Asperger’s syndrome (AS), originally described by Hans Asperger in 1944 (Attwood, 2007, p. 23), was historically considered a distinct high-functioning subtype of autism. It is now considered simply an autism spectrum disorder (ASD) following a change to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 2013 (Kite, Gullifer, & Tyson, 2013). “Autism spectrum disorders are severe disorders of development that can affect social interaction, communication, play, and learning” (The Speech Pathologist, 2014).
Because AS was only recently identified as a diagnosis, the total number of individuals affected by this syndrome remains difficult to determine. The National Institute of Child Health and Mental Development estimated in a recent survey that 0. 2% of the general population have some form of AS, or about 1 in 500 people. AS is also almost five times more likely to occur in boys (1 in 42) than girls (1 in 189) (Baio/CDC ADDM Network,2014, p. 14) with a corresponding ratio of 4:1 (Autism/Asperger Network). It is also not a discriminatory disorder as it has been reported in all racial, ethnic, and socioeconomic groups.
The most commonly reported measure of frequency of AS is not incidence, but prevalence. This is due to the fact that the onset of the disorder usually begins long before a diagnosis is given. This time interval is influenced by a wide range of factors (Newschaffer, 2007). In addition, the overall prevalence of ASD worldwide, including AS, is 7. 6/1000, or 1 in 132 persons (Baxter, Brugha, Erskine, Scheurer, Vos, & Scott, 2015). In comparison, we have an overall higher prevalence of ASD, including AS, in the United States, at 14. /1000, or 1 in 68 children (Baio/CDC ADDM Network, 2014, p. 1). AS is a neurodevelopmental disorder that changes the way the brain processes information. It is identified by its deficits in social communication and interaction, and the presence of repetitive, quirky behaviors, interests, and activities (Autism Spectrum Disorder: Overview, n. d. ).
Complications with social communication include: impairments in joint attention and social reciprocity, as well as impairments in using verbal and nonverbal communicative behaviors for social interaction. Repetitive, quirky behaviors (e. . , crowding another’s personal space (Myles, B. S. , & Simpson, R. L. , 2002)), interests (e. g. , space crafts), or activities (e. g. , a cup of milk daily at 3:00 p. m. ) are seen in stereotyped, and repetitive speech and/or motor movement. They are also detected in rigidity of routines; and hyper- and/or hyposensitivity to sensory input (Autism Spectrum Disorder: Overview, n. d. ). This can be off-putting to peers. AS is also by and large considered a social disorder (Hutton,M. , n. d). Children with AS often put forth effort to make social connections with their peers.
However, their social difficulties, often times, stem from an incompetence and lack of understanding, and skill in initiating, and responding in various social situations, and under variable conditions” (Hutton, M. , n. d. ). The difference between those with AS, and their peers, lies in the fact that there is still a disconnect due to the missing of subtle social cues. This makes it almost impossible to respond to social situations correctly. Furthermore, the abilities to express and understand emotions are crucial in order for effective communication to occur.
We are able to use emotions to tell whether a person is happy, upset, worried, etc. Those with AS are not born with this innate ability. They have difficulty knowing what to do in situations involving emotion. They also have to work to overcome a few different emotional hurdles. Some of these obstacles include: managing emotions, making sense of the emotions of others, and being mindful of their habit of intellectualizing feelings (Attwood, 2007, p. 24). As a result of their inability to process other’s emotions, they may give a reaction that others may perceive as insensitive (Myles & Simpson, 2002).
In terms of intellect and academics, there are a few key elements that are indicative of AS. As AS is on the Autism Spectrum, at times, it could be falsely assumed that as a result, intelligibility is low. In fact, those with AS have have normal IQs; and in some cases, their IQ may be very high, even in the genius range (“Asperger’s Syndrome: Normal IQ”, 2010). Nearly half (46%) of children with AS have average to above average intellectual ability (IQ>85) (Baio, 2014, p. 1). Students may experience difficulty paying attention in class (Attwood, 2007, p. 44).
This may be due to sensory overload. Those with AS have a difficult time tuning out certain sensory information in order to pay attention to other information, such as a teacher’s voice during class. Many struggle with a hypersensitivity to certain sounds, aromas, textures, and touches. Thus, instead of tuning out any secondary information (e,g,. “Sound of chalk on a chalkboard”), students focus on the secondary information, and tune out any primary information (Attwood, 2007, p. 44). Lastly, there are numerous speech and language characteristics that are great indicators of AS.
These include, but are not limited to: strength in vocabulary and syntax, delayed conversational abilities, and a tendency to be pedantic (Attwood, 2007, p. 44). Speech and Language Characteristics of the Disorder Children with AS have subtle speech and language characteristics that make reaching a diagnosis difficult. Nonetheless, there are signs to look for during assessment that expose their speech and language challenges. AS is characterized first and foremost as a social disorder (Myles & Simpson, 2002, p. 132).
Although children with AS have a desire to make friends, their intentions are not always well executed or accepted by their peers (Myles & Simpson, 2002, p. 133). Often times, they appear awkward in conversation and inflexible to change (Myles & Simpson, 2002, p. 133). AS children are better understood in a one-on-one setting and “cannot interpret the simultaneous presentation of facial expression, posture, gestures, and voice tone in social context” (Myles & Simpson, 2002, p. 133). AS children have unusual speech patterns (Gibbons & Goins, 2008, p. 349). Some may talk at inappropriate times while others may take longer than is typical to respond to a question or comment” (Gibbons & Goins, 2008, p. 349).
Not only that, but AS patients may not communicate pain or discomfort to a doctor. They have a high threshold for pain. Thus, parents have difficulty determining when their child needs medical attention, (Attwood, 2007, p. 289). “Medical staff may be surprised at the audacity of the child, or consider the parent’s negligent” (Attwood, 2007, p. 289). Typically by the time they seek help, symptoms are so severe that what started as a minor problem has escalated to something dangerous.
In the pediatric population, psychotherapists often evaluate AS children. However, it is difficult to do so because they “have a limited ability to express inner thoughts and emotions eloquently using speech” and “in processing the psychotherapist’s speech and intentions” (Attwood, 2007, p. 319). In comparison to Autism, AS symptoms are hard to detect, although it is vital to look for “delayed speech development,” “repetitive patterns of speech,” “abnormalities in inflection,” and “lack of cohesion to conversation” (Attwood, 2007).
AS children have signs that parallel Semantic Pragmatic Language Disorder, (Attwood, 2007, p. 16). These children “have relatively good language skills in the areas of syntax, vocabulary and phonology but poor use of language in a social context, i. e. the art of conversation or the pragmatic aspects of language” (Attwood, 2007, p. 16). Often times, these children may talk too little or too much during a conversation (Attwood, 2007, p. 223). Especially in stressful, high populated areas those with AS tend to retreat and withdraw from conversation (Attwood, 2007, p. 224).
Children with AS have language acquisition characterized by impairments across all five domains of language: phonology, morphology, syntax, semantics, and pragmatics (Bland-Stewart, 2013). Among those with AS who do acquire language, there is wide variation in impairment severity (Bland-Stewart, 2013). Of all the language domains, pragmatics is the most widely affected in those with AS. Pragmatic deficits include lack of gestures, eye contact, and interest in people, as well as lack of topic maintenance and turn-taking, an inability to answer questions concisely, and a lack of cohesion while speaking (Bland-Stewart, 2013).
Not only is verbal communication an important component in assessing, body language is also a characteristic of the disorder. “There can be a lack of variation in facial movement to express thoughts and feelings,” and they can have “clumsy or gauche body language” (Attwood, 2007, p. 261). Overall, a child with AS may have “superficially perfect expressive language,” “odd prosody, peculiar voice characteristics,” and “formal pedantic language” (Attwood, 2007, p. 37). Evaluation Tools and Methods SLPs evaluate language skills involving language content (semantics), form (phonology, syntax, and morphology), and social use (pragmatics).
Several normed assessments exist to formally assess language, such as the Test of Pragmatic Skills (TOPS), the Comprehensive Assessment of Spoken Language (CASL), and the Test of Pragmatic Language (TOPL). SLPs obtain a comprehensive linguistic and behavioral profile of a child by combining history data from parents, observation of the child in various settings, audio and video sampling of the child’s language, and results from checklists, surveillance materials, and standardized or criterion reference tests (Bland-Stewart, 2013, p. 0-61).
Some of the most frequently cited evidence-based assessment tools preferred by SLPs in assessing ASD children include: the Rossetti Infant-Toddler Scale, the Expressive One Word Vocabulary Test (4th Edition); the Peabody Picture Vocabulary Test; Pragmatic Language Skills; the Language Processing Test; and the Clinical Evaluation of Language Fundamentals (4th Edition) (Bland-Stewart, 2013, p. 60).
Using the results of the comprehensive assessment, the SLP devises treatment goals and objectives appropriate to each child in order to target treatment of speech, language, and communication deficits (Bland-Stewart, 2013, p. 60-61). “Narrative assessment has long been a tool used by SLPs to assess a range of language fundamentals and communication functions” (Young, Diehl, Morris, Hyman & Bennetto, 2005, p. 65). Strong Narrative Assessment Procedure is available to evaluate narration, but was not developed with a focus of assessing pragmatic social skills.
Young et al. describes the difficulty evaluating language of those with AS due to the fact that the disorder itself is characterized by deficits in social language which cannot be measured in the same ways as other areas of language (Young, et al. , 2005, p. 64). “The most commonly used means to assess and describe pragmatic behaviors are observation and the coding of behaviors with checklists and behavioral profiles” as quoted by Gallagher & Prutting (1983), Loveland, Landry, Hughes, Hall, & McEvoy (1988), and Wetherby & Prizant (1989) in (Young et al. 2005, p. 64). “It is unrealistic to assume that a single instrument, no matter how thoroughly researched can be used in isolation to ascertain diagnosis” (Howlin, 2000, p. 127). Since pragmatic language is the main area of deficiency, it is problematic to standardize and norm a test that needs to take into account the environment of the AS child along with the standards and norms that are expected with whom that child interacts.
Treatment Programs or Methods Children with AS vary widely in abilities, behaviors, interests, and intellectual functioning (ASHA, n. . ). The goal of speech-language intervention is to improve a child’s social communication and other language impairments, and to modify the child’s language and behaviors to improve his/her quality of life, develop relationships, and increase social acceptance (ASHA, n. d. ). There are many different speech and language intervention approaches and strategies for individuals with AS. Programs differ in the method used to address goals and in how goals are prioritized and addressed (ASHA, n. d. ).
Treatment modes and modalities include Augmentative and Alternative Communication (AAC), activity schedules/visual supports, computer-based instruction, and video-based instruction (ASHA, n. d. ). SLPs determine which methods and strategies will be effective for a particular child by considering many facets of the child’s life: the child’s level of social and linguistic development, cultural background and values, family resources, personal interests, learning style, and communication needs (ASHA, n. . ). The SLP may use traditional speech therapy methods, play-based therapy, augmentative or alternative communication, or structured commercialized program (Bland-Stewart, 2013). Left to the SLP’s discretion is the optimal service delivery model, frequency of therapy, need for involvement of other therapists, and setting for intervention (Bland-Stewart, 2013).