Wednesday, December 30, 2009

Interventions for Adults with ASD

Although there are no definitive intervention guidelines or single treatment that can dramatically enhance long-term outcomes, strategies exist that can be used to address the core deficits of adults with autism spectrum disorder (ASD). I consider these core deficits as “skill deficits” because they have not been learned instinctively as with the “neurotypical” individual. While psychotherapy (e.g., CBT) and counseling are helpful, the overarching goal of intervention planning should be the development of social and communicative competency through direct teaching, modeling, coaching, and role playing activities in real world situations.
There is no adult-onset ASD. Symptoms have generally been present in childhood and extend into adulthood. Following an accurate diagnosis, education about the effects of ASD on home, community, and occupational functioning is an important starting point. Providing reading materials and basic information about the disorder can result in greater self-knowledge and self-awareness on how ASD affects personal development, behavior, relationships, and view of the world. Discussion topics might focus on important aspects of everyday life such as communication, understanding feelings, and friendships, and written activities to enhance self-discovery, positive action, change, and shift in perspective. Autobiographical accounts such as “Pretending to be Normal: Living with Asperger’s Syndrome” (Willey, 1999) and “Unwritten rules of Social relationships” (Grandin & Barron, 2005) can also be helpful in promoting a greater self-understanding and positive self-schema. A personal perspective can be valuable in explaining the nature of adult ASD and help realize a positive reaction to the diagnosis.
Social Stories
Social stories are a popular method for teaching individuals with ASD about social behavior (Gray, 1998). A social story is a brief narrative used to explain social rules and concepts. The description may include where and why a specific situation occurs, how others feel and react, or what prompts the individual’s feelings and reactions. The story features an introduction that clearly identifies the topic (e.g., friendship, maintaining a conversation, listening), a core section that adds detail and social knowledge, and a conclusion that reinforces the information and any new suggestions. Social stories may be written documents or used with videotapes. They can be used effectively to enhance perspective-taking skills and to introduce the idea of inferring the mental state of others.
Computer programs such as Mind Reading: The Interactive Guide to Emotions (Baron-Cohen, 2007) may also be used with adults to help them understand emotions and improve theory-of-mind abilities. This interactive software teaches the individual with ASD to recognize and understand the thoughts, emotions, and intentions of others by demonstrating facial expressions, body language and speech qualities associated with a wide range of emotions. The individual is provided immediate feedback on how to identify the subtle cues that signal the thoughts and feelings of others.
Social Autopsies
A social skills autopsy is a problem-solving strategy designed to decrease the possibility that a social misunderstanding will reoccur. The individual actively participates in analyzing real world social interactions to identify the cause and effect relationship between his or her behavior and the positive and negative reactions of others. Specific social problems are discussed after the event and reviewed in sequential form. The clinician helps the individual identify the who, what, when, and where of the situation. Several behavioral options are then considered by identifying one or more alternative actions he or she could have taken. Following each option discussed, a consequence is clarified. A plan or strategy is then formulated to carry out the appropriate alternative if the social situation occurs again. The individual also practices carrying out the plan by visualizing the strategy, writing down the plan, talking with a safe person about the plan, and/or role-playing. 
There is a large and heterogeneous group of adults with ASD who were not identified in childhood and did not receive the appropriate interventions and supports. It is not uncommon for many adults with ASD to escape formal diagnosis until they come to the attention of psychologists and other mental health professionals. The late diagnosis of ASD in adulthood and treatment of adult ASD argues for a more intense focus on education and research to improve outcomes for this group of individuals whose social problems and often subtle theory-of-mind challenges impact their personal and social lives.
Reference list available upon request -
© Lee A. Wilkinson, PhD

Tuesday, December 15, 2009

A Lost Generation: Adults with Asperger Syndrome

 The inclusion of Asperger’s Disorder (Asperger syndrome) in the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases has produced a marked interest in the identification and treatment of this autism-related condition. Although there has been a dramatic increase in the research and clinical studies related to children and adolescents, there is a paucity of information regarding Asperger syndrome in adults. It is only recently that psychologists have begun to appreciate the complex challenges faced by a “lost generation” of adults with Asperger syndrome who were not diagnosed in childhood and have become an underserved population.

Accurate differential diagnosis and a greater appreciation of the social difficulties associated with Asperger syndrome are critical because the high proportion of individuals who may be overlooked, misdiagnosed with another psychiatric condition, or present with comorbid psychiatric disorders such as depression and anxiety. Although there is a wealth of information regarding children with autism spectrum disorders, little is known about the identification of adults on the higher end of the autism spectrum. While there is no single set of criteria or “gold standard” for making a late diagnosis of Asperger syndrome in adults, there are a limited number of instruments that can be used for screening and assessment. The following phenotypic screening instruments are useful for adults who may have Asperger syndrome.

• The Autism Spectrum Disorder in Adults Screening Questionnaire (ASDASQ; Nylander & Gillberg, 2001).

• The Asperger Syndrome (and high-functioning autism) Diagnostic Interview (ASDI; Gillberg, Gillberg, Restam, & Wentz, 2001).

• The Autism-Spectrum Quotient (AQ; Baron-Cohen, Wheelwright, Skinner, Martin, and Clubley, 2001).

• The Empathy Quotient (EQ; Baron-Cohen & Wheelwright, 2004).

Although these screening measures can be useful in the identification process, they cannot substitute for a diagnostic assessment and validation of the symptomatology identified by these instruments. We now have a diagnostic assessment specifically designed for adults. The Adult Asperger Assessment (AAA; Baron-Cohen, Wheelwright, Robinson, & Woodbury-Smith, 2005) is a relatively new semi-structured interview schedule developed for the late diagnosis of Asperger syndrome in adulthood. It links the above referenced AQ and EQ screening instruments, and uses more stringent diagnostic criteria specifically related to adults. These criteria include all the symptoms from the DSM-IV as well as several other criteria based on the characteristics of Asperger syndrome in adults. The AAA employs a template in which the individual is asked to endorse items from the AQ and EQ to provide examples of symptoms. During the clinical interview, the clinician validates these symptom examples by gathering information from both the individual and his or her relative or other informant. Following the interview, the clinician then formulates a diagnostic impression based on confirmation of the symptoms and prerequisites of the Asperger syndrome criteria.

Little is known about the prognosis and outcomes in adults with Asperger syndrome in that there are relatively few long-term follow-up studies available. However, it does seem clear that outcome can depend greatly on the degree of support provided in adulthood. Although early adulthood may bring about symptom reduction and improved functioning, individuals with Asperger syndrome continue to have a need for services. As the knowledge and awareness of Asperger syndrome increases, many adults are expected to recognize their symptomatology, even though they may have not experienced major social difficulties and clinical impairment earlier in life. This late recognition and disclosure will result in a greater need for services as individuals seek treatment to address the secondary problems associated with the condition. A diagnosis in adulthood can also lead to greater self-understanding, self-advocacy, and better decision-making in life span activities such as employment and personal relationships.

References available.


Gaus, V.L. (2007). Cognitive-behavioral therapy for adult Asperger syndrome. New York: Guilford.

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