February 18 is International Asperger’s Day: a comment by Prof. Anna Ogliari
On 18th February 1906 Hans Asperger was born in Wien, the Austrian pediatrician who in 1944 first described a development condition characterized by eccentricity, motor awkwardness, difficulties in social relations, limited interests and repetitiveness of behavior: these are some characteristics of the Asperger’s Syndrome, precisely named after him.
On the occasion of his birth, 18th February is now the International Asperger’s Day. What is this syndrome? How can it be recognized? How can this be treated? We talked about this with Prof. Anna Ogliari, M.D., Associate of Clinical Psychology at UniSR, Specialist in Clinical Psychology and Psychotherapist at the Servizio di Psicopatologia dello sviluppo, as well as Rector Delegate for Disabilities.
Prof. Ogliari, what is Asperger’s Syndrome?
The new Statistical Diagnostic Manual of Mental Disorders (DSM 5) published in 2014 has assimilated Asperger’s syndrome to Autism Spectrum Disorders, a diagnostic category in which the syndrome now falls. But first things first, and try to describe a clinical picture and some salient features, rather than entering into the difficult diatribe of the diagnostic classification.
First of all, Asperger’s syndrome is a pervasive developmental disorder that appears right from the first stages of development and has specific characteristics that may appear to be highly of mildly disabling depending on the severity of the clinical picture.
The difficulties lie in different domains; the most evident and easily identifiable are some important difficulties in social interaction, for which the person diagnosed with Asperger often lacks reciprocity in the relationship with peers or with reference adults, is not able to start or support the process of socialization, cannot use eye contact, cannot hold conversations. Asperger’s patients show limited and stereotyped interests compared to their peers and are hardly distracted from such interests. Sometimes even the behaviors of Asperger subjects are limited and are almost obsessive, repetitive and ritualized. They often appear clumsy and uncoordinated, and show marked difficulties in learning complex motor patterns, net of a cognitive profile (intelligence) in the norm or sometimes above average. The language learning skills are intact, unlike what happens to other Autism Spectrum Disorders. Some tell a marked sensory reactivity, such as the effort to tolerate loud noises.
For the characteristics we have described so far it is quite intuitive to understand how Asperger’s syndrome is not often recognized before year 5 or 6, both because of the typical development of language skills and because around this age social demands (scholastic and not only) begin to highlight the difficulties of those who will be diagnosed.
The symptomatology can take on different shades as the subject’s age varies, but the main characteristics seem to remain stable throughout the lifespan; they can improve the subject’s ability to recognize their own difficulties and therefore the subject’s will to find strategies to improve himself. The numbers in the literature are not always unique and the prevalences reported vary from 1 child in 250 to 1 child in 5000, while the prevalence in the adult population is not clear. What we know with certainty is that the syndrome is more frequent in males than in females and that probably the prevalences are strongly underestimated.
What are its causes?
Although the causes of the syndrome are not yet clearly identified, and the etiopathogenetic path leading to its development not described in detail, the researchers have identified some neurobiological bases, investigating also specific genetic traits and their interaction with some environmental aspects. However, although the literature is increasingly rich in data in favor of the biological aspects there is still no single etiopathogenic theory.
We know for sure that Asperger, as well as other neuro-developmental diseases, aggregates in families, i.e. in families where the diagnosis of Asperger is present is increased the possibility of finding at least one other subject with diagnosis or with a nuanced symptomatology.
The study of ‘Asperger families’ or highly at risk, as well as the study of healthy close relatives (brothers, sisters, parents without disease) is essential to recognize some nuanced features of the syndrome and identify its evolutionary antecedents or early indicators (behaviors, distinctive traits) that are fundamental for the early identification of the pathological tract, so as to monitor its development and prevent its severity.
How can it be recognized/diagnosed?
Children or young people come to the attention of the specialist clinician for the presence of problems that fall within the sphere of socialization, movement, behavior, emotionality, but they can also emerge difficulties in school learning, hyperactivity.
It seems trivial, but the diagnosis must be made by an expert specialist (Neuropsychiatrist), as there are many nuances of the syndrome and many are the assessments that must be made to get to the diagnostic certainty. Sometimes the scenario manifests itself in such a way that it is difficult to read even by experienced Neuropsychiatrists.
The variability and the different intensity of the symptomatology therefore requires an accurate investigation and we hope that precocious diagnoses, based on the study of the developmental antecedents of the syndrome itself, can be more and more frequent.
As already mentioned, early diagnosis is the best way to help these individuals to work better, is carried out by the specialist through an extensive clinical interview to gather information from parents but also from the different socio-relational contexts in which the patient is involved. The information is used to describe the mode of social relationship of the subject in the various contexts and must be accompanied by a careful clinical observation of the subject. Some standardized tools that the clinical and scientific literature can offer us, such as questionnaires, can be useful in the screening phase, but diagnosis or suspected diagnosis must always be confirmed by the clinical investigation. As sometimes happens, the diagnosis of Asperger may be accompanied by other neuropsychiatric diagnoses such as ADHD, Anxiety Disorder or Depressive Disorder.
What are its treatments/how can this be addressed?
We have already stressed the chronicity of the syndrome and the persistence throughout life. This feature, however disabling, in some cases has resulted in an improvement in the clinical picture due to the subject’s ability to identify their difficulties and find some strategies to deal with them (we said before that Asperger subjects have a lively and high intelligence).
It is easy to understand how the treatment of choice is a psychological treatment aimed at letting the Asperger person learn the social and emotional skills he lacks, but also to support the social context in which he lives (parents, teachers, brothers ) with psycho-educational training aimed at explaining the functioning of the disease and giving practical guidance in resolving the difficulties described above. Often the syndrome is in comorbidity with other neuropsychiatric disorders: if the clinical conditions require so, there may be the possibility of implementing pharmacological treatments aimed at alleviating the symptoms.
Are there practical indications and advice for children and their parents?
Esistono indicazioni pratiche e consigli per i ragazzi e i loro genitori?
Children and teen with Asperger’s syndrome often have difficulty with the social skills necessary for success in social settings and at school. It is therefore very important to help them find strategies to interact in these contexts, remembering that what seems simple to us is a real achievement.
It is therefore very important to help them find strategies to interact in these contexts, remembering that what seems simple to us is a real achievement. For instance, you can teach the child some skills to integrate into social contexts, for example by practicing introductory conversation techniques. There are specific programs for rehabilitation of Social Skills (such as SET-C by Prof.ssa Deborah Beidel) that can be adapted to Asperger kids.
Let’s picture it: think about how many people we meet every day, how many times we use metaphors to better explain what we want to say, how we manage to shift our attention from one interest to another, to understand the mood of those besides us by the expression of their face or their voice. Imagine now that from tomorrow morning we are unable to do any of this: how would we feel? A subject with Asperger must learn every day what for us is normal or even trivial. It is as if they continually needed instructions and maps to move in sociality.
The advice is to give them explanations, to be sure they can repeat them, to provide emotional behavioral social maps to move in the everyday small challenges, certain that their intelligence will support them but that their fragile emotions must be collected and supported.