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Asperger’s Syndrome: An Enigma for Social Work

Ernst O. VanBergeijk Oren Shtayermman NOT

ABSTRACT. Asperger’s Syndrome (AS), a Pervasive Developmental Disorder on the Autism Spectrum, is a burgeoning mental health con- cern facedFOR by children, their families, schools, and mental health practi- tioners. Although it is a relatively new phenomenon, prevalence rates have increased 10 fold in the past decade. Whether this increase is a true increase in the prevalence of the syndrome has been the subject of great debate. The assessment and treatment of AS is a complicated process re- quiring social workers toDISTRIBUTION partner with families and helping profes- sionals. Given the growing size of the AS population, it is critical that social workers understand the disorder, its co-morbidity, and treatment. The authors review the prevalence and history of the syndrome, current definitions, and discuss implications for social work practice, policy, and research. [Article copies available for a fee from The Haworth Document De- livery Service: 1-800-HAWORTH. E-mail address: Website: © 2005 by The , Inc. All rights reserved.]

Downloaded By: [ internal users] At: 19:35 15 July 2009 KEYWORDS. Asperger’s syndrome, autism, assessment, diagnosis, autism social work

Ernst O. VanBergeijk, PhD, MSW (E-mail: [email protected]) and Oren Shtayermman, CSW (E-mail: Shtayermman@ fordham.edu) are affiliated with the Fordham University, Graduate School of Social Service, 113 West 60th Street, New York, NY 10023.. The authors would like to thank Dr. Marianne Yoshioka from Columbia University School of Social Work for her comments on earlier drafts of this article. Journal of Human Behavior in the Social Environment, Vol. 12(1) 2005 Available online at http://www.haworthpress.com/web/JHBSE © 2005 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J137v12n01_02 23 24 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

INTRODUCTION

Asperger’s Syndrome (AS) is an autism spectrum disorder that is characterized by highly impaired social skills, difficulty relating to oth- ers, a lack of flexible imaginative play, and often a preoccupation with a finite and highly specific topic. AS, which typically presents less severe symptoms than classic autism, has seen a dramatic increase in its preva- lence within the last 10 years. Current estimates of the prevalence of Asperger’sNOT Syndrome range between 0.3 to 67 per 10,000 children (Bertrand, Mars, Boyle, Bove, Yeargin-Allsop, & Decoufle, 2001; Fom- bonne, 2001). The numbers of children affected by this syndrome are al- most double the number of children who exhibit classic autism. Recent estimates of the autism prevalence rate are in the range of 3.4-26 per 10,000 childrenFOR (Yeargin-Allsopp, Rice, Karapurkar, & Doemberg, 2003; Kadesjo, Gillberg, & Hagberg, 1999). Both the popular press and scholarly researchers have documented an “explosion” in the incidence of cases of autism and autism spectrum disorders within the past decade, labeling it as an “epidemic” (Cowley, Underwood, Murr, Springen, & Sennott, 2003; Ehlers &DISTRIBUTION Gillberg, 1993; Bryson & Smith, 1998; Fombonne, 2001; Fording, 2003; Nash, 2002; Ozonoff, Rogers, & Pen- nington, 1991). Before the 1990s, the prevalence of autism was thought to be 1 in 10,000 (Klin, Volkmar, & Sparrow, 2000; Brasic, 2001) mak- ing this spectrum of disorders relatively rare. Children with AS are considered to be relatively high functioning in many areas of their lives which creates confusion for parents, teachers, and helping professionals in understanding the many socially difficult behaviors that a child with AS may exhibit. Because children with AS are commonly the target of negative peer interactions and have special

Downloaded By: [informa internal users] At: 19:35 15 July 2009 learning needs, it is essential that an accurate diagnosis is made early in the child’s life. Social workers working with children and families, schools, or health settings may play an important role in early screening for AS, helping parents through the diagnostic process and developing and/or linking children with AS to services.

What Is Asperger’s Syndrome and How Does It Differ from Other Autism Spectrum Disorders?

Part of the complexity in answering these questions lies in the history of the disorder, the definitions of autism spectrum disorders, other disci- plines’ labels for the syndrome, and the strengths of these exceptional Ernst O. VanBergeijk and Oren Shtayermman 25

children. The social work profession’s lack of familiarity with the syn- drome further obfuscates the answers. In the 1940s Leo Kanner (1943) a Baltimore child psychiatrist and Hans Asperger (1944) a Viennese pediatrician, in two separate publica- tions, describe the behavioral profiles of two similar, yet potentially dis- tinct disorders. In these independent samples, both groups of children showed a non-purposeful disregard for social rules, a difficulty in under- standing other’s emotional experience, stereotypy (e.g., hand flapping), andNOT for those children who did possess verbal skills, an excellent memory in a finite topic. Kanner (1943) referred to the condition afflicting the children as “Autistic disturbances of affective contact.” Asperger, un- aware of Kanner’s publication, labeled the children’s disorder as “Autis- tic Psychopathy.” It was not until 1991 when Lorna Wing documented 10 similarities betweenFOR Asperger’s description and Kanner’s earlier writing on autism. Today, the disorder that Kanner described is known as “classic autism.” Asperger’s “autistic psychopathy” is simply referred to as Asp- erger’s Syndrome (AS). Although the features of the clinical syndromes in both groups of children were similar, thereDISTRIBUTION were some distinct differences between the two groups of children. Namely, the children Asperger wrote about were higher functioning than those Kanner observed. Asperger ob- served fine and gross motor problems with his population. Also, the age of onset was not before three years of age. The children in Asperger’s sample had acquired language normally. In contrast, the children work- ing with Kanner either did not develop verbal language or there was a significant speech delay. No motor problems were noted in Kanner’s writings. Asperger believed these children “possessed normal intelli- gence and were capable of gainful employment” (Miller & Ozonoff, 2000, p. 227). Later research on children fitting Kanner’s diagnostic cri-

Downloaded By: [informa internal users] At: 19:35 15 July 2009 teria revealed impaired cognitive abilities and a marked inability to at- tain gainful employment (Miller & Ozonoff, 2000). Furthermore, Kanner’s autism is associated with mental retardation in about 65-90% of the cases (Wing, 1993; as cited in Gilberg, Nordin, & Ehlers, 1996). The fact that both Kanner’s and Asperger’s diagnostic features of their syndromes overlap and they used similar nomenclature obfuscates the differences between the two syndromes. What further clouds the distinction between the two disorders is that in 1990 Asperger’s Syn- drome was added to the International Classification of Diseases (ICD- 10) as a pervasive developmental disorder. According to Wing (1991) alternative labels for the syndrome included “Schizoid Disorder of Childhood” and “Autistic Psychopathy” (p.105) in this publication. The 26 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

American Psychiatric Association finally added Asperger’s Syndrome to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) using the umbrella rubric of pervasive developmental disorders (Barnhill, Tapscott Cook, Tebbenkamp, & Smith Myles, 2002), which is alternatively known as “Autism Spectrum Disorders” (Wing, 1991). Autism spectrum disorders are conceptualized as a continuum of syndromes ranging from Autistic Disorder to Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). The continuum in- cludesNOT Rett’s Disorder, Childhood Disintegrative Disorder, Atypical Autism, and Asperger’s Disorder (DSM-IV-TR, 2000). Among the au- tism community High Functioning Autism (HFA) is used to distinguish between individuals with classic autism symptoms (i.e., those with little or no speech) and those with speech that had a late onset. The currentFOR diagnostic features of AS include a qualitative impair- ment in social relationships. The diagnosis of AS typically occurs much later than autism. Children with autism are diagnosed in early childhood because of their profound inability to interact with others. The diagnosis of autism can be made as early as 18 months and can be made reliably by 30 months of age (Gillberg,DISTRIBUTION Nordin, & Ehlers, 1996). Children with AS are diagnosed on average between 6-10 years old, only after having years of difficulties learning and relating to peers (Gillberg, Nordin, & Ehlers, 1996). AS children are socially isolated and this isolation cannot be explained by other personality features such as shyness or aggres- siveness (Barnhill, Taspscott Cook, Tebbenkamp, & Smith Myles, 2002; McLaughlin-Cheng, 1998; Klin, Volkmar, & Sparrow, 2000). What limited social interaction they do engage in revolves around their own obsessive interests. Their impairment not only lies in a social skills realm, but also in speech. Although children with AS acquire speech,

Downloaded By: [informa internal users] At: 19:35 15 July 2009 they have impairments in pragmatics and semantics of speech. They have difficulty providing a listener with relevant contextual informa- tion. They do not know how to begin a conversation or maintain a topic in a reciprocal exchange between themselves and another child. Conse- quently AS children tend to dominate a conversation on a potentially es- oteric topic. This perseveration on obscure topics compounds their isolation. AS children’s speech pattern can also be distinct. They posses a pedantic style of speech (Miller & Ozonoff, 2000; Frith, 1991). This formal way of speaking often earns the child a moniker of “the little pro- fessor” (Volkmar & Klin, 2000). Another distinguishing feature of their speech is prosody. Their voice inflection and tone can be “odd,” mono- tone, or robotic like. Ernst O. VanBergeijk and Oren Shtayermman 27

Some individuals with AS have marked abnormalities of facial ex- pression and gestures and yet they are able to convey feeling and have some degree of empathy for others (Tantam, 1991). Not only do indi- viduals with AS have difficulty expressing themselves, but they also have impairments in understanding verbal and non-verbal communica- tion (Miller & Ozonof, 2000; Barnhill, Tapscott Cook, Tebbenkamp, & Smith Myles, 2002; McLaughlin-Cheng, 1998). They understand spo- ken words quite literally, often do not recognize non-verbal language, andNOT so may have difficulty comprehending jokes or sarcasm. This is not to say that individuals with AS do not have a sense of humor. However, much of the verbal humor that other individuals share will be relatively inaccessible to an individual with AS. Asperger’s Syndrome lies between Autistic Disorder and PDD-NOS on the continuum.FOR It is considered highly controversial as to whether or not Asperger’s Syndrome is a distinct clinical entity from High Func- tioning Autism (HFA) (Baron-Cohen, 2000; Miller & Ozonoff, 2000; Perrintgo, 1991; Szatmari, 1991; Szatmari, 1989; Marriage, Gordon, & Brand, 1995; Bishop 1989; Bruer, 1996; Ozonoff, Rogers, & Penning- ton, 1991; Prior, Eisenmajer,DISTRIBUTION Leekam, Wing, Gould, Ong, & Dowe, 1998; Elder, 2001; Louiselle, 2001; Fine, 1991; Fidler, 2000). Children with high functioning autism unlike children with Asperger’s Syn- drome acquire language later than neurotypical children or AS children do, and have an impairment in symbolic play (McLaughlin-Cheng, 1998; Philbin Bowman, 1988; Szatmari, Bremner, & Nagy 1989; Baron- Cohen, 2000). In addition, children with HFA do not appear to have ei- ther fine or gross motor impairments that are associated with AS by some researchers (Rhea, 2003; Prior, Eisenmajer, Leekam, Wing, Gould, Ong, & Dowe, 1998; Klin, 2000). In terms of intellectual functioning, both HFA and AS populations

Downloaded By: [informa internal users] At: 19:35 15 July 2009 range from normal to superior on standardized I.Q. tests. It should be noted that a red flag of HFA and AS is a large discrepancy between ver- bal and performance I.Q. This discrepancy can be well over 13 I.Q. points on the WISC-R (Ehlers, Nyden, Gillberg, Dahlgren Sandberg, Dalhgren, Hjelmquist, & Oden, 1997; Klin, Volkmar, & Sparrow, 2000; Klin, 2000). Interestingly, there is evidence to suggest that the profiles of people with AS differ from those with HFA. Individuals with AS score significantly higher on the verbal section of the WISC-R than the performance section of the test. The scores for individuals with HFA are the opposite. Their strengths lie in the performance section of the WISC-R. Individuals with HFA score more poorly on the verbal sec- tions of the test (Prior, Eisenmajer, Leekam, Wing, Gould, Ong, & 28 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

Dowe, 1998). Within the last few years, this distinction has been con- tested across studies (Schriberg, McSweeney, Klin, Cohen, & Volk- mar, 2001; Jolliffe & Baron-Cohen, 1999; Klin, 2000).

You Say “P t$t‘.” I Say “P t$t ?”

Adding to the complexity of AS is the fact that the behavioral and cognitive profile of AS has been given a range of different labels by otherNOT professions. Just like the pronunciation of words such as “potato” or “tomato,” is influenced by the environment in which one lives, the professional environment influences the pronunciation of the symp- toms we describe as Asperger’s Syndrome. Occupational therapists often conceptualize AS “Sensory Integration Dysfunction” givenFOR the focus of this profession on how a child moves in his or her world, children who have sensory integration dysfunction are characterized as having gravitational insecurity, poor proprio- ceptive sense, and either under or over sensitivity to olfactory, tactile, auditory, and visual stimuli (Ayers, 1979; Kranowitz, 1998). They have difficulty learning and dealing with peers.DISTRIBUTION Psychiatrists may use the term “Schiz- oid Personality Disorder” to refer to individuals who have AS. Under the Schizoid Personality Disorder label, these persons have social isola- tion, bizarre pre-occupations, and odd speech. They are perceived as strange, eccentric, cold, or aloof (DSM-IV-TR, 2000). Neuro- psychol- ogists use the term Non-Verbal Learning Disability (NLD). Persons with NLD have “significant deficits in social perceptions, social judg- ment, and social interaction skills, marked deficits in nonverbal prob- lem solving and outstanding relative deficiencies in mechanical arith- metic and compared to proficiencies in reading and spelling” (Rourke &

Downloaded By: [informa internal users] At: 19:35 15 July 2009 Tsatsanis, 2000; pp. 235-236). Speech pathologists use the term Seman- tic Pragmatic Disorder (SPD). Individuals with SPD exhibit similar so- cial interaction deficits as an individual with Asperger’s Syndrome (Adams, Green, Gilchrist, & Cox, 2002).

The Co-Morbidity of AS

It is highly likely that a diagnosis of AS will be accompanied by a second mental health diagnosis. Ghaziuddin, Weimer-Mikhail, and Ghaziuddin (1998) found that among 35 AS patients, 65% had an addi- tional psychiatric diagnosis. The etiology of the co-morbid psychiatric disorder can be either endogenous or environmental in nature. Ernst O. VanBergeijk and Oren Shtayermman 29

The environmental stressors for individuals with AS likely exacer- bate their vulnerability to mood and anxiety disorders. Due to their so- cial isolation, and higher levels of frustration associated with social interactions, there is high co-morbidity with both unipolar and bi-polar depression (Barnhill, 2001; Kim, Szatmari, Bryson, Streiner, & Wilson, 2000; Ghaziuddin, Weldmer-Mikhall, & Ghaziuddin, 1998; Kim, Szatmari, Bryson, Streiner, & Wilson, 2000; Rubenstein, 2001; Barn- hill, 2001; Rourke, Young, & Leenaars, 1989). NOTAge of the patient may influence the type of secondary diagnosis they receive. Ghaziuddin et al. (1998) found that adolescents and adults were more likely to be diagnosed with depression than any other co-morbid disorder. Twenty-five percent of the children in Ghaziuddin et al.’s (1998) report had a diagnosis of depression. Fifty-three percent of teens and adults in thatFOR sample were diagnosed as depressed. These numbers are considerably higher than those of Klin and Volkmar (1997) (as cited in Martin, Patzer, & Volkmar, 2000). They found only 15% of their sample was diagnosed with depression. In a different study that was done by Tantam (2003) it was suggested that 22.2% of a sample of 234 adolescents with AS also receivedDISTRIBUTION a previous diagnosis of anxiety and anxiety related disorders. About 19.7% of the sample was diagnosed with depression. The unpredictability of the social environment can cause some indi- viduals with AS to develop anxiety disorders. Compulsive rituals among individuals with AS lead psychiatrists to think that this may be a display of obsessive-compulsive disorder (OCD) (Tantam, 2000) and they may in fact have co-morbid OCD. Klin and Volkmar (1997) identi- fied 19% of their sample of 99 AS patients as having OCD (as cited in Martin, Patzer, & Volkmar, 2000). Social phobia is a sub category of anxiety disorders where the individual displays a persistent fear of so-

Downloaded By: [informa internal users] At: 19:35 15 July 2009 cial interactions or public performance. The resultant behavior can be a panic attack when thinking about or confronted with a social situation, with which they are unfamiliar. Tantam (2000) noted that adolescents with social phobia may, in fact, have undiagnosed cases of AS, espe- cially when there is an absence of a complete developmental history. Children with AS are more likely to be diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) as a secondary diagnosis or even as an initial diagnosis than either teens or adults. This is not sur- prising given the fact that AS and ADHD share similar features and ADHD is a diagnosis of early childhood. Klin and Volkmar’s (1997) study of 99 individuals with AS found that 28% of their sample exhib- ited ADHD (as cited in Martin, Patzer, & Volkmar, 2000). A survey of 30 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

the Online Asperger Syndrome Information and Support Website (OASIS) found that “. . . 65% [of parents] indicated that their child had been initially described as one or another type of ADHD, while 44% stated that their child had a dual diagnosis of AS and a form of ADHD” (Romanowski-Bashe & Kirby, 2001, p. 69). Another survey of 514 par- ents of children with AS found that 42.8% had ADHD. An additional 30% of the AS children had a diagnosis of Attention Deficit Disorder (ADD) (Romanowski-Bashe & Kirby, 2001). NOTTourette’s Syndrome (TS) in the general population is thought to be approximately 1 per 169 people (Ringman & Jankovich, 2001). The co-occurrence of both Tourette’s and AS would be 5 per 100 million if the two disorders were to occur randomly (Baron-Cohen, Mortimore, & Moriarty, 1999). In actuality, the prevalence of Tourette’s among the AS populationFOR is significantly higher. Volkmar, Klin, Schultz, Pauls, and Cohen (1996) recognized 2% of their AS study participants as also having Tourette’s (as cited in Klin, Sparrow, Marans, Carter, & Volk- mar, 2000). This is almost four times higher than the prevalence in the general population. Ehlers and Gillberg (1993) identified 20% of school-aged children with co-morbidDISTRIBUTION AS and Tourette’s in their Swed- ish general population study (as cited in Gillberg & Billstedt, 2000). A second Swedish population study only revealed 10% of the children who had Tourette’s also had a diagnosis of AS (Kadesjö & Gilberg, 2000). Baron-Cohen et al. (1999) contends that the co-morbidity of Tourette’s Syndrome and AS far exceeds the rate of TS and autism. They estimate that 50% of individuals with AS also have TS, whereas only between 2.6-20.3% of individuals with autism have Tourette’s Syndrome.

Implications for Social Work Downloaded By: [informa internal users] At: 19:35 15 July 2009 The convolution of co-morbidity emphasizes the importance of a multidisciplinary approach for diagnosis, evaluation, and treatment of individuals with AS. There is a need for collaboration between social workers and pediatricians, psychiatrists, physical therapists, psycholo- gists, teachers, speech therapists, neurologists, occupational therapists, and other service providers. Since no two individuals with AS are alike, clinicians should take special consideration to the implication the syn- drome has on the individual’s day-to-day living (Klin, Volkmar, & Sparrow, 2000). A viable and extremely important source of information in assess- ment is the parents. The family members are the ones that spend most of Ernst O. VanBergeijk and Oren Shtayermman 31

the time with the individual, therefore, they will be able to participate and make a meaningful contribution to the evaluation process. Family members will be more likely to recall key developmental milestones such as when the child first spoke, or when they first walked, which can assist in the differential diagnosis between HFA and AS. An area that has not been given much attention in the literature is the relationship of individuals with AS with their siblings. The sibling in- teractions are an important window into the level of social functioning ofNOT an individual with AS. Basic social interactions and communication patterns at home can and should be incorporated to the evaluation pro- cess as strengths of the individual. Teachers should be included as key participants in the assessment, planning, and implementation of educational and social goals for indi- viduals with AS.FOR Observations that are made by schoolteachers and paraprofessionals are extremely valuable as they could specify particu- lar areas of struggle for the individual. The day-to-day interaction in class setting with peers can serve as a mirror to the challenges individ- ual’s with Asperger’s encounter and the strengths they may possess. In- class and after-school activitiesDISTRIBUTION are significantly important part of a com- prehensive assessment and treatment plan for an individual with AS. An emphasis on the unique needs of the individual should be the or- ganizing principle of a professional’s approach to working this popula- tion. Professionals working with individuals with AS not only need to keep the idiosyncratic expression of this disorder in mind, but also need to adopt a long-term case management perspective to assessment and treatment. As the individual with Asperger’s ages, the social worker will be presented with a series of challenges depending on the client’s developmental stage, level of family support, social isolation, and per- sonal strengths. Treatment should focus on negotiating the social envi-

Downloaded By: [informa internal users] At: 19:35 15 July 2009 ronment and learning situation specific social skills. Insight oriented therapies are not recommended with this population. Cognitive and be- havioral therapies are more appropriate. Collaborating with speech therapists, social workers can address the client’s issues with semantic and pragmatic speech. To more effectively collaborate with school per- sonnel and potential employers, the social worker providing treatment ought to be fluent in the workings of two Federal : The Individuals With Disabilities Act (IDEA) and Americans With Disabili- ties Act (ADA). As a young adult the person with Asperger’s will need work with vocational and guidance counselors to plan their post high school endeavors. Many of the individuals with AS are highly intelli- gent, articulate people who will need a social worker to help them match 32 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

their strengths and capabilities to appropriate post-secondary educa- tional or vocational opportunities. These individuals go to university and hold professional positions. It is crucial that practitioners not under- estimate the potential of a client with AS. Early intervention is critical to their success. Social workers may be tempted to focus solely on the needs of the in- dividual with AS. However, other members of the individual’s ecosys- tem are also in need of assistance. Once the parents of a child with AS learnNOT of the diagnosis, they will need education and support. To help deal with a new diagnosis, social workers should create psychoeduca- tional support groups for parents. Parenting support groups for parents of children with AS are helpful because often parents have begun avoid- ing social situations because of their child’s difficult behavior. These psycho-educationalFOR support groups can also be instrumental in helping the families understand the unique learning needs of children with AS and how to advocate effectively for those needs. The groups can support parents in working with schools to meet their child’s needs or help them decide when alternative school placements are necessary. There are few services specific to AS, therefore,DISTRIBUTION social workers will need to link fami- lies to services and develop services in areas where there are none. Again, a case management approach is recommended, here emphasiz- ing a need for effective communication between service providers and family members. The siblings of children with AS may need support in understanding what it means to have a brother or a sister with this developmental dis- ability. Because children with AS may not look like something is differ- ent about them, this can be very confusing for the siblings and peers. There may be a unique stigma attached to having a sibling who looks “normal,” but may behave oddly.

Downloaded By: [informa internal users] At: 19:35 15 July 2009 The classroom teachers and administrators are key people in the eco- system of a child with AS. More than likely, these professionals are un- familiar with AS. The social worker’s role is to educate principals and teachers as to the needs of children with AS, as well as the legal pro- tections afforded to them under IDEA and the ADA. Social workers should act as a source of support for the teachers and help them manage in-class behavior of children with AS. Part of that management would involve the identification of the child’s interests and strengths and using those as a positive basis for social interaction with peers. School-based social workers should consider using small group formats with these children to reduce their sense of social isolation and to create natural op- portunities to practice social skills. Ernst O. VanBergeijk and Oren Shtayermman 33

Within the realm of policy, social workers should be advocating for full funding for the Individuals with Disabilities Education Act (IDEA) to help children and their families to receive special education services. Re- sources through IDEA should be allocated for early assessment and inter- vention. This would require professionals to receive training on the complexity of identifying and treating AS clients. A second policy change that social workers should advocate for is a restructuring of Social Security Disability to include monies for the treatment of AS. The monies couldNOT be directly spent on related services such as speech or occupational therapy, or Applied Behavior Analysis (ABA). Moreover, the income eli- gibility criterion prevents many families from receiving these costly ser- vices. Private insurance often excludes the treatment of developmental disabilities or deem the services as education related and therefore not covered by theFOR families’ health insurance policies. Funding for research has begun to increase. Currently, funded research focuses upon identifying genetic and neurological structures and causes of the syndrome. Some funded research has attempted to estimate the preva- lence of AS. However, funding is needed to develop rapid assessment in- struments with high discriminantDISTRIBUTION validity. These instruments and protocols need to be able to detect early indicators of AS, thereby allowing early in- tervention. Funding is also needed for studies that will explore the impact the syndrome has on the individuals and their families. Furthermore, spe- cific funding should be allocated for the evaluation of effective treatments for the syndrome. These treatments will need to incorporate a multi-disci- plinary approach since the syndrome is so enigmatic. No single profession currently possesses the knowledge and skills to ef- fectively assess and treat a syndrome as complex as Asperger’s. The social work profession using an ecological approach can coordinate and collabo- rate with a team of professionals in the diagnosis and treatment of AS. With Downloaded By: [informa internal users] At: 19:35 15 July 2009 a broad perspective, the social work profession can assist the Asperger’s client and his or her family in tailoring a unique intervention plan that ad- dresses the idiosyncrasies of the manifestation of his or her Asperger’s. Only through such collaboration can social work solve the riddle of AS.

REFERENCES

Adams, C., Green, J., Gilchrist, A., & Cox, A. (2002). Conversational behavior of chil- dren with Asperger Syndrome and conduct disorder. Journal of Child & Psychiatry, 43(5), 679-690. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders. (3rd ed.) New York: Wiley. 34 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders. (4th ed.) New York: Wiley. Ayres, J. A. (2000). Sensory integration and the child. Los Angeles. Western Psychologi- cal Services. Barnhill, G. P., Tapscott Cool, K., Tebbenkamp, K., & Smith Myles, B. (2002). The ef- fectiveness of social skills intervention targeting nonverbal communication for ado- lescents with Asperger Syndrome and related pervasive developmental delays. Focus on Autism and Other Developmental Disabilities, 17 (2), 112-118. Barnhill, G. P. (2001). Social attribution and depression in adolescents with Asperger NOTSyndrome. Focus on Autism & Other Developmental Disabilities, 16(1), 46-54. Baron-Cohen, S. (2000). Is Asperger Syndrome/High-Functioning Autism necessarily a disability? Developmental Psychopathology, 12(3), 489-500. Baron-Cohen, S., Mortimore, C., Moriatry, J., Izaguirre, J., & Robertson, M. (1999). The prevalence of Gilles de la Tourette’s Syndrome in children and adolescents with autism. Journal of Child Psychology & Psychiatry, 40(2), 213-218. Baron-Cohen, S., O’Riordan,FOR M., Stone, V., & Jones, R. (1999). Recognition of faux pas by normally developing children and children with Asperger Syndrome or High-Func- tioning Autism. Journal of Autism & Developmental Disorders, 29(5), 407-18. Bertrand, J., Mars, A., Boyle, C., Bove, F., Yergin-Allsop, M., & Decoufle, P. (2001). Prevalence of Autism in United States Population: The Brick Township, New Jer- sey; Investigation. Pediatrics, 108DISTRIBUTION(5), 1155-1161. Bishop, D. (1989). Autism, Asperger’s Syndrome and Semantic-Pragmatic Disorder: Where are the boundaries? British Journal of Disorders of Communication, 24, 107-121. Bowman, E. P. (1988). Asperger’s Syndrome and Autism: The case for a connection. British Journal of Psychiatry, 152, 377-382. Brasic, J. R. (2001). Pervasive Developmental Disorder: Asperger Syndrome. eMedicine Journal, 2(1), 1-21. Bryon, S. E., & Smith, I. M. (1998). Epidemiology of autism: Prevalence, associated characteristics, and implications for research and service delivery. Mental Retarda- tion and Developmental Disabilities Research Review, 4, 97-103. Cowley, G., Underwood, A., Murr, A., Springen, K., & Sennott, S. (2003, September

Downloaded By: [informa internal users] At: 19:35 15 July 2009 8). Boys, girls, and autism. Newsweek. Ehlers, S., & Gillberg, C. (1993). The epidemiology of Asperger Syndrome. A total pop- ulation study. Journal of Child Psychology & Psychiatry, 34(8), 1327-1350. Ehlers, S., Nyden, A., Gillberg, C., Sandberg, A. D., Dahlgren, S. & Hjelmquist, E. et al. (1997). Asperger Syndrome, autism, and attention disorders: A comparative study of the cognitive profiles of 120 children. Journal of Child Psychology & Psychiatry, 38(2), 207-217. Elder, J. H. (2001). A follow-up study beliefs held by parents of children with perva- sive developmental delay. Journal of Child & Adolescent Psychiatric Nursing, 14 (2), 55-60. Fidler, D., Bailey, J., & Smalley, S. (2000). Macrocephaly in autism and other perva- sive developmental disorders. Developmental Medicine and Child Neurology, 42, 737-740. Ernst O. VanBergeijk and Oren Shtayermman 35

Fine, J., Bartolucci, G., Ginsberg, G., & Szatmari, P. (1991). The use of intonation to communicate in Pervasive Developmental Disorders. Journal of Child Psychology & Psychiatry, 32(5), 771-782. Fombonne, E. (2001). What is the prevalence of Asperger Disorder? Journal of Autism & Developmental Disorders, 31(3), 363-364. Fording, L. (2003, May 17). Autism alert. Newsweek. Frith, U. (1991). Autism and Asperger Syndrome. : Cambridge University Press. Ghaziuddin, M., Weidmer-Mikhail, E., & Ghaziuddin, N. (1998). Comorbidity of Asperger Syndrome: A preliminary report. Journal of Intellectual Disability Re- NOTsearch, 42(4), 279-283. Ghaziuddin, M., & Gerstein, L. (1996). Pedantic speaking style differentiates Asperger Syndrome from High-Functioning Autism. Journal of Autism & Developmental Dis- orders, 26(6), 585-595. Gilchrist, A., Cox, A., Rutter, M., Green, J., Burton, D., & Le Couteur, A. (2001). De- velopment and current functioning in adolescents with Asperger Syndrome: A com- parative study.FORJournal of Child Psychology & Psychiatry, 42(2), 227-240. Gillberg, C., & Billstedt, E. (2000). Autism and Asperger Syndrome: Coexistence with other clinical disorders. ACTA Psychiatrica Scandivavica, 103, 321-330. Gillberg, C., Gillberg, I., & Steffenburg, S. (1992). Siblings and parents of children with autism: A controlled population-based study. Developmental Medicine of Child Neurology, 34(5), 389-98. DISTRIBUTION Gillberg, C., Nordin, V., & Ehlers, S. (1996). Early detection of autism. Diagnostic in- struments for clinicians. European Child and Adolescent Psychiatry, 5, 67-74. Jolliffe, T., & Baron-Cohen, S. (1999). A test of central coherence theory: Linguistic processing in high functioning adults with autism or asperger syndrome: Is local co- herence impaired? Cognition, 71, 149-185. Kadesjo, B., Gillberg, C., & Hagberg, B. (1999). Brief Report: Autism and Asperger Syndrome in seven-year-old children: A total population study. Journal of Autism & Developmental Disorders, 29(4), 327-331. Kerbel, D., & Grunwell, P. (1998). A study of idiom comprehension in children with semantic-pragmatic difficulties. Part II: Between-groups results and discussion. In- ternational Journal of Language & Communication Disorders, 33(1), 23-44.

Downloaded By: [informa internal users] At: 19:35 15 July 2009 Kim, J. A., Szatmari, P., Bryson, S. E., Streiner, D. L., & Wilson, F. J. (2000). The prevalence of anxiety and mood problems among children with autism and Asperger Syndrome. Autism, 4(2), 117-132. Klin, A., & Volkmar, F.R. (1997). Asperger’s Syndrome. In D.J. Cohen & F.R. Volkmar (Eds.), Handbook of Autism and Pervasive Developmental Disorders.New York: Wiley. Klin, A., Volkmar, F., Sparrow, S., Cicchetti, D., & Rourke, B. (1996). Validity and neuropsychological characterization of Asperger Syndrome: Convergence with Nonverbal Learning Disabilities Syndrome. Annual Progress in Child Psychiatry and Development, pp. 241-259. Klin, A. (2000). Attributing social meaning ambiguous visual stimuli in high function- ing Autism and Asperger Syndrome: The social attribution task. Journal of Child Psychology & Psychiatry, 47(7), 831-846. 36 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

Klin, A., Sparrow, S. S., Marans, W. D., Carter, A., & Volkmar, F. R. (2000). In Klin, Volkmar, & Sparrow (Eds.), Asperger Syndrome. The Guilford Press. Klin, A., & Volkmar, F. R. (2000). Treatment and intervention guidelines for individu- als with Asperger Syndrome. In A. Klin, F. Volkmar, & S. Sparrow (Eds.), Asperger Syndrome (pp. 340-366). The Guilford Press: New York London. Klin, A., Volkmar, F. R., & Sparrow, S. S. (2000). Asperger Syndrome.NewYork,Lon- don: The Guilford Press. Klin, A., & Volkmar, F. R. (1997). Asperger Syndrome. In D. J. Cohen & F. R. Volkmar (Eds.), Handbook of Autism and Pervasive Developmental Disorders (2nd NOTed., pp. 94-112). New York: Wiley. Kranowitz, C. S. (1998). The Out-of-Sync Child. New York: The Berkley Publishing Group. Marriage, K., Fau-Gordon, V., & Brand, L. (1995, Mar). A social skills group for boys with Asperger’s Syndrome. Australia and Journal of Psychiatry, 29(1), 58-62. McLaughlin-Cheng,FOR E. (1998). Asperger Syndrome and Autism: Focus on Autism & Other Developmental Disabilities, 13(4), 234-245. Miller, J., Ozonoff, S., & Ozonoff, S. (2000). The external validity of Asperger disor- der: Lack of evidence from the domain of neuropsychology. Journal of Abnormal Psychology, 109(2), 227-238. Nash, J. M. (2002, May 6). The secrets of Autism. Time. Ozonoff, S., Rogers, S. J., & Pennington,DISTRIBUTION B. F. (1991). Asperger’s Syndrome: Evi- dence of an empirical distinction from High-Functioning Autism. Journal of Child Psychology & Psychiatry, 32(7), 1107-1122. Philibin Bowman, E. (1988). Asperger Syndrome and Autism: The case for a connec- tion. British Journal of Psychiatry, 152, 377-382. Prior, M., Leekam, S., Ong, B., Eisenmajer, R., Wing, L., Gould, J. et al. (1998). Are there subgroups within the autistic spectrum? A cluster analysis of a group of chil- dren with autistic spectrum disorders. Journal of Child Psychology & Psychiatry, 39(6), 893-902. Rhea, P. (2003). Promoting social communication in high functioning individuals with Autistic Spectrum Disorders. Child and Adolescent Psychiatric Clinic of North Amer- ica, 12(1), 87-106. Downloaded By: [informa internal users] At: 19:35 15 July 2009 Ringman, J. M., & Jankovich, J. (2000). Occurrence of tics in Asperger’s Syndrome and Autistic Disorder. Journal of Child Neurology, 15(6), 394-400. Romanowski Bashe, P., & Kirby, B. L. (2001). The OASIS guide to Asperger Syndrome. New York: Crown Publisher. Rourke, B. P., Tsatsanis, K. D. (2000). In Klin, Volkmar, & Sparrow (Eds.), Asperger Syndrome. New York: The Guilford Press. Rourke, B. P., Young, G. C., & Leenaars, A. A. (1989). A childhood learning disability that predisposed those afflicted to adolescent adult depression and suicide risk. Journal of Learning Disabilities, 22(3), 169-175. Rubenstein Gardner, M. (2001). Understanding and caring for the child with Asperger Syndrome. The Journal of School Nursing, 17(4), 178-184. Shriberg, L. D., Rhea, P., McSweeny, J. L., Klin, A., Cohen, D. J., & Volkmar, F. R. (2001). Speech and prosody characteristics of adolescents and adults with Ernst O. VanBergeijk and Oren Shtayermman 37

High-Functioning Autism and Asperger Syndrome. Journal of Speech, Language, and Hearing Research, 44, 1097-1115. Szatmari, P. (1991). Asperger’s Syndrome: Diagnosis, treatment, and outcome. Psy- chiatric Clinic of North America, 14(1), 81-93. Szatmari, P., Bremner, R., & Nagy, J. (1989). Asperger’s Syndrome: A review of clini- cal features. Canadian Journal of Psychiatry, 34(6), 554-560. Tantam, D. (1991). Asperger’s Syndrome in adulthood. In U. Frith (Ed.), Autism and Asperger Syndrome. Cambridge: Cambridge University Press. Tantam, D. (2000). Psychological disorder in adolescents and adults with Asperger NOTSyndrome. Autism , 4(1), 47-62. Tantam, D. (2003). The challenge of adolescents and adults with Asperger Syndrome. Child and Adolescent Psychiatric Clinic of North America, 12(1), 143-163. Volkmar, F., & Klin, A. (2000). Diagnostic issues in Asperger Syndrome. In Klin, Volkmar, & Sparrow (Eds.), Asperger Syndrome. New York: Guilford Press. Wing, L. (1993). The definition and prevalence of autism: A review. European Child & Adolescent PsychiatryFOR, 2, 61-74. Wing, L. (1991). The relationship between Asperger’s Syndrome and Kanner’s Au- tism. In U. Frith (Ed.), Autism and Asperger Syndrome. New York: Cambridge Uni- versity Press. Yergina-Allsopp, M., Rice, C., Karapurkar, T., & Doernberg, N. (2003). Prevalence of Autism in a U.S. metropolitan area. The Journal of the American Medical Associa- tion, 289(1), 49-55. DISTRIBUTION Downloaded By: [informa internal users] At: 19:35 15 July 2009