Carolyn Bridgemohan, MD
H. Bridgemohan, MD, director of the Autism Care Program within Children's Hospital Boston's Division
of Developmental Medicine, sat down with Pediatric Views to talk about Asperger's
syndrome, why it can be hard to diagnose and what kinds of treatment she recommends.
Children with Asperger's have difficulties with social and behavioral functions, but they don't have significant language delays. They may have trouble with conversation despite having good grammatical knowledge and all the building blocks of language. In addition, children with Asperger's have normal to above-average cognitive abilities. That being said, many people with Asperger's can have learning disabilities or trouble with abstract thinking. Children with autism or pervasive
developmental disorder (PDD), on the other hand, have a history of language delay and/or some really unusual ways of using language, such as repeating dialogue or scripting.
If you look at a child with autism and a child with Asperger's who have similar cognitive abilities, there's no difference in their long-term outcome. It's not worse to be diagnosed with autism, necessarily, but some families view a diagnosis of Asperger's as less severe than autism or PDD.
There's no biological marker that lets you be very precise and say, "This is Asperger's." We make these diagnoses by observing children's behaviors and abilities in a number of different developmental areas.
Children with Asperger's have normal intellectual development, so they'll pass early tests that might pick up autism. Often, they aren't diagnosed until elementary school. Eventually, the requirements of an age-appropriate interaction exceed their abilities. If they're bright and have good verbal skills, or if they often come up with good ideas during play, it's not as obvious that they're terribly rigid or socially impaired. When they get to an age when their peers won't tolerate them being so directive anymore, we start to see problems.
When they get older, they have trouble discussing emotions and understanding the nuances of social relationships—the kinds of abilities you can't assess until a child is 8 or 9 years old. Then:
- They're not able to tell you the difference between a friend
and an acquaintance.
- They're not able to tell you how they physically feel when they're sad.
- They often have significant behavioral rigidity and trouble handling changes in routine.
- Although they may be on track or above average academically, they may be struggling in school due to frequent tantrums and temper outbursts.
It can be difficult to distinguish mild Asperger's syndrome from other learning or attentional disorders. If a child is quirky and a little bit socially awkward, but is doing great in school, has friends, is happy and is doing well, then she doesn't really meet the criteria. If she's not having a functional impairment, it's not a disorder.
Treatment should be geared to a child's individual needs, so you should look at her social, language, cognitive, academic and adaptive self-care skills. Are there behavioral problems that are going to impact her ability to learn in school that might be targeted? At Children's, we offer a range of services, and there are three departments where a child with Asperger's would most likely be cared for.
In Developmental Medicine, we offer diagnostic evaluations and ongoing follow-up care, which is the most important element of treating a child with Asperger's. We've built collaborations with other programs around Boston and have a Resource Specialist who makes sure they're connected with services. We review a child's progress in school programs, manage medical issues, such as mental health, attention and learning problems, problems with sleep, toileting or feeding and we make sure that an appropriate medical diagnostic workup has been done.
of Psychiatry helps families with the social skills and pragmatic issues as well as mental health issues. Children with Asperger's are at higher risk for both anxiety problems and depression, particularly as they go through adolescence.
of Neurology also evaluates children with autism spectrum disorders, particularly those kids who are having seizures, associated tics or Tourette's syndrome.
Pediatricians should refer children for diagnostic evaluation when there are concerns with social, language and behavioral issues that are impacting the child's functioning at school, at home or in the community. For children who already have a diagnosis, pediatricians should refer when there are questions about appropriate educational programming and therapy; concerns with learning, attention or emotional health; problems with sleep or toileting skills or neurologic concerns.
Make a referral:
Developmental Medicine: 617-355-7971