Management

Asperger syndrome treatment attempts to manage distressing symptoms and to teach age-appropriate social, communication and vocational skills that are not naturally acquired during development, with intervention tailored to the needs of the individual child, based on multidisciplinary assessment. Although progress has been made, data supporting the efficacy of particular interventions are limited.

Therapies

The ideal treatment for AS coordinates therapies that address core symptoms of the disorder, including poor communication skills and obsessive or repetitive routines. While most professionals agree that the earlier the intervention, the better, there is no single best treatment package. AS treatment resembles that of other high-functioning ASDs, except that it takes into account the linguistic capabilities, verbal strengths, and nonverbal vulnerabilities of individuals with AS. A typical program generally includes:

• the training of social skills for more effective interpersonal interactions,
• cognitive behavioural therapy to improve stress management relating to anxiety or explosive emotions, and to cut back on obsessive interests and repetitive routines,
• medication, for coexisting conditions such as major depressive disorder and anxiety disorder,
• occupational or physical therapy to assist with poor sensory integration and motor coordination,
• social communication intervention, which is specialized speech therapy to help with the pragmatics of the give and take of normal conversation,
• the training and support of parents, particularly in behavioural techniques to use in the home.

Of the many studies on behaviour-based early intervention programs, most are case studies of up to five participants, and typically examine a few problem behaviours such as self-injury, aggression, noncompliance, stereotypies, or spontaneous language; unintended side effects are largely ignored. Despite the popularity of social skills training, its effectiveness is not firmly established. A randomized controlled study of a model for training parents in problem behaviours in their children with AS showed that parents attending a one-day workshop or six individual lessons reported fewer behavioural problems, while parents receiving the individual lessons reported less intense behavioural problems in their AS children. Vocational training is important to teach job interview etiquette and workplace behaviour to older children and adults with AS, and organization software and personal data assistants to improve the work and life management of people with AS are useful.

Medications

No medications directly treat the core symptoms of AS. Although research into the efficacy of pharmaceutical intervention for AS is limited, it is essential to diagnose and treat comorbid conditions. Deficits in self-identifying emotions or in observing effects of one's behaviour on others can make it difficult for individuals with AS to see why medication may be appropriate. Medication can be effective in combination with behavioural interventions and environmental accommodations in treating comorbid symptoms such as anxiety disorder, major depressive disorder, inattention and aggression. The atypical neuroleptic medications risperidone and olanzapine have been shown to reduce the associated symptoms of AS; risperidone can reduce repetitive and self-injurious behaviours, aggressive outbursts and impulsivity, and improve stereotypical patterns of behaviour and social relatedness. The selective serotonin reuptake inhibitors (SSRIs) fluoxetine, fluvoxamine and sertraline have been effective in treating restricted and repetitive interests and behaviours.

Care must be taken with medications; abnormalities in metabolism, cardiac conduction times, and an increased risk of type 2 diabetes have been raised as concerns with these medications, along with serious long-term neurological side effects. SSRIs can lead to manifestations of behavioural activation such as increased impulsivity, aggression and sleep disturbance. Weight gain and fatigue are commonly reported side effects of risperidone, which may also lead to increased risk for extrapyramidal symptoms such as restlessness and dystonia and increased serum prolactin levels. Sedation and weight gain are more common with olanzapine, which has also been linked with diabetes. Sedative side-effects in school-age children have ramifications for classroom learning. Individuals with AS may be unable to identify and communicate their internal moods and emotions or to tolerate side effects that for most people would not be problematic.

Prognosis

There is some evidence that as many as 20% of children with AS "grow out" of it, and fail to meet the diagnostic criteria as adults. As of 2006, no studies addressing the long-term outcome of individuals with Asperger syndrome are available and there are no systematic long-term follow-up studies of children with AS.[5] Individuals with AS appear to have normal life expectancy but have an increased prevalence of comorbid psychiatric conditions such as major depressive disorder and anxiety disorder that may significantly affect prognosis. Although social impairment is lifelong, outcome is generally more positive than with individuals with lower functioning autism spectrum disorders; for example, ASD symptoms are more likely to diminish with time in children with AS or HFA. Although most students with AS/HFA have average mathematical ability and test slightly worse in mathematics than in general intelligence, some are gifted in mathematics and AS has not prevented some adults from major accomplishments such as winning the Nobel Prize.

Children with AS may require special education services because of their social and behavioural difficulties although many attend regular education classes.[5] Adolescents with AS may exhibit ongoing difficulty with self care, organization and disturbances in social and romantic relationships; despite high cognitive potential, most young adults with AS remain at home, although some do marry and work independently. The "different-ness" adolescents experience can be traumatic. Anxiety may stem from preoccupation over possible violations of routines and rituals, from being placed in a situation without a clear schedule or expectations, or from concern with failing in social encounters; the resulting stress may manifest as inattention, withdrawal, reliance on obsessions, hyperactivity, or aggressive or oppositional behaviour. Depression is often the result of chronic frustration from repeated failure to engage others socially, and mood disorders requiring treatment may develop. Clinical experience suggests the rate of suicide may be higher among those with AS, but this has not been confirmed by systematic empirical studies.

Education of families is critical in developing strategies for understanding strengths and weaknesses; helping the family to cope improves outcomes in children. Prognosis may be improved by diagnosis at a younger age that allows for early interventions, while interventions in adulthood are valuable but less beneficial.[2] There are legal implications for individuals with AS as they run the risk of exploitation by others and may be unable to comprehend the societal implications of their actions.

Epidemiology

Prevalence estimates vary enormously. A 2003 review of epidemiological studies of children found prevalence rates ranging from 0.03 to 4.84 per 1,000, with the ratio of autism to Asperger syndrome ranging from 1.5:1 to 16:1; combining the average ratio of 5:1 with a conservative prevalence estimate for autism of 1.3 per 1,000 suggests indirectly that the prevalence of AS might be around 0.26 per 1,000. Part of the variance in estimates arises from differences in diagnostic criteria. For example, a relatively small 2007 study of 5,484 eight-year-old children in Finland found 2.9 children per 1,000 met the ICD-10 criteria for an AS diagnosis, 2.7 per 1,000 for Gillberg and Gillberg criteria, 2.5 for DSM-IV, 1.6 for Szatmari et al., and 4.3 per 1,000 for the union of the four criteria. Boys seem to be more likely to have AS than girls; estimates of the sex ratio range from 1.6:1 to 4:1, using the Gillberg and Gillberg criteria.

Anxiety disorder and major depressive disorder are the most common conditions seen at the same time; comorbidity of these in persons with AS is estimated at 65%. Depression is common in adolescents and adults; children are likely to present with ADHD. Reports have associated AS with medical conditions such as aminoaciduria and ligamentous laxity, but these have been case reports or small studies and no factors have been associated with AS across studies. One study of males with AS found an increased rate of epilepsy and a high rate (51%) of nonverbal learning disorder.] AS is associated with tics, Tourette syndrome, and bipolar disorder, and the repetitive behaviours of AS have many similarities with the symptoms of obsessive-compulsive disorder and obsessive-compulsive personality disorder. Although many of these studies are based on psychiatric clinic samples without using standardized measures, it seems reasonable to conclude that comorbid conditions are relatively common.

Cultural aspects

People with Asperger syndrome may refer to themselves in casual conversation as aspies, coined by Liane Holliday Willey in 1999. The word neurotypical (abbreviated NT) describes a person whose neurological development and state are typical, and is often used to refer to non-autistic people. The Internet has allowed individuals with AS to communicate and celebrate with each other in a way that was not previously possible because of their rarity and geographic dispersal. A subculture of aspies has formed. Internet sites like Wrong Planet have made it easier for individuals to connect.

Autistic people have advocated a shift in perception of autism spectrum disorders as complex syndromes rather than diseases that must be cured. Proponents of this view reject the notion that there is an "ideal" brain configuration and that any deviation from the norm is pathological; they promote tolerance for what they call neurodiversity. These views are the basis for the autistic rights and autistic pride movements. There is a contrast between the attitude of adults with self-identified AS, who typically do not want to be cured and are proud of their identity, and parents of children with AS, who typically seek assistance and a cure for their children.

Some researchers have argued that AS can be viewed as a different cognitive style, not a disorder or a disability.[7][94] In a 2002 paper, Simon Baron-Cohen wrote of those with AS, "In the social world there is no great benefit to a precise eye for detail, but in the worlds of math, computing, cataloguing, music, linguistics, engineering, and science, such an eye for detail can lead to success rather than failure." Baron-Cohen cited two reasons why it might still be useful to consider AS to be a disability: to ensure provision for legally required special support, and to recognize emotional difficulties from reduced empathy. It has been argued that the genes for Asperger's combination of abilities have operated throughout recent human evolution and have made remarkable contributions to human history.