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Asperger Syndrome or
Autistic Disorder?
The Diagnostic Dilemma
B. J. Freeman, Pegeen Cronin, and Pete Candela

The diagnosis of Asperger syndrome (AS) has been plagued with controversy and con- order was considered a developmental
fusion since it was introduced into the psychiatric nomenclature, in the Diagnostic and disability.
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Rourke (1989) described another
Association [APA], 1994). This quandary has been portrayed in both the popular media, group of children with a neuropsycho-
including newsmagazines and movies, and the scientific literature. Similarly, different logical profile identified as nonverbal
views of the syndrome have emerged over the years as different diagnostic criteria
learning disability (NLD). These children
were developed and investigated. Connotations that have become popular include
had difficulties with tactile perception,
high-functioning autism, adults with autism, eccentric people, and “nerds.” Confusion
remains as to whether AS is in fact a separate diagnostic category, distinct from autistic psychomotor coordination, visual–spatial
disorder (AD), or is on a spectrum of social communication learning disability with organization, nonverbal problem-solving
autistic disorder. The latter question results directly from the significant overlap of di- skills, and affect expression, but exhibited
agnostic criteria for AS and AD in DSM-IV and its text revision (DSM-IV-TR; APA, 2000). well-developed rote verbal skills.
Klin, Volkmar, and Sparrow (2000) recently summarized the state of the science regard- In the 1990s, different views of As-
ing Asperger’s syndrome and its relationship to other disorders. The purpose of the perger syndrome (AS) were put forth
present article is to provide a brief overview of the diagnostic concept of AS and to (Gillberg, 1989; Szatmari, Tuff, Finlay-
help clinicians with diagnostic decisions. Regardless of the diagnostic category, a son, & Bartolucci, 1990). The question
significant number of children and adults with social communication learning disability was whether AS was a distinctive disor-
require intervention.
der. Was it related to autism? Was it a
condition that needed further study? In
the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition

I
n 1943, Kanner described as autistic nostic criteria for autistic disorder (AD), (DSM-IV; American Psychiatric Associa-
a group of children who, he said, Asperger did not delineate specific diag- tion [APA], 1994) field trials, 977 par-
were basically normal but had with- nostic criteria. ticipants from 21 sites were evaluated by
drawn into their psychotic world. As- Wing (1981) translated Asperger’s 125 raters or diagnosticians. Interrater
perger, in 1944, described a group of (1944) original paper into English and reliability was found across sites. The
four boys who had problems with social stated that Asperger basically described goal was to avoid overdiagnosis in indi-
interaction, communication, and idio- the same group of children as Kanner viduals with mental retardation and un-
syncratic patterns of interest. The initial (1943), noting that in the children was a derdiagnosis in individuals with higher
cases presented in boys, and similar social lack of empathy, naivete, inappropriate cognitive abilities. Across the same sites
problems were observed in family mem- one-sided reactions, pedantic and mono- and raters, 48 cases were identified with
bers, particularly the fathers. Asperger tonic speech, and poor nonverbal com- AS, but 12 did not meet the “restricted
noted that the boys in his sample were munication. Previously, in 1979, Wolff interest” criterion, and there was no reli-
different from Kanner’s in that their and Barlow described a similar group of ability or agreement between raters
speech was not delayed, they had motor children with schizoid personality disor- across sites for diagnosis of these 48 in-
delays, and social difficulties appeared der; the criteria for that diagnosis in- dividuals.
later. Intense absorption and circum- cluded social deficits, behavioral rigidity, The consensus in the DSM-IV field
scribed interests, clumsy motor move- odd communication, and increased risk trial was that there was enough informa-
ments, and odd postures characterized of other psychiatric problems. These di- tion to include AS as one of the Perva-
the boys Asperger described. In contrast agnostic impressions were considered sta- sive Developmental Disorders (PDD).
to Kanner, who provided specific diag- ble personality traits, whereas autistic dis- However, the criteria have created a num-

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ber of difficulties for diagnosticians. In fered from other individuals with PDD in followed up at a later age, the investiga-
the DSM-IV the criteria for AS of im- their delayed and deviant language de- tors reported that few clinical differences
pairment in social interaction and re- velopment. Participants were adminis- existed between high-functioning AD
stricted, repetitive, and stereotypic pat- tered the Autism Diagnostic Interview, and AS, as characterized by the clinician.
terns of interest are the same as those for Vineland Adaptive Behavior Scales, Leiter Normal onset of speech did not preclude
AD. However, to make a diagnosis of AS International Performance Scale, Stan- later language or communication prob-
there has to be a lack of any clinically sig- ford Binet Intelligence Scale, Reynell lems. They concluded that children with
nificant delay in language and a lack of Developmental Language Scale, and de- AS, as a group, present with fewer signif-
any clinically significant delay in cogni- velopmental tests of visual motor inte- icant delays than AD and tend to be iden-
tive development, including develop- gration. Significant differences between tified somewhat later relative to their
ment of age-appropriate self-help skills. the groups existed on many PDD symp- chronological ages.
In addition, for AD, speech delay is not toms, adaptive behaviors, and cognitive The only difference reported by Eisen-
required but, rather, is one of the possi- measures of language competence, but majer et al. (1996) was that the group
ble signs of deviance in language devel- the groups did not differ on aspects of with AS tended to have a higher inci-
opment. nonverbal communication, nonverbal dence of co-morbid attention-deficit/
There is also a threshold problem with cognition, or motor development. The hyperactivity disorder (ADHD) than the
DSM-IV in that if an individual meets cri- authors hypothesized that subtypes of group with AD. Of particular signifi-
teria for the diagnosis of AD, the diag- children with PDD can be identified that cance was that the groups did not differ
nosis of Asperger syndrome must be ex- differ on variables relatively independent on any of the classic autistic impairments.
cluded. These are just a few of the issues of defining characteristics. Deficits were evident in both groups in
that make it extremely difficult to accu- Later, Satzmari (2000) reviewed the (a) imagination, (b) imitation, (c) non-
rately diagnose people with AS using the current classification of PDD as concep- verbal communication, (d) awareness of
DSM-IV criteria. The majority of chil- tualized in both the DSM-IV and the In- social rules, (e) stereotypic movements,
dren and individuals with AS show delays ternational Classification of Diseases– (f ) spontaneity and accommodating
in other areas of adaptive functioning, 10th Edition (ICD-10; World Health change, and (g) figurative understanding
causing further confusion. DSM-IV does Organization, 1993). He sought to de- of language. They concluded that clini-
not elaborate on the symptoms that must termine whether the diagnostic validity cians were identifying a subgroup of chil-
be present when making the diagnosis. of the various disorders simply lacked dren with autism who desired friends;
empirical data for full substantiation or were less likely to have speech delays;
the overall conception of the category exhibited pedantic language; and had
Is There a Spectrum?
had some fundamental problems. He narrow, circumscribed interests. Their re-
A number of studies have attempted to concluded that the overall conceptualiza- sults suggested that AS was on a con-
look at the validity of the diagnosis of AS, tion had fundamental flaws. Szatmari re- tinuum with AD and not a separate dis-
reviewing the differentiation between AD viewed the literature up to that point, order.
and AS. Kulger (1998) reviewed similar- summarized recent empirical data on is- Mayes, Calhoun, and Crites (2001)
ities and differences in symptomatology sues of reliability and validity, and sug- studied forty-seven 2- to 12-year-olds with
with reference both to the history of AS gested the need for a different approach normal intelligence who had clinical fea-
and to current research. Symptoms that to understanding AS. tures of AD. These groups were divided
have been suggested as possibly differen- Eisenmajer et al. (1996) compared into whether or not the children had a
tial for diagnosis (e.g., problems with two groups of children: one diagnosed speech delay. The purpose of this study
motor skills, language abilities, and cog- clinically with high-functioning autism was to determine if clinical meaningful
nitive functioning) and shared diagnostic (AD) and the other diagnosed with AS. differences existed between the two
features were considered separately. Al- They reported that there were three di- groups and would support absence of
though the paucity of reliable research agnostic differences between the two speech delay as the DSM-IV criteria for
findings allows few definitive conclusions groups in the preschool years: (a) The AS. Clinical development and demo-
to be drawn, it is suggested that attempts communication and imagination impair- graphic data were analyzed, and no sig-
to identify subgroups and achieve a bet- ments for AD were not present for AS; nificant differences were found between
ter understanding of the behavioral het- (b) there was no clinically significant lan- the 23 children with speech delay and the
erogeneity within an autism spectrum of guage delay for AS (i.e., single words by 24 children without speech delay on any
PDD are crucial to improving clinical age 2 years, phrases by 3 years); and of the 71 variables analyzed, including
practice and research. (c) there was no significant delay in cog- autistic symptoms and expressive lan-
Szatmari, Archer, Fisman, Streiner, nitive development or developmentally guage. Results suggested that early
and Wilson (1995) examined differences age-appropriate self-help skills and adap- speech delay may be irrelevant to later
in the behavior, cognition, and adaptive tive behaviors other than in social in- functioning in children who have normal
functioning of 47 children with autism teraction and curiosity about the en- intelligence and a clinical diagnosis of
and 21 with AS. These participants dif- vironment. When these children were AD or AS, and that the DSM-IV distinc-
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tion of speech delay between AS and AD those in the DSM-IV. Gillberg’s criteria AD on various cognitive measures and
may not be warranted. were as follows: impairments in social in- using various adaptive behavior scales.
In a later study, Eisenmajer et al. teraction (including inappropriate pub- Overall, the results suggested that chil-
(1998) looked at comparative data on lic behavior), narrow interests, repetitive dren and adolescents with AS perform
the developmental history and current routines, speech and language deficits, better than those with AD on intelli-
behaviors of a large sample of high- nonverbal communication deficits, and gence and cognitive measures and mea-
functioning 3- to 21-year-olds with a di- motor clumsiness. Leekam et al. studied sures of adaptive behavior functioning,
agnosis of AD, AS, and other related dis- 200 children and adults using the Diag- thus AS should be viewed as a distinctive
orders. These individuals provided the nostic Interview for Social and Commu- diagnostic category, separate from AD.
basis for a taxonomic analysis of diagnos- nication Disorder (DISC) and found dif- Klin et al. (2000) reviewed in detail di-
tic subgroups. Most participants also ferences depending on the diagnostic agnostic issues surrounding AS and re-
completed theory-of-mind tasks. Three criteria used. If the ICD-10/DSM-IV ported that the issues involved include
clusters of subgroups were obtained with criteria were applied strictly, only 3 of the definition, avoiding circularity, and
differences in scores on theory-of-mind 200 children, or 1% of the population, comparison groups other than persons
tasks and performance and nonverbal met criteria for AS. On the other hand, if with AS. The authors indicated that if AS
abilities. Although subgroups were iden- the Gillberg criteria were utilized, 91 out is indeed a distinctive disorder, clinical
tified that bore some similarities to clini- of 200, or 45%, of the children met cri- features have to be identified that are not
cal differentiation of AD or AS and teria for AS. The result was attributed to a part of the confounding definition. The
pervasive developmental disorder not the requirement for ICD-10/DSM-IV analysis of research to date by Klin and
otherwise specified (PDD NOS), the na- AS criteria of normal onset of cognitive others continues to identify gross social
ture of the differences among them and adaptive abilities. These investigators deficits in both individuals with AD and
seemed to be strongly related to ability concluded that ICD-10/DSM-IV identi- those with AS, with no significant differ-
variables. Examination of the kinds of be- fied a subgroup with no delay in early ences in cognitive or adaptive function-
haviors that differentiated the groups cognitive, language, or adaptive devel- ing. At times, “milder symptoms” in
suggested that a spectrum of autistic dis- opment. Furthermore, the ICD-10 and early development differentiate partici-
orders explained the findings that chil- DSM-IV identified a subgroup even pants with AS from those with AD. The
dren differ primarily in terms of social though clinical features later were the natural course of the disorder and its
and cognitive impairment. same as AD. They also reported that Gill- neuropsychology, biological markers,
Ozonoff, South, and Miller (2000) berg’s criteria seemed to be consistent and associated features, along with the
compared 23 children with high- with the DSM-IV criteria for Atypical person’s family history, need to be dif-
functioning autism and 12 children with Autism or PDD NOS, a subgroup of in- ferent to make it a meaningful concept.
AS. They used DSM-IV (1994) criteria dividuals with autism that tends to have The Yale Learning Disabilities project, in
and matched the groups on chronologi- better language and more intellectual in- their work to determine whether AS and
cal age and intellectual abilities. They ex- terests. They concluded that their results AD can be reliably differentiated, is also
amined the groups for differences in questioned the validity of defining a sep- using a theory-of-mind task and salient
cognitive function, current symptoma- arate subgroup and suggested that a di- social skills measures to study differences
tology, and early history and found few mensional approach to AS was more ap- between high-functioning persons with
differences in the current presentation of propriate than a categorical approach. AD and those with AS. Their research
cognitive functioning between the groups, That is, AS is not a distinctive disorder. also focuses on brain structure and func-
but many in early development. The chil- tion, visual tracking, behavioral manifes-
dren diagnosed with AS tended to have tations, family and molecular genetics,
milder symptoms in early development. and psychopharmacology to identify
AD and AS as Separate
The group differences seemed to be re- whether external differences exist be-
Diagnostic Categories
lated to the diagnostic process. These re- tween AD and AS. Whether AS and AD
sults suggest that individuals with AS and are distinctive disorders remains an em-
high-functioning AD exhibit the same McLaughlin-Cheng (1998) reviewed and pirical question.
fundamental symptoms, differing only in synthesized clinical and diagnostic crite-
their severity. However, there was a ria, empirical data, and studies on AS and
major methodological problem with the AD from an historical perspective. The
Diagnosing Asperger
study in that a circular definition was results of the synthesis suggest that these
used and differences found could be at- two groups of children differ in cognitive
Syndrome
tributed to the diagnostic process alone. and adaptive behavior deficits and there-
Leekam, Libby, Wing, Gould, and Gill- fore do not fall on the same autism Currently, AS, like AD, is a clinical diag-
berg (2000) compared ICD-10 criteria continuum. McLaughlin-Cheng’s meta- nosis. Therefore, it is mandatory to have
for AS with Gillberg’s (1991) criteria. analysis procedure compared children trained and experienced providers to co-
The ICD-10 criteria are the same as and adolescents with AS to those with ordinate the results of the complex diag-
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nostic process and to determine the vari- and (e) family and psychosocial factors. ioral changes, adaptation, and develop-
ety, intensity, and comprehensiveness of Aspects of the assessment will vary de- ment are documented.
services required. The American Acad- pending on the child’s age, history, and
emy of Child and Adolescent Psychiatry previous evaluations; however, the first
Use of Rating Scales
published practice parameters for the as- and most important step is to gather his-
sessment of individuals with AD and torical information (developmental mile- Structured, systematic assessment pro-
PDD (Volkmar, Cook, Pomeroy, Real- stones) by interviewing the primary care- vides further information for diagnostic
muto, & Tanguay, 1999). A multiaxial giver. When gathering a developmental clarification; however, rating scales were
approach was suggested, to interpret spe- history, one should ask parents or care- not designed to be used in isolation to
cific behaviors in the context of intellec- givers about their initial concerns about make a diagnosis. They are useful to the
tual, communication, social, emotional, the individual’s development. The clini- clinician but are only one source of qual-
and other skills. Evaluators must be cian must be aware of features important itative information for a comprehensive
knowledgeable of the full range of symp- in the differential diagnosis, such as the clinical assessment.
toms in both AD and AS. nature of social relatedness in the first Specific instruments that have been
Second, it is important to assess all year of life, inconsistencies in speech and widely used in diagnostic evaluations of
areas of development independently and communication development, and atypi- autism spectrum disorders include the
identify the child’s relative strengths and cal responses to the environment. Checklist for Autism in Toddlers (CHAT;
weaknesses. Independent assessment in For parents of older children, it is Baron-Cohen, Allen, & Gillberg, 1992),
terms of intellect, communication, be- sometimes helpful to describe a major used for assessment of children prior to
havioral presentation, and functional ad- event in the child’s history, such as his 18 months of age; the Autism Behavior
justment must be noted throughout the first birthday party. Information from Checklist (ABC; Krug, Arick, & Almond,
evaluation. Results should indicate a di- photo albums, baby books, and videos is 1980), a screening instrument com-
agnosis, organize specific services, mea- also useful. The clinician may use rating pleted by the parents or teachers; the
sure efficacy of intervention, and provide scales and symptom checklists to gather Childhood Autism Rating Scale (CARS;
prognostic information. Because AS and information (but never in isolation to Schopler, Reichler, & Renner, 1998),
AD both imply that multiple areas of de- make a diagnosis). The clinician should which requires training and primarily
velopment are affected, all areas must be obtain a history of interventions, that assesses sensory motor behaviors; the
evaluated in the context of developmen- is, which interventions have been at- Autism Diagnostic Interview–Revised
tal level. tempted, their quality, intensity, and ap- (ADI-R; Lord, Rutter, & LeConteur,
Similarly, behaviors must be examined propriateness, and the benefit derived. In 1994) a structured interview for parents;
for developmental delay or deviance. Is- addition, it is important to obtain infor- and the Autism Diagnostic Observation
sues in assessment will vary with the age mation from teachers and other profes- Schedule (ADOS; Lord et al., 1989), a
of the child examined and the context of sionals. measure of social communication. Both
the evaluation. The certainty of a diag- Early social communication skills are the ADI and the ADOS require training
nosis will always depend on the reliabil- an important area of focus. Typical chil- to administer. Furthermore, they are
ity and certainty of data obtained from dren, by 4 to 5 months of age, are at- most useful in discriminating between
multiple sources. It is mandatory that a tempting to interact with their parents the absence and the presence of ASD,
child be observed in both structured and and caregivers. Thus, parents or care- AD, or PDD. They have not yet been
unstructured environments. Parents or givers should be asked whether the child standardized for further diagnostic clari-
primary caregivers must provide histori- played baby games. Although the re- fication.
cal information, with additional informa- sponse is often “yes,” when they are A number of rating scales specific to
tion supplied by other professionals. asked if the child initiated baby games, AS have been developed, but as these are
deficits become evident. Other areas of new instruments, there is little research
inquiry include, Did the child (a) show on them. The Asperger Syndrome Diag-
Developmental History
separation anxiety at the appropriate nostic Scale (ASDS; Myles, Bock, &
Pertinent developmental information in- age? (b) wave good-bye at 12 months? Simpson, 1998), is a self-report measure
cludes (a) pregnancy, neonatal, and post- (c) incorporate other nonverbal ges- with normative data on 227 responders;
natal history, with a specific focus on tures? (d) imitate at the appropriate age? the Autism Screening Questionnaire
social, communication, and motor skills; and (e) let the parent or caregiver know (ASSQ; Ehlers, Gillberg, & Wing, 1999)
(b) medical history, including a discus- if he or she was wet or hungry and, if differentiated learning disabilities from
sion of possible seizure and sensory defi- so, how? Descriptions of the child’s first disruptive behaviors in 110 consecutive
cits, such as ones involving hearing and nursery school experience, and concerns referrals to a clinic; the Australian Scale
vision; (c) history of behavior-modifying the nursery school teacher might have re- for Asperger’s Syndrome (ASAS; Attwood,
medications; (d) family history of devel- ported, are pertinent to the evaluation 1998) does not have normative data or
opmental disorder and psychiatric illness; process. With this information, behav- cutoff scores; and the Autism Screening
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Questionnaire (ASQ; Berument, Rutter, often true in children with ASD: Chil- how does he or she communicate? Clearly,
Lord, Pickles, & Bailey, 1999) has cutoff dren perform well on the developmental/ an assessment needs to indicate goals for
scores and was normed on 200 individu- intelligence measures but exhibit signifi- the intervention required to teach a child
als with a variety of neuropsychiatric di- cant impairments in adaptive skills. The communication skills.
agnoses. All of these questionnaires have Vineland Adaptive Behavior Scales (Spar-
been designed as screening measures row, Ball, & Cicchetti, 1984) are ex-
Occupational and Physical
only and cannot be substituted for clini- tremely useful for assessing social adap-
Therapy Assessment
cal assessment. tive skills.
In addition to assessment of In addition to the prior evaluations men-
development/intelligence and adaptive tioned, occupational and physical ther-
Medical Assessment
skills, it is important to assess academic apy assessments are often an important
The goal of a medical assessment is to skills independent of intelligence testing part of the initial process of determining
search for a treatable medical condition. in the school-age child. There are chil- whether a child has any motor delays or
A medical assessment includes a careful dren with ASD who develop academic hypo- or hypersensitivities to sensory
medical history, physical examination, skills at a faster rate than their intellectual stimuli. Many children with AS present
auditory and visual examinations, neuro- skills. For example, a child may read be- with gross and fine motor delays.
logical assessment, and laboratory stud- fore learning to speak.
ies, if necessary. Currently, there are no
Family Assessment
specific medical tests recommended for
Assessment of Communication
individuals in association with the diag- Assessment of the family and parental
nosis of AS. To evaluate communication, one must support system is mandatory, including
first ask the question, Is the child verbal the effects of the diagnosis on typical sib-
or mute? If the child is mute, is there any lings. This is particularly important for
Psychological Assessment
attempt at nonverbal communication? If preschool children, as the family is the
To allow diagnosis of a developmental the child is verbal, does he or she initiate most important source of their support
disability, including PDD, the evaluation and maintain a conversation? What is and is integral to coordinating educa-
must include both a cognitive (intelli- characteristic of the child’s language? tional and community services.
gence) and an adaptive assessment. The Qualitatively, is the child’s speech fluent
psychological assessment includes devel- (full sentences), echolalic (including pro-
Mental Status Assessment
opmental and intelligence testing. It is noun reversals) or characterized by pe-
critical to independently assess verbal and dantic language? Is the voice quality mo- Once historical information is obtained,
nonverbal skills. In addition, skills and notonic? Does the child pursue one topic it becomes important for the examiner to
abilities typically measured to identify regardless of the conversation? Does the assess the child’s behavioral presentation
mental retardation develop inconsis- child make inferences, understand hu- in a mental status examination. The ex-
tently in individuals with AS and AD, so mor, respond to indirect requests, and amination must occur in both structured
it is not possible to diagnose mental re- take into account the perspective of his and unstructured settings and must in-
tardation in children under 5 years of age conversational partner? And, finally, is clude observation of the child’s rela-
who also have ASD. Extreme caution is there any suggestion of disturbances in tionships and behavior with familiar and
necessary to avoid a diagnosis of mental thought process or content? nonfamiliar people. The mental status
retardation too early in development. examination, as well as the developmen-
Measuring adaptive skills is an impor- tal history, should attend to the areas
Language Assessment
tant part of the psychological assessment. relevant for diagnosis, including social
Specifically, this includes a current sum- Speech, language, and communication interactions, communication skills, re-
mary of the individual’s independent assessments are important for indicating stricted range of interest, and unusual
daily functioning in the areas of commu- the deficits evident in language process- behaviors.
nication, self-help skills, social skills, and ing and pragmatics. Primary deficits do
motor skills. In typical development, not always include an inability to speak or
Assessment of Social
when a skill is mastered, it is used and receptive and expressive vocabulary defi-
Interaction
generalized. For example, when a child cits. Therefore, an evaluation for speech
masters toileting, he toilets appropriately is insufficient and should be accompa- Observational queries include the fol-
in all environments. In children who have nied by a comprehensive communication lowing: Is the child interested in social
mental retardation, difficulties and delays assessment. In early diagnosis, the ques- interaction or is he or she aloof ? How
are evident in developmental and cogni- tion is, In the absence of language, has does the child respond to peers’ over-
tive measures but are not as prominent the child developed an alternative means tures? Does the child passively accept so-
in social adaptive skills. The opposite is of communicating to compensate? If so, cial interactions but not initiate? Is the
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child interested in a variety of social in- functional–symbolic, simple constructive, AS and AD persist in early child develop-
teractions, or is he limited to his eccen- imaginative, dramatic and social play). ment, specifically related to language and
tricities or restricted interests? Does the Often, in children with ASD, the devel- cognitive abilities, comorbid conditions
child use eye contact to regulate social in- opmental level of play is lower than their and symptoms, and adaptive functioning.
teractions? Does the child use any other measured cognitive abilities. Although AS and AD may be distinct di-
nonverbal behaviors to regulate social agnostic categories, a spectrum exists in
interaction? What is the nature of the each category. Regardless, if AS is shown
Differential Diagnosis
child’s attachment to the family? Does to be a disorder distinct from AD, we
the child share in the enjoyment of oth- Because there is so much confusion need to develop differences related to
ers? Does the child have friends? Are his around the diagnosis of AS, it is difficult phenomenology, the natural course of
or her peer relationships appropriate to to assess comorbidity and other diag- the disorder, neurobiological markers,
his or her developmental level? noses. To date, the literature has relied family history, response to treatment,
primarily on case reports. Conditions and appropriate behavioral and psy-
that have been reported to be associated chopharmacological interventions. In
Restricted Range of Interests
with AS include psychosis, depression, the interim, there are clearly groups of
Once social interaction and communica- obsessive–compulsive disorder, ADHD, children who are very verbal and have in-
tion skills have been assessed, it is neces- oppositional–defiant disorder, and inter- tense interests who require (early) diag-
sary to assess whether or not the child has mittent explosive disorder. Tantum (2000) nosis and appropriate early intervention,
a restricted range of interests and displays reviewed the literature on comorbid psy- with a particular focus on improving so-
unusual behaviors. The questions should chiatric conditions with persons diag- cial, communication, and vocational
include, Does the child have a particular nosed with AS and suggested that all of skills. In addition, there continues to be
preoccupation or special interest? If the these comorbid conditions are secondary an increased need for public awareness of
child has a special interest, does it inter- to the core social deficits in AS. the abilities, not disabilities, of people di-
fere with functioning? Does the individ- Studies of prognosis for children with agnosed with ASD, including inaccurate
ual have difficulty with change? Does he AS have been fraught with similar meth- depictions in the media.
or she have difficulty with transitions or odological problems. Howlin (2000) re-
have specific routines? Are stereotypic viewed the outcomes studies to date and ABOUT THE AUTHORS
motor movements present, and if they found that they are confounded by the
B. J. Freeman, PhD, is a psychologist and pro-
are present, when do they occur and can fact that AS and AD are difficult to sep- fessor of medical psychology in the Department
they be interrupted? Is the child preoc- arate. A summary of studies to date sug- of Psychiatry and Biobehavioral Science at the
cupied with parts of objects? Does the gests that persons with high-functioning University of California, Los Angeles, School of
child have hand-wringing behavior often AD and AS may succeed as adults but Medicine. Currently, she is the co-director of an
associated with Rett’s Disorder? with a great deal of difficulty, and most early intervention and assessment partial hos-
rely on their families. Social contacts usu- pitalization program for children diagnosed
ally center on their special interests, with developmental disabilities between the ages
Other Assessments of 3 and 7 years. In addition, she is the director
rather than close friendships. The con-
In addition to attending to the areas of stant pressure to fit in may lead to other of the Autism Evaluation Clinic in the out-
patient department of psychiatry. Pegeen Cro-
diagnostic concern and the criteria listed psychiatric difficulties. Most of the peo-
nin, PhD, is a psychologist and associate direc-
in DSM-IV-TR, it is also important to as- ple who have been studied to date have
tor of the outpatient Autism Evaluation Clinic
sess play behaviors in the young child and not had early intervention; there is a need in the Department of Psychiatry at UCLA. She
leisure activities in the older individual. for better educational, vocational, social, has been working with Dr. Freeman since the
Questions that pertain to both the young and emotional support programs to help inception of this clinic 4 years ago, and contin-
child and the developmental history of people challenged by AD and AS. ues to provide services and training to both the
the older individual include the follow- inpatient and partial hospitalization services.
ing: Were play materials used in a truly In addition, with Dr. Freeman, Dr. Cronin has
imaginative way? Have unusual aspects of Summary been a contributing member to the variety of re-
the play material, such as the feel or the search projects related to autistic disorder. Pete
sound, preoccupied the child? Was play The difference between AS and AD re- Candela, MS, has extensive experience working
with children and families affected by autistic
repetitive and stereotypic in nature? In mains an interesting research issue. Un-
disorder. He works as a case manager in assist-
addition, by observing play in young fortunately, this poses significant chal-
ing families as they seek educational and com-
children, it is possible to obtain an esti- lenges for clinicians when assigning munity services. In addition, he leads social
mate of a child’s cognitive ability, as either of these diagnoses. Most research skills groups for children who present with au-
play reflects cognitive abilities. The ex- indicates a great deal of overlap in symp- tism. Address: B. J. Freeman, UCLA Neuro-
aminer should note the current develop- tomatology, specifically in the core social psychiatric Institute, Department of Child and
mental level of play (e.g., sensory-motor, deficits. However, differences between Adolescence Psychiatry, 300 UCLA Medical
05. freeman, pp. 145-151 8/29/02 10:36 AM Page 151

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Plaza Room 1261, Box 956967, Los Angeles, ican Academy of Child and Adolescent Psy- ferentiation from high-functioning autism.
CA 90095-6967. chiatry, 30, 375–382. Autism, 1, 29–46.
Howlin, P. (2000). Outcome in adult life for Rourke, B. P. (1989). Nonverbal learning dis-
more able individuals with autism or Asper- abilities: The syndrome and the model. New
REFERENCES
ger’s syndrome. Autism: The International York: Guilford Press.
American Psychiatric Association. (1994). Journal of Research and Practice, 4(1), 63– Schopler, E., Reichler, R. J., & Renner, B. R.
Diagnostic and statistical manual of mental 84. (1998). The childhood autism rating scale
disorders (4th ed.). Washington, DC: Au- Kanner, L. (1943). Autistic disturbances of af- (CARS). Los Angeles: Western Psycholog-
thor. fective contact. Nervous Child, 2, 217–253. ical Services.
American Psychiatric Association. (2000). Klin, A., Volkmar, F. R., & Sparrow, S. S. Sparrow, S., Balla, D., & Cicchetti, D. V.
Diagnostic and statistical manual of mental (2000). Asperger’s syndrome. New York: (1984). Vineland adaptive behavior scales,
disorders (4th edition, text rev.). Washing- Guilford Press. interview edition. Circle Pines, MN: AGS.
ton, DC: Author. Krug, D. A., Arick, J., & Almond, P. (1980). Szatmari, P. (2000). Perspectives on the clas-
Asperger, H. (1944). Die “Autistischen Psy- Behavior checklist for identifying severely sification of Asperger’s syndrome. In A.
chopathen” im Kindesalter. Archiv fur Psy- handicapped individuals with high levels of Klin, F. Volkmar, & S. Sparrow (Eds.), As-
chiatrie und Nervenkrankheiten, 117, 76– autistic behavior. Journal of Child Psychol- perger’s syndrome (pp. 403–417). New
136. ogy and Psychiatry, 21, 221–229. York: Guilford Press.
Attwood, T. (1998). Asperger’s syndrome: A Kugler, B. (1998). The differentiation be-
Szatmari, P., Archer, L., Fishman, S., Streiner,
guide for parents and professionals. Philadel- tween autism and Asperger’s syndrome.
D. L., & Wilson, F. (1995). Asperger’s syn-
phia: Jessica Kingsley. Autism, 1, 11–31.
drome and autism: Differences in behavior,
Baron-Cohen, S., Allen, J., & Gillberg, C. Leekam, S., Libby S., Wing, L., Gould, J., &
cognition, and adaptive functioning. Jour-
(1992). Can autism be detected at 18 Gillberg, C. (2000). Comparison of ICD-
nal of the American Academy of Child and
months? The needle, the haystack and the 10 and Gilberg’s criteria for Asperger’s Syn-
Adolescent Psychiatry, 34, 1662–1671.
CHAT. British Journal of Psychiatry, T68, drome. Autism, 4(1), 11–28.
Szatmari, P., Tuff, L., Finlayson, M. A. J., &
58T–163T. Lord, C., Groode, S., Heemsbergen, J., Jor-
Bartolucci, G. (1990). Asperger’s syn-
Berument, S., Rutter, M., Lord, C., Pickles, dan, H., Mawhood, L., & Rutter, M.
drome and autism: Neurocognitve aspects.
A., & Bailey, A. (1999). Autism Screening (1989). Autism Diagnostic Observation
Journal of the American Academy of Child
Questionnaire: Diagnostic Validity. British Schedule: A standardized observation of
and Adolescent Psychiatry, 29, 130–136.
Journal of Psychiatry, 175, 444–451. communicative and social behavior. Jour-
Ehlers, S., Gillberg, C., & Wing, L. (1999). nal of Autism and Developmental Disorders, Tantum, D. (2000). Psychological disorder in
A screening questionnaire for Asperger syn- 19, 185–212. adolescents and adults with Asperger’s syn-
drome and other high-functioning autism Lord, C., Rutter, M., & LeConteur, A. drome. Autism, 4(1), 47–62.
spectrum disorders in school age children. (1994). Autism Diagnostic Interview– Volkmar, F., Cook, E., Pomeroy, J., Real-
Journal of Autism and Developmental Dis- Revised: A revised version of a diagnostic muto, G., & Tanguay, P. (1999). Practice
abilities, 24, 3–22. interview for caregivers of individuals with parameters for the assessment and treat-
Eisenmajer, R., Prior, M., Leekam, S., Wing, possible pervasive developmental disorder. ment of children, adolescents, and adults
L., Gould, J., Welham, M., & Ong, B. Journal of Autism and Developmental Dis- with autism and other pervasive develop-
(1996). Comparison of clinical symptoms orders, 24, 659–685. mental disorders. Journal of the American
in autism and Asperger’s disorder. Journal Mayes, S. D., Calhoun, S. L., & Crites, D. L. Academy of Child and Adolescent Psychiatry,
of the American Academy of Child and Ado- (2001). Does DSM-IV Asperger’s disorder 38, 32S–54S.
lescent Psychiatry, 35, 1523–1531. exist? Journal of Abnormal Child Psychology, Wing, L. (1981). Asperger’s syndrome: A
Eisenmajer, R., Prior, M., Leekam, S., Wing, 3, 263–271. clinical account. Psychological Medicine, 11,
L., Gould, J., Welham, M., & Ong, B. McLaughlin-Cheng, E. (1998). Asperger syn- 115–129.
(1998). Delayed language onset as a pre- drome and autism: A literature review and Wolff, S., & Barlow, A. (1979). Schizoid per-
dictor of clinical symptoms in pervasive de- meta-analysis. Focus on Autism and Other sonality in childhood: A comparative study
velopmental disorders. Journal of Autism Developmental Disabilities, 13, 234–245. of schizoid, autistic and normal children.
and Developmental Disorders, 6, 527–533. Myles, B. S., Bock, S. J., & Simpson, R. L. Journal of Child Psychology and Psychiatry,
Gillberg, C. (1989). Asperger’s syndrome in (1998). Asperger syndrome diagnostic scale. 20, 19–46.
23 Swedish children. Developmental Medi- Austin: PRO-ED. World Health Organization. (1993). Inter-
cine and Child Neurology, 31, 520–531. Ozonoff, S., South, M., & Miller, J. (2000). national classification of diseases & re-
Gillberg, C. (1991). Outcome in autism and DSM-IV–defined Asperger’s Syndrome: lated health problems. (10th rev.). Geneva:
autistic-like conditions. Journal of the Amer- Cognitive, behavioral and early history dif- Author.