Chapter 6

    The Understanding and Expression of Emotions    

 The children cannot be understood simply in terms of the concept ‘poverty of emotion’ used in a quantitative sense. Rather what characterises these children is a qualitative difference, a disharmony in emotion and disposition.   Hans Asperger (1944)     Extensive clinical experience and autobiographies confirm that while the person with Asperger’s syndrome can have considerable intellectual ability, especially in the area of knowing facts, there is invariably confusion and immaturity with regard to feelings. The diagnostic assessment for Asperger’s syndrome will need to include an evaluation of the person’s ability to understand and express emotions, not only to confirm the diagnosis, but to also screen for the possibility of an additional mood disorder, especially anxiety or depression.   A qualitative difference in the understanding and expression of emotions that was originally described by Hans Asperger is acknowledged in the diagnostic criteria. The DSM-IV criteria for Asperger’s syndrome refer to ‘lack of social or emotional reciprocity’ and the diagnostic criteria in ICD-10 refer to ‘a failure to develop peer relationships that involve a mutual sharing of interests, activities and emotions’. The lack of socio-emotional reciprocity is expressed as ‘an impaired or deviant response to other people’s emotions; and/or lack of modulation of behaviour according to the social context; and/or a weak integration of social, emotional and communicative behaviours’. The criteria of Christopher Gillberg refer to ‘socially and emotionally inappropriate behaviour and limited or inappropriate facial expression’. (Gillberg and Gillberg 1989). The diagnostic criteria of Peter Szatmari and colleagues refer to ‘difficulty sensing feelings of others, detached from feelings of others, limited facial expression, unable to read emotion from facial expressions of child, and unable to give message with eyes’ [sic] (Szatmari et al. 1989) . In other words, these criteria state that the person with Asperger’s syndrome has a clinically significant difficulty with the understanding, expression and regulation of emotions.   The explanatory text included in the DSM-IV description of Asperger’s syndrome refers to an association between Asperger’s syndrome and the development of an additional or secondary mood disorder, especially depression or an anxiety disorder. Current research indicates that around 65 per cent of adolescents with Asperger’s syndrome have an affective or mood disorder. Perhaps the most common is an anxiety disorder (Ghaziuddin, Wieder-Mikhail and Ghaziuddin 1998; Gillot, Furniss and Walter 2001; Green et al. 2000; Kim et al. 2000; Konstantareas 2005; Russell and Sofronoff 2004; Tantam 2000; Tonge et al. 1999). However, the prevalence of depression is also high (Clarke et al. 1999; Gillot, Furniss and Walter 2001; Green et al. 2000; Kim et al. 2000; Konstantareas 2005). Research has indicated a greater risk of developing bipolar disorder (DeLong and Dwyer 1988; Frazier et al. 2002) and there is evidence to suggest an association with delusional disorders (Kurita 1999), paranoia (Blackshaw et al. 2001), and conduct disorders (Green et al. 2000; Tantam 2000). For teenagers with Asperger’s syndrome, an additional mood disorder is the rule rather than the exception.   Research has been conducted on the family histories of children with autism and Asperger’s syndrome and has identified a higher than expected incidence of mood disorders in family members (Bolton et al. 1998, De Long 1994; Ghaziuddin and Greden 1998, Lainhart and Folstein 1994; Micali, Chakrabarti and Fombonne 2004; Piven and Palmer 1999). The research studies acknowledged the ironic comment that ‘madness is hereditary: you get it from your children’ and examined the parents’ mood states before the child with Asperger’s syndrome was born. We do not know why there is an association between a parent (mother or father) having a mood disorder and having a child with Asperger’s syndrome. Research studies will eventually explain the association.   If a parent has a mood disorder, a child with Asperger’s syndrome could have a genetic predisposition to strong emotions. This may be one of the factors that explain problems with the intensity and management of emotions that are characteristics of Asperger’s syndrome. However, there are other factors. When one considers the inevitable difficulties people with Asperger’s syndrome have with regard to social reasoning, empathy, conversation skills, a different learning style and heightened sensory perception, they are clearly prone to considerable stress, anxiety, frustration and emotional exhaustion. They are also prone to being rejected by peers and frequently being teased and bullied, which can lead to low self-esteem and feeling depressed. During adolescence, there can be an increasing awareness of a lack of social success, and greater insight into being different to other people - another factor in the development of a reactive depression. Thus, there may be genetic and environmental factors that explain the higher incidence of mood disorders.   The theoretical models of autism developed within cognitive psychology, and research in neuro-psychology and neuro-imaging also provide some explanation as to why children and adults with Asperger’s syndrome are prone to secondary mood disorders. The extensive research on Theory of Mind skills (see Chapter 5) confirms that people with Asperger’s syndrome have considerable difficulty identifying and conceptualizing the thoughts and feelings of other people and themselves. The interpersonal and inner world of emotions appears to be uncharted territory for people with Asperger’s syndrome. This will affect the person’s ability to monitor and manage emotions, within themselves and others.   Research on Executive Function and Asperger’s syndrome suggests characteristics of being disinhibited and impulsive, with a relative lack of insight that affects general functioning (Eisenmajer et al. 1996; Nyden et al. 1999; Ozonoff, South and Miller 2000; Pennington and Ozonoff 1996). Impaired Executive Function can also affect the cognitive control of emotions. Clinical experience indicates there is a tendency to react to emotional cues without thinking. A fast and impulsive retaliation can cause the child with Asperger’s syndrome to be considered to have a conduct disorder or a problem with anger management.   Research using neuro-imaging technology with people who have autism and Asperger’s syndrome has also identified structural and functional abnormalities of the amygdala, a part of the brain associated with the recognition and regulation of emotions (Adolphs, Sears and Piven, 2001; Baron Cohen et al. 1999; Critchely et al. 2000; Fine, Lumsden and Blair, 2001). The amygdala is known to regulate a range of emotions including anger, anxiety and sadness. Thus we also have neuro-anatomical evidence that suggests there will be problems with the perception and regulation of emotions.   Research studies have also suggested that people with Asperger’s syndrome may have signs of prosopagnosia, which is rather difficult to pronounce and means face blindness (Barton et al. 2004; Duchaine et al. 2003; Kracke 1994; Nieminen-von Wendt 2004; Njiokiktjien et al. 2001; Pietz, Ebinger and Rating 2003). The person with Asperger’s syndrome has difficulty reading facial expressions. Typical people have special areas of the brain that process facial information, but this seems not to be the case for people with Asperger’s syndrome, who process faces as if they were objects and appear to only focus on the individual components of the face. This can contribute to the misinterpretation of someone’s emotional expression. For example, a furrowed brow can be one of the facial signs of being angry. However, a furrowed brow can also indicate feelings of confusion. Typical children would consider and integrate all the facial signs and context to determine which emotion is being conveyed.   We now have a psychological term, alexithymia, to describe another characteristic associated with Asperger’s syndrome, namely someone who has an impaired ability to identify and describe feeling states. Clinical experience and research have confirmed that alexithymia can be recognized in the profile of abilities of people with Asperger’s syndrome (Berthoz and Hill 2005; Hill, Berthoz and Frith 2004; Nieminen-von Wendt 2004; Rastam et al. 1997; Tani et al. 2004).  Children and adults with Asperger’s syndrome often have a limited vocabulary of words to describe feeling states, especially the more subtle or complex emotions.    The assessment of the comprehension and expression of emotions The first stage in the assessment of the communication of emotions is to establish the child’s or adult’s maturity of emotional expression, range of vocabulary to express and describe feelings, and ability to regulate or control emotions and stress (Berthoz and Hill 2005; Groden et al. 2001; Laurent and Rubin 2004). I have noted that the emotional maturity of children with Asperger’s syndrome is usually at least three years behind that of their peers, and we now have some research evidence to confirm this observation (Rieffe, Terwogt and Stockman 2000). The child may express anger and affection at a level expected of a much younger child. There can be a limited vocabulary to describe emotions and a lack of subtlety and variety in emotional expression. When other children would be sad, confused, embarrassed, anxious or jealous, the child may have only one response, and that is to feel angry. The degree of expression of negative emotions such as anger, anxiety and sadness can be extreme, and described by parents as an on/off switch set at maximum volume.   The ability to identify emotions in facial expressions can be assessed by showing the child or adult photographs of faces and asking the person to say what emotion is being expressed, noting any errors or confusion and the time taken to provide the answer. The answer may be correct, but has been achieved by time-consuming intellectual analysis of the features and reference to previous experiences of a similar facial expression. Typical children or adults can find these activities relatively easy and achievable with little intellectual effort. A child with Asperger’s syndrome can usually identify the extremes of basic emotions, such as intense sadness, anger or happiness, but the understanding of more subtle expressions such as confusion, jealousy or disbelief may be elusive.   During the diagnostic assessment I usually ask the person to make the facial expression for a designated emotion. Typical pre-school children can easily make a happy, sad, angry or scared face on request. In contrast, I have noted that some children, and even some adults, with Asperger’s syndrome have considerable difficulty with this task. The person may achieve the facial expression by physically manipulating his or her face, providing only one element, such as the mouth shape associated with being sad, or producing a grimace that does not appear to resemble the facial expression of any human emotion. The person may also explain that it is difficult to express the emotion as he or she is not experiencing that feeling at that moment.   The ability to understand, express and regulate emotions can be assessed by asking parents specific questions, for example:   ·                Does the child have any unusual emotional mannerisms, such as flapping his or her hands when excited or gently rocking when trying to concentrate or relax?   ·                Does the child understand the need in some situations for an expression of gratitude, an apology or an expression of remorse?   ·                Does the child have difficulty reading the signs of someone being bored, annoyed or embarrassed?   ·                Does the child lack subtlety or maturity in his or her expression of anger, affection anxiety and sadness?   ·                Does the child have rapid mood changes?   ·                How does the child express and respond to affection?   Conversations with parents can examine whether the child suppresses feelings of confusion and frustration at school but releases such feelings at home. I describe some children with Asperger’s syndrome as being a ‘Dr Jekyll and Mr Hyde’ - an angel at school but a devil at home. This has been described in the literature as masquerading (Carrington and Graham 2001). Unfortunately, a parent may be personally criticized for not being able to manage his or her child with Asperger’s syndrome at home. A teacher reports that the child has exemplary behaviour in class so the behaviour must be due to a defect in how the parents manage the child’s emotions. It is important that school authorities recognize that children with Asperger’s syndrome can sometimes consciously suppress their feelings at school and wait until they are home to release their anguish on younger siblings and a loving parent. Such children are more confused, frustrated and stressed at school than their body language communicates, and the constrained emotions are eventually expressed and released at home. The cause of the problem is the child not communicating extreme stress at school, and not a parent who does not know how to control his or her child.   The diagnostic assessment should also include an examination of any examples of inappropriate or unconventional emotional reactions when distressed, such as giggling (Berthier 1995), or a delayed emotional response. The child may worry about something, not communicate his or her feelings to parents and eventually, perhaps hours or days later, release the build up of emotions in a ‘volcanic’ emotional explosion. Such children keep their thoughts to themselves and replay an event in their thoughts to try to understand what happened. Each mental action replay causes the release of the associated emotions and eventually the child can cope no longer. The frustration, fear or confusion has reached an intensity that is expressed by very agitated behaviour. When parents discover what the child has been ruminating about, they often ask the child why he or she did not tell them so that they could help. However, such children are unable to effectively articulate and explain their feelings to alert a parent to their distress, and do not seem to know how a parent could help them understand or solve the problem.   Some children and adolescents with Asperger’s syndrome can feel responsible for another person’s agitation or distress and apologize or appease when he or she did not cause the other person’s feelings. Wendy Lawson explained, ‘Until recently I always believed that if someone close to me was “angry” then it must be because of me. Now I am beginning to realise that people can be unhappy or even angry, for many different reasons. In fact it may have nothing to do with me at all!’ (Lawson 2001, p.118-119).   The child may have a history of being overly attached to a parent, or detached; or having an intense emotional reaction to changes in routines or expectations, or when experiencing frustration and failure. The child may rapidly switch from one emotion to another. I ask parents if the child’s emotions over a short period of time are sometimes like a pinball in a pinball machine, bouncing between and lighting up intense emotions. Wendy Lawson wrote about her emotions and explained that ‘Life tends to be either “happy” or “not happy”, “angry” or “not angry”. All the “in between” emotions on the continuum get missed. I jump from calm to panic in one major step’ (Lawson 2001, p.119).   I have noted that many parents say that the child or adult may be most happy when alone (McGee, Feldman and Chermin 1991), or when engaged in his or her special interest (Attwood 2003). The person with Asperger’s syndrome may not associate happiness with people or not know what to do when someone is happy. Sometimes happiness is expressed in an immature or unusual way, such as literally jumping for joy or flapping hands excitedly.   Observation of the child by a clinician can reveal aspects that are qualitatively different from typical children. Hans Asperger noted that the child’s face might lack subtle emotional expressions and be unusually ‘wooden’ or mask like, sometimes having an unnatural expression, or appear unusually serious (Hippler and Klicpera 2004). An adult with Asperger’s syndrome said to me, ‘I’ve just got one facial look’, and another said, ‘People tell me to smile, even though I feel great inside.’   During the diagnostic assessment of children with Asperger’s syndrome, I tell several stories and ask the child specific questions to determine the degree of maturity in Theory of Mind abilities (see Chapter 5). The stories include descriptions of someone’s feelings, including feelings of excitement and disappointment. I carefully observe the facial expressions and body language of the child who is listening to the story, to see if the child’s expressions mirror the emotion being described. I have found that typical children will show facial expressions that indicate they are sympathizing with the central character, but children with Asperger’s syndrome often have a look of attention but not emotion. I have also noted that adults with Asperger’s syndrome may not sympathize with characters in a film, and have a ‘poker face’ when other people in the cinema are clearly expressing emotions sympathetic to the actors.   When discussing emotions, adults with Asperger’s syndrome may intellectualize feelings, despise emotionality in others and describe difficulties understanding specific emotions such as love. There is often a conspicuous emotional immaturity; the professor of mathematics may have the emotional maturity of a teenager. Despite their being notorious for becoming irritable over relatively trivial matters, I have noted that some adults with Asperger’s syndrome are renowned for remaining calm in a crisis when some typical adults would panic. This ability has been very useful for adults with Asperger’s syndrome who have been medical staff in Accident and Emergency departments of hospitals, or soldiers on active duty.   The person with Asperger’s syndrome may have an unusual or immature concept of emotions in terms of understanding that someone can have two feelings at the same time, for example being delighted to have a promotion at work but also anxious about the new responsibilities. Sean Barron explained that:   I was in my early twenties before I learned a simple rule of social interactions that opened the door to greater understanding of others: that people can and usually do feel more than one emotion at the same time. It was inconceivable to me, for instance, that someone could be happy in general, yet furious with a specific incident, etc. – that two contradictory emotions could be operating at once in the same person. (Grandin and Barron 2005, p.255)   The assessment includes an examination of the ability to identify and express emotions but also the ability to repair emotions. For children, I use a story to assess a child’s ability to understand how to repair someone’s feelings. The child is asked to imagine coming home from school, walking into the kitchen, and seeing his or her mother at the kitchen sink. She has her back to the child, who greets her, and she turns round. As she turns round, the child notices she is crying and appears to be very sad. The child is reassured that her sadness is not due to anything the child has done. I then ask, ‘If she was crying and very sad, what would you do?’   The initial response of both typical children and those with Asperger’s syndrome is to ask her what’s wrong. I commend the response and then say, ‘But what could you say or do that would make her feel better?’ Typical children quickly suggest words or gestures of affection to cheer her up. Children with Asperger’s syndrome tend to prefer a practical action to make her feel better, such as getting her some tissues for the tears, making her a cup of tea, doing their homework, talking to her about their special interest (which is what would cheer up the child) or leaving her alone so that she will get over it more quickly.   Sometimes children with Asperger’s syndrome will suggest a hug, but when asked why that would help, may reply that they don’t know why, but it is what you are supposed to do. The child with Asperger’s syndrome does care and genuinely wants her to feel better, but emotional repair is achieved by a practical action, solitude or imitating the observed response of others. The conspicuous absence or quality of words and gestures of affection is clinically significant, not only in terms of a diagnosis but also in identifying the emotional repair mechanisms that are effective for the child. The clinician examines the quality and quantity of emotional repair suggestions as part of the diagnostic assessment, but the information can be valuable in determining which emotional repair strategies are likely to be effective if the child needs treatment for a mood disorder.   As much as there can be problems with the understanding, expression, regulation and repair of emotions, there can also be problems regarding the confidence to respond appropriately. I had just diagnosed Asperger’s syndrome in a young boy during a diagnostic assessment at the family home. The son went to the neighbour’s house so that we could discuss the diagnosis, remedial strategies and likely prognosis. As I confirmed the diagnosis, the child’s mother, who had suspected for several years that her son had Asperger’s syndrome, released her feelings in a torrent of tears. The tears were of relief not despair. I intuitively knew that she needed comforting. As she was sitting next to her husband, I anticipated that her husband would comfort her. However, he showed no emotion or attempt to console her. A little later, after some discussion of the family and relationship history, and while her husband was out of the room, she asked me if there were signs of Asperger’s syndrome in her husband. There were in fact many signs in his descriptions of his childhood and current profile of abilities. When he returned to the room, I asked him if he could tell me what he was thinking when his wife was crying a short while ago. He said, ‘I knew she was upset, but I didn’t want to do the wrong thing.’   In summary, the person with Asperger’s syndrome may have difficulty understanding the cues that indicate feelings; as one child said, as his mother was crying, ‘Why is it raining in your eyes?’ There can be difficulty knowing how to respond to the cues; a child saw his young sister fall from a swing.  As she approached him and his mother, in tears, he asked his mother, ‘What face do I make?’ Those who do develop the ability to read the signals may not have the confidence to respond in case they make a mistake and there can be a limited range of emotional repair mechanisms.   Rating scales for emotions There are several self-rating scales used by clinicians to measure the degree of depression, anxiety or anger that have been designed for typical children and adults but can also be administered to children and adults with Asperger’s syndrome. However, there are specific modifications that can be used for someone with Asperger’s syndrome. He or she may be more able to accurately quantify an emotional response using a numerical representation of the gradation in experience and expression of emotions rather than a precise and subtle vocabulary of words. I use the concept of an emotion ‘thermometer’, bar graph or a ‘volume’ scale. These analogue measures are used to establish a baseline assessment as well as being incorporated in the emotion education component of the treatment of a mood disorder.   The assessment of the understanding and expression of emotions should include the construction of a list of behavioural indicators of mood changes. The indicators can include changes in the characteristics associated with Asperger’s syndrome: for example, an increase in time spent engaged in solitude or in the special interest; rigidity or incoherence in thought processes due to anxiety or depression; or behaviour intended to impose control in the person’s daily life and over others. This is in addition to conventional indicators such as panic attacks, comments indicating low self-worth, and episodes of anger.   The person and his or her family can also complete a daily mood diary to determine whether there is any cyclical nature to, or specific triggers for, mood changes. For example, if the child has an anxiety disorder, parents can consider the child’s level of anxiety during the day and rate the level of anxiety on a scale from zero to twenty. A score near zero would indicate a relatively relaxed day, ten a typical level of anxiety and a score near twenty would indicate the child was extremely anxious that day. Over time a pattern can emerge. This can be related to a menstrual or lunar cycle, a particular time of year or a clear cycle or wave pattern that may or may not be related to environmental factors. Medical investigations can then determine whether the person has an unusual fluctuation in hormones or a cycle of mood swings that suggests a diagnosis of bipolar disorder.   Anxiety disorders We all feel a little anxious sometimes, but many children and adults with Asperger’s syndrome appear to be prone to being anxious for much of their day, or to be extremely anxious about a specific event. The late Marc Segar had Asperger’s syndrome and in his essay ‘The Battles of the Autistic Thinker’ wrote that one thing autistic people are often good at is worrying. I have talked to adults with Asperger’s syndrome who have needed treatment for chronic anxiety, and many have said that they cannot think of a time in their lives when they did not feel anxious, even in very early childhood. I am not sure if this is a constitutional feature for some people with Asperger’s syndrome or a result of being overly stressed from trying to socialize and cope with the unpredictability and sensory experiences of daily life.   The specific event that can elicit feelings of anxiety can be anticipated change such as a replacement class teacher for the day, unexpected changes in routines, public criticism or praise, or a sensory experience. Very sensitive sensory perception, especially for sounds, can cause the person with Asperger’s syndrome to worry about when the next painful sensory experience will occur. My sister-in-law has Asperger’s syndrome, and the sound of a dog barking is an excruciating experience for her. At times, this has caused her to be almost agoraphobic, fearing leaving her home as a journey to the local shops could include hearing a dog bark. The sensory sensitivity will create a feeling of anxiety, but unfortunately feeling anxious also heightens sensory perception, and the combination of sensory sensitivity and anxiety thus has a profound effect on the person’s quality of life.   Being anxious will affect the person’s thinking and lead to the development of strategies to reduce the level of anxiety. When we are relaxed, our bodies are flexible but when anxious we tense our muscles and become rigid. The same occurs for thinking and problem solving. When a person with Asperger’s syndrome is anxious, his or her thinking tends to become more rigid. One of the signs of anxiety for such individuals is ‘tunnel vision’ or a ‘one track mind’ in thinking. Marc Segar said that ‘The problem with worrying is that it will often distract you from what you need to be concentrating on if you are to solve the problem.’   A means of avoiding anxiety-provoking situations is to develop the type of personality that is unfortunately perceived as controlling or oppositional. The child can use tantrums, emotional blackmail, rigid defiance and non-compliance to ensure he or she avoids circumstances that could increase anxiety. Another way of avoiding situations associated with anxiety is to retreat into solitude or the special interest. The greatest anxiety is usually associated with social situations, and being alone ensures the person does not make any social errors or suffer humiliation or torment by others. The special interest can be so engrossing and enjoyable that no anxious thought intrudes into the person’s thinking. Clinicians also need to be aware that one way of reducing anxiety is self-medication, using alcohol and cannabis.   When the level of anxiety is extreme and long-standing, there can be a breakdown of the sense of reality such that the person develops mood congruent delusions. The obsession can become a delusion, especially when resistance to obsessive or intrusive thoughts is abandoned and insight disappears. The thinking appears disorganized and psychotic, and clearly the person displaying such characteristics should to be referred to a psychiatrist who specialises in the treatment of mood disorders in someone with Asperger’s syndrome.   Having suffered long-term anxiety, the person will become extremely sensitive to any situation that could increase anxiety. There can be a tendency to ‘press the panic button’ too quickly. This will also affect the quality of life of those who support the person with Asperger’s syndrome who has a chronic anxiety disorder. Family life is affected in terms of avoiding potentially anxiety provoking situations, with the person with Asperger’s syndrome and family members feeling they are ‘walking through an anxiety minefield’.   For some people with Asperger’s syndrome, there can be worries about events and experiences that are very unlikely to happen. Marc Fleisher has written a book on survival strategies for people with Asperger’s syndrome. He describes his own anxiety and that:   One critical observation is the fact that as much as 99 per cent of the things that worried me never happened. Autistic people can waste an incredible amount of energy getting every part of their body tensed up in a state of anxiety while dwelling on something that they will probably never have to face. (Fleisher 2006, p.32)   The most common types of anxiety disorders for children and adults with Asperger’s syndrome are Obsessive Compulsive Disorder (OCD), Post Traumatic Stress Disorder (PTSD), school refusal, selective mutism and social anxiety disorder (Ghaziuddin 2005).   Obsessive Compulsive Disorder About 25 per cent of adults with Asperger’s syndrome also have the clear clinical signs of Obsessive Compulsive Disorder (Russell et al. 2005). In OCD the person has intrusive thoughts that he or she does not want to think about: the thoughts are described as egodystonic, i.e. distressing and unpleasant. In typical people the intrusive thoughts are often about cleanliness, aggression, religion and sex. Clinical experience and research studies indicate that the obsessive thoughts of children and adults with Asperger’s syndrome are much more likely to be about cleanliness, bullying, teasing, making a mistake and being criticized than the other categories of intrusive thoughts (McDougle et al. 1995). The vulnerable times to develop OCD in the general population and for those with Asperger’s syndrome are between 10 and 12 years and the early adult years (Ghaziuddin 2005). Treatment for OCD is a combination of psychotherapy such as Cognitive Behaviour Therapy (see subsequent section of this chapter), and medication.   Sometimes parents describe the person’s special interest as an ‘obsession’ which suggests a diagnosis of OCD, but there is a distinct qualitative difference between an interest and a clinical obsession. The person with Asperger’s syndrome clearly enjoys the interest: it is not egodystonic and therefore not necessarily indicative of OCD (Attwood 2003; Baron-Cohen 1990).   Compulsions are a sequence of actions and rituals, usually with a repetitive quality, to reduce the level of anxiety. This can include actions such as washing hands to prevent contamination by germs, or checking several times that all the electricity switches in a house are in the off position. The typical behaviour of children with Asperger’s syndrome includes repetitive or compulsive actions. This can include ensuring that objects are in a line or symmetrical, hoarding and counting items or having a ritual that must be completed before the child can fall asleep. While these are known characteristics of Asperger’s syndrome, the additional diagnosis of OCD is made when the intensity or degree of expression has gone beyond that expected of someone with Asperger’s syndrome, and reached clinical significance. However, what is clinically significant is the subjective decision of the psychologist or psychiatrist.   Post Traumatic Stress Disorder Post Traumatic Stress Disorder (PTSD) can be the consequence of experiencing a traumatic event or series of events. The clinical signs of PTSD include attempts to avoid the incident or memories of the incident, and signs of anxiety, depression, anger and even hallucinations associated with the precipitating event or events. In the general population, PTSD is associated with war experiences and sexual, physical and emotional abuse. I know that severe and repeated bullying can precipitate the clinical signs of PTSD in children with Asperger’s syndrome (see Chapter 4) and a fear of physical injury through bullying is often reported by children with Asperger’s syndrome who are anxious (Russell and Sofronoff 2004).   The person can have intrusive memories of the traumatic event that are very difficult to ‘block’. An adolescent with Asperger’s syndrome explained to me that the intrusive thoughts (about being the target of very malicious bullying) appear to almost argue with him. He explained his inner voice ‘does not let me calm down easily. It keeps on going on about what happened and going on how wrong the other person was to me.’ The original event was obviously traumatic but intrusive thoughts and mental re-enactments will cause the person to repeatedly experience the same feelings of fear and distress.   The treatment is medication and psychotherapy. I use Comic Strip Conversations (i.e. drawings of stick figures and thought, feeling and speech bubbles) to explore the child’s or adult’s traumatic experiences and to provide explanations of why the event may have occurred, the person’s perception of the event, and the thoughts and motives of various participants, including the person with Asperger’s syndrome. The cognitive restructuring component of CBT is then used to change thoughts and reactions, and achieve resolution or closure (see later section of this chapter).   School refusal Typical children can refuse to go to school for many reasons, including being anxious, wanting to avoid specific lessons and to be with friends outside the school grounds. School refusal for children with Asperger’s syndrome is usually due to anxiety. With young children this can be separation anxiety and not wanting to leave the company of their mother. The child needs the presence of a parent to provide reassurance and guidance. The classroom can be a very daunting environment which creates considerable anxiety. This can result in genuine physiological signs associated with anxiety such as nausea, headaches and bowel problems.   Later in childhood, the contrast between the lifestyle and circumstances at home and those at school can lead to school refusal. A lack of academic and social success, fear of being teased, and a sense of being overwhelmed by the experiences in the classroom and playground can lead to a phobic reaction to school. Treatment programs will need first to determine which aspects of school provoke anxiety and then to encourage success in school work and social integration.   Selective mutism Girls are more commonly affected by selective mutism than boys, and the cause of the avoidance of speech is usually anxiety. When anyone is anxious, the reaction can be one of fight, flight or freeze. Thus anxiety may make the person agitated and restless, (fight), try to escape or avoid the situation (flight), or freeze, in terms of being unable to participate or talk. Children with Asperger’s syndrome who develop selective mutism in their early years can talk fluently when relaxed, for example at home, but when in school, their level of anxiety is so severe that they are unable (not unwilling) to speak. Treatment programs should focus on which aspects of the context provoke anxiety, and developing strategies to encourage relaxation and confidence.   Social phobia Social phobia, or social anxiety disorder, would be expected to be relatively common for those with Asperger’s syndrome, especially in the teenage and adult years when they are more acutely aware of their confusion in social situations, of making social mistakes, and possibly suffering ridicule. A typical person who develops social phobia is very concerned as to what others will think of them, with a fear of being embarrassed. I have noted that young people with Asperger’s syndrome who develop signs of social phobia are more avoidant of self-criticism than the criticism of others, and have a pathological fear of making a social mistake. Treatment includes medication and CBT, but someone with Asperger’s syndrome who has social phobia will also need guidance in improving social skills, and encouragement to be less self-critical and to cope with social mistakes.   Depression Our psychological and biological models of mood disorders suggest a continuum between long-standing anxiety and depression. When anxious, the person thinks ‘What if X happens?’ But in depression, the person assumes the worst outcome is unavoidable. It is interesting that anxiety and depressive disorders both respond positively to the same medications and Cognitive Behaviour Therapy.   There are a number of characteristics of depression: physical and mental exhaustion; feeling sad or empty; and having little interest in previously pleasurable experiences. There can be social withdrawal, a change in appetite with either weight gain or loss, and a change in sleep pattern with little, or excessive, sleep. The person talks about feeling worthless and guilty, is unable to concentrate, and may have thoughts about death.   People with Asperger’s syndrome appear vulnerable to feeling depressed, with about one in three children and adults having a clinical depression (Ghaziuddin, Weider-Mikhail and Ghaziuddin 1998; Kim et al. 2000; Tantam 1988; Wing 1981). The reasons for people with Asperger’s syndrome to be depressed are many and include the long-term consequences on self-esteem of feeling unaccepted and misunderstood, the mental exhaustion from trying to succeed socially, feelings of loneliness, being tormented, teased, bullied and ridiculed by peers, and a cognitive style that is pessimistic, focusing on what could go wrong. I have listened to adolescents with Asperger’s syndrome who are clinically depressed and often heard the comment, ‘I feel I don’t belong.’ The depression can lead to a severe withdrawal from social contact and thoughts that, without social success, there is no point in life.   People with Asperger’s syndrome are often perfectionists, tend to be exceptionally good at noticing mistakes, and have a conspicuous fear of failure. There can be a relative lack of optimism, with a tendency to expect failure and not to be able to control events (Barnhill and Smith Myles 2001). As the adolescent with Asperger’s syndrome achieves greater intellectual maturity, this can be associated with an increased insight into being different and self-perception of being irreparably defective and socially stupid.   Some of the characteristics of Asperger’s syndrome can prolong the duration and increase the intensity of depression. The person with Asperger’s syndrome may not disclose his or her inner feelings, preferring to retreat into solitude, avoiding conversation (especially when the conversation is about feelings and experiences), and trying to resolve the depression by subjective thought. Typical people are better at, and more confident about, disclosing feelings and knowing that another person may provide a more objective opinion and act as an emotional restorative. Family and friends of a typical person may be able to temporarily halt, and to a certain extent alleviate, the mood by words and gestures of reassurance and affection. They may be able to distract the person who is depressed by initiating enjoyable experiences, or using humour. These emotional rescue strategies are sometimes less effective for people with Asperger’s syndrome, who try to solve personal and practical issues by themselves and for whom affection and compassion may not be as effective an emotional restorative.   The signs of depression can be the same as would be expected of typical children and adults, but clinicians who specialize in Asperger’s syndrome have noted another feature that can be indicative of depression. The special interest of the person with Asperger’s syndrome is often associated with pleasure and the acquisition of knowledge about the physical rather than the social world (see Chapter 7). However, when the person becomes depressed the interest can become morbid, and the person preoccupied with aspects of death.   Sometimes the reason for the change in the focus of the interest to the macabre can be mystifying, but is the child’s attempt to communicate confusion, sadness and uncertainty about what to do. In her book on autism and Asperger’s syndrome, Pat Howlin described Joshua, whose father was a news cameraman on war assignment. His father was missing for several days and the family was extremely worried. Joshua began asking his mother incessant questions about the weapons used by each side, and how many people were being killed. During this time of anxiety for the family, Joshua did not express worry or seek comfort from family members. On his father’s return, he wanted to know how many dead bodies he had photographed. When Joshua was asked about his apparent lack of concern or compassion, he said that he was aware that his mother and sister were upset but he was unable to reassure them since he did not know what had happened to his father, and he did not want to tell a lie - he did not know what to say. His morbid interest and questions were actually ‘a cry for help’, and his attempt to try to communicate and understand his own feelings (Howlin 2004). Parents and clinicians may need to look beyond the focus of the interest and recognize a mood disorder (anxiety or depression) that is being expressed in an unconventional way, but a way that may be expected in someone who has difficulty understanding and expressing emotions.   Clinical experience confirms that some adolescents and adults with Asperger’s syndrome who are clinically depressed can consider suicide as a means of ending the emotional pain and despair. The person carefully plans a means of suicide over days or weeks. However, children and some adolescents with Asperger’s syndrome can experience what I describe as a ‘suicide attack’, a spur of the moment decision to make a dramatic end to life. Liliana, an adult with Asperger’s syndrome, conceptualized her intense depression as a ‘soul migraine’. We recognize the occurrence of a panic attack in typical people, which can occur very quickly and be unanticipated; the person has a sudden and overwhelming feeling of anxiety. In a depression attack, the person with Asperger’s syndrome has a sudden and overwhelming feeling of depression and there can be an impulsive and dramatic attempt at suicide. The child can suddenly run in front of a moving vehicle or go to a bridge to jump from a height to end his or her life. Those who have been with the person may not have identified any conspicuous preceding depressive thoughts, but a minor irritation, such as being teased or making a mistake, can trigger an intense emotional reaction, a depression attack. The person can be restrained and prevented from injury, and remarkably, a short while later, usually returns to his or her typical emotional state, which is not indicative of a severe clinical depression.   When a person is depressed, there is also the risk of self-injury. Nita Jackson explained in her autobiography that:   Another thing about depression is that anything can cause a tear: a tune, chord sequence, a picture, an object out of place, a speck of dust on a picture frame… and then all I can think about is how to escape the pain in my head, of which the only route is through the physical. Self-abuse can take many forms. It’s not all about razors and knives. (Jackson 2002, p.63)   It is not always true that Asperger people are self-centred and uncaring. A number of my Asperger friends say they keep their self-mutilation secret because they don’t want to upset their families.  (Jackson 2002, p.63)   Treatment for a conventional clinical depression in someone with Asperger’s syndrome should be a combination of medication, Cognitive Behaviour Therapy and programs to encourage social success, self-esteem and a more optimistic outlook.  This is discussed in a subsequent section of this chapter.   Anger We do not know how common anger management problems are with children and adults with Asperger’s syndrome, but we do know that when problems with the expression of anger occur, the person with Asperger’s syndrome and family members are very keen to reduce the frequency, intensity and consequences of anger. The rapidity and intensity of anger, often in response to a relatively trivial event, can be extreme. Using the metaphor of a volume control for the emotional intensity of expression, with a gradation from one to ten, a typical child will gradually increase his or her expression of anger through all volume levels. The child or adult with Asperger’s syndrome may only have two settings, between one and two, and nine and ten. Events that may precipitate a three to eight reaction in a typical child can precipitate a nine or ten level of expression in someone with Asperger’s syndrome. Thus, for some people with Asperger’s syndrome, there appears to be a faulty emotion regulation or control mechanism for expressing anger.   When feeling angry, the person with Asperger’s syndrome does not appear to be able to pause and think of alternative strategies to resolve the situation, considering his or her intellectual capacity and age. There is often an instantaneous physical response without careful thought. When the anger is intense, the person with Asperger’s syndrome may be in a ‘blind rage’ and unable to see the signals indicating that it would be appropriate to stop.   Feelings of anger can also be the response in situations where we would expect other emotions. I have noted that sadness may be expressed as anger. When conducting a CBT program on emotion management for a group of teenagers with Asperger’s syndrome, I asked the group members how each of them expressed feeling sad. Some of the responses were typical of their peers, for example ‘be alone’, ‘go for a walk’ and ‘sometimes cry’. However, several members of the group said ‘try and smash glass’, ‘play violent computer games’ and ‘hit my pillow’. Observation of these behaviours in a typical teenager would indicate feelings of anger, not sadness. The confusing combination of anger and depression occurred when Luke said, ‘When I’m angry I say I want to kill myself.’   One of the teenagers with Asperger’s syndrome in the group informed me that when he feels sad, he ‘gets angry with someone who is trying to cheer me up.’  Words and gestures of affection are not an emotional restorative for him, and can result in an angry and aggressive response. A teenage girl in the group said, ‘Crying doesn’t work for me, so I get angry instead and throw sticks.’ For her, too, tears are not an emotional release. However, a physical and destructive action does repair the sad feeling. Unfortunately, others would interpret such behaviour as indicative of feeling angry and aggressive. When typical children and adults have a ‘negative’ emotion or thought such as feeling sad, anxious, confused or embarrassed, they have an extensive vocabulary of emotional expression that can be subtle, precise and easily understood by others. Those with Asperger’s syndrome have a limited vocabulary of emotional expression that lacks subtlety and precision and can easily be misinterpreted by others.   There are other reasons why anger management can become a problem for someone with Asperger’s syndrome. For very young children and even some adults with Asperger’s syndrome, aggression can have the function of achieving solitude. The pre-school age child feels angry due to being interrupted by other children or having to play with them, and soon learns that offensive language and aggressive gestures and actions can keep other children at a distance. Such behaviour can continue throughout life. Doug, an adult with Asperger’s syndrome who is concerned about his temper, said, ‘Anger is a tool to push people away’, and Grant said, ‘People leave me alone if I look imposing.’   In a conflict situation, typical young children will become angry and use acts of aggression to achieve possessions, dominance and control. Gradually, acts of aggression and threats are replaced by negotiation, compromise and cooperation, and the knowledge that one can sometimes get what one wants by being nice. These strategies may not be obvious to children with Asperger’s syndrome, who tend to rely on immature, but sometimes effective, confrontation strategies and emotional blackmail. I have noted that some children with Asperger’s syndrome can develop a conduct disorder in terms of using threats and acts of violence to control their circumstances and experiences. For example, they may threaten to hurt their mother if she insists on their going to school; or they may use violence to make her buy something associated with their special interest. It is interesting that such confrontational, oppositional and aggressive behaviour is usually not modelled on a member of the family. Indeed, the parents who are subjected to threats and acts of violence are often very meek people who may lack assertiveness in conflict situations.   Feelings of anger in response to what someone is doing can lead to acts of aggression as an effective means of making people stop. For example, if the child with Asperger’s syndrome is being teased or bullied, he or she may have a relatively limited range of options to end the experience. The first option is to tell the person to stop, but if this does not work, and neither has ignoring the person, nor reporting the situation to an adult, then the only option remaining for the child with Asperger’s syndrome is to engage in an act of explosive aggression to end the unbearable teasing and tormenting. I use the expression, ‘three strikes and you are out’. The child with Asperger’s syndrome may several times ask the person teasing or tormenting them to stop. If this does not work, the only alternative known to the child that will stop the other person is to use violence. Although the child may be aware of the consequences of such unacceptable behaviour, he or she cannot continue to endure being tormented, and may not know what else to do.   In Chapter 1, reference was made to the four psychological responses a child can have to the recognition of being different to other children and having the profile of abilities and behaviour indicative of Asperger’s syndrome. One of the reactions is to become arrogant, with high standards in expectations of self and others, and a tendency to feel very angry when confused or frustrated. Other people are perceived as being stupid or deliberately trying to confuse or annoy the child. Feelings of anger quickly become thoughts of retribution, destruction, punishment and physical retaliation.   A previous section of this chapter referred to a high incidence of depression in children and adults with Asperger’s syndrome. In a typical depression, there is a lack of energy, low self-esteem and self-blame. The feelings are internalized. However, sometimes depression is externalized (blaming others) rather than internalized, and associated with periods of intense emotional energy. Clinicians will use the term ‘externalized, agitated depression’. When I receive a referral for a child or adult with Asperger’s syndrome who has problems with anger management, part of the assessment process is to determine whether signs of anger are actually signs of a clinical depression and should be treated as such.   There may be neurological reasons why there is a problem with emotion management in general and anger management in particular. We know that a part of the brain called the amygdala can be structurally and functionally abnormal in children and adults with Asperger’s syndrome.  The amygdala has many functions, including the perception and regulation of emotions, especially fear and anger. A metaphor to help understand the function of the amygdala is that of a vehicle being driven on a highway. The frontal lobes of the brain are the driver, who makes executive decisions on what to do, where to go, etc. The amygdala functions as the dashboard of the car, providing the driver with warning signals regarding the temperature of the engine, the amount of oil and fuel, and speed of the vehicle. In the case of people with Asperger’s syndrome, the ‘dashboard’ is not functioning consistently. Information on the increasing emotional ‘heat’ and functioning of the engine (emotion and stress levels) are not available to the driver as a warning of impending break down.   This can explain why the child or adult does not appear to be consciously aware of increasing emotional stress, and his or her thoughts and behaviour are not indicative of deterioration in mood. Eventually the degree of emotion or stress is overwhelming, but it may be too late for the cognitive or thoughtful control of the emotion. There were no early warning signals of an emotional meltdown in observable behaviour that could be used by another person to repair the mood, or warning signals in the conscious thoughts of the person with Asperger’s syndrome to enable the person to use self-control.   While a dysfunction of the amygdala is a plausible explanation of the difficulties in emotion communication and regulation, it is speculative, and it is important to state that impaired amygdala function should not be used as an excuse to avoid appropriate responsibilities and consequences. I do not want children to say that they couldn’t help feeling angry and breaking something or hurting someone, and that it was his or her defective amygdala that was to blame.   Other reasons for problems with anger management include having a difficulty expressing feelings using words (alexithymia), and using physical acts to articulate the mood and release the emotional energy. Sometimes the anger is deliberately targeted at a person as a mood restorative. A girl with Asperger’s syndrome was famous at school for her polite and compliant behaviour but notorious for the opposite when she returned home. She had contained her stress in the classroom and playground but on returning home was verbally and physically abusive to her younger sister. When I asked her why she was so mean to her sister when she came home from school, she looked at me as though the reason was obvious and replied, ‘Because it makes me feel better.’ The psychological term for such behaviour is negative reinforcement. Hurting her sister ended her own distress and was a powerful reinforcement for the aggressive behaviour.   Sometimes acts of aggression are pre-emptive strikes. The child with Asperger’s syndrome has previous experience to suggest, or reason to believe, that a particular child will be deliberately mean to him or her. Without any provocation from the other child, the boy or girl with Asperger’s syndrome anticipates conflict and makes the first strike: ‘He was going to be mean to me, so I hurt him first.’   Unfortunately, feelings of anger and subsequent aggression further alienate the child with Asperger’s syndrome from constructive interactions with peers. Since peers do not consider the child with Asperger’s syndrome to be their friend, they can relinquish any responsibility to calm the child down when he or she is angry.   Managing rage A subsequent section of this chapter will describe Cognitive Behaviour Therapy programs for anger management, but at this stage it is important for the reader to know what to do and what not to do when the person with Asperger’s syndrome is feeling extremely angry and rapidly losing control, i.e. losing his or her temper and entering a state of rage.   We all feel angry sometimes, and I know children and adults with Asperger’s syndrome who very rarely feel angry. However, when the feelings of anger are extremely intense and lead to an explosive rage, there is a diagnostic term that may be applicable to some people with Asperger’s syndrome. Intermittent Explosive Disorder (IED) is included in the diagnostic manual DSM-IV, and is defined as follows:   The person has several discrete episodes of failure to resist impulses that result in serious assault or destruction of property, the degree of aggression is grossly out of proportion to any precipitating psychosocial stressors and not accounted for by other mental disorders such as a personality disorder, psychotic disorder, conduct disorder or ADHD, or alcohol or drugs. (American Psychiatric Association 2000, p.667)   Thus, if a person with Asperger’s syndrome has problems with the management of anger that is intermittent and extreme, there may be a relevant diagnostic category that should enable the person to access appropriate treatment.   When managing someone with Asperger’s syndrome who is feeling angry, it is important to know that some actions can cause feelings of anger to increase; these include raising your voice, confrontation, sarcasm, being emotional and using physical restraint. Raising one’s voice and confrontation (emphasizing punishments) will inflame the situation and cause the person with Asperger’s syndrome to become more agitated and less flexible in thinking, which inhibits the ability to consider appropriate options to reduce the feeling of anger. Sarcasm will make the person with Asperger’s syndrome more confused; and the other person becoming emotional, being angry, and sometimes even being affectionate, can be counterproductive and ‘add fuel to the fire’.   When I was discussing with a child with Asperger’s syndrome strategies to encourage him not to go into a rage, I asked him if a hug from his mother would help him feel better. He replied with an emphatic ‘No! It makes me madder.’ That was very useful information to know. Touch, and especially attempts at physical restraint, can increase the feelings of anger and energy levels. Sometimes asking the person ‘What’s the matter?’ can also inflame the situation, because when experiencing severe emotional distress, the person’s ability to articulate the cause of the anger can be significantly diminished and create further frustration.   I recommend that when the child or adult with Asperger’s syndrome is in a rage, the person managing the situation uses a quiet and assertive voice, perhaps not enquiring about the cause of the agitation, but focusing on distraction or more constructive means of releasing the emotional energy. This can include suggesting access to the special interest, which can be mentally absorbing and extremely enjoyable, such that the angry feelings are excluded from the person’s thoughts; solitude, to slowly calm down; or an energetic physical activity, such as a long run, to ‘burn off’ the destructive energy.     Love We know that people with Asperger’s syndrome have impaired or delayed Theory of Mind abilities that explain their difficulties conceptualizing the thoughts and feelings of other people, and conceptualizing their own thoughts and feelings. When a person with Asperger’s syndrome is referred for the treatment of a mood disorder, the referral is almost invariably resulting from concerns regarding feelings of anxiety, sadness and anger. However, from my extensive clinical experience of children and adults with Asperger’s syndrome, I would suggest that there is a fourth emotion that is of concern to the person with Asperger’s syndrome in terms of his or her understanding and expression, and that is love.   Typical children enjoy and seek affection from their parents; they are able to read the signals when someone expects affection from them and recognize when to give affection to communicate reciprocal feelings of love, or to repair someone’s feelings. Children less than two years old know that words and gestures of affection are perhaps the most effective emotional restorative for themselves and for someone who is sad. However, the person with Asperger’s syndrome may not understand why typical people are so obsessed with expressing reciprocal love and affection. For a person with Asperger’s syndrome, a hug can be experienced as an uncomfortable squeeze, and the young child with Asperger’s syndrome may soon learn not to cry, as this will elicit a squeeze from someone.   Donna Williams eloquently explained in her autobiography:   Anne screamed in terrified hysterics as one of the professionals sat on the bed beside her tucking a doll in next to her, which seemed to horrify her all the more. Oh, these symbols of normality, dolls, I thought. Oh, these terrifying reminders that one is meant to be comforted by people and if one can’t one is meant at least to feel comforted by their effigies. (Williams 1992, p.177)   When considering the feeling of love, the person with Asperger’s syndrome may enjoy a very brief and low intensity expression of affection, and become confused or overwhelmed when greater levels of expression are experienced or expected. However, the reverse can occur for some children and adults with Asperger’s syndrome, with the person needing frequent expressions of affection (sometimes for reassurance) and often expressing affection that can be overbearing for others. There may not be the varied vocabulary of affection expression that includes subtle, and for children, age appropriate expressions. For some people with Asperger’s syndrome the expression is excessive. An adult with Asperger’s syndrome said to me, ‘We feel and show affection but not often enough, and at the wrong intensity.’   In his autobiography, Edgar Schneider explains his confusion regarding love:   At one point my mother, exasperated at me, said, ‘You know what the trouble is? You don’t know how to love! You need to learn how to love!’ I was taken aback totally. I hadn’t the faintest notion what she meant. I still don’t. (Schneider, 1999, p.43)   A psychoanalytic study of Asperger’s syndrome suggests that such people do not fall in love readily (Mayes, Cohen and Klin 1993). I have conducted relationship counselling for couples where one partner has a diagnosis of Asperger’s syndrome. A question that I ask each partner is his or her description of love. The following are the thoughts of women and men who do not share their partner’s diagnosis of Asperger’s syndrome:   Love is: Tolerance, non-judgemental, supportive. Love is: A complex of beliefs that tap into our childhood languages and experiences; it is inspired when you meet someone that has a quality that maybe you admire, or do not have (admiration and respect) – or that they (someone you admire) reflects back to your ideal self – which is what you want to be or see yourself as. Love is: Passion, acceptance, affection, reassurance, mutual enjoyment. Love is: What I feel for myself when I am with another person.    The following are some of the descriptions of their partners with Asperger’s syndrome:   Love is: Helping and doing things for your lover. Love is: An attempt to connect to the other person’s feelings and emotions. Love is: Companionship, someone to depend on to help you in the right direction. Love is: I have no idea what is involved. Love is: Tolerance, loyal, allows ‘space’. Love is: I don’t know the correct answer. Love is: yet to be felt and experienced by myself.   In her book Aspergers in Love, Maxine Aston explains that:   In relationships AS men are often very honest, loyal and hardworking, most will be faithful and remain with their chosen partner for life. They will give and offer love in the ways that they can. If their partners understand Asperger syndrome they will appreciate that this giving will often take a practical form. It is unlikely that an AS man will be able to offer emotional support or empathic feelings. Some women will not be able to live with the emptiness and loneliness that this can bring. (Aston 2003, p.197)   The person with Asperger’s syndrome may have remarkable compassion for someone’s physical suffering and be clearly moved by pictures of the results of a famine or natural disaster. However, I sometimes have to explain to a person with Asperger’s syndrome that as much as blood trickling from a wound indicates physical pain, tears trickling down a face can indicate emotional pain, and there are practical actions that he or she could do to alleviate emotional pain in someone.    A child’s rare use of gestures and words of affection can be lamented by the child’s parents, and especially the child’s mother. When she expresses her love for her child, with an affectionate hug, the child’s body may become ‘stiff’ and the child may not always be soothed by demonstrative affection when distressed. A mother may wonder what she can do to console her child with Asperger’s syndrome when an expression of love and affection is rejected or simply is not an effective emotional restorative.   The child with Asperger’s syndrome may find confusing or misinterpret the expressions of love from his or her parents. For example, the mother of an anxious eight-year-old child with Asperger’s syndrome would lie next to him in his bed as he fell asleep. This was an expression of her love for him, and ensured that, as he fell asleep, he would be next to someone who loved him. When I asked the child why his mother lay next to him, his reply was, ‘She’s tired and she said that my bed is the most comfortable bed.’   Teachers soon realize that the child with Asperger’s syndrome may intensely dislike public praise that includes gestures or words of affection. The person with Asperger’s syndrome has a limited tolerance of affectionate and sentimental behaviour in others. Chris explained that, ‘I detest sentimentality, which I think is a wilful display of empty emotion over matters of no consequence, and it really should be avoided because it devalues the true expression of feeling.’ (Slater-Walker and Slater-Walker 2002, p.88)   While the person with Asperger’s syndrome can enjoy and express low levels of the expression of love, there can be a problem when he or she develops a ‘crush’ on someone during adolescence and the early adult years. The expression of love and acts of affection can be too intense. Someone’s kind act may be misinterpreted as having a more significant meaning than was intended. Due to impaired or delayed Theory of Mind abilities, the person with Asperger’s syndrome may assume that the other person feels a reciprocal level of love, and may persistently follow around and try to talk to the other person. This can result in accusations of stalking.   While we have treatment programs and medication for the management of anxiety, depression and anger, clinicians are rarely asked to treat a typical person for ‘love sickness’. However, specialists in Asperger’s syndrome are recognizing that children and adults with Asperger’s syndrome need education in the understanding and expression of affection and love, from liking someone and giving compliments, to being in love and appreciating the expectations a partner may have for sentimentality, romance and passion within the relationship. The education program on love and relationships needs to include an explanation using a series of Social StoriesÔ or Social Articles, of why typical people like affection and how it helps them; how to show you like someone and to know when they like you; and how to achieve a compromise between the level of affection enjoyed by a person with Asperger’s syndrome, and the level expected by family members and friends.   For a partner and parent with Asperger’s syndrome, therapy can include education in when and how to express love and affection, and with what frequency. Sometimes I use the strategies used in Cognitive Behaviour Therapy, such as affective education, to help the person with Asperger’s syndrome understand the concept and feelings of love; cognitive restructuring to change thinking and behaviour; and desensitization to reduce the anxiety, confusion and frustration often associated with feelings of love. The intention is to gradually increase the person’s tolerance, enjoyment, and ability and confidence to express the range of feelings we express from like to love.   Temple Grandin explained that:   My brain scan shows that some emotional circuits between the frontal cortex and the amygdala just aren’t hooked up – circuits that affect my emotions and are tied to my ability to feel love. I experience the emotion of love, but it’s not the same way that most neurotypicals people do. Does this mean my love is less valuable than what other people feel? (Grandin and Barron 2005, p.40)   Cognitive Behaviour Therapy When a mood disorder is diagnosed in a child or adult with Asperger’s syndrome, the clinical psychologist or psychiatrist will need to know how to modify psychological treatments for mood disorders to accommodate the unusual cognitive profile of people with Asperger’s syndrome. The primary psychological treatment for mood disorders is Cognitive Behaviour Therapy (CBT), which has been developed and refined over several decades. Research studies have established that CBT is an effective treatment to change the way a person thinks about and responds to emotions such as anxiety, sadness and anger (Graham, 1998; Grave and Blissett 2004; Kendall, 2000). CBT focuses on the maturity, complexity, subtlety and vocabulary of emotions, and dysfunctional or illogical thinking and incorrect assumptions. Thus, it has direct applicability to children and adults with Asperger’s syndrome who have impaired or delayed Theory of Mind abilities and difficulty understanding, expressing and managing emotions. The theoretical model of emotions used in CBT is consistent with current scientific models of human emotions, namely becoming more consciously aware of one’s emotional state, knowing how to respond to the emotion, and becoming more sensitive to how others are feeling (Ekman 2003). We now have published case studies and objective scientific evidence that CBT does significantly reduce mood disorders in children and adults with Asperger’s syndrome (Bauminger 2002; Fitzpatrick 2004; Hare 1997; Reaven and Hepburn 2003; Sofronoff, Attwood and Hinton 2005).   Cognitive Behaviour Therapy has several components or stages, the first being an assessment of the nature and degree of mood disorder using self-report scales and a clinical interview. The subsequent component is affective education to increase the person’s knowledge of emotions. Discussion and activities explore the connection between thoughts, emotions and behaviour, and identify the way in which the person conceptualizes emotions and perceives various situations. The more someone understands emotions, the more he or she is able to express and control them appropriately. The third stage of CBT is cognitive restructuring to correct distorted conceptualizations and dysfunctional beliefs and to constructively manage emotions. The last stage is a schedule of activities to practice new cognitive skills to manage emotions in real life situations.   I have designed two CBT programs, entitled Exploring Feelings, for children and adolescents with Asperger’s syndrome, one to manage anxiety, the other to manage anger (Attwood 2004a,b). A clinical psychologist usually implements a CBT program, but the Exploring Feelings programs are designed to be implemented by a psychologist (educational or clinical), psychiatrist, teacher, speech and language pathologist, occupational therapist or parent.   A previous section of this chapter has explained the assessment strategies that can be used with children and adults with Asperger’s syndrome to measure the degree of mood disorder and identify specific situations that are associated with difficulties in managing emotions. The actual therapy begins with an opportunity to learn about emotions, described by psychologists as affective education.   Affective Education In the affective education component of CBT the person learns about the advantages and disadvantages of emotions and the identification of the different levels of expression in words and actions, within the person him- or herself and others. For children, this can be undertaken as a science project. A basic principle is to explore one emotion at a time, starting with a positive emotion before moving on to an emotion of clinical concern. The psychologist or therapist often chooses the first emotion, usually happiness or pleasure. The following are activities and strategies that can be included in the affective education component of CBT.   Creation of an emotions scrapbook One of the first tasks is to create a scrapbook that illustrates the emotion. This can include pictures or representations that have a personal association with the emotion for the person with Asperger’s syndrome: for example, if the emotion is happiness or pleasure, the book can include a photograph of a rare spider for the person who has a special interest in insects and spiders. It is important to remember that the scrapbook illustrates the pleasures in the person’s life, which may not always be those more conventional pleasures of typical children or adults. I have noted that adults with Asperger’s syndrome often include pictures in their pleasures book but the pictures are usually of scenes and animals without the presence of people.   Young children can cut out and place in the book pictures of happy people from magazine advertisements and pictures of enjoyable actions and events. Pictures may also be chosen to illustrate how what may appear to be insurmountable problems can be overcome; for example, one photograph may depict the child in the first stages of learning a skill, such as riding a bicycle. A note is made of the lack of competence at this stage, and the related emotions, such as anxiety or frustration. Adjacent to this photograph, another one is placed to illustrate the child’s eventual success, and his or her enjoyment. The book can also include pictures and descriptions of favourite food, toys and people.   The education program also explores the sensations associated with the feeling, such as aromas, tastes and textures. These should be recorded in the scrapbook, which can also be used as a diary to include compliments that the person has received, records of achievement such as certificates, and memorabilia associated with enjoyable occasions. The scrapbook is regularly updated and can be used at a later stage in CBT to help change a particular mood and encourage confidence and self-esteem.   The happiness or pleasures scrapbook can also be used to illustrate different perceptions of a situation. For example, if the therapy is conducted in a group, the participants’ scrapbooks can be compared and contrasted. It will become clear that one person’s favourite topic is not necessarily another’s - talking about trains may be an enjoyable experience for one participant, but perceived as remarkably boring by someone else. Part of the education, therefore, is to explain that while a certain topic may create a feeling of well-being for you, attempting to cheer up another person by using the same topic may not be a successful strategy.   Perception of emotional states Another important aspect of affective education in CBT is to enable an individual to discover the salient cues that indicate a particular level of emotion in terms of his or her body sensations, behaviour and thoughts. These sensations can act as early warning signs of an impending escalation of emotion. In part, affective education is designed to improve the function of the amygdala in informing the frontal lobes of the brain about increasing stress levels and emotional arousal. Technology can be used to identify internal cues in the form of biofeedback instruments, such as auditory EMG and GSR machines. The intention is to encourage the person to be more consciously aware of his or her own emotional state and to be able to manage an emotion before losing cognitive control.   The affective education includes information on how to read the emotional states of others. In her autobiography Nita Jackson explained that:   I discovered that I couldn’t comprehend people’s facial expressions, what they said or the way in which they said it. Reminiscing on my early school days I realised how I used to laugh when someone cried because I thought the other person was laughing. I can’t understand how I made this mistake – all I know is that I did this often. (Jackson 2002, p.20)   The extreme facial expressions for someone crying and laughing can be very similar. Both emotions can produce tears. The confusion for someone with Asperger’s syndrome is quite understandable but can be misinterpreted by others. Children with Asperger’s syndrome can become very distressed when someone laughs in response to something they have said or done. The child may not know why someone would find the comment or actions amusing or know if the person is intending to laugh with them or to laugh at them. The affective education  activities can include strategies to improve Theory of Mind abilities (see Chapter 5), including the abilities to read facial expressions and determine the intentions of others, especially whether an act was friendly, accidental or malicious.   Affective education includes information on the facial expression, tone of voice, and body language that indicate the feelings of another person. The face is described as an ‘information centre’ for emotions. The typical errors include not identifying which cues are relevant or redundant, and misinterpreting cues. The therapist uses a range of games and resources to ‘spot the message’, and to explain the multiple meanings: for example a furrowed brow can mean anger, bewilderment, or be a sign of aging skin; a loud voice does not automatically mean that the person is angry.  Participants use pictures to compare the facial expressions of different emotions, and explore the combination of facial elements used in these expressions.   To learn how to identify mood from verbal cues, participants can listen to audiotapes of someone’s speech, and note the changes in prosody and emphasis.  Another activity is for the same sentence to be repeated using a different tone of voice to indicate the person’s mood: for example, ‘Come here’ can be whispered, shouted, accompanied with a sigh or said quickly, and has very different meanings (Pyles 2002).  Tuition in gestural communication can be provided using a modified version of ‘Charades’, by requiring the person to mime an action to and simultaneously portray a particular mood. The other participants have to guess both the action and the emotion. For example, the action could be playing tennis while feeling confused, or cleaning the dishes while feeling relaxed.   The affective education activities are also designed to increase the person’s vocabulary of emotional expression. What may often be missing are the subtle expressions of feelings, for example the states in between being mildly irritated and being in a rage, or feeling a little sad and wanting to end the suffering by suicide. Parents can be concerned that when agitated over what should be a relatively minor event, the child can have an extreme over reaction. The child realises that the jar of his favourite jam or jelly is empty, a replacement jar is not in the pantry and the shops are closed. His response can be overly dramatic, saying through his tears that it is his mother’s fault and that his mother does not love him. To a parent this is a ridiculous and hurtful over reaction but can be an example of a limited vocabulary of emotional response.    I saw a teenager with Asperger’s syndrome whose mother was concerned that several times a week he would say he was going to kill himself. I immediately conducted an examination for the clinical signs of depression. There were none. I then explained to him the concept of an emotion thermometer to measure the intensity of emotions, and wrote on a small piece of paper the words he uses that had caused so much concern: ‘I am going to kill myself.’ The thermometer had a scale from zero to ten and I asked him to place the quotation at the point on the thermometer when he would say those words. He placed the quotation at level 2. We discovered that he had an extremely limited vocabulary to express feelings of disappointment and sadness. He had remembered the words from a film when the actor was suicidal with grief, and assumed that was the way of communicating all levels of sadness.   An increase in the vocabulary of emotional expression can help when the person with Asperger’s syndrome does not know what would be the appropriate emotional response. In his autobiography, Stephen Shore explained that:   There are times when I find myself very interested in the study of feelings and emotions. This happens especially when I see someone experience a strong emotion or I sense that I don’t seem to have an ‘appropriate’ emotion for a given situation…I find that music can serve as an amplifier of feelings. If I am in a particular mood I listen to, or run in my head, music expressing that feeling…Sometimes I think that I should be feeling a particular emotion but it just doesn’t seem to be ‘there’ to feel…After my first girlfriend left to study in Sweden for a year, I played Gustav Mahler’s Ninth Symphony. The last movement in particular, helped me deal with the sadness and loss relating to her departure. Added to that was the realization that our relationship as boyfriend and girlfriend was probably over. (Shore 2001, p.107)   Measuring the intensity of emotion Once the key elements that indicate a particular emotion have been identified, it is important to use a measuring instrument to determine the degree of intensity. The therapist can use a model ‘thermometer’, ‘gauge’, or ‘volume control’, and a range of activities to define the level of expression. For example, a series of pictures of faces expressing varying degrees of happiness can be selected, and each placed at the appropriate point on the instrument. Alternatively, a variety of words that define different levels of happiness can be generated, and placed appropriately on the gauge.   Pictures of other emotions, such as sadness, anger or affection, can be less easy to find than those depicting happiness. I have used weekly news magazines to collect pictures of sad situations such as the human suffering from a natural disaster, or sports publications to obtain pictures of people expressing anger. Pictures of affection can be cut out of magazines of popular entertainers.   During therapy for emotion management it is important to ensure the child or adult with Asperger’s syndrome has the same definition or interpretation of words and gestures as the therapist, and to clarify any semantic confusion. Clinical experience has indicated that some children and adolescents with Asperger’s syndrome tend to use extreme statements when agitated. Affective education increases the person’s vocabulary of emotional expression to ensure precision and accuracy in verbal expression, thereby avoiding extreme and offensive or hurtful expressions.   Stephen Shore teaches music. He explained to me that a child with Asperger’s syndrome who is one of his music students had a problem with the gradation of emotional expression and Stephen taught him conducting to bring the concept of gradation into the physical realm. Stephen and his student would take turns conducting each other through the entire dynamic range which enabled the student to transfer this concept to emotions and other areas of his life where more than just an ‘on’ or ‘off’ approach is required.   Once the concept of a measuring instrument is established, it can also be used to determine the degree of emotional experience in particular situations. When exploring the dimension of a given emotion, questions can be asked, such as ‘How happy/sad/angry would you feel if …?’, requiring both a numerical rating on the ‘instrument’, and the associated words, facial expression, tone of voice and body language that represent that degree of expression.   This activity is particularly useful to determine the person’s emotional response to specific situations that elicit anxiety, sadness or anger, and can be used to explore how the words and actions of others affect the feelings of the person with Asperger’s syndrome. I have noticed how people with Asperger’s syndrome have considerable difficulty recognizing how their own words and actions affect the feelings of others, a consequence of impaired Theory of Mind and empathy skills. Questions can be asked, such as, ‘How happy would your mother/partner feel if you said that you love him/her?’ or, ‘How sad does he/she feel when you say …?’ This can be quite an important discovery for both parties.   Photographs of emotions, reading material and computer programs The affective education program can include the creation of a photograph album with pictures of the child and family members expressing particular emotions; or video recordings of the child expressing his or her feelings in real life situations. This can be particularly valuable to demonstrate his or her behaviour when angry. Another activity, entitled ‘Guess the message’, can include the presentation of specific, less obvious cues such as a cough as a warning sign, or a raised eyebrow to indicate doubt.   Books on specific emotions can be a valuable part of the program. The literature on emotions will need to be appropriate for the reading level of the child. For example, young children can read the Mr Men books by Roger Hargreaves, as the titles include such characters as Mr Happy and Mr Grumpy. We now have age-appropriate literature on specific mood disorders, and fictional stories can be read to discover how the central character eventually understands and is able to control his or her emotions. Some of the books that I have used with children and adults with Asperger’s syndrome to learn about emotions are included in the appendix.   An invaluable component of affective education programs for children and adults with Asperger’s syndrome are computer programs that explain how to identify the thoughts and feelings of someone (Carrington and Forder 1999; Silver and Oakes 2001). Perhaps the most widely used is Mind Reading: The interactive guide to emotions developed by Simon Baron-Cohen and colleagues (see Chapter 5). There is also a new affective education resource kit specifically designed by myself and colleagues in Denmark for children and adults with Asperger’s syndrome, the CAT-kit.  Further information is available at www.cat-kit.com   Incorporating the special interest in the affective education program It is important to incorporate the person’s special interest in the program to improve motivation, attention and conceptualization. For example, I have worked with adolescents whose special interest has been the weather, and have suggested that their emotions are expressed as a weather report. A field study for emotions for a child whose special interest is aircraft can be a visit to an airport to observe the emotions of passengers saying farewell, greeting friends and relatives, and waiting in the line for security screening. An interest in theme parks can be constructively used to explore emotions that range from the thrilling feelings of being on a roller coaster to the feeling of fear when riding the ghost train.   Alternative ways to express emotion The person conducting the affective education program can also explore different ways of expressing feelings. I have noted that while the person with Asperger’s syndrome can have considerable difficulty talking about emotions, there can be a greater eloquence and insight when expressing his or her emotions typing an e-mail, writing a diary or composing a poem; or perhaps choosing or playing music, drawing a picture that represents the emotions or recalling a scene from a movie.   Moving through the program When an enjoyable or positive emotion such as happiness or affection and the levels of expression are understood, the next component of affective education is to use the same activities and procedures for a contrasting negative emotion such as anxiety, sadness or anger. When exploring the negative emotions of anxiety and anger, activities are used to explain the concept of fight, flight or freeze as a response to perceived danger or threat. The child explores how the negative emotions of anxiety and anger affect his or her body and thinking. Adrenalin causes increased heart rate, excessive perspiration, tension of muscles, and affects perception, problem-solving ability and physical strength. Over many thousands of years, these changes have been an advantage in anxiety-provoking or life-threatening situations. However, in our modern society, we may experience the same intensity of physiological and psychological reaction to what we imagine or misperceive as a threat. It is also important to explain that when we are emotional, we can be less logical and rational and this affects our problem-solving abilities and decision-making. To be calm and ‘cool’ will help the child in both interpersonal and practical situations.   From my clinical experience, some children and adults with Asperger’s syndrome are extremely sensitive about exploring and expressing an emotion that they find very difficult to control or has caused considerable confusion or negative consequences. For example, the child may have been referred for problems with anger management but when I start to explore this emotion, the child is extremely reluctant to discuss even low levels of the expression of anger. In such circumstances I tend to start with another negative emotion that can be used to illustrate what can be achieved and to give the child confidence in being able to control other emotions before focussing on the clinically important emotion.   Cognitive restructuring The cognitive restructuring component of CBT enables the person to correct the thinking that creates emotions such as anxiety and anger, or feelings of low self-esteem. The therapist helps the person change his or her thoughts, emotions and behaviour using reasoning and logic. CBT also encourages the person to be more confident and optimistic by using the recognized qualities of a person with Asperger’s syndrome, namely logic and intelligence.   The first stage is to establish the evidence for a particular thought or belief.  People with Asperger’s syndrome can make false assumptions of their circumstances and the intentions of others due to impaired or delayed Theory of Mind abilities. They also have a tendency to make a literal interpretation, and a casual comment may be taken out of context or to the extreme. For example, another child at school may have strong feelings of anger directed at the child with Asperger’s syndrome and in the ‘heat of the moment’ say, ‘Tomorrow, when you come to school, I’m going to kill you’. The child with Asperger’s syndrome can make a literal interpretation of what was said and fear that tomorrow he or she could be killed. Another example of misinterpreting feelings or intentions, this time for affection, is when a five-year-old girl with Asperger’s syndrome came home from school, clearly worried about something and started packing a suitcase, insisting she and her mother left town that evening. Eventually her mother discovered the reason for her desperation to leave town was that a little boy of the same age had come up to her and said, ‘I’m going to marry you.’   An essential and effective component of cognitive restructuring is to challenge certain beliefs with facts and logic. Information can be provided that establishes the real intentions of others and that the statistical risk of a particular event is highly unlikely and not necessarily fatal. We are all vulnerable to distorted conceptualizations but people with Asperger’s syndrome are less able to put things in perspective, to seek clarification or to consider alternative explanations or responses. In CBT the person is encouraged to be more flexible in his or her thinking and to seek clarification, using questions or comments such as, ‘Are you joking?’, or, ‘I’m confused about what you just said.’ Such comments can also be used when misinterpreting someone’s intentions, such as, ‘Are you serious?’, or, ‘Did you do that deliberately?’, and to rescue the situation after the person has made an inappropriate response, with a comment such as, ‘I’m sorry I offended you’, or, ‘Oh dear, what should I have done? Stephen Shore uses questions such as, ‘I can see you have an expression on your face but I am unable to read it. Is there anything I said that is bothering you?’   Another aspect of cognitive restructuring is increasing the range of constructive responses to a particular situation. Unfortunately, children and adults with Asperger’s syndrome usually have a limited range of responses to situations that elicit anxiety or anger.  The therapist and child create a list of appropriate and inappropriate responses and the consequences of each response. Various options can be drawn as a flow diagram that enables the child to determine the most appropriate response in the long-term for all participants.   Comic Strip Conversations To explain alternative perspectives or to correct errors or assumptions, Comic Strip Conversations, developed by Carol Gray (see Chapter 5) can help the child or adult determine the thoughts, beliefs, knowledge and intentions of the participants in a particular situation. The strategy is to draw an event or sequence of events in storyboard form with stick figures to represent each participant, and speech and thought bubbles to represent their words and thoughts. The child and therapist use an assortment of fibre-tipped coloured pens, with each colour representing an emotion. As they write in the speech or thought bubbles, the child’s choice of colour indicates his or her perception of the emotion and thoughts conveyed or intended. This can clarify the child’s interpretation of events and the rationale for his or her thoughts and response. This technique can help the child identify and correct any misperception and determine how alternative responses will affect the participants’ thoughts and feelings.   Comic Strip Conversations also allow the child to analyze and understand the range of messages and meanings that are a natural part of conversation and interaction. I have found that children with Asperger’s syndrome often assume that other people are thinking exactly what they (the children) are thinking; or they assume other people think exactly what they say, and nothing else.  The Comic Strip Conversations can then be used to show that each person may have very different thoughts and feelings and opinions about what to think and do in a particular situation. This technique can also be used to determine what someone is likely to think or do in response to the range of alternative reactions being explored by the client and therapist. The client can then choose what to think, say and do in order to achieve the best outcome for all concerned.   An Emotional Toolbox From an early age, children will know a toolbox contains a variety of different tools to repair a machine or fix a household problem. I recently developed the concept of an Emotional Toolbox, which has proved an extremely successful strategy for cognitive restructuring and in the treatment of anxiety and anger in children with Asperger’s syndrome (Sofronoff, Attwood and Hinton 2005). The idea is to identify different types of ‘tools’ to fix the problems associated with negative emotions, especially anxiety, anger and sadness. The range of tools can be divided into those that quickly and constructively release or slowly reduce emotional energy, and those that improve thinking. The therapist works with the child or adult with Asperger’s syndrome, and the family, to identify different tools that help fix the feeling, as well as some tools that can make the emotions or consequences worse. Together they use paper and pens during a brainstorming session in which they draw a toolbox, and depict and write descriptions of different types of tools and activities that can encourage constructive emotion repair.   Physical tools The emotion management for children and adults with Asperger’s syndrome can be conceptualized as a problem with ‘energy management’, namely an excessive amount of emotional energy and difficulty controlling and releasing the energy constructively. Children and adults with Asperger’s syndrome appear less able to slowly release emotional energy by relaxation and reflection, and usually prefer to fix or release the feeling by an energetic action.   I ask the person to list the types of tools found in a tool box and use different categories of tools to represent different energy management strategies. A hammer can represent tools or actions that physically release emotional energy through a constructive activity. A picture of a hammer is drawn on a large sheet of paper and the person with Asperger’s syndrome and the therapist devise a list of safe and appropriate physical energy release activities. For young children this can include bouncing on the trampoline or going on a swing. For older children and adults, going for a run, sports practice or dancing may be used to ‘let off steam’ or release emotional energy. One child with Asperger’s syndrome nominated a game of tennis as one of his physical tools, as it ‘takes the fight out of me.’ Other activities may include cycling, swimming or playing the drums. Some household activities can provide a satisfying release of energy: these might include squeezing oranges or pounding meat in the kitchen; or adults may consider some aspect of gardening or household renovations.   Some children and adults with Asperger’s syndrome may have identified that destruction is a physical tool that can be a very effective ‘quick fix’ to end unpleasant feelings of frustration. There are some household activities that provide a satisfying and constructive release of potentially destructive energy without causing the sort of damage that requires expensive repairs.  For example, cans or packaging can be crushed for recycling, or old clothes torn up to make rags. This ‘creative destruction’ might be the repair mechanism of first choice for adolescents with Asperger’s syndrome.   Relaxation tools Relaxation tools help to calm the person, lower the heart rate and gradually release emotional energy. Perhaps a picture of a paintbrush could be used to illustrate this category of tools for emotional repair. Relaxation tools or activities could include drawing, reading and especially listening to calming music to slowly unwind thoughts and fears. People with Asperger’s syndrome often find that solitude is a very effective means of relaxing. They may need to retreat to a quiet, secluded sanctuary as an effective emotional repair mechanism. There will need to be an emotionally restoring sanctuary at home, perhaps the child’s bedroom, and a sanctuary at school - perhaps a secluded area of the classroom, or a secluded area of the playground that is safe from predatory children (see Chapter 4). Young children may relax by using gentle rocking actions or engaging in a repetitive action: this can include manipulating an object such as a stress ball, Rubik’s cube or relaxing equivalent of worry beads. Repetition and predictability can induce relaxation and an adolescent or adult with Asperger’s syndrome may listen to the same song again and again. However, this is not usually relaxing for anyone else.   Sean Barron explained that:   I have no idea how many ways there are to deal with a level of fear so great that it hangs over you like a storm cloud. The three remedies I chose and that made the most sense to me in all areas of my life were repetition, repetition and repetition. (Grandin and Barron 2005, p.85)   For adults, a routine chore such as making the house clean and tidy or organizing belongings can be a repetitive action that results in satisfaction and relaxation when complete. Such routine chores may also be used by teachers in the classroom situation. For example, a teacher who notices that a child is becoming distressed may suggest a high status responsibility that will enable the child to escape a stressful situation, such as leaving the class to take an important message or document to the school office; or she may distract the child with an activity that restores order and consistency, such as tidying the book cupboard and placing all the books in alphabetical order. An adult with Asperger’s syndrome may nominate his or her own relaxation tools for use at work and at home.   The CBT program will include training in relaxation techniques that emphasize breathing, muscle relaxation and imagery to induce a feeling of being calm and in control of one’s emotions. This is particularly valuable when the person with Asperger’s syndrome is notorious for becoming extremely agitated when something is not working, or he or she cannot solve the problem. For children, I explain that if you remain calm, you remain smart. If you become agitated you become stupid. For adults I explain that if you become anxious about solving the problem, your IQ drops 30 points, and if you become angry, the IQ drops 60 points. When calm and in control of feelings, the solution will be less elusive and more easily discovered.   When a child with Asperger’s syndrome is in an agitated state because the solution is not apparent, I ask his or her parent or teacher to first concentrate on helping the child calm down. Only when relaxed, will the child be able to listen or be flexible enough in thought to consider your suggestion or find another solution.   Social tools This category of tools uses other people or animals as a means of managing emotions. The strategy is to find and be with someone, or an animal, that can help repair the mood. The social activity will need to be enjoyable and without the stress that can sometimes be associated with social interaction, especially when the interaction involves more than one other person.   The supportive social contact needs to be someone who genuinely admires or loves the child, gives compliments (not criticism) and manages to say the right words to repair the feelings. The social emotional restorative can be a family member, friend, or member of staff at school, who has time to be patient with the child, listen (without judgement), validate feelings and be understanding. For young children, the person who is the most able emotional restorative may be a grandparent. I sometimes suggest that the grandparent record soothing comments about the child that he or she can listen to at times of stress and when the child needs to relax, for example, to fall asleep.   Sometimes the best friend may be a pet. Despite the negative mood or stressful events of the day, dogs are delighted to see their owner, show unconditional adoration and clearly enjoy the person’s company, as demonstrated by the wagging tail. Time spent in the company of animals can be a very effective emotional restorative for children and adults with Asperger’s syndrome. Pets are the best non-judgemental listeners and more forgiving than humans.   For adolescents, Internet chat lines can be a successful social activity that can be an emotional repair mechanism. People with Asperger’s syndrome may have greater eloquence and insight in disclosing their thoughts and feelings by typing rather than talking. One does not need skills with eye contact, or to be able to read a face or understand changes in vocal tone or body language when engaged in a ‘conversation’ on the Internet. The chat line can include other people with Asperger’s syndrome who have genuine empathy and may offer constructive suggestions to repair a mood or situation. I have known several mature adults with Asperger’s syndrome who have provided wise support and advice on emotion management for younger members of the ‘Asperger community’ using the Internet.   Another social tool or activity that can repair feelings of despair is the act of helping someone and being needed - an altruistic act. I have noted that some children, and especially adults, with Asperger’s syndrome can change their mood from self-criticism and pessimism to a feeling of self-worth and enthusiasm when helping others. This can include activities such as helping someone who has difficulties in an area of the child’s talents or expertise: for example, helping an adult fix a problem with a computer, or guiding another classmate who does not have the child’s ability with a subject such as mathematics. Adults with Asperger’s syndrome can enjoy and benefit emotionally from voluntary work, particularly with the elderly, very young children and animals. Being needed and appreciated is a significant emotional repair mechanism for all of us, including those with Asperger’s syndrome.   Thinking tools The child or adult can nominate another type of implement, such as a screwdriver or wrench, to represent a category of tools that can be used to change thinking or knowledge. The person is encouraged to use his or her intellectual strength to control feelings using a variety of techniques. We can control feelings and behaviour by talking to ourselves, an internal dialogue, and self-talk is a valuable emotion management strategy. The person is encouraged to use thoughts, or ‘inner speech’, such as, ‘I can control my feelings’ or, ‘I can stay calm’, when under stress. The words are reassuring and encourage self-esteem.   Evan, a young man with Asperger’s syndrome, developed his own form of thinking tools and created his ‘antidotes to poisonous thoughts’. The procedure is to think of a comment that neutralizes or is an antidote to negative (poisonous) thoughts. For example, the negative thought, ‘I can’t do it’ (poisonous thought) can be neutralized by the antidote, ‘Asking for help is the smart way to fix the problem’, or ‘I’m a loser’ can be neutralized by the antidote, ‘but I’m a winner at chess.’ A list is created of the person’s negative or poisonous thoughts and the therapist and client create a personalized antidote to each thought. Evan carried everywhere with him a list of antidotes to his poisonous thoughts, which were ‘administered’ or remembered when needed. The antidotes are based on the person’s abilities and thoughts that are logical and reasonable.   Another thinking tool is to put the event in perspective: a reality check. The approach is to use logic and facts with a series of questions such as, ‘Is there another shop where I could buy that computer game?’ or, ‘Will children teasing me about my interest in astronomy prevent me from being an astronomer?’   Temple Grandin explained that:   When I was in my twenties, my Aunt Anne successfully used cognitive therapy on me. When I was depressed and complaining, she gave me objective reasons why I should be happy. She said, “You have a nice, new truck and I have an old, crummy one.” She also gave me other examples of things that were positive or were going right in my life. It perked me up when I compared the pictures in my head of the two trucks. It concretely helped me understand that some of my thoughts were illogical and not based on fact. Emotions can do that; they confuse thinking. (Grandin and Barron 2005, p. 110)   Nita Jackson explained how she now sees in perspective a problem that previously caused feelings of intense anger.   If things anger me now I don’t charge around the room fuming, red in the face, with steam shooting out of my ears and nostrils. Instead, I apply the tactics my best friend and mentor Jodie taught me – to distract my anger by concentrating on something else for a minute, for example my studies, my music or my novels, and then returning to the problem and trying to solve it. It’s honestly true that after this, the problem doesn’t seem half as bad as it did before because I can put it in perspective. (Nita Jackson 2002, p.91)   One thinking tool that can be used by children with Asperger’s syndrome to improve mood and self-esteem is achieving academic success, which is often not the emotion repair mechanism of other children. When a child with Asperger’s syndrome is agitated, the teacher may instruct the child to complete a school activity that he or she enjoys and for which the child has a natural talent, such as solving mathematic problems or spelling. This is in contrast to other children, who would probably try to avoid academic tasks when stressed.   Cue controlled relaxation is also a useful thinking tool. The strategy is for the child to have an object in his or her pocket that symbolizes relaxation, or to which, through classical conditioning or association, he or she responds by feeling relaxed. For example, Caroline, a teenage girl with Asperger’s syndrome, was an avid reader of fiction, her favourite book being The Secret Garden. She kept a key in her pocket to metaphorically ‘open the door to the secret garden’, an imaginary place where she felt relaxed and happy. A few moments touching or looking at the key helped her to contemplate a scene described in the book and consequently to relax and achieve a more positive state of mind. Adults can have a special picture in their wallet, such as a photograph of a woodland scene, which reminds them of solitude and tranquillity.   Special interest tools Children and adults with Asperger’s syndrome can experience intense pleasure when engaged in their special interest (see Chapter 6). The degree of enjoyment may be far in excess of other potentially pleasurable experiences and can be a very effective emotional restorative. The interest can sometimes appear to be mesmerizing and dominating all thought, but this can effectively exclude negative thoughts such as anxiety and anger, and is, in effect, a form of ‘thought blocking’. The interest can be a source of intense enjoyment, relaxation and act as an ‘off switch’ when agitated.   We know that in the general population, routines, rituals and repetition are calming activities, and one of the characteristics of the special interests of children and adults with Asperger’s syndrome is the repetitive, routine and ritualistic nature of the activities associated with them. An adolescent with Asperger’s syndrome had a great interest in Japanese culture, and performed the elaborate and ritualized tea ceremony whenever she felt anxious. The activity was clearly very soothing for her. Luke Jackson (2002), a teenager with Asperger’s syndrome with remarkable ability with computers, describes the cataloguing of the examples of his interests as a means of ‘personal defrag’. The activity creates a sense of comfort and security.   I have observed that the degree of motivation and duration of time spent on the interest is proportional to the degree of stress, anxiety or agitation. The more the person experiences worries, confusion and agitation, the more the interest becomes obtrusive in thinking or dominant in the person’s daily life. If the child or adult with Asperger’s syndrome has few means of enjoyment and relaxation, i.e., few emotional repair tools in the toolbox, what may have started as a source of pleasure and relaxation, under conditions of extreme stress can become a compulsive act reminiscent of an Obsessive Compulsive Disorder. If the special interest is the exclusive source of relaxation or mental escape, then access to the interest can become irresistible, a compulsion. Being prevented from achieving uninterrupted access to such a powerful emotional restorative creates even more stress.   A program of controlled or timed access can be introduced to ensure the time spent on the interest is not excessive. Unfortunately, from the child’s point of view, time goes quickly when one is enjoying oneself. There may need to be some negotiation and compromise regarding the duration of access.   When a child with Asperger’s syndrome is extremely agitated, the range of emotion repair tools becomes limited and is often reduced to three tools, physical release of energy, solitude or having access to the special interest. The interest is not only pleasurable, but also becomes mesmerizing and no negative thoughts can intrude on the fixation. I have found that an effective ‘off switch’ can be access to the special interest. For example, if the adolescent has a special interest in soccer teams and the results of matches and the league table, suggesting writing out the results from the games played last Saturday can have a remarkably calming effect. This is not rewarding inappropriate behaviour. In an emotional emergency, it is finding a quick way of preventing further agitation in a situation where the tool box has no other tools.   Medication Medication is often prescribed for children and adults with Asperger’s syndrome to manage emotions. If the child or adult is showing clear signs of a mood disorder then medication is recommended as an emotion management tool. Clinical experience has confirmed the value of medication for the treatment of anxiety, depression and anger in children and adults with Asperger’s syndrome but there are some concerns often voiced by parents and those with Asperger’s syndrome. One concern of parents and physicians is that, at present, we do not have longitudinal studies of the long-term effect of psychotropic medication on young children with Asperger’s syndrome. However, there is evidence that low doses of such medication can benefit some adults with Asperger’s syndrome (Alexander, Michael and Gangadharan 2004)   Another concern for parents, teachers and especially the child and adult with Asperger’s syndrome, is the effect on the person’s clarity of thought.  Many children and adults with Asperger’s syndrome report that medication slows their thinking and hinders their cognitive skills. People with Asperger’s syndrome often value their clarity of thought: one adult described his reaction to medication: ‘It was like I was locked out of my own home.’ Several adults with Asperger’s syndrome who have taken anti-psychotic medication to manage anger have explained to me that the medication does not change the inner experience but reduces the energy to express the feeling.   Some mood disorders are so severe, psychotherapy such as CBT does not have the ‘strength’ to help the person manage the intense emotions. When medication has ‘lifted’ the mood or reduced the intensity of the emotion, other strategies can become more effective and may eventually replace the need for medication. However, there are those with Asperger’s syndrome whose ability to manage emotions and quality of life has been greatly enhanced by the long-term use of a relatively low dosage of medication to alleviate feelings of anxiety and depression.   While medication for emotion management can be a very valuable tool in the emotion management toolbox, my personal concern is when medication is the only tool added to the tool box because it is relatively cheap and easy to administer. It is important to establish why specific feelings occur and to address the cause of the emotion.   Other tools in the toolbox Other potential tools for the emotion management toolbox are enjoyable activities such as watching a favourite comedy. Sometimes a good laugh can be a very effective emotional restorative. Another tool is to read the autobiographies (of which there are several) of adolescents and adults with Asperger’s syndrome for inspiration, encouragement and advice.   There is one important category of tool that is used by the CBT therapist, namely education to change the knowledge and attitude of people who interact with or supervise the person with Asperger’s syndrome. Tools that change attitudes can prevent situations that can cause considerable emotional distress. At a conference I attended in the United States, a teenager with Asperger’s syndrome had the following words printed on the front of his T-shirt: ‘People like you are the reason people like me have to take medication’.   A tool that can encourage self-control is the suggestion of a prize or reward. The reward can be to earn access to preferred activities, the special interest or even money. I have noted that some children with Asperger’s syndrome are natural capitalists. Unfortunately, the subsequent problem can be inflation and manipulation of the economy.   Another category of tools, which could be described as sensory tools, involves assessing the person’s ability to cope with the sensory world and identifying strategies to avoid specific sensory experiences (see Chapter 11). For example, the position of the child’s desk in class or the adult’s workstation may be changed, and if necessary moved, to reduce the general level of noise, light intensity and proximity to aromas such as cleaning products. The chapter on cognitive abilities explains other strategies to reduce confusion and frustration when teaching academic tasks.   When a known situation will cause a child with Asperger’s syndrome to become extremely distressed, it may be wise to avoid that situation if possible. For example, if the young child is almost certainly going to become extremely anxious if his or her teacher is away for a day and there will be a temporary replacement, a Social StoryÔ could prepare the child for the changes in routine, class atmosphere and changes in behaviour of the other children. If this is not an effective strategy to prepare for the event, then parents can suggest that the child completes the assignments of the day at home.   Sometimes the degree of stress and emotional exhaustion from coping with school can have a detrimental effect on the child’s mental health. Information from the rising emotional temperature using the thermometer and mood diary can indicate an imminent ‘melt down’, and parents, therapist and teacher may determine whether the child would benefit from a short break from school. If the child was ill with a typical childhood illness, he or she would be expected to have time at home to recover. The same can occur for an emotional illness. However, parents and teachers will need to be vigilant that the child genuinely needs the break away from being at school and is not trying to manipulate the situation to his or her advantage.   Inappropriate tools When explaining the concept of an emotional toolbox, the therapist and client discuss inappropriate tools (noting that one would not use a hammer to fix a computer) in order to explain how some actions, such as violence, thoughts of suicide and engaging in retaliation, are not appropriate tools or emotional repair mechanisms. Another emotional repair strategy that could become inappropriate is the retreat into a fantasy world. The use of fantasy literature and games as a means of escape can be a typical tool for ordinary adolescents but is of concern when this becomes the dominant or exclusive coping mechanism. The border between fantasy and reality may become unclear, leading to concern regarding the development of signs of schizophrenia. The therapist also needs to assess whether teenagers or adults with Asperger’s syndrome are using illegal drugs and alcohol to manage stress levels and mood, and, if so, whether prescription medication would be more effective, and safer. Other inappropriate tools could include taking stress out on someone else through violence, self-injury or the destruction of something valuable or precious.   It is also necessary for the therapist to evaluate emotional repair tools used by parents, family members and teachers and to remove from the toolbox those that may be inappropriate or counter-productive. Children and adults with Asperger’s syndrome are often confused by certain emotions and this can be the case with the expression of affection, which can be the cause of more agitation or confusion. A teenage boy with Asperger’s syndrome was describing how sometimes he feels very sad, but pointed out, ‘I get angry when someone tries to cheer me up.’ Retaliation by sarcasm will increase the confusion and agitation of a person with Asperger’s syndrome, and threats could escalate the situation. One of the reasons why CBT is so effective with people with Asperger’s syndrome is that the strategies are based on logic not punishment. From my extensive clinical experience, punishment rarely changes the emotions and behaviour of a person with Asperger’s syndrome. Punishment may be a tool used by parents and teachers and when clearly not working, should be removed from the emotion management toolbox.   Finally, the concept of a toolbox can be extremely helpful in enabling people with Asperger’s syndrome to repair their own feelings but also to repair the feelings of others. They often benefit from tuition in learning what tools to use to help friends and family, and which tools others use, so that they may ‘borrow’ tools to add to their own emotional repair kit.   Putting the Emotional Toolbox into practice When the child has a list of emotion repair tools, the therapist can make a replica tool box. This can be an index card box, with each card representing a category of tools. Each card can have a picture of the type of tool, for example a hammer or screw driver, and the list of tools or strategies that belong in that category. As the therapy evolves, new tools can be discovered and added to the list. A parent may have the emotion thermometer on the fridge door to be easily accessible. In this way, the child can point to the degree of emotion or stress he or she is experiencing, for example when returning home from school in the afternoon, and decide which are the tools of first choice to lower the emotional temperature. Adults can use an alternative to the card box, such as a credit card wallet, with each category of tool written as a different card, and stored in the wallet for easy access.   The practical application of the emotional toolbox can be described in a Social StoryÔ. The following Social StoryÔ was written by Carol Gray and me for a teenager with Asperger’s syndrome.   Using the Toolbox to stay calm and in control   As teenagers go through each day there will be times when they feel sad, anxious, confused or frustrated. There are also times when they feel confident, calm and in control. The art and science of emotion management is learning to draw upon positive emotions and strategies to keep moving through the tough times.   Staying calm and in control is the smart thing to do.   As people grow older they learn to use their intelligence to keep their emotions in control. That way, everyone around them feels comfortable. Keeping negative feelings in control is important in a friendship and when working with others. Each person is accountable for how his or her emotions impact on others. The first step to staying in control is to know when emotions are becoming more intense. Each person has his or her own signals that their emotions are on the rise. Mine are: (list)   When emotions become stronger, each person learns to stay in control by using a personal emotion repair toolbox. My tools include: (list)   When other people know about my toolbox and how I am feeling, they can help me stay in control.   Practising CBT strategies Once the child or adult with Asperger’s syndrome has improved his or her intellectual understanding of emotions and identified strategies (or tools) to manage emotions, the next stage of CBT is to start practising the strategies in a graduated sequence of assignments. The first stage is for the therapist to model the appropriate thinking and actions in role-play with the child or adult with Asperger’s syndrome, vocalizing thoughts to monitor cognitive processes. A form of graduated practice is used, starting with situations associated with a relatively mild level of distress or agitation. A list of situations or ‘triggers’ that precipitate specific emotions is created from the emotion assessment conducted at the start of the therapy, with each situation written on a small card. The child or adult uses the thermometer or measuring instrument originally used in the affective education activities to determine the hierarchy or rank order of situations. The most distressing are placed at the upper level of the thermometer. As the therapy progresses, the person works through the hierarchy to manage more intense emotions.   After practice during the therapy session, the child or adult has a project to apply his or her new knowledge and abilities in real life situations. Successful exposure exercises are an essential aspect of CBT. The therapist will obviously need to communicate and coordinate with those who will be supporting the person in everyday circumstances. After each practical experience there is a discussion of the degree of success, using activities such as Comic Strip Conversations to debrief; reinforcement for achievements, such as a certificate of achievement; and a ‘boasting book’ or the writing of a Social StoryÔ to record emotion management success.   One of the issues during the practice stage of CBT will be generalization. People with Asperger’s syndrome tend to be quite rigid in terms of recognizing when the new strategies are applicable in a situation that does not obviously resemble the practice sessions.  It will be necessary to ensure that strategies are used in a wide range of circumstances and no assumption made that once an appropriate emotion management strategy has proved successful, it will continue to be used in all settings.   The duration of the practice stage is dependent upon the degree of success and list of situations. Gradually the therapist provides less direct guidance and support, thus encouraging confidence in independently using the new strategies. The goal is to provide a template for current and future problems, but it will probably be necessary to maintain contact for some time to prevent relapse.   Summary and concluding thoughts People with Asperger’s syndrome clearly have problems understanding emotions within themselves and others, and expressing emotions at an appropriate level for the situation. We now have strategies to help people with Asperger’s syndrome to learn about emotions, and effective psychological treatment for any secondary mood disorder. Unfortunately, typical people have difficulty empathizing with such experiences, and can only imagine what it must be like to live in a world of powerful emotions that are confusing and overwhelming. Liliana, an adult with Asperger’s syndrome, explained one of the reasons people with Asperger’s syndrome may lead an emotionally reclusive life when she said to me, ‘We don’t have emotional skin or protection.  We are exposed, and that is why we hide.’     Key points and strategies ž            A qualitative difference in the understanding and expression of emotions, originally described by Hans Asperger, is acknowledged in the diagnostic criteria for Asperger’s syndrome.   ž            The emotional maturity of children with Asperger’s syndrome is usually at least three years behind that of their peers.   ž            There can be a limited vocabulary to describe emotions and a lack of subtlety and variety in emotional expression.   ž            There is an association between Asperger’s syndrome and the development of an additional or secondary mood disorder, including depression, anxiety disorder, and problems with anger management and the communication of love and affection.   ž            About 25 per cent of adults with Asperger’s syndrome also have the clear clinical signs of Obsessive Compulsive Disorder.   ž            People with Asperger’s syndrome appear vulnerable to feeling depressed, with about one in three children and adults with Asperger’s syndrome having a clinical depression.   ž            We do not know how common anger management problems are with children and adults with Asperger’s syndrome, but we do know that when problems with the expression of anger occur, the person with Asperger’s syndrome and family members are very keen to reduce the frequency, intensity and consequences of anger.   ž            A person with Asperger’s syndrome may enjoy a very brief and low intensity expression of affection, and become confused or overwhelmed when greater levels of expression are experienced or expected.   ž            The primary psychological treatment for mood disorders is Cognitive Behaviour Therapy (CBT). 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