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? · Neuropsychiatry, Neuropsychology and Behavioural Neurology 8, 222-228. Berthoz, S. and Hill, E. (2005) ‘The validity of using self-reports to assess emotion regulation abilities in adults with autism spectrum disorder.’ European Psychiatry 20, 291-298. Blackshaw, A.J., Kinderman, P., Hare, D.J. and Hatton, C. (2001) ‘Theory of mind, causal attribution and paranoia in Asperger syndrome.’ Autism 5, 147-163. Bolton, P., Pickles, A., Murphy, M. and Rutter, M. (1998) ‘Autism, affective and other psychiatric disorders: Patterns of familial aggregation.’ Psychological Medicine 28, 385-395. Carrington, S. and Forder, T. (1999) ‘An affective skills programme using multimedia for a child with Asperger’s syndrome.’ Australian Journal of Learning Disabilities 4, 5-9. Carrington, S. and Graham, L. (2001) ‘Perceptions of school by two teenage boys with Asperger syndrome and their mothers: A qualitative study.’ Autism 5, 37-48. Clarke, D., Baxter, M., Perry, D. and Prasher, V. (1999) ‘Affective and psychotic disorders in adults with autism: Seven case reports.’ Autism 3, 149-164. Critchley, H.D., Daly, E.M., Bullmore, E.T., Williams, S.C.R., Van Amelsvoort, T., Robertson, D.M., Rowe, A., Phillips, M., McAlonan, G., Howlin, P. and Murphy, D. (2000) ‘The functional neuroanatomy of social behaviour.’ Brain 123, 2203-2212. De Long, G. (1994) ‘Children with autistic spectrum disorder and a family history of affective disorder.’ Developmental Medicine and Child Neurology 36, 647-688. De Long G. and Dwyer J. (1988) ‘Correlation of family history with specific autistic subgroups: Asperger’s syndrome and bipolar affective disease.’ Journal of Autism and Developmental Disorders 18, 593-600. Duchaine, B., Nieminen-von Wendt, T., New, J. and Kulomaki, T. (2003) ‘Dissociations of visual recognition in a genetic prosopagnosic: Evidence for separate developmental processes.’ Neurocase 9, 380-389. Eisenmajer, R., Prior, M., Leekman, S., Wing, L., Gould, J., Welham, M. and Ong, N. (1996) ‘Comparison of clinical symptoms in autism and Asperger’s Syndrome.’Journal of the American Academy of Child and Adolescent Psychiatry 35, 1523-1531. Ekman, P. (2003) Emotions Revealed: Recognizing faces and feelings to improve communication and emotional life. New York: Times Books. Fine, C., Lumsden, J. and Blair, R.J.R. (2001) ‘Dissociation between theory of mind and executive functions in a patient with early left amygdala damage.’ Brain Journal of Neurology 124, 287-298. Fitzpatrick, E. (2004) ‘The use of cognitive behavioural strategies in the management of anger in a child with an autistic disorder: An evaluation.’ Good Autism Practice 5, 3-17. Fleisher, M. (2006) Survival Strategies for People on the Autism Spectrum. London, Jessica Kingsley Publishers. Frazier, J., Doyle, R., Chiu, S. and Coyle, J. (2002) ‘Treating a child with Asperger’s disorder and comorbid bipolar disorder.’ American Journal of Psychiatry 159, 13-21. Ghaziuddin, M. (2005) Mental Health Aspects of Autism and Asperger Syndrome. London: Jessica Kingsley Publishers. Ghaziuddin, M. and Greden, J. (1998) ‘Depression in children with autism/pervasive developmental disorders: A case-control family history study.’ Journal of Autism and Developmental Disorders 28, 111-115. Ghaziuddin, M., Wieder-Mikhail, W. and Ghaziuddin, N. (1998) ‘Comorbidity of Asperger Syndrome: A Preliminary Report.’ Journal of Intellectual Disability Research 42, 279-283. Gillberg, C. and Gillberg, I.C. (1989) ‘Asperger Syndrome – Some epidemiological considerations : A research note.’ Journal of Child Psychology and Psychiatry 30, 631-638. Gillot, A., Furniss, F. and Walter, A. (2001) ‘Anxiety in high-functioning children with autism.’ Autism 5, 277-286. Graham, P. (1998) Cognitive Behaviour Therapy for Children and Families. Cambridge: Cambridge University Press. Grandin, T. and Barron, S. (2005) Unwritten Rules of Social relationships: Decoding social mysteries through the unique perspectives of autism. Arlington, TX: Future Horizons. Grave, J. and Blissett, J. (2004) ‘Is cognitive behavior therapy developmentally appropriate for young children? Review of the evidence.’ Clinical Psychology Review 24, 399-420. Green, J., Gilchrist, A., Burton, D. and Cox, A. (2000) ‘Social and Psychiatric Functioning in Adolescents with Asperger Syndrome Compared with Conduct Disorder.’ Journal of Autism and Developmental Disorders 30, 279-293. Groden, J., Diller, A., Bausman, M., Velicer, W., Norman, G. and Cautella, J. (2001) ‘The Development of a Stress Survey Schedule for Persons with Autism and Other Developmental Disabilities.’ Journal of Autism and Developmental Disorders 31, 207-217. Hare, D.J. (1997) ‘The use of Cognitive-Behavioural Therapy with people with Asperger Syndrome:A case study.’ Autism 1, 215-225. Hill, E., Berthoz, S. and Frith, U. (2004) ‘Cognitive processing of own emotions in individuals with autistic spectrum disorder and in their relatives.’ Journal of Autism and Developmental Disorders 34, 229-235. Hippler, K. and Klicpera, C. (2004) ‘A retrospective analysis of the clinical case records of “autistic psychopaths” diagnosed by Hans Asperger and his team at the University Children’s Hospital, Vienna.’ In U. Frith and E. Hill (eds) Autism: Mind and Brain. Oxford: Oxford University Press. Howlin, P. (2004) Autism and Asperger Syndrome: Preparing for Adulthood, 2nd edition. London: Routledge. Jackson, L. (2002) Freaks, Geeks and Asperger Syndrome: A User Guide to Adolescence. London: Jessica Kingsley Publishers. Jackson, N. (2002) Standing Down Falling Up: Asperger’s syndrome from the inside out. Bristol: Lucky Duck Publishing. Kendall, P.C. (2000) Child and Adolescent Therapy: Cognitive Behavioural Therapy Procedures. New York: The Guilford Press. Kim, J.A., Szatmari, P., Bryson, S.E., Streiner, D.L. and Wilson, F. (2000) ‘The Prevalence of Anxiety and Mood Problems among Children with Autism and Asperger Syndrome.’ Autism 4, 117-132. Konstantareas, M. (2005) ‘Anxiety and depression in children and adolescents with Asperger syndrome.’ In K. Stoddart (ed) Children, Youth and Adults with Asperger Syndrome: Integrating Multiple Perspectives. London: Jessica Kingsley Publishers. Kracke, I. (1994) ‘Developmental prosopagnosia in Asperger syndrome: presentation and discussion of an individual case.’ Developmental Medicine and Child Neurology 36, 873-876. Kurita, H. (1999) ‘Brief Report: Delusional Disorder in a Male Adolescent with High-Functioning PDDNOS.’ Journal of Autism and Developmental Disorders 29, 419-423. Lainhart, J. and Folstein, S. (1994) ‘Affective disorders in people with autism: A review of published cases.’ Journal of Autism and Developmental Disorders 24, 587-601. Laurent, A. and Rubin, E. (2004) ‘Challenges in emotional regulation in Asperger Syndrome and High Functioning Autism.’ Topics in Language Disorders 24, 286-297. Lawson, W. (2001) Understanding and Working with the Spectrum of Autism: An Insider’s View. London: Jessica Kingsley Publishers. Mayes, L., Cohen, D. and Klin, A. (1993) ‘Desire and fantasy: a psychoanalytic perspective on theory of mind and autism.’ In S. Baron-Cohen, T. Tager-Flusberg, and D. Cohen (eds) Understanding Other Minds: Perspectives from Autism. Oxford: Oxford Medical Publications. McDougle, C., Kresch, L., Goodman, W. and Naylor, S. (1995) ‘A case controlled study of repetitive thoughts and behavior in adults with autistic disorder and obsessive compulsive disorder.’ American Journal of Psychiatry 152, 772-777. McGee, G., Feldman, R. and Chernin, L. (1991) ‘A comparison of emotional facial display by children with autism and typical preschoolers.’ Journal of Early Intervention 15, 237-245. Micali, N., Chakrabarti, S. and Fombonne, E. (2004) ‘The broad autism phenotype: Findings from an epidemiological survey.’ Autism 8, 21-37. Nieminen-von Wendt, T. (2004) ‘On the origins and diagnosis of Asperger syndrome: A clinical, neuroimaging and genetic study.’ Academic dissertation, Medical Faculty of the University of Helsinki. Njiokiktjien, C., Verschoor, A., de Sonneville, L., Huyser, C., Op het Veld, V. and Toorenaar, N. (2001) ‘Disordered recognition of facial identity and emotions in three Asperger type autists.’ European Journal of Child and Adolescent Psychiatry 10, 79-90. Nyden, A., Gillberg, C., Hjelmquist, E. and Heiman, M. (1999) ‘Executive Function/Attention Deficits in Boys with Asperger Syndrome, Attention Disorder and Reading/Writing Disorder.’ Autism 3, 213-228. Ozonoff, S., South, M. and Miller, J. (2000) ‘DSM-IV defined Asperger syndrome: cognitive behavioural and early history differentiation from high-functioning autism.’ Autism 4, 29-46. Pennington, B.F and Ozonoff, S. (1996) ‘Executive functions and developmental psychopathology.’ Journal of Child Psychology and Psychiatry Annual Research Review 37, 51-87. Pietz, J., Ebinger, F. and Rating, D. (2003) ‘Prosopagnosia in a preschool child with Asperger syndrome.’ Developmental Medicine and Child Neurology 45, 55-57. Piven, J. and Palmer, P. (1999) ‘Psychological disorder and the broad autism phenotype: Evidence from a family study of multiple-incidence autism families.’ American Journal of Psychiatry 156, 557-563. Pyles, L. (2002) Hitchhiking Through Asperger Syndrome. London: Jessica Kingsley Publishers. Rastam, M., Gillberg, C., Gillberg, I.C. and Johansson, M. (1997) ‘Alexithymia in anorexia nervosa: A controlled study using the 20-item Toronto Alexithymia Scale.’ Acta Psychiatrica Scandinavica 95, 385-388. Reaven, J. and Hepburn, S. (2003) ‘Cognitive-behavioural treatment of obsessive-compulsive disorder in a child with Asperger syndrome.’ Autism 7, 145-164. Rieffe, C., Terwogt, M. and Stockman, L. (2000) ‘Understanding atypical emotions among children with autism.’ Journal of Autism and Developmental Disorders 30, 195-202. Russell, A., Mataix Cols, D., Anson, M. and Murphy, D. (2005) ‘Obsessions and compulsions in Asperger syndrome and high functioning autism.’ British Journal of Psychiatry 186, 525-528 Russell, E. and Sofronoff, K. (2004) ‘Anxiety and social worries in children with Asperger syndrome.’ Australian and New Zealand Journal of Psychiatry 39, 633-638. Schneider, E. (1999) Discovering My Autism. London: Jessica Kingsley Publishers. Silver, M. and Oakes, P. (2001) ‘Evaluation of a new computer intervention to teach people with autism or Asperger syndrome to recognize and predict emotions in others.’ Autism 5, 299-316. Slater-Walker, G. and Slater-Walker, C. (2002) An Asperger Marriage. London: Jessica Kingsley Publishers. Sofronoff, K., Attwood, T. and Hinton, S. (2005) ‘A randomised controlled trial of a CBT intervention for anxiety in children with Asperger syndrome.’ Journal of Child Psychology and Psychiatry 46, 1143-1151. Szatmari, P., Brenner, R. and Nagy, J. (1989) ‘Asperger’s syndrome: A review of clinical features.’ Canadian Journal of Psychiatry 34, 554-560. Tani, P., Joukamaa, M., Lindberg, N., Nieminen-von Wendt, T., Virkkala, J., Appelberg, B. and Porkka-Heiskanen, T. (2004) ‘Asperger syndrome, Alexithymia and sleep.’ Neuropsychobiology 49, 64-70. Tantam, D. (1988) ‘Asperger’s syndrome.’ Journal of Child Psychology and Psychiatry 29, 245-253. Tantam, D. (2000) ‘Psychological disorder in adolescents and adults with Asperger disorder.’ Autism 4, 47-62. Tonge, B., Brereton, A., Gray, K. and Einfeld, S. (1999) ‘Behavioural and Emotional Disturbance in High-Functioning Autism and Asperger Syndrome.’ Autism 3, 117-130. Wing, L. (1981) ‘Asperger’s Syndrome: A clinical account.’ Psychological Medicine 11, 115-130.