05. freeman, pp.

145-151 8/29/02 10:36 AM Page 145

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

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VOLUME 17, NUMBER 3, FALL 2002
PAGES 145–151
05. freeman, pp. 145-151 8/29/02 10:36 AM
FOCUS ON AUTISM AND OTHER DEVELOPMENTAL DISABILITIES
146
ber of difficulties for diagnosticians. In
the DSM-IV the criteria for AS of im-
pairment in social interaction and re-
stricted, repetitive, and stereotypic pat-
terns of interest are the same as those for
AD. However, to make a diagnosis of AS
there has to be a lack of any clinically sig-
nificant delay in language and a lack of
any clinically significant delay in cogni-
tive development, including develop-
ment of age-appropriate self-help skills.
In addition, for AD, speech delay is not
required but, rather, is one of the possi-
ble signs of deviance in language devel-
opment.
There is also a threshold problem with
DSM-IV in that if an individual meets cri-
teria for the diagnosis of AD, the diag-
nosis of Asperger syndrome must be ex-
cluded. These are just a few of the issues
that make it extremely difficult to accu-
rately diagnose people with AS using the
DSM-IV criteria. The majority of chil-
dren and individuals with AS show delays
in other areas of adaptive functioning,
causing further confusion. DSM-IV does
not elaborate on the symptoms that must
be present when making the diagnosis.
Is There a Spectrum?
A number of studies have attempted to
look at the validity of the diagnosis of AS,
reviewing the differentiation between AD
and AS. Kulger (1998) reviewed similar-
ities and differences in symptomatology
with reference both to the history of AS
and to current research. Symptoms that
have been suggested as possibly differen-
tial for diagnosis (e.g., problems with
motor skills, language abilities, and cog-
nitive functioning) and shared diagnostic
features were considered separately. Al-
though the paucity of reliable research
findings allows few definitive conclusions
to be drawn, it is suggested that attempts
to identify subgroups and achieve a bet-
ter understanding of the behavioral het-
erogeneity within an autism spectrum of
PDD are crucial to improving clinical
practice and research.
Szatmari, Archer, Fisman, Streiner,
and Wilson (1995) examined differences
in the behavior, cognition, and adaptive
functioning of 47 children with autism
and 21 with AS. These participants dif-
Page 146
fered from other individuals with PDD in
their delayed and deviant language de-
velopment. Participants were adminis-
tered the Autism Diagnostic Interview,
Vineland Adaptive Behavior Scales, Leiter
International Performance Scale, Stan-
ford Binet Intelligence Scale, Reynell
Developmental Language Scale, and de-
velopmental tests of visual motor inte-
gration. Significant differences between
the groups existed on many PDD symp-
toms, adaptive behaviors, and cognitive
measures of language competence, but
the groups did not differ on aspects of
nonverbal communication, nonverbal
cognition, or motor development. The
authors hypothesized that subtypes of
children with PDD can be identified that
differ on variables relatively independent
of defining characteristics.
Later, Satzmari (2000) reviewed the
current classification of PDD as concep-
tualized in both the DSM-IV and the In-
ternational Classification of Diseases–
10th Edition (ICD-10; World Health
Organization, 1993). He sought to de-
termine whether the diagnostic validity
of the various disorders simply lacked
empirical data for full substantiation or
the overall conception of the category
had some fundamental problems. He
concluded that the overall conceptualiza-
tion had fundamental flaws. Szatmari re-
viewed the literature up to that point,
summarized recent empirical data on is-
sues of reliability and validity, and sug-
gested the need for a different approach
to understanding AS.
Eisenmajer et al. (1996) compared
two groups of children: one diagnosed
clinically with high-functioning autism
(AD) and the other diagnosed with AS.
They reported that there were three di-
agnostic differences between the two
groups in the preschool years: (a) The
communication and imagination impair-
ments for AD were not present for AS;
(b) there was no clinically significant lan-
guage delay for AS (i.e., single words by
age 2 years, phrases by 3 years); and
(c) there was no significant delay in cog-
nitive development or developmentally
age-appropriate self-help skills and adap-
tive behaviors other than in social in-
teraction and curiosity about the en-
vironment. When these children were
followed up at a later age, the investiga-
tors reported that few clinical differences
existed between high-functioning AD
and AS, as characterized by the clinician.
Normal onset of speech did not preclude
later language or communication prob-
lems. They concluded that children with
AS, as a group, present with fewer signif-
icant delays than AD and tend to be iden-
tified somewhat later relative to their
chronological ages.
The only difference reported by Eisen-
majer et al. (1996) was that the group
with AS tended to have a higher inci-
dence of co-morbid attention-deficit/
hyperactivity disorder (ADHD) than the
group with AD. Of particular signifi-
cance was that the groups did not differ
on any of the classic autistic impairments.
Deficits were evident in both groups in
(a) imagination, (b) imitation, (c) non-
verbal communication, (d) awareness of
social rules, (e) stereotypic movements,
(f ) spontaneity and accommodating
change, and (g) figurative understanding
of language. They concluded that clini-
cians were identifying a subgroup of chil-
dren with autism who desired friends;
were less likely to have speech delays;
exhibited pedantic language; and had
narrow, circumscribed interests. Their re-
sults suggested that AS was on a con-
tinuum with AD and not a separate dis-
order.
Mayes, Calhoun, and Crites (2001)
studied forty-seven 2- to 12-year-olds with
normal intelligence who had clinical fea-
tures of AD. These groups were divided
into whether or not the children had a
speech delay. The purpose of this study
was to determine if clinical meaningful
differences existed between the two
groups and would support absence of
speech delay as the DSM-IV criteria for
AS. Clinical development and demo-
graphic data were analyzed, and no sig-
nificant differences were found between
the 23 children with speech delay and the
24 children without speech delay on any
of the 71 variables analyzed, including
autistic symptoms and expressive lan-
guage. Results suggested that early
speech delay may be irrelevant to later
functioning in children who have normal
intelligence and a clinical diagnosis of
AD or AS, and that the DSM-IV distinc-
05. freeman, pp. 145-151 8/29/02 10:36 AM
tion of speech delay between AS and AD
may not be warranted.
In a later study, Eisenmajer et al.
(1998) looked at comparative data on
the developmental history and current
behaviors of a large sample of high-
functioning 3- to 21-year-olds with a di-
agnosis of AD, AS, and other related dis-
orders. These individuals provided the
basis for a taxonomic analysis of diagnos-
tic subgroups. Most participants also
completed theory-of-mind tasks. Three
clusters of subgroups were obtained with
differences in scores on theory-of-mind
tasks and performance and nonverbal
abilities. Although subgroups were iden-
tified that bore some similarities to clini-
cal differentiation of AD or AS and
pervasive developmental disorder not
otherwise specified (PDD NOS), the na-
ture of the differences among them
seemed to be strongly related to ability
variables. Examination of the kinds of be-
haviors that differentiated the groups
suggested that a spectrum of autistic dis-
orders explained the findings that chil-
dren differ primarily in terms of social
and cognitive impairment.
Ozonoff, South, and Miller (2000)
compared 23 children with high-
functioning autism and 12 children with
AS. They used DSM-IV (1994) criteria
and matched the groups on chronologi-
cal age and intellectual abilities. They ex-
amined the groups for differences in
cognitive function, current symptoma-
tology, and early history and found few
differences in the current presentation of
cognitive functioning between the groups,
but many in early development. The chil-
dren diagnosed with AS tended to have
milder symptoms in early development.
The group differences seemed to be re-
lated to the diagnostic process. These re-
sults suggest that individuals with AS and
high-functioning AD exhibit the same
fundamental symptoms, differing only in
their severity. However, there was a
major methodological problem with the
study in that a circular definition was
used and differences found could be at-
tributed to the diagnostic process alone.
Leekam, Libby, Wing, Gould, and Gill-
berg (2000) compared ICD-10 criteria
for AS with Gillberg’s (1991) criteria.
The ICD-10 criteria are the same as
Page 147
VOLUME 17, NUMBER 3, FALL 2002
those in the DSM-IV. Gillberg’s criteria
were as follows: impairments in social in-
teraction (including inappropriate pub-
lic behavior), narrow interests, repetitive
routines, speech and language deficits,
nonverbal communication deficits, and
motor clumsiness. Leekam et al. studied
200 children and adults using the Diag-
nostic Interview for Social and Commu-
nication Disorder (DISC) and found dif-
ferences depending on the diagnostic
criteria used. If the ICD-10/DSM-IV
criteria were applied strictly, only 3 of
200 children, or 1% of the population,
met criteria for AS. On the other hand, if
the Gillberg criteria were utilized, 91 out
of 200, or 45%, of the children met cri-
teria for AS. The result was attributed to
the requirement for ICD-10/DSM-IV
AS criteria of normal onset of cognitive
and adaptive abilities. These investigators
concluded that ICD-10/DSM-IV identi-
fied a subgroup with no delay in early
cognitive, language, or adaptive devel-
opment. Furthermore, the ICD-10 and
DSM-IV identified a subgroup even
though clinical features later were the
same as AD. They also reported that Gill-
berg’s criteria seemed to be consistent
with the DSM-IV criteria for Atypical
Autism or PDD NOS, a subgroup of in-
dividuals with autism that tends to have
better language and more intellectual in-
terests. They concluded that their results
questioned the validity of defining a sep-
arate subgroup and suggested that a di-
mensional approach to AS was more ap-
propriate than a categorical approach.
That is, AS is not a distinctive disorder.
AD and AS as Separate
Diagnostic Categories
McLaughlin-Cheng (1998) reviewed and
synthesized clinical and diagnostic crite-
ria, empirical data, and studies on AS and
AD from an historical perspective. The
results of the synthesis suggest that these
two groups of children differ in cognitive
and adaptive behavior deficits and there-
fore do not fall on the same autism
continuum. McLaughlin-Cheng’s meta-
analysis procedure compared children
and adolescents with AS to those with
147
AD on various cognitive measures and
using various adaptive behavior scales.
Overall, the results suggested that chil-
dren and adolescents with AS perform
better than those with AD on intelli-
gence and cognitive measures and mea-
sures of adaptive behavior functioning,
thus AS should be viewed as a distinctive
diagnostic category, separate from AD.
Klin et al. (2000) reviewed in detail di-
agnostic issues surrounding AS and re-
ported that the issues involved include
the definition, avoiding circularity, and
comparison groups other than persons
with AS. The authors indicated that if AS
is indeed a distinctive disorder, clinical
features have to be identified that are not
a part of the confounding definition. The
analysis of research to date by Klin and
others continues to identify gross social
deficits in both individuals with AD and
those with AS, with no significant differ-
ences in cognitive or adaptive function-
ing. At times, “milder symptoms” in
early development differentiate partici-
pants with AS from those with AD. The
natural course of the disorder and its
neuropsychology, biological markers,
and associated features, along with the
person’s family history, need to be dif-
ferent to make it a meaningful concept.
The Yale Learning Disabilities project, in
their work to determine whether AS and
AD can be reliably differentiated, is also
using a theory-of-mind task and salient
social skills measures to study differences
between high-functioning persons with
AD and those with AS. Their research
also focuses on brain structure and func-
tion, visual tracking, behavioral manifes-
tations, family and molecular genetics,
and psychopharmacology to identify
whether external differences exist be-
tween AD and AS. Whether AS and AD
are distinctive disorders remains an em-
pirical question.
Diagnosing Asperger
Syndrome
Currently, AS, like AD, is a clinical diag-
nosis. Therefore, it is mandatory to have
trained and experienced providers to co-
ordinate the results of the complex diag-
05. freeman, pp. 145-151 8/29/02 10:36 AM
FOCUS ON AUTISM AND OTHER DEVELOPMENTAL DISABILITIES
148
nostic process and to determine the vari-
ety, intensity, and comprehensiveness of
services required. The American Acad-
emy of Child and Adolescent Psychiatry
published practice parameters for the as-
sessment of individuals with AD and
PDD (Volkmar, Cook, Pomeroy, Real-
muto, & Tanguay, 1999). A multiaxial
approach was suggested, to interpret spe-
cific behaviors in the context of intellec-
tual, communication, social, emotional,
and other skills. Evaluators must be
knowledgeable of the full range of symp-
toms in both AD and AS.
Second, it is important to assess all
areas of development independently and
identify the child’s relative strengths and
weaknesses. Independent assessment in
terms of intellect, communication, be-
havioral presentation, and functional ad-
justment must be noted throughout the
evaluation. Results should indicate a di-
agnosis, organize specific services, mea-
sure efficacy of intervention, and provide
prognostic information. Because AS and
AD both imply that multiple areas of de-
velopment are affected, all areas must be
evaluated in the context of developmen-
tal level.
Similarly, behaviors must be examined
for developmental delay or deviance. Is-
sues in assessment will vary with the age
of the child examined and the context of
the evaluation. The certainty of a diag-
nosis will always depend on the reliabil-
ity and certainty of data obtained from
multiple sources. It is mandatory that a
child be observed in both structured and
unstructured environments. Parents or
primary caregivers must provide histori-
cal information, with additional informa-
tion supplied by other professionals.
Developmental History
Pertinent developmental information in-
cludes (a) pregnancy, neonatal, and post-
natal history, with a specific focus on
social, communication, and motor skills;
(b) medical history, including a discus-
sion of possible seizure and sensory defi-
cits, such as ones involving hearing and
vision; (c) history of behavior-modifying
medications; (d) family history of devel-
opmental disorder and psychiatric illness;
Page 148
and (e) family and psychosocial factors.
Aspects of the assessment will vary de-
pending on the child’s age, history, and
previous evaluations; however, the first
and most important step is to gather his-
torical information (developmental mile-
stones) by interviewing the primary care-
giver. When gathering a developmental
history, one should ask parents or care-
givers about their initial concerns about
the individual’s development. The clini-
cian must be aware of features important
in the differential diagnosis, such as the
nature of social relatedness in the first
year of life, inconsistencies in speech and
communication development, and atypi-
cal responses to the environment.
For parents of older children, it is
sometimes helpful to describe a major
event in the child’s history, such as his
first birthday party. Information from
photo albums, baby books, and videos is
also useful. The clinician may use rating
scales and symptom checklists to gather
information (but never in isolation to
make a diagnosis). The clinician should
obtain a history of interventions, that
is, which interventions have been at-
tempted, their quality, intensity, and ap-
propriateness, and the benefit derived. In
addition, it is important to obtain infor-
mation from teachers and other profes-
sionals.
Early social communication skills are
an important area of focus. Typical chil-
dren, by 4 to 5 months of age, are at-
tempting to interact with their parents
and caregivers. Thus, parents or care-
givers should be asked whether the child
played baby games. Although the re-
sponse is often “yes,” when they are
asked if the child initiated baby games,
deficits become evident. Other areas of
inquiry include, Did the child (a) show
separation anxiety at the appropriate
age? (b) wave good-bye at 12 months?
(c) incorporate other nonverbal ges-
tures? (d) imitate at the appropriate age?
and (e) let the parent or caregiver know
if he or she was wet or hungry and, if
so, how? Descriptions of the child’s first
nursery school experience, and concerns
the nursery school teacher might have re-
ported, are pertinent to the evaluation
process. With this information, behav-
ioral changes, adaptation, and develop-
ment are documented.
Use of Rating Scales
Structured, systematic assessment pro-
vides further information for diagnostic
clarification; however, rating scales were
not designed to be used in isolation to
make a diagnosis. They are useful to the
clinician but are only one source of qual-
itative information for a comprehensive
clinical assessment.
Specific instruments that have been
widely used in diagnostic evaluations of
autism spectrum disorders include the
Checklist for Autism in Toddlers (CHAT;
Baron-Cohen, Allen, & Gillberg, 1992),
used for assessment of children prior to
18 months of age; the Autism Behavior
Checklist (ABC; Krug, Arick, & Almond,
1980), a screening instrument com-
pleted by the parents or teachers; the
Childhood Autism Rating Scale (CARS;
Schopler, Reichler, & Renner, 1998),
which requires training and primarily
assesses sensory motor behaviors; the
Autism Diagnostic Interview–Revised
(ADI-R; Lord, Rutter, & LeConteur,
1994) a structured interview for parents;
and the Autism Diagnostic Observation
Schedule (ADOS; Lord et al., 1989), a
measure of social communication. Both
the ADI and the ADOS require training
to administer. Furthermore, they are
most useful in discriminating between
the absence and the presence of ASD,
AD, or PDD. They have not yet been
standardized for further diagnostic clari-
fication.
A number of rating scales specific to
AS have been developed, but as these are
new instruments, there is little research
on them. The Asperger Syndrome Diag-
nostic Scale (ASDS; Myles, Bock, &
Simpson, 1998), is a self-report measure
with normative data on 227 responders;
the Autism Screening Questionnaire
(ASSQ; Ehlers, Gillberg, & Wing, 1999)
differentiated learning disabilities from
disruptive behaviors in 110 consecutive
referrals to a clinic; the Australian Scale
for Asperger’s Syndrome (ASAS; Attwood,
1998) does not have normative data or
cutoff scores; and the Autism Screening
05. freeman, pp. 145-151 8/29/02 10:36 AM
Questionnaire (ASQ; Berument, Rutter,
Lord, Pickles, & Bailey, 1999) has cutoff
scores and was normed on 200 individu-
als with a variety of neuropsychiatric di-
agnoses. All of these questionnaires have
been designed as screening measures
only and cannot be substituted for clini-
cal assessment.
Medical Assessment
The goal of a medical assessment is to
search for a treatable medical condition.
A medical assessment includes a careful
medical history, physical examination,
auditory and visual examinations, neuro-
logical assessment, and laboratory stud-
ies, if necessary. Currently, there are no
specific medical tests recommended for
individuals in association with the diag-
nosis of AS.
Psychological Assessment
To allow diagnosis of a developmental
disability, including PDD, the evaluation
must include both a cognitive (intelli-
gence) and an adaptive assessment. The
psychological assessment includes devel-
opmental and intelligence testing. It is
critical to independently assess verbal and
nonverbal skills. In addition, skills and
abilities typically measured to identify
mental retardation develop inconsis-
tently in individuals with AS and AD, so
it is not possible to diagnose mental re-
tardation in children under 5 years of age
who also have ASD. Extreme caution is
necessary to avoid a diagnosis of mental
retardation too early in development.
Measuring adaptive skills is an impor-
tant part of the psychological assessment.
Specifically, this includes a current sum-
mary of the individual’s independent
daily functioning in the areas of commu-
nication, self-help skills, social skills, and
motor skills. In typical development,
when a skill is mastered, it is used and
generalized. For example, when a child
masters toileting, he toilets appropriately
in all environments. In children who have
mental retardation, difficulties and delays
are evident in developmental and cogni-
tive measures but are not as prominent
in social adaptive skills. The opposite is
Page 149
VOLUME 17, NUMBER 3, FALL 2002
often true in children with ASD: Chil-
dren perform well on the developmental/
intelligence measures but exhibit signifi-
cant impairments in adaptive skills. The
Vineland Adaptive Behavior Scales (Spar-
row, Ball, & Cicchetti, 1984) are ex-
tremely useful for assessing social adap-
tive skills.
In addition to assessment of
development/intelligence and adaptive
skills, it is important to assess academic
skills independent of intelligence testing
in the school-age child. There are chil-
dren with ASD who develop academic
skills at a faster rate than their intellectual
skills. For example, a child may read be-
fore learning to speak.
Assessment of Communication
To evaluate communication, one must
first ask the question, Is the child verbal
or mute? If the child is mute, is there any
attempt at nonverbal communication? If
the child is verbal, does he or she initiate
and maintain a conversation? What is
characteristic of the child’s language?
Qualitatively, is the child’s speech fluent
(full sentences), echolalic (including pro-
noun reversals) or characterized by pe-
dantic language? Is the voice quality mo-
notonic? Does the child pursue one topic
regardless of the conversation? Does the
child make inferences, understand hu-
mor, respond to indirect requests, and
take into account the perspective of his
conversational partner? And, finally, is
there any suggestion of disturbances in
thought process or content?
Language Assessment
Speech, language, and communication
assessments are important for indicating
the deficits evident in language process-
ing and pragmatics. Primary deficits do
not always include an inability to speak or
receptive and expressive vocabulary defi-
cits. Therefore, an evaluation for speech
is insufficient and should be accompa-
nied by a comprehensive communication
assessment. In early diagnosis, the ques-
tion is, In the absence of language, has
the child developed an alternative means
of communicating to compensate? If so,
149
how does he or she communicate? Clearly,
an assessment needs to indicate goals for
the intervention required to teach a child
communication skills.
Occupational and Physical
Therapy Assessment
In addition to the prior evaluations men-
tioned, occupational and physical ther-
apy assessments are often an important
part of the initial process of determining
whether a child has any motor delays or
hypo- or hypersensitivities to sensory
stimuli. Many children with AS present
with gross and fine motor delays.
Family Assessment
Assessment of the family and parental
support system is mandatory, including
the effects of the diagnosis on typical sib-
lings. This is particularly important for
preschool children, as the family is the
most important source of their support
and is integral to coordinating educa-
tional and community services.
Mental Status Assessment
Once historical information is obtained,
it becomes important for the examiner to
assess the child’s behavioral presentation
in a mental status examination. The ex-
amination must occur in both structured
and unstructured settings and must in-
clude observation of the child’s rela-
tionships and behavior with familiar and
nonfamiliar people. The mental status
examination, as well as the developmen-
tal history, should attend to the areas
relevant for diagnosis, including social
interactions, communication skills, re-
stricted range of interest, and unusual
behaviors.
Assessment of Social
Interaction
Observational queries include the fol-
lowing: Is the child interested in social
interaction or is he or she aloof ? How
does the child respond to peers’ over-
tures? Does the child passively accept so-
cial interactions but not initiate? Is the
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FOCUS ON AUTISM AND OTHER DEVELOPMENTAL DISABILITIES
150
child interested in a variety of social in-
teractions, or is he limited to his eccen-
tricities or restricted interests? Does the
child use eye contact to regulate social in-
teractions? Does the child use any other
nonverbal behaviors to regulate social
interaction? What is the nature of the
child’s attachment to the family? Does
the child share in the enjoyment of oth-
ers? Does the child have friends? Are his
or her peer relationships appropriate to
his or her developmental level?
Restricted Range of Interests
Once social interaction and communica-
tion skills have been assessed, it is neces-
sary to assess whether or not the child has
a restricted range of interests and displays
unusual behaviors. The questions should
include, Does the child have a particular
preoccupation or special interest? If the
child has a special interest, does it inter-
fere with functioning? Does the individ-
ual have difficulty with change? Does he
or she have difficulty with transitions or
have specific routines? Are stereotypic
motor movements present, and if they
are present, when do they occur and can
they be interrupted? Is the child preoc-
cupied with parts of objects? Does the
child have hand-wringing behavior often
associated with Rett’s Disorder?
Other Assessments
In addition to attending to the areas of
diagnostic concern and the criteria listed
in DSM-IV-TR, it is also important to as-
sess play behaviors in the young child and
leisure activities in the older individual.
Questions that pertain to both the young
child and the developmental history of
the older individual include the follow-
ing: Were play materials used in a truly
imaginative way? Have unusual aspects of
the play material, such as the feel or the
sound, preoccupied the child? Was play
repetitive and stereotypic in nature? In
addition, by observing play in young
children, it is possible to obtain an esti-
mate of a child’s cognitive ability, as
play reflects cognitive abilities. The ex-
aminer should note the current develop-
mental level of play (e.g., sensory-motor,
Page 150
functional–symbolic, simple constructive,
imaginative, dramatic and social play).
Often, in children with ASD, the devel-
opmental level of play is lower than their
measured cognitive abilities.
Differential Diagnosis
Because there is so much confusion
around the diagnosis of AS, it is difficult
to assess comorbidity and other diag-
noses. To date, the literature has relied
primarily on case reports. Conditions
that have been reported to be associated
with AS include psychosis, depression,
obsessive–compulsive disorder, ADHD,
oppositional–defiant disorder, and inter-
mittent explosive disorder. Tantum (2000)
reviewed the literature on comorbid psy-
chiatric conditions with persons diag-
nosed with AS and suggested that all of
these comorbid conditions are secondary
to the core social deficits in AS.
Studies of prognosis for children with
AS have been fraught with similar meth-
odological problems. Howlin (2000) re-
viewed the outcomes studies to date and
found that they are confounded by the
fact that AS and AD are difficult to sep-
arate. A summary of studies to date sug-
gests that persons with high-functioning
AD and AS may succeed as adults but
with a great deal of difficulty, and most
rely on their families. Social contacts usu-
ally center on their special interests,
rather than close friendships. The con-
stant pressure to fit in may lead to other
psychiatric difficulties. Most of the peo-
ple who have been studied to date have
not had early intervention; there is a need
for better educational, vocational, social,
and emotional support programs to help
people challenged by AD and AS.
Summary
The difference between AS and AD re-
mains an interesting research issue. Un-
fortunately, this poses significant chal-
lenges for clinicians when assigning
either of these diagnoses. Most research
indicates a great deal of overlap in symp-
tomatology, specifically in the core social
deficits. However, differences between
AS and AD persist in early child develop-
ment, specifically related to language and
cognitive abilities, comorbid conditions
and symptoms, and adaptive functioning.
Although AS and AD may be distinct di-
agnostic categories, a spectrum exists in
each category. Regardless, if AS is shown
to be a disorder distinct from AD, we
need to develop differences related to
phenomenology, the natural course of
the disorder, neurobiological markers,
family history, response to treatment,
and appropriate behavioral and psy-
chopharmacological interventions. In
the interim, there are clearly groups of
children who are very verbal and have in-
tense interests who require (early) diag-
nosis and appropriate early intervention,
with a particular focus on improving so-
cial, communication, and vocational
skills. In addition, there continues to be
an increased need for public awareness of
the abilities, not disabilities, of people di-
agnosed with ASD, including inaccurate
depictions in the media.
ABOUT THE AUTHORS
B. J. Freeman, PhD, is a psychologist and pro-
fessor of medical psychology in the Department
of Psychiatry and Biobehavioral Science at the
University of California, Los Angeles, School of
Medicine. Currently, she is the co-director of an
early intervention and assessment partial hos-
pitalization program for children diagnosed
with developmental disabilities between the ages
of 3 and 7 years. In addition, she is the director
of the Autism Evaluation Clinic in the out-
patient department of psychiatry. Pegeen Cro-
nin, PhD, is a psychologist and associate direc-
tor of the outpatient Autism Evaluation Clinic
in the Department of Psychiatry at UCLA. She
has been working with Dr. Freeman since the
inception of this clinic 4 years ago, and contin-
ues to provide services and training to both the
inpatient and partial hospitalization services.
In addition, with Dr. Freeman, Dr. Cronin has
been a contributing member to the variety of re-
search projects related to autistic disorder. Pete
Candela, MS, has extensive experience working
with children and families affected by autistic
disorder. He works as a case manager in assist-
ing families as they seek educational and com-
munity services. In addition, he leads social
skills groups for children who present with au-
tism. Address: B. J. Freeman, UCLA Neuro-
psychiatric Institute, Department of Child and
Adolescence Psychiatry, 300 UCLA Medical
05. freeman, pp. 145-151 8/29/02 10:36 AM
Plaza Room 1261, Box 956967, Los Angeles,
CA 90095-6967.
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