Larry Lipsitz, M.Ed.
In the last ten years, increasingly large numbers of individuals have been identified with Asperger Syndrome (AS) (Department of Developmental Services, 1999). To handle that increase, the clinician needs to be aware of the distinctive characteristics of AS and positive practices for implementation with greater success.
AS, considered to be within the autism spectrum, is a neurological disability affecting an assortment of daily functions, manifesting itself in many inappropriate behavioral forms. Although the AS individual usually has normal or high intelligence in most areas, socially, he is significantly behind his peers. This lag becomes exaggerated as the AS individual matures and greater social expectations are placed on him in the complex social world.
The AS individual has either an underdeveloped neurological system or one that is "wired" differently. Positive behavioral techniques can be used to identify and reinforce "good wiring," while attempting to replace maladaptive behaviors with suitable behavior. The "rewiring" style of the clinician would be significantly different from the standard therapeutic model.
An example of a worse case scenario could involve an AS individual who reports that he is new to the area and misses his friends who still live in Texas. Initially the clinician works with the AS person on identifying his feelings and talking about those friends. After the initial therapy the AS person begins to perseverate heavily, becoming "stuck" on how he misses those friends. This perseveration is identified incorrectly as an increase in his depressive symptoms. Medication is prescribed for the increase and more intense therapy is provided. This can actually lead to further deterioration as the individual with AS has an opposite/adverse to the medication due to his atypical neurological system, maybe causing him to become more agitated. Also, therapy, which continues to focus on his sadness, only increases his perseveration. This can result in hospitalization for his depression where the individual with AS has the opportunity to observe and model some of the other clients who are truly "depressed." Now the AS individual models those greater signs of depression and makes suicidal statements. This could result in providers determining the need for more invasive and restrictive interventions, allegedly to protect the person and keep him safe.
Knowledge of AS would change the focus of therapy. Emphasis would center on the social skills necessary to make new friends. Sessions would include teaching social skills and practicing appropriate, positive social interventions. Group sessions could be established that would allow the AS individual time to practice with others, and if possible, in the community or other natural settings. Concentrating on making new friends would alleviate the AS individual's depressive symptoms. Acknowledgement of missing old friends would occur, but the therapeutic center would be creating real friendships in the present.
To avoid a similar scenario providers need to identify the characteristics of AS early so that appropriate interventions can be implemented. Providers need to be aware of the following:
Age of Onset:
AS is a developmental disorder, unlike a mental health issue, where many of the symptoms of AS appear as the original make-up of the person. These symptoms are often misinterpreted throughout the individual's development and lifespan causing providers to have inaccurate perspectives. Those inaccuracies may result in a mental health diagnosis that fails to consider the previous realities of the individual. Accurate diagnosis is more likely to follow if the provider is aware of an individual's developmental history. Deficits in any of the following areas: communication and social reciprocity, sensory systems (hearing, smell, etc.), and scattered cognitive skills (meeting or exceeding most developmental milestones while displaying significant delay in social skills) are associated with AS.
When working with AS individuals an understanding of Asperger LAW is necessary. Those LAWS are:
"Individuals with AS have LAWS that they must follow. Some LAWS are created by the individual to solve a problem no one else may be aware of or that no one else has been able to solve to that individual's satisfaction. Other LAWS are innate.
"When a person with AS establishes a LAW, they assume that everyone else is aware of the LAW and will allow the AS individual to follow the LAW without question.
"When attempting to change the LAW a "neuro-typical" person must understand the "Asperger Logic" of the person with AS. By using "Asperger Logic" the provider can try to replace the original LAW with a more appropriate LAW.
"Ignoring "Asperger Logic" can result in a sharp increase in disruptive and bizarre behaviors as the AS person will often begin to perseverate on the LAW, become overloaded, and go into a "melt-down" mode.
Theory of Mind:
Individuals with AS are very concrete and literal in their thought processes. This type of thinking can be misinterpreted as a symptom of some type of mental illness. Using an AS model, the explanation for this behavioral reaction is known as theory of mind or mindblindness. For example, if an AS individual was asked, "Do you hear voices?" He would probably concretely answer, "Yes." Literally he does hear voices, he hears the voice of his father when he thinks about what his father would say, or while in church he may "hear" what G-d would say, etc. Providers might then commit the AS individual to a psychiatric unit or take him to a psychiatrist because he is crazy. Eventually, the AS individual learns that those voices he hears are actually his thoughts, not real voices. He then begins to tell people that he does not hear voices; however, providers may not believe him, think he is lying, tell him he is in denial, or assume that the medication he was given cured him and that is why he no longer hears voices. Meanwhile, if the AS individual is in the hospital he will probably begin to mimic the other patients around him, since he is very susceptible to his environment, especially when he is anxious. So, when he is admitted to a hospital for being crazy, he will readily confirm the staff's suspicions by modeling the crazy behaviors of others. This is interpreted as further proof that he is mentally ill and needs therapy, more medications, or both.
Further misinterpretation occurs because one of the symptoms of AS is having a communication disorder. For example, the AS individual may engage in the use of "scripted conversation," memorized phrases/ideas from previous experiences he is unable to adapt to the moment. For example, he may not know how to greet a person he would like to meet. He does remember a scene in a movie where two people meet and the AS individual decides to use the scripted conversation from the movie. Thus his effort to communicate socially appears "psychotic" to the person listening, instead of out of context. Or, the individual may have an information- processing problem so he talks to himself. By engaging in self-talk, the AS individual is able to process the information he needs to understand, a characteristic that many people engage in; however, the typical individual is more socially aware, and avoids engaging in self-talk when others are around. The AS individual is so focused on trying to understand he continues to engage in self-talk, again interpreted as a sign of psychosis. Eventually, someone concretely explains to the AS individual the difference between self-talk and psychotic-talk. The AS individual is then taught to whisper when he needs to engage in self-talk; thus he can still process the necessary information but will no longer appear psychotic since he never was psychotic.
Deficits can appear in a variety of other areas. For example, often individuals with AS have sleep pattern problems because they have trouble distinguishing whether a dream is real or fantasy. Therefore, the individual may refuse to go to sleep because he is overly concerned that the monster of his dreams will get him or will be anxious during the day due to the monster he dreamed about earlier. This is a developmental issue that all individuals go through. However, a typical person is more likely to unconsciously "develop through" this issue at a young age. Individuals with AS may have to be consciously taught that when they dream during sleep it is not a real story.
Lacking theory of mind also means that the AS individual may make assumptions about what others know. An extreme instance of an individual lacking in theory of mind occurs when person A shows person B a ball and then places it in his pocket before person C enters the room. When person C enters the room and asks where the ball is person B is surprised or may comment that person C must know where it is, since he, person B knows where it is. Person B, lacking in theory of mind, is unable to distinguish what he knows from what Person C knows. This is an illustration of a developmental processing deficit that a typical individual is going to develop quickly through, while the AS individual continues to struggle with the concept (Baron-Cohen, 1997).
Another theory many professionals have is that there are actually six senses. The sixth sense is the one that allows an individual to notice and evaluate non-verbal cues. For example, if a person comes home, slams the car door, walks into the house, and covers his or her face while slumping into a chair. Everyone automatically reacts by staying clear of that person because it is obvious s/he must have had "a bad day at work." That is their sixth sense at work. Nothing was said but they could feel what the person was feeling. The AS individual will still run up to that individual like he has every other day because he lacks the sixth sense and therefore misses or is unable to interpret the non-verbal cues that say, "this is not a typical day."
Circle of Friends:
Individuals with AS are usually totally clueless on how to act during social situations and use scripts to compensate for that deficit. For example, an AS individual is asked to play a game of monster chase. When the AS individual is "it," he chases his peers and bites them. His peers strike back and then he is blamed for causing trouble. However, the AS individual is now very confused because on television he saw that monsters eat people. In his eyes he was doing exactly what his friends asked, acting like a monster.
Fast-forward ten years. The AS individual is involved with some peers that he would really like to become friends with, but he still is socially clueless, especially since social situations have become significantly more complex. Recently, the AS individual watched a movie with double meanings that he did NOT understand at all levels, although he thought the movie was great. The AS individual attempts to interact positively with his peers by taking a "script" from the movie that is inappropriate and begins repeating it to them. Their reactions, because they understand the double meanings in the movie are negative towards him, and they interpret his actions as attempting to cause trouble.
The AS individual is now confused by his peers' reaction. Some peers, observing this confusion, and knowing his desire for friendship, quickly identify him as the perfect victim. They suggest he engage in an inappropriate behavior (like becoming involved with drugs) so that he can become their friend. The AS individual is suckered in, engages in the bad behavior and gets in trouble.
The best way to stop this cycle is to create a support system that can help the AS individual make friends. Providers can assist with this by creating a Circle of Friends program. The goal of the Circle of Friends would be to help the AS individual learn the complex social skills that he has trouble with. When utilizing a Circle of Friends the following concepts need to be understood:
"It is NOT therapy.
"It is NOT insight oriented.
"It is moderated by an adult trained in working with individuals with AS, but run by friends or potential friends.
"The adult may first have to work with the AS individual and prepare him before the group becomes involved by role playing appropriate "group behaviors."
"Techniques need to emphasize concrete examples, role-playing and scripting.
"The focus is not talking about social skills. Instead the group practices using the social skills needed by the AS individual.
"The friends are positive role models the AS individual has contact with during the day.
"The friends are taught how to teach and model social skills relevant to the AS individual's needs.
"The Circle will act and practice the different skills in the group.
"If possible the Circle will arrange situations in "the real world" so that the skills taught in Circle can be practiced in reality.
"Explaining or moralizing why a skill should be learned DOES NOT occur.
"The size of the group would vary depending on the specific social skill being taught.
Scripting vs. Self-Talk vs. Psychotic Talk:
Scripting or Self-Talk is sometimes interpreted as a disruptive behavior, or a sign of mental illness, instead of as a necessary reaction for an individual who has difficulty processing information. What causes the processing problem is unclear, although hypothetically many professionals agree that the different parts of the brain are not able to coordinate the movement of information from one part of the brain to a different part on a timely basis (theory of canalesthsia). AS individuals are often superior memorizers, when they look at a situation they memorize what they observe. This is not the same as comprehension. Comprehension comes when the AS individual has the time to process the pictures that he has memorized. He completes that procedure by "looking at the picture in his mind" and verbally processes the information until he gains comprehension. This information process can occur hours after the actual incident was observed and may include engaging in self-talk. Providers can attempt to shape the AS individual's self-talk or scripting to make it more socially acceptable. Efforts can be made to lower the volume, to see if the AS individual can learn to "talk in his head" without making any noise or by teaching him to engage in self-talk, but only in a certain area or at a certain time. Providers need to move cautiously and monitor whether a decrease in self-talk also causes a decrease in comprehension and/or an increase in anxiety. If it does, then providers should probably choose to accept a higher level of self-talk and attempt to shape it so that it does not cause a disturbance to others around the AS individual.
Individuals with AS have a greater amount of stress due to a deficit in their ability to analyze new and/or abstract concepts and the need they have for extended processing time. Providers often interpret an AS individual's reaction to this problem as non-compliant or disruptive behavior and implement a penalty, such as time-out. Time-Out is not the same as Calm-Down. If providers use the term interchangeably a peer will eventually comment to the AS person how bad he must be since he always goes to Time-Out. Asperger Law will then go into effect. The AS person will refuse to go to Time-Out because he is not BAD! This means one of the best interventions an AS individual can use is less effective. However, the possibility of the AS person becoming over-stimulated remains, thus the targeted behaviors will more likely occur and cause a disruption. Calm-Down allows the person time to process, time to think, and most important time to calm himself down. Therefore providers should stop presenting "time" as a punishment (i.e., time-out), but teach the person that time is something he needs to gain personal control (i.e., calm-down). A calm-down place should be created in all environments. It should be:
"A place that the person can always go to and be left alone.
"The place should be "calming," i.e., have few distracters, although items that are calming could be provided in this area. Caution should be taken. Probably allowing time to play with a game-boy in calm-down is beyond calming to the point of rewarding. In other words the person would want to go to calm-down because he wants to play, not because he needs to calm down.
"As the person moves about his environment the calm-down area needs to be mobile. For example, at school, during one subject the calm-down area may be a separate room nearby. In another room the calm-down area may be a quiet spot in the room. At home, his own room made be used. At the mall it could be a chair by a certain entrance.
"Initially the person should be encouraged to use calm-down as a positive option. Once the calm-down process is learned, providers may think the person is using the "system" to his advantage by escaping from demand(s). Calm-down should continue to be used, but after a certain amount of time has passed the provider should prompt the person back to his schedule.
"The schedule, once properly adjusted, will reduce the chance that calm-down will be used inappropriately. Scheduling can be created that will motivate the AS individual to use calm-down only when necessary.
The world of autism, which includes AS, is complex. Therapeutically, providers need to strongly consider gaining greater understanding of this syndrome so that appropriate and positive interventions can be implemented quickly and in a pro-active fashion. A diagnosis is only important if it results in specific interventions. AS is one of those diagnoses where identification can mean distinct interventions.
Baron-Cohen, S., Cosmidis, L., & Tooly, J. (1997). Mindblindness: An essay on autism and theory of mind. Cambridge, MA: MIT Press.
Department of Developmental Services. (1999, March). Changes in the population of persons with Autism and Pervasive Developmental Disorders in California's Developmental Services System: 1987 through 1998. http://www.dds.ca.gov
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