but rather views the disability as a function of the medical deficits that individual has, meaning that, under this viewpoint, the individual, and their deficit, is the problem, and not society. Under the medical model, society only comes to view individuals as disabled as a result of the impairment/deficit that they have, with individuals with Asperger's syndrome being viewed as unable to communicate emotionally and/or socially and, as a function of this, being labeled as 'disabled'. As society, and policies aimed at mainstreaming disabled people and providing them the opportunity to enter normally into society, has moved more towards a social model of disability, the opportunity has arisen for children with Asperger's syndrome to be mainstreamed and dealt with, in mainstream schools, as children with special educational needs. As Howlin (2000b) argues, in contra to Molloy and Vasil (2002), this is the correct approach for the more able children with Asperger's syndrome as high-functioning individuals with Asperger's syndrome can, if supported, achieve excellent outcomes in education and in their lives.

Bronfenbrenner's ecological model can also be used to understand Asperger's syndrome, as this model approaches child development from a joint sociological and development psychology perspective, with the thesis that individuals and their environments are mutually shaping, that is that they both have an effect on each other and, through this, change each other (Bronfenbrenner, 1979). As Bronfenbrenner (1979) states, "child development takes place through processes…of…the complex interaction between an active child and the persons, objects and symbol in its immediate environment", such that this model implies that a disability such as Asperger's syndrome is a result of a lack of environmental support, and that, as such, the negative manifestations of the disability can be smoothed by placing the child in a more appropriate environment.

It is clear, then, that Asperger's sydrome can be understood, and represented, from a variety of theoretical perspectives, all of which affect the expectations placed on individuals living with Asperger's sydrome. As Howlin (2000b) argues, however, with the correct support, high-functioning individuals with Asperger's sydrome can go on to achieve great things in their lives. This finding by Howlin (2000b) ties in with the ecological model of Bronfenbrenner (1979), which suggests that the disabilities caused by living with Asperger's syndrome are superable, if only the child is placed in the correct environment. This point will be returned to in the discussion of teaching approaches.

As Molloy and Vasil (2002) argue, defining Asperger's syndrome in terms of any one model is extremely problematic. It is clear that children living with Asperger's syndrome require more attention than 'normal' children because they crave more attention and have difficulties respecting social norms, meaning that, in a school setting, their behaviour would be picked up upon and corrected, attracting more attention from teachers. Yet, whether this is a disability as understood by the medical model (i.e., an impairment or deficit) is a moot point, especially as children with Asperger's syndrome usually excel in other areas meaning that they do have the capacity to fit in to mainstream schooling and society, despite the fact, as Molloy and Vasil (2002) argue, labeling children as living with Asperger's syndrome automatically means that they will be labeled, also, as special needs children. As Molloy and Vasil (2002) argue, with adequate support, children living with Asperger's syndrome can excel in the areas that interest them and so, instead of these children being the failures for not fitting in to educational expectations, it is the education system that is failing these children. This becomes especially clear when it is recognized that some cases of Asperger's syndrome are only diagnosed when children enter the school system and are labeled 'problematic' with referrals to psychologists then offering a diagnosis of Asperger's syndrome.

As Molloy and Vail (2002) argue, the situational nature of disability is important in understanding the practical implications of a child living with symptoms that can be labeled as Asperger's syndrome. If, for example, a child living with Asperger's syndrome is obsessed with mechanics and finds a specialized tutor to teach them mechanic, this child would excel in this field, above and beyond any child in a mainstream school. There are, thus, arguments on both sides regarding how and where children with Asperger's syndrome should be educated. Children with Asperger's syndrome are individuals, with different individual needs and it is not helpful or ethical for these children to be grouped in to one terminology - special educational needs - as this does not provide enough individual support to these individuals in order to allow these individuals to excel (Howlin, 2000b). That these children have problems understanding, and mastering, social interactions should not, argue Molloy and Vasil (2002), be a reason for these children to be marginalized and for this marginalization to be justified on the grounds of either the medical or social models of disability. This is especially problematic given the fact that children living with Asperger's syndrome can have their social interactions facilitated by certain interventions.

Teaching approaches

There are, therefore, many practical implications for these differing theoretical perspectives on Asperger's sydrome, in terms of diagnosis, assessment and intervention. How and when children living with Asperger's syndrome are assessed to have this condition affects their education: as has been discussed, the situational nature of the diagnosis of Asperger's syndrome can affect, for example, how and where they are schooled. This, as shown by Howlin (2000b) can affect their life chances and outcomes, given that, in the right circumstances, with the right levels of support, individuals with Asperger's syndrome can achieve great things in their lives, often above and beyond 'normal' individuals. The 'Who - what - how - where - when' of diagnosis and schooling, beyond this diagnosis, thus has a major impact on the life chances, and outcomes, of children living with Asperger's syndrome.

Each of these different theoretical perspectives provides different insights in to the most appropriate teaching approaches and teaching strategies for individuals with Asperger's syndrome. A whole range of options are available for education for children living with Asperger's syndrome, from whole class to differentiated teaching. A Safran (2002) argues, it is feasible that children living with Asperger's syndrome can be taught in mainstream schools, and indeed many are, as these children usually have an extremely high IQ, with this gift needing only to be directed, and chanelled, adequately whilst controlling for the other more negative aspects of the manifestations of their condition. Yet, under the different theoretical perspectives, different educational models would be recommended for children living with Asperger's syndrome. The medical model would, for example, seem to suggest that these children are somehow deficient, and would see their weaknesses and not their holistic perspective, failing to recognize their giftedness in other areas. The social model would, as has been seen, in the discussion of the work of Molloy and Vasil (2002), suggest that the diagnostic criteria for Asperger's syndrome have been socially constructed, with 'Asperger's syndrome' being readily accepted as a diagnosis, as a way of being able to deal with these children under the umbrella of special educational needs. This, whilst not having the disadvantages that the perspective of the medical model presents, is itself problematic because, as has been seen, children living with Asperger's syndrome can often, aside from their behavioural problems, be extremely gifted academically.

Gallagher and Gallagher (2002) argue that there is a case to be made that children living with Asperger's syndrome should be treated as gifted children, in terms of their education, given that many children living with Asperger's syndrome have extraordinary capacities in certain areas. As Bronfenbrenner's (1979) ecological model suggests, if a child with Asperger's syndrome is placed in the right environment, they will flourish. It is clear, therefore, that this model differs in its applicability to, and approach towards, Asperger's syndrome, as something that can overcome, not as something that causes a permanent, insuperable, deficit in the child. As Jindal-Snape et al. (2005) argue, children with autistic spectrum conditions can be taught effectively, especially if Bronfenbrenner's (1979) ecological model is implemented, with functional links being found between all 'parts' of the child's ecosystem, i.e., the child's home environment, their school and the other agencies that help them deal with their condition.

It has to be noted, however, that their inability to interact socially and their low tolerance for routine, however, makes it difficult, in practical terms, to see how children living with Asperger's syndrome could be educated alongside gifted children. Although, as Safran (2002) argues, if all school personnel are made aware of the child's condition and its manifestations, then it would be possible for certain children living with Asperger's syndrome to enter mainstream school with one-to-one help, from a classroom assistant, for example, who would be there to help them with their behavioural difficulties. Interventions as simple as arranging the seating in the classroom to ensure that the child with Asperger's syndrome is not sitting next to children who will aggravate them has been shown to be effective in managing the manifestations of the condition, allowing these children to be schooled in a mainstream setting (Safran, 2002).

It is my personal opinion, from my personal perspective, that certain children living with Asperger's syndrome are well suited to a mainstream classroom setting, although this is said with caution, as these children can take a lot of the teachers time, if they are not assisted, leaving little time for the other members of the class. As to whether mainstreaming special educational needs children is fair to the mainstream children is the topic of a whole other essay, but it is my experience that, indeed, as Safran (2002), Howlin (2000b) and Gallagher and Gallagher (2002) argue, certain children with Asperger's syndrome are academically excellent and, as such, should be given a chance at achieving great outcomes in their lives. As Safran (2002) states, "people with Asperger's syndrome are often creative, highly intelligent, mathematically or scientifically astute…(and)…have the potential for momentous contributions to out society". As such, it should be the place of mainstream education to find a place for these children; indeed, as Safran (2002) reports, children with Asperger's syndrome can often see great improvements in their condition as a result of interacting with other children in mainstream school. This is certainly my experience, as I have had students with Asperger's syndrome in my classroom whose confidence has soared as a result of making friendships and being involved in events and activities that captured their interest. Many of their parents expressed their thanks that their children had been engaged in such a manner whilst at school.

I have also known many parents of children with Asperger's syndrome who have not had such positive experiences of sending their children to mainstream and/or schools catering for children with special educational needs, and who decided not to send their children through the traditional school system and who decided to home school their children. There are many hundreds of cases like this in the UK, supported by the Asperger Home Education organization, and other local organizations, which act as a source of support for parents who are home-schooling children with Asperger's syndrome (Asperger Home Education, 2010). The vast majority of experiences of people I know who have home schooled their children with this condition have had hugely positive experiences, with their children growing up to lead full lives, most usually specializing in the area that captured their interest as a child. One friend, in particular, has gone on from being obsessed with LEGO as a small child to become a structural engineer, employed in one of the UK's largest construction companies, something that was made possible by the dedication of his mother who didn't give up on him, believed in him and gave him the tools and skills he needed to be able to make a success of his adult life.

However a child with Asperger's syndrome is taught, it should be borne in mind, as recommended by The National Autistic Society (2010) that children with this condition are likely to have problems with group work, with a lack of comprehension, with a lack of empathy and with their motivation levels. It is also likely that, at some point, children living with this condition might suffer from distress as a result of a perceived lack of information. The good teacher should, thus, be aware that these problems may arise and should attempt to handle the classroom situation, and the student within that situation, so that the opportunities for these problems to arise are limited. If they arise, the teacher should also have strategies in place for dealing with the behavioural manifestations of these problems in the child. There are, therefore, various teaching approaches that can be adopted in order to minimize the distress caused to the child with Asperger's syndrome and minimize, as a result, the disruption to the classroom that is caused when a child with this condition becomes confused and distressed. The social model would suggest that if this condition is accommodated by an appropriate teaching approach, then the child should be able to be schooled normally, accommodating, as far as possible, their disability.

Conclusion

This essay has looked in detail at Asperger's syndrome, from its definition to its differences in comparison to autism. Several models have been discussed, with which to understand the disability caused by Asperger's syndrome, with these models being applied to teaching approaches and a discussion presented of possible teaching approaches for children living with Asperger's syndrome in light of these different models. My personal experiences of teaching and/or knowing some children with this condition were also related, showing, on the whole, that children with this condition are usually academically gifted and that the problems their disability presents can be overcome by, as Bronfenbrenner's (1979) ecological model suggests, fitting the child's environment to their condition. Home schooling is an ideal way of ensuring this and giving the Asperger's child the best chance of making a success of their lives. It should be noted, however, that not all parents can afford, or have the ability to, home school and, as such, other teaching approaches were discussed, including mainstreaming and institutes providing special needs education. In conclusion, Asperger's syndrome is a complex condition, dealt with in many ways, depending on the perspective from which the condition is viewed.

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