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. 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