Article about AS Aggression towards others by Digby Tantam

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What do you all think about Challenge 8 (towards the end, in bold)? I call BS.

The challenge of adolescents and adults with Asperger syndrome

Digby Tantam, MA, MPH, PhD, AFBPsS, FRCPsych, Centre for the Study of Conflict and Reconciliation, School of Health and Related Research, University of Sheffield, Regent’s Court, 30 Regent Street, Sheffield S1 4DA, United Kingdom

Despite the rapid growth of interest in Asperger disorder in children, there
continues to be a lack of awareness of the diagnosis and its implications for
adolescents and adults. The reasons for this lack of awareness lie in the history of
the disorder and in the historical development of mental health services. Because,
as Santayana wrote, ‘‘Those who cannot remember the past are condemned to
repeat it,’’ this article reprises some of the history given elsewhere in this volume,
but in a highly partial way, to bring out what the author believes to be the
historically grounded prejudices that are the first challenge to anyone wanting to
help adolescents and adults with Asperger syndrome.
The diagnosis of Asperger syndrome (AS) is more than 50 years old, nearly as
old as autistic disorder. The year of 1943 saw the publication of Kanner’s
description of autistic disturbances in children [1], and 1944, Asperger’s paper
on autistic personality disorder [2]. Asperger, like Kanner, worked with children,
and his paper, like Kanner’s, was about children. It had no impact on the Englishspeaking
world for almost 40 years and was only published in an English
translation in 1991 [3]. The 15 years after Kanner’s paper was published saw
considerable debate about the validity of autistic disorder, the development of a
variety of standardized diagnostic criteria, and the overthrow, at least in the United
Kingdom and the United States, of psychogenic theories of autism. There was
considerable anxiety about the possibility of criteria for a diagnosis of autism
becoming too lax, and highly restricted research criteria were devised that could be
applied to the first generation of epidemiologic studies, such as those of Lotter [4].
The development of research criteria coincided with the demarcation of autism
and other neuropsychiatric, or neurodevelopmental disorders as they have come to
be called in children such as developmental dyspraxia and speech and language
disorders of childhood. The powerful influence of Jaspers lingered, however, and
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Child Adolesc Psychiatric Clin N Am
12 (2003) 143– 163
child psychiatrists, like their adult colleagues, made the distinction between brain
and mind disorders their starting point. A corollary of this distinction was the
assumption that disorders of the brain were fixed and, equally erroneously,
disorders of the mind were considered plastic. Thus, although the recognition of
neurodevelopmental disorders was an advance on assuming that children with
communicative disorders were the victims of bad parenting, it was also assumed
that little could be done to help children so affected.
Fortunately, this therapeutic nihilism motivated some parents to band together
to find their own solutions, in particular to press for their children’s educational
needs to be met more effectively. United Kingdom parents founded the National
Autistic Society in 1962 and United States parents the Autism Society of
America in 1965. Both societies focused their efforts on education, understandably,
as it was their children’s needs with which the founders were concerned.
The success of their efforts to get special education established has contributed to
the statutory recognition in North America and in the United Kingdom that
children with special needs have a right to have those educational needs
systematically assessed with a presumption that any identified educational needs
would be met.
Parents who believed that they had secured their children’s future by establishing
programs for their education discovered that their children continued to have
considerable needs once school-leaving age was reached. Parents began to turn
their attention to creating suitable communities for these children, extending and
building on the experiences that had grown from the schools. It seemed like a
natural progression. Most of the children were severally impaired and their
awareness of themselves with other people was much diminished. They thrived if
they had caring and understanding parental figures at the age of 15 or 25 years
just as much as they had at the age of 5 years.
This period can be said to have ended and a new period begun with the
publication in the late 1970s and early 1980s of papers bringing the attention
of English-speaking professionals back to AS. These included the paper by
van Krevelen and Kuipers [5], the transcription of a paper given to the United
Kingdom National Autistic Society by Asperger himself [6], and most influentially,
by a paper published in Psychological Medicine by Lorna Wing [7]. The
impact of the renewal of interest in AS criteria of autistic personality disorder,
and of Lorna Wing’s introduction of the eponymous term AS, or Asperger
disorder as it is known in the United States, has been to refocus attention on the
conditions similar to autism [8] that had been excluded by earlier researchoriented
criteria. The response of the nosologists who have such an influence on
psychiatry was to move in two directions at once. First, to import Wing and
Gould’s triad of social impairments into the list of diagnostic criteria of autistic
disorder, thus considerably widening their scope. Second, to add AS, defined
completely arbitrarily, as a separate, named syndrome, although almost everyone
who met the criteria for AS also met the widened criteria for autistic disorder [9].
Professionals are now reaping the confusion that this has sown, with repeated
and fruitless attempts to distinguish AS from autistic disorder. But what was a
144 D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163
taxonomic blunder has proved to be a practical success. Parents and caregivers
know that there are some people with autism who lack sufficient self- and otherawareness
to be autonomous, but there are others who demand that their
autonomy is recognized. The author tried to capture this difference when writing
a booklet on AS by calling it ‘‘A Mind of Their Own’’ [10]. What parents and
caregivers have done is to ignore the stipulations in ICD-10 and DSM-IVTR that
people with AS are those people with an autistic spectrum disorder but no delay
in their cognitive or language development. Instead, they have simply equated
AS with self-awareness. Many of the children and adults diagnosed with autistic
spectrum disorders in the past seemed lost in their own world. They seemed not
to register pain or danger, as if they did not have sufficient sense of themselves to
be able to be concerned about their own welfare or survival. People with AS do
not live in their own world so much as live on their own island floating in a sea of
humanity. They do have projects and plans for themselves, and they do compare
themselves with other people, often painfully.
The author believes that parents and caregivers have been right in giving AS
this operational definition. They are right because people with AS often suffer
emotionally because of their self-awareness, and because increasing self-awareness
and its attendant distress often occur in adolescence in association with an
improvement in communicative ability.
AS has not been so popular a label in North America as in Europe. In the United
States, many professionals have advocated the term ‘‘high-functioning autism’’ as
an alternative [11]. This term has the advantage that it is not pegged to official diagnostic
criteria, but the disadvantage is that it suggests the issue is ‘‘functioning.’’
‘‘High functioning’’ is not so different from the ‘‘less severe’’ tag that is often
given to people with AS, as in the question often put to the author by colleagues,
‘‘AS? Isn’t that a less severe kind of autism?’’ The concept of functioning is a
familiar one to service managers, especially in the learning difficulty/mental
handicap field. There is a clear analogy with high and low IQ. The reason that
function is so familiar, and so important, is that it is a divide between the services
for people with learning difficulty/mental handicap, and other services. Lower
functioning people, people with an IQ less than 70, are their responsibility. Other
people with autistic disorder are the responsibility of . . . someone else.
Continuing pressure from caregivers has resulted in some special education
programs being developed for children with AS, but in many areas of North
America and the United Kingdom, high functioning means mainstream school
with little or no additional support. This is changing, as documented elsewhere in
this volume. But what is not changing is that the high functioning adolescent
finds that on leaving school, no support is available from pediatric services, from
child and adolescent psychiatry, and, because he or she is high functioning, from
learning disability services, either.
It is a healthy sign that, in the last 10 years, autistic spectrum disorders have
become detached from learning difficulty and now are seen as a new kind of
problem, the pervasive developmental disorder. It has been particularly good for
people with AS, because few of them feel comfortable with services that grant
D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163 145
them little autonomy. Indeed, people with AS are often particularly demanding
that services are configured around them, rather than them fitting into the service.
But the outcome of the vicissitudes in the recent history of autism, some of
which have been considered here, is that adolescents and adults with AS may have
no call on specialist services at all. Many psychiatrists seem to take the view, as
one local psychiatrist did in a recent letter, that a person with a known diagnosis of
AS has ‘‘no mental health problem’’ to be detected. Third-party payers focusing on
more and more defined targets are partly to blame. In the United Kingdom, where
there is one overwhelmingly large third-party payer, the National Health Service
(NHS), recent papers in the modernization agenda for the NHS have defined the
priority conditions for mental health [12] and for learning difficulties [13] and
have left AS out of them both. Although the United States has no comparable
national policy, individual states are in a similar situation as the United Kingdom.
Connecticut admits that it ‘‘has no principal state agency assigned the role of
coordinating and delivering services and supports for adults with developmental
disabilities, who do not have mental retardation’’ and that ‘‘The Department of
Mental Health and Addiction Services (DMHAS) is the single state agency for
providing comprehensive mental health and substance abuse services throughout
Connecticut . . . DMHAS provides services to persons with developmental disabilities
only if there is a concomitant psychiatric disorder’’ [14]. Massachusetts
has not even gotten that far. A bill has been introduced (for details, see http://
www.state.ma.us/mddc/legislative/), arguing, ‘‘Many adults with Autism Spectrum
Disorder do not meet DMR eligibility requirements despite the debilitating
nature of their disability. This bill would establish a study commission that will (1)
define the population to be served, (2) identify the types of services and supports
needed, (3) identify how such services and supports can best be delivered, and (4)
identify the costs for such services and supports. This information would be used
to address these unmet needs.’’ At the time of writing, it has not been enacted.
There have been some exceptional developments, contrary to this trend,
emanating from universities and nonstatutory providers. Supported employment
has been one of the success stories, with schemes in several countries based on
the blueprint developed by the University of North Carolina’s program Treatment
and Education of Autistic and Related Communication Handicapped Children
(TEACCH) in 1989. As before in the history of education developments for
autistic children, however, services have been provided mainly by self-help,
although this time it has been groups of people with Asperger syndrome, rather
than their parents, who are answering the challenge. There has been no statutory
or legally enforced acceptance of the responsibility to provide services.
Challenge 1: who is responsible for helping adolescents and adults with
Asperger syndrome?
It is clear from the historical summary that, by default and by tradition, the
answer to this challenge is ‘‘parents or other caregivers.’’ Parents readily accept
146 D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163
this responsibility because they have felt responsible for their child since he (or
less often, she) was born, or shortly thereafter. From the time, in fact, that they
realized that their child was different and was in some way, albeit difficult to
characterize, vulnerable to others’ exploitation and influence.
Another answer might be ‘‘people with AS themselves.’’ It is true that more
and more people with AS are discovering alternative methods to empowerment.
The Internet has provided many of these, enabling people with AS to get in touch
with each other by email, discussion groups, or through web pages. Even more
helpfully, the net provides a means of communicating with others that emphasizes
technology know-how and de-emphasizes the subtleties of social interaction, both
of which are advantages for people with AS.
What is disturbing about this challenge, however, is that there is no
professional group that has accepted responsibility. There are psychiatrists,
neuropsychologists, clinical psychologists, educators, employment specialists,
counselors, occupational therapists, and others who have made themselves into
specialists. But there is no group that has accepted that AS is part of their mission.
This means that parents and sufferers are constantly the subject of turf wars in
which they find themselves being referred back and forth until someone takes
responsibility for their care or until they give up and break contact with services
altogether. The latter is an all too common outcome.
Autistic spectrum disorders, including AS, are neurobiologic disorders with a
strong heritability. Twin studies suggest that genetic and environmental factors
often may interact. Outcome is also influenced by social and emotional factors.
They are, therefore, even more so than the psychiatrists’ bread and butter—
schizophrenia—disorders that require the combination of knowledge of brain
development, environmental factors, and psychology.
Furthermore, there is an association between AS and psychiatric disorder. One
recent study showed that 32% of adults with an autistic spectrum disorder had
been diagnosed with a disorder, most commonly (56%), depression [15].
Although AS itself does not respond to medication, these conditions do. Indeed,
appropriate medication is after the most relevant intervention.
Finally, a range of medical disorders is reportedly more common in AS. These
include epilepsy; disorders affecting brain development in childhood, such as
hydrocephalus, tuberous sclerosis, and neurofibromatosis; congenital perceptual
disorders affecting early social interaction, such as congenital disorders of visual
acuity and congenital causes of deafness; and disorders affecting motor control,
such as myotonia and myopathy.
Given all these considerations, there is a strong case for psychiatrists to take
responsibility for adolescents and adults with AS. And not just any psychiatrists,
but the same psychiatrists who deal with other, presumptively neurodevelopmental,
disorders such as schizophrenia.
A case also could be made for licensed psychologists having particular,
relevant skills, however. Neuropsychologists are more attuned to dimensional
disorders and are also more experienced in assessing cognitive disorders. Recent
research on AS has shown that it results in several distinct functional difficulties,
D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163 147
all of which affect social interaction, although in different ways. These are shown
in the Table 1.
Identical triplets with autistic spectrum disorders may be affected by their
disorder very differently [16], despite sharing the same genotype. Making a
diagnosis of AS is an essential step to appropriate intervention, but it is not
sufficient. The individual profile of a person’s cognitive difficulties is necessary,
too, and here the skills of a clinical psychologist are particularly useful.
AS has a greater than chance association with several other developmental
disorders, such as attention deficit/hyperactivity disorder, Tourette syndrome,
dysexecutive syndrome, developmental dyspraxia, dyscalculia, and possibly
some unusual disorders of volition, such as elective mutism and elective dysgraphia,
in which a person has an inability to write. These associated disorders
can profoundly affect education and later, life employment. Despite being
obvious that a person has a marked impairment, it may not be obvious what
the cause is, unless a person is tested. The reduction of working memory that
leads to dysexecutive syndrome, often associated with ‘‘atypical AS’’ (see later
discussion) is particularly difficult to detect clinically, as is the lack of empathy
that is the central feature of atypical AS.
Obtaining a cognitive profile of an adolescent or adult with AS has three
potential benefits. It can inform the patient when deciding about future occupation
or employment. It can help them plan how they can work to overcome
their own difficulties. And it gives credence to the fact they have difficulties.
One of the greatest problems faced by adolescents and adults with AS is that
their impairments fall squarely in the interpersonal and motivational areas.
Care example
Hilda had worked as an administrator when her father was alive, but when the
company closed and he died, she did not seek further work. She carried on living
in the family home, which became more and more neglected. Hilda enjoyed
novels, and was reading Tolstoy’s War and Peace when the author met her, but
she did not know who to contact to change a broken light fitting or how to change
it herself. So she read by candlelight. Her neighbors thought her weird, and the
various doctors who saw her found her uncooperative. They believed that she was
Table 1
The core syndrome of AS
Impaired non-verbal communication
Impaired speech but not language
Impaired intersubjectivity (theory of mind, empathy)
Anxiety
Idiosyncratic, stereotyped, asocial interests and activities
Need for predictability
Motor or sensorimotor impairment
148 D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163
simply unmotivated to change. Although none of them said it, there was a
definite implication that she was lazy and difficult.
Hilda, and many other people with AS, continue to be dismissed by
professionals as having moral failings, but not impairments. Sometimes, therefore,
the biggest impact of having an abnormal MRI scan or abnormal psychometry
is that professionals take the problem seriously.
But what is good for the professional is not always good for the sufferer.
Adolescence is particularly a time of identity change and identity confusion.
Adolescents, understandably, do not want to define themselves in terms of
impairments, but in terms of aspirations and desires. In telling an adolescent
that they have AS—and the author believes that the clinician should have
considerable reservations about making a diagnosis and then keeping it from
the patient—it is important to make this a facilitative and not a restrictive
intervention. There is a balance to be struck between being seen as a person with
difficulties and being seen as someone with all to play for in the future. Balance
needs to be maintained in the family of the person with the AS and in the mind of
the affected person. Too much emphasis on moral failings by parents or spouse,
and the atmosphere becomes one of high ‘‘expressed emotion,’’ as unhelpful for
people with developmental disorders as it is for people with schizophrenia. Too
great an emphasis on cognitive deficits, however, may lead to overprotection and
to the undermining of autonomy.
Neuropsychologists rarely need to consider whether a neuropatholigical abnormality
is a deficit or an opportunity. But counselors and psychotherapists work
constantly within the room for maneuver that we all retain despite our heredity, our
environment, and our life history. It matters to them and their clients whether an
action is said to be due to obstinacy or perseverance, to impulsivity or spontaneity.
Moral evaluation of this kind is especially important in adolescence. This is partly
because the core Asperger impairment often improves somewhat in adolescence,
and partly because emotional and social factors are particularly important then.
Care example
Alex was fascinated by fluid dynamics. He designed, built, and fitted a
succession of farings to his bicycle that would cut down on wind resistance. He
took immense pleasure in pelting down hills, feeling that his ingenuity had
created the extra speed. But he was changing and his AS was becoming less
overt. One day he noticed someone looking at him and, for the first time in his
life, imagined what they were seeing when they looked at him. He thought he
must look a sight. Over the next few months he became unwontedly depressed
and irritable. His mother thought that he was deteriorating and asked for an urgent
appointment with the psychologist who had diagnosed Alex. The psychologist
said the problem was that Alex was improving neurodevelopmentally, but
that this had created new and more painful emotional problems. Unfortunately his
mother would not accept this, and went to see another practitioner who suggested
megavitamin therapy.
D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163 149
Alex probably was judging himself, if the truth be told, according to the values
that were upheld in his family. People with AS, however, are more often judged
by society than by themselves, and they and their parents can come to feel that
society is excessively judgmental. Indeed, many people with AS may identify
with people that society considers evil, because such people are also marginalized.
Peers are much more judgmental than either older or younger people.
So adolescents, for whom peer relationships are paramount, face the greatest
challenge in this respect.
The friction between the idiosyncrasies of people with AS and the social
expectations placed on them only becomes more intense after childhood.
Although there has been little evaluation of counseling in AS, the author’s
experience has been that it can be of particular value in adolescence by relieving
distress and improving social functioning when this friction has led, as it often
does, to anxiety, hostility, or depression. Counseling people with Asperger
syndrome is specialized. Counselors need to have mastered the skills of their
profession, and in addition, to have an understanding and experience of working
with people with AS. There is little training currently available in how to modify
counseling techniques to make them suitable for people with AS. Many
counselors of people with AS are parents who have learned from their own
experience how to communicate with a person with AS, and have gone on to do a
counseling training.
Perhaps the single most important issue that counselors for people with AS
deal with is accountability. Accountability is being able to give an account that
satisfies others. That account often has various strands: contingency is one
(‘‘I couldn’t help it; it just fell’’); another is incapacity (‘‘You know I’m deaf.
How could I have heard what he said?’’; and a third, intention (‘‘I wanted to hurt
him. So would you, if he’d done it to you’’). Overplaying the ‘‘I couldn’t help it’’
account leads to frustration in others and criticism. But one of the fundamental
facts about AS is that a person cannot help having it. What matters, though, is
what they do with it. By the time a person with AS reaches adolescence, he or she
will have made many choices that may have made their situation worse or better.
Overplaying the contingency card, however, much as it may tweak parents’
heartstrings, is a choice that often makes the situation worse, and not simply
because making one’s parents feel guilty is rarely a good long-term strategy.
Being the victim of circumstance means that a person is not an effective agent.
Not being an effective social agent is something that people with AS feel a lot,
particularly if they lack empathy for others. It leads to a sense of being socially
powerless. This is a common feeling for adolescents with AS who have got into
trouble at school or in the community. The adolescent finds that he or more rarely
she has increasingly fewer effective means of influencing others except by more
and more challenging behaviors.
Overplaying incapacity may not lead to a loss of others’ esteem, but it
certainly leads to a loss of one’s own esteem. Claiming that one intends all the
consequences of one’s action is, however, also a risky strategy, because it can
lead to obloquy and rejection.
150 D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163
Challenge 2: how much of a service do we need to provide?
The upshot of my consideration of the first challenge—who should be
responsible for helping people with AS—is that no one profession has all the
necessary skills. Teamwork is therefore necessary. But teams are even more expensive
than individuals and in these cost conscious days, how much can we
afford to spend on AS? How much should third-party payers and parents spend?
One kind of answer is to find out how prevalent AS is. As studies considered
elsewhere in this issue have shown, there has been an inflationary spiral in the
findings of prevalence studies. These studies have been carried out in children, but
DSM-IVTR asserts, ‘‘Asperger disorder is a continuous and lifelong disorder.’’
Recent studies indicate that 1 in 150 children have a PDD and 1 in 350 have either
Asperger disorder or PDD-NOS [17]. Fombonne has reached a more conservative
estimate in a review of multiple studies of 1 in 500 children [18].
At the time of writing, the United States Census Bureau estimates the United
States population to be 287,387,124 people, of whom 78.8% are 15 years of age
or older. This means that, even at the more conservative estimate, if Asperger
disorder is lifelong and continuous, there are at least half a million American
adolescents and adults who have AS and, if we include the wider group of PDDs,
perhaps as many as 1.5 million.
Asperger himself said that the syndrome he described had ‘‘a good prognosis,’’
if special education was provided. But it is not clear whether he meant
that there are substantially fewer adolescents and adults with the disorder than
there are children, or that adolescents and adults are better able to live with the
impairment, or perhaps that other people are better able to live with them. Or
perhaps he meant that once people leave school they disappear from sight, even
though they remain as handicapped as before.
The data to weigh up these different possibilities simply are not available.
What is clear from clinical experience, however, is that people with AS may
present for the first time at almost any age. The author has seen six people over
the age of 50 years, five men and one woman, who had never been diagnosed
previously. What is also apparent from clinical experience is that presentation is
more likely during a developmental crisis: relationship breakdown, redundancy,
or child-rearing problems are common examples.
Until outcome data, or adult prevalence data, are available, the best guess is that,
although AS rarely if ever completely remits, its impact on social or emotional
functioning may fall below the threshold for presentation during late adolescence
or early adulthood. The threshold may be exceeded again, however, under pressure
from demands for new social adaptation arising in adulthood. People with AS may
therefore present, or re-present, in adolescence and adulthood.
There have been few studies of the needs of autistic children and no systematic
study of the needs of adults with AS. Two recent reports of nonrandom surveys
conducted by the United Kingdom National Autistic Society, however, do
provide relevant details. In Ignored and Ineligible (National Autistic Society,
NAS, 2001) the authors report that 49% of adults with autism or AS still live at
D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163 151
home with their parents, that 46% of people with AS were diagnosed only after
the age of 16 years, and only 12% of high functioning adults are in fulltime
employment. These figures are strikingly similar to the rates in the first 46 patients
with AS that the author systematically studied between 1980 and 1983, of whom
9% were employed and 41% were living with parents [19]. This suggests that
there has been little change in community support in the last 20 years, in the
United Kingdom at least.
Another survey of the NAS (2000) involved people with AS prioritizing their
own needs. There was general agreement that having a job and making friends
were the first priorities, with a proportion also saying that having a sexual
relationship was important. This survey is likely to have included only those
people with a diagnosis. It is probable, as considered earlier, that there are many
more people with AS who have not been diagnosed. Some of them only come to
attention because of others’ worries about them. Common sources of others’
concern are forensic problems, neglect of children, and neglect of their homes
and surroundings.
The author has noted already that there is an increased incidence of
psychologic disorder in people with AS. In fact, people with AS may be more
at risk than other people on the autistic spectrum. This certainly seems true of the
risk for bipolar disorder [20].
Collating these facts suggests that the following people with AS have a need
for service:

Those who want a diagnosis

Those who want help to live more independently

Those who want help to find or maintain work

Those who want help to make or maintain friendships

Those who want help to engage in a sexual relationship

Those who have an additional mental health problem

Those who present problems or concerns to others
Challenge 3: social exclusion
The first five items on this list begin with the expression, ‘‘Those who
want . . .’’ People’s wants are shaped by their understanding of what is available
to them. They discover what is available through advertising, but also through
word of mouth or through their general cultural understanding. The latter two
sources of information may be denied people with AS who, as many parents
and spouses often say, may live in a world of their own. Even when people
with AS are not deliberately marginalized by others, they may be inadvertently
excluded from many social resources, including access to appropriate health
and social care. This lack of self-advocacy, coupled with the fact that AS,
unlike psychosis or dementia, rarely causes public nuisance, means that it has
been all too easy for services to assume that they do not need to provide for
152 D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163
people with AS because adults with AS are not complaining about the lack of
service. But their reason for not doing so is that they do not know they could
benefit from it.
Challenge 4: working with caregivers
Children’s interests are fiercely guarded by most parents. Only children
with AS who are unfortunate enough to live in a dysfunctional family or lack
parental care miss out. But parents are more loath to push for services for an adult
child, and their reluctance is usually reinforced by the institutional resistance in
adult services to dealing with parents. The preoccupation with individual rights
and autonomy that has superseded the excessively paternalistic services of
yesteryear means that psychiatrists and psychologists, more used to dealing with
adults, often refuse to engage with parents or caregivers.
This has two immediate and unfortunate consequences. The first is that a
developmental history is almost never taken. That a disorder has been lifelong
is one of the simplest and most reliable means of differentiating it from an
acquired disorder such as schizophrenia. The signs of AS often are most distinct
in early childhood. Best diagnostic practice therefore requires that an appropriate
developmental history is taken from parents or lifelong caregivers whenever
possible.
Not dealing with parents means not taking a developmental history, and this
usually has the consequence that a firm diagnosis is not made. But without a firm
diagnosis, services are not provided. Not dealing with caregivers, however, may
result in an even more basic breakdown in service provision. Services may simply
refuse to engage with caregivers at all, perhaps telling a concerned parent or
spouse that the person suspected of AS should contact them directly. This is
unrealistic. Many intelligent people with AS do not even know what their source
of income is or that having an appointment with a psychiatrist does not mean being
admitted to a hospital. Asking them to know who to contact or how to ask for a
service is asking too much.
Psychiatrists, psychologists, and others wishing to provide services to people
with AS need to find ways of dealing with them and their caregivers. This requires
a response to the ethical requirement of preserving autonomy and confidentiality
that is different from that of other mental health problems. At the very least, it
involves an assessment of the capacity of the adolescent or adult suspected of
having AS to understand the issues involved, and an explicit negotiation about the
issues within the limits posed by his or her capacity.
Challenge 5: diagnosis in adulthood
The diagnostic criteria of DSM-IV and ICD-10 incorporate Wing and Gould’s
triad of social impairments. These were developed in an epidemiologic survey of
D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163 153
children [21], and they are less applicable to adolescents and adults. For example,
the stereotypies, preoccupation with parts of objects and the lack of showing,
bringing, or pointing out objects of interests—all features listed in DSM-IV—are
signs of AS that usually disappear by adolescence. Other features, such as
obsessive interests, a lack of peer relationships, and a lack of social and emotional
reciprocity are shown by many ‘‘difficult’’ adolescents.
Because the expression of AS changes with age, a syndromal diagnosis in
adulthood has to be made on the signs of the disorder in childhood—another
reason for taking a developmental history. Parents may have died or the adult
with AS may have moved away, however, and a developmental history may not
be obtainable. How can a diagnosis be made then?
Before a diagnosis can be made, the diagnosis has to be suspected. The indices
of suspicion in the DSM-IV criteria that are most useful are ‘‘failure to develop
peer relationships appropriate to developmental level’’ and ‘‘apparently inflexible
adherence to specific, nonfunctional routines or rituals.’’ What DSM-IV does not
specify, surprisingly, is that AS has its onset in early childhood, although this is
implied by its inclusion in the group of ‘‘disorders usually first diagnosed in
infancy, childhood, or adolescence.’’ Gillberg is the only Asperger researcher
who recognizes AS acquired after early childhood [22], but his criteria have
proved over the years more inclusive than those of other experts.
Any psychiatrist confronted with an unusual problem in an adolescent or adult
who cannot make relationships with peers, has apparently been socially isolated
from early or middle childhood, and who has unusual routines, rituals, or
obsessively pursued interests should suspect AS.
There are several psychiatric disorders other than AS that might present with
these features. Routines and rituals can be the consequence of a combination of
anxiety and social isolation. So they may occur in other conditions that have these
two consequences, such as avoidant personality disorder, schizoid personality
disorder, and early onset obsessive-compulsive disorder. Rituals also can be the
result of social privation, and children who are neglected in infancy may develop
these symptoms and they may sometimes persist [23].
What psychiatrists need for a confident diagnosis is to detect a specific
impairment that is always and only associated with AS. Unfortunately, there is no
expert consensus as to what this might be. The author’s view is that we do know
enough to say that the specific impairment is an abnormality of nonverbal
communication, and the author uses this criterion in his own practice. It also
appears in DSM-IV, where it is referred to as ‘‘marked impairments in the use of
multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body
posture, and gestures to regulate social interaction.’’
Evaluating nonverbal communication may not be simple. Abnormal performance
does not necessarily imply impaired competence. The author sometimes
reads reports stating that person X cannot have Asperger disorder because they
show eye contact. In fact, avoidance of eye contact is an indication of hostility,
not of a PDD. Adolescents with PDDs, including people with autism, show a
normal amount of other-directed gaze. They do not, however, preferentially direct
154 D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163
their gaze to another’s eyes when the other is looking at them, but evenly
distribute other-directed gaze regardless of where the other person is looking or
what they are doing [24]. People with AS may be told that they avoid gaze and
try to compensate for this by increasing their total time looking at another
person’s eyes. This may increase the amount of shared gaze, but not the
proportion of shared gaze to unshared gaze. The result may be a stare that can
be as disconcerting as a lack of expected mutual gaze.
Even experienced clinicians need to take care in making inferences from
simple observation of nonverbal communication. The author’s practice is to ask
parents about nonverbal communication and to make his own observations. It is
also important to observe the patient in social settings other than the office if
there continues to be doubt. A further problem is that although nonverbal
expression is directly observable, the ability of a person to interpret other
people’s nonverbal expressions is not. Impaired nonverbal interpretation, for
example, impaired interpretation of facial expressions, is one of the most durable
findings in research into autistic spectrum disorders, but it is rarely noted in
clinical assessments.
Because there is no single test or criterion of AS that can be applied easily,
psychiatrists need to develop experience assessing people with AS before making
the diagnosis for the first time. This can, and should, be provided in training. An
alternative is to ask for people with AS to volunteer to participate in assessments.
Even then the author would not advise psychiatrists to make the diagnosis in the
absence of a developmental history until they feel confident that they are familiar
with the variety of presentations of AS that may be bewildering at first.
There are several screening tests, some involving self-administered questionnaires
(eg, the AQ [25]) that can be used to supplement diagnosis. Wired
magazine has placed a copy of the AQ on the web for the benefit of ‘‘Geeks’’
(see http://www.wired.com/wired/archive/9.12/aqtest.html). There also exist
standardized developmental questionnaires (the one the author uses can be found
at www.dilemmas.org/development.htm) and symptom inventories. Past inventories
often were too insensitive to pick up AS, but more recent inventories are
more sensitive. Often they are, however, time-consuming to administer.
Psychiatrists who find adolescents and adults with AS congenial and who do
develop diagnostic expertise will find that parents, spouses, and sufferers themselves
will beat a path to their door as having a diagnosis.
Challenge 6: why make a diagnosis?
Diagnosis has traditionally been the route by which people with AS and their
caregivers or supporters have accessed specialist services. But this tradition has
grown out of the services for people with autism who were severely disabled by
their condition under all circumstances. The group of people with AS, who
Fitzgerald has argued [26] may have Wittgenstein, Newton, and Einstein among
their number, include many people whose social impairment is arguable. Is a
D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163 155
loner with a passionate interest in old diesel engines socially impaired? Is a
timid father with an eccentric manner who is nevertheless devoted to his wife
and child socially impaired? What about when his son is diagnosed with AS,
and his wife begins to think of her frustrations with her husband during
the marriage? Does he become socially impaired because he is suspected of
having AS?
Checking off the boxes is not sufficient for making a diagnosis. Making a
diagnosis has to result in a useful product for the patient. There is no hard and fast
rule about whether a diagnosis of AS will be useful. A decision needs to be made
in each case, usually following an open discussion about what benefits or costs
the patient anticipates from a diagnosis. And the situation may change. Someone
who is facing redundancy because he is acting strangely and whose routines at
home are becoming a major source of harassment for his parents, may in a year or
two be coping well and happily with another job and be a pleasant if eccentric
house companion. Although a diagnosis might have been useful on the first
occasion, it may be unhelpful on the second.
There are many other conditions in medicine that are dimensional and not
categorical, and that may dip in and out of the pathologic range. Hypertension is
one example. They require a different kind of management. The family physician
must remember that his or her patient had a raised blood pressure once, and that it
needs to be checked from time to time without treating the patient as if he or she
has a current disorder. For psychiatric services dealing with people with AS, this
translates into being able to maintain contact with adults with AS, perhaps over
long periods and without specific treatment; or, alternatively, it translates into
enabling people with AS to access services for themselves and giving them the
means to decide when it is in their interest to do so. Of course, there has to be a
service to access.
The author has noted that people with AS may need help particularly during
developmental transitions and during crises. Specialist psychiatric help may
not be needed at these times, although help from someone who is knowledgeable
about AS and comfortable relating to people with AS is important. There
are, however, some crises that call for specialist psychiatric or psychologic
Table 2
Previous diagnoses in personal series of 234 adolescents or adults with AS (note not all of these
diagnoses were upheld retrospectively)
Previous diagnosis Rate
Anxiety and anxiety-related disorders 22.2%
Depression 19.7%
Obsessive-compulsive disorder 17.17%
Schizophrenia diagnosed previously 10.3%
Schizophrenia definite 0%
Mania 2.1%
Substance abuse 1.3%
156 D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163
help. These include crises associated with psychiatric comorbidity and forensic
problems.
Challenge 7: the challenge of comorbidity
There has been little systematic inquiry about psychiatric morbidity in AS after
childhood (see Towbin, this issue). In the author’s practice, a consecutive sample of
234 adolescent and adult patients had received the previous diagnoses shown in
Table 2 (some diagnoses were duplicated). The diagnostic rate of schizophrenia is
over-inflated because schizophrenia was the commonest diagnosis used to explain
the symptoms of AS. Careful retrospective assessment of the cases in which this
diagnosis had been made did not find evidence for schizophrenia independent of
AS, although in two cases there had been an episode of brief psychosis associated
with thought broadcast, and marked ideas of reference in one case.
OCD presents a similar problem. Routines or rituals associated with AS may be
diagnosed as being evidence of OCD before the AS diagnosis is made. There were
examples, however, of adolescents who developed typical OCD symptoms, such as
repeated hand washing or obsessions to undo the possibility of future disasters, at or
just before puberty. Other anxiety-related disorders developing then included
dysmorphophobia, panic disorder, generalized anxiety disorder, and social phobia.
Depression occasionally arose in the context of bipolar disorder, but generally in
the context of anxiety.
Anxiety is perhaps the most universal and persistent disorder associated with all
of the PDDs, so much so that it has been suggested in the past that it is a cause of
autism [27]. The author does not believe this, but anxiety is strongly linked to PDD
from an early age. The author’s view is that people with AS live in a world that is
more unpredictable and uncertain than it is for others whose intact nonverbal
communication enables them to pick up patterns in social behavior. It is this
uncertainty that produces anxiety, and not anxiety that causes AS. But it is certainly
true that anxiety increases the social impairment that AS produces, by decreasing
social skill performance and by increasing the frequency of any dysfunctional
means that a person with AS might use in the face of anxiety. Repetitive questions,
slowness, ritualizing, making social blunders, and aggression or irritability are all
likely to worsen when a person with AS becomes anxious.
The usual range of treatments for anxiety also works for anxiety in the context
of AS (see Myles, this issue). Counseling may be particularly effective. Although
cognitive methods might be expected to be especially useful, this has not been the
author’s experience. Person-centered or existential methods [27,28] have the
advantage that they address the situations about which the person with AS is
concerned, however idiosyncratic those concerns might be to others.
Although substance misuse is less common in adolescents with AS than in
nonaffected adolescents, it does occur. Drugs are often those that are readily
available to someone who is not street-wise, usually alcohol or cannabis. Alcohol
misuse may become a problem in older people with AS, too.
D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163 157
Challenge 8: people with AS as aggressors and not just victims
The history of PDD has been one of parents or caregivers pushing for
recognition and help for PDD. People with AS, like other people with PDD,
are regularly victimized and even more regularly misunderstood. Naturally, they
and their parents feel that they are unjustly treated and inappropriately discriminated
against. They are the victims of a society that puts a considerable premium
on reciprocal social relationships.
Considering people with AS as aggressors seems to fall in with exactly the
kind of stigma that has led to the injustice in the past. Aggression is a common
problem, however, as parents will privately admit: out of 262 consecutive patients
with AS that the author has seen, 40% of parents reported ‘‘hitting people’’ to be
a problem.
Aggression in patients with AS can develop for different reasons. It can be:
1. Retaliation
2. Outrage
3. A membership card in a deviant group
4. A special interest
5. Defensive
6. Gaining ascendancy
Retaliation
Many people with AS have strict codes of behavior that often include a dislike
or even hatred of violence. Even among them, however, aggression can be a
problem when a person becomes frustrated, feels unfairly treated, or, more rarely,
feels excluded. People with AS can persuade themselves that aggression is
justified in these circumstances. Aggression toward younger siblings may be a
problem, as may aggression at school, but the usual arena is at home.
This kind of aggression may be explosive, in which case there is often a
sharp onset and a sharp offset. The person with AS may be even more unaware
of the impact of their aggression than others who have temper tantrums.
Spouses or parents may say that he or she, ‘‘calmed down immediately, long
before we could feel calm. He just seems to want to carry on as if nothing had
happened. If we try to talk about the tantrum, we might set him off again.’’
Tantrums of this kind may begin at an early age and parents find them difficult
to deal with. Counter-violence makes matters worse, but it is a solution that
often appeals to fathers. Withdrawal during the tantrum, and then discussing
how it felt to be on the receiving end of it, are often useful, but living with this
level of aggression can be one of the most difficult aspects of living with
someone with AS.
People with AS have a lively sense of self-preservation. They may therefore
suppress an aggressive response to a bully or another aggressor, but turn the
aggression on to a more vulnerable person later, who may have had nothing to do
158 D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163
with the situation. The target of aggression is most likely to be a person’s mother,
or, later in life, a spouse.
Emotional processing is difficult for people with AS. They cannot tell
themselves to ‘‘just forget it’’ or ‘‘life’s too short to worry so much.’’ They want
answers and they want justice. An adolescent with AS who has a clinic
appointment may start to worry about this for several days, and then may ask
repeated questions about what will happen, the route to be taken, and so on.
‘‘Kicking off’’ may also happen during this period of heightened stress. Incidents
that have happened in the past, sometimes many years before, may linger in the
mind of an adult with AS and may resurface at regular intervals (‘‘rumination’’).
When they do, it is as if the person is re-experiencing the episode over again and
they may become suddenly and unexpectedly aggressive.
The unexpectedness of the timing and of the target of aggression makes risk
assessment particularly difficult. Treatment also can be difficult because the person
with AS, lacking empathy for others’ reactions to their violence, may continue
to feel that they were justified. When aggression is a symptom of irritability,
treatment of an underlying mood disorder may be useful. In the rare cases in which
aggression is an ictal symptom, anticonvulsants may be useful, and they also may
be indicated in hypomania, as may lithium. Many colleagues use ‘‘mood stabilizing’’
drugs in the absence of a mood disorder, and the author has come across
a few cases when this has been reported to be helpful. The author’s impression,
however, is that this is most often because it reassures the doctor and the caregivers
that something is being done, rather than that the drug has a specific effect.
The level of aggression so far described is frightening and may lead to social
isolation because parents are ashamed for friends and family to call at the house
and see broken furniture or walls with holes punched in them. It rarely leads to
criminal prosecution, however, although the author knows of one man who was
convicted of attempted murder after he threatened his mother with a knife.
Outrage and uproar
There is a subgroup of people who have developmental histories typical of AS
(Atypical Asperger Syndrome) but whose impairment of nonverbal interpretation
is substantially greater than their impairment of nonverbal expression. These
children may reach adolescence without any suspicion that they have a PDD. They
often have learning difficulties that are picked up, such as dyslexia, dyscalculia,
ADHD, and dysexecutive syndrome. Their social experience is of not fitting into
the mainstream and of not being able to influence others. Both occur because
empathy is essential for what Gilbert calls ‘‘social attraction power.’’
Entering adolescence feeling lonely and powerless, struggling with learning
difficulty, and having other people attribute both of these problems to personal
shortcomings, are all unpleasant experiences. Two options often seem to present
themselves: to become the class joker who is prepared to do the craziest things to
be a member of the gang or to become outrageous. Outrage has the advantage
that other people’s reactions to it are extreme, and therefore easier to read. It also
D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163 159
provides a sense of power, at least if others are distressed by it. It has the
disadvantage that it rapidly leads to marginalization. Aggression is an easy route
to outrage, although usually it is incidental to a wider strategy of disrupting a
social situation. A young adolescent may just need to refuse to obey school rules,
swear at the teacher, or knock down school furniture. As the person gets older,
more serious acts may be necessary to produce outrage and these can involve
aggression, although they are more likely to be sexual or to involve arson (see
later discussion).
Membership card
The other option for someone with atypical AS is to ally themselves with other
marginalized or disruptive children. By the time that such a person reaches
adolescence, their group membership may be in jeopardy and they may have to
behave more and more outrageously, and sometimes more and more aggressively.
Aggression, however, is not usually the central method of staying in the group.
This subgroup of people with AS may be engaged in other ‘‘normal’’ criminal
and antisocial activities, like getting drunk, vandalism, and theft of property.
These are typical misdemeanors of adolescence, but are not usual misdemeanors
in people with AS. The person with AS who carries out these apparent typical
crimes, however, and who does so in a group, is often different from other group
members. He, and it is almost always a he, will often be egged on by the other
members of the group to be the one who breaks the window or the one to drop the
match. And, if property is stolen, the person with AS will rarely know what to do
with it or how to profit from it.
Special interests
Some people with AS become fascinated with powerful others. This might be
expressed through an interest in worldwide wrestling or martial arts training. The
author has not personally come across a person with AS with a vicarious interest
in violence who later became a perpetrator of violence themselves.
People with AS may have a special interest in fire that can lead to arson. There
is often a period of covert fire setting in the garden or in a local wood that
precedes the incident that comes to public attention. People with AS who have
such an interest enjoy looking at fires and feel satisfaction from setting a fire.
They may use fire-setting to escape a situation, for example, by setting a fire in a
hospital ward, or they may use fires to pay back others. An interest in fire may
persist for many years: 20 years in one of the author’s patients.
Special sexual interests also may be a problem for people with AS and is
described later.
Defensive aggression
Although there is no reason to suppose the families of people with AS are
more troubled than those of anyone else, there is every reason to think they are as
160 D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163
troubled. A person with AS who is brought up in a troubled family may have to
fight back to defend themselves, and this aggression may spill out into other situations.
There is one kind of defensive aggression, however, that occurs even
in people with AS whose families of origin have been aggression-free. This is
when aggression is intended to terminate an aversive stimulus, such as a highpitched
sound. The author knows of one man who tried to strangle a female child
who was crying in a supermarket, because he could not bear the noise [29], and
others who have become violent when hearing certain kinds of music. Aggression
also may result if a person’s belongings are upset or if they are interrupted in an
activity that is important to them. An example of this is the 10-year-old boy who
hit his sister with a baseball bat because she pulled the plug of the computer when
he was immersed in a game. He broke his sister’s arm, and still, some years later,
thought that was justified.
Gaining ascendancy
Some of the most serious acts of aggression the author has come across are
committed by the person with AS who feels so isolated and so powerless that
they feel they have nothing to lose. In these circumstances, an act of violence that
makes others take notice can become the stuff of daydreams and can then be
translated into practice. There is usually some additional ingredient from the
preceding list required. This kind of aggression often has a detached quality,
almost like an experiment. Indeed, the person with AS may sometimes say, ‘‘I
wanted to see what would happen.’’ An example of this is a young woman who
lived with her father and his new wife, who had just born the father a child. This
young woman was left to look after the baby and wanted to see what would
happen if she mixed ground glass into the baby’s feed, which she did.
Sexual deviation
Many people with AS manage to suppress their sexuality; those who do not
often find it troublesome. Possibly because of the absence of a reference group,
sexual interests may be unusual. Fetishes are not uncommon and may occasionally
lead to forensic problems, as with the person who liked to impersonate
doctors and ask women intimate questions about reproduction. People with AS
rarely may get into trouble indecently exposing themselves, but this may turn out
to be something that someone else (often a girl) put them up to. Men with AS
may become addicted to adult internet sites, and a few the author knows have
attracted police attention by downloading pictures of children. Young adolescents
with AS may relate better to younger children than they do to their peers, and
may occasionally make inappropriate sexual approaches to them. Older adolescents
and adults may idealize childhood, and may be sexually attracted to
children for that reason. Participation by people with AS in pedophile rings,
indecent assault of children, or other serious sexual offence against children is
rare, however, in the author’s experience.
D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163 161
Stalking is the area in which the sex life of people with AS gives most cause
for concern. ‘‘Crushes’’ are common in adolescence, and young men and women
with AS often develop them. Although other adolescents are aware that their
feelings are not going to be reciprocated, however, this may not be obvious to the
person with AS who may become inappropriately attached. There is usually an
initial phase during which the object of the attraction feels a bit flattered, a bit
alarmed, and very caring toward the person who has become fixated on them.
There may be phone calls at home, inappropriate notes, or statements made to
others that lead the person who is the object of adoration to decide that enough is
enough, however. There is usually a confrontation that is often clumsily handled
because the object of adoration is frequently someone like a teacher or nurse who
has a duty of care for the young person. The problems begin if this rejection is not
accepted. The object of adoration may become an object of hatred and may be
targeted with abusive calls or letters. His or her friends may be the victims of
jealous attacks, and he or she may be followed.
The current climate means that any pedophile tendencies or any harassment of
women (although not men) leads to a fierce reaction. It is therefore difficult to
find evidence on which to base a risk assessment, as these situations are usually
treated as high risk.
Acknowledgments
The author is grateful to the many patients and caregivers who have taught so
much about AS. Being able to get to know about their struggles and successes has
been one of the most rewarding experiences of the author’s professional life. The
author is indebted to Emmy van Deurzen, whose ability to accept and work with
difference has been an inspiration and who has consistently provided wise counsel.
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D. Tantam / Child Adolesc Psychiatric Clin N Am 12 (2003) 143–163 163[i]

Yes, but that is only going by my own experience. I remember always picking fights on purpose because I liked to physicaly fight with people but was always pulled away by a parent or teacher. I think I could get a job as one of those cage fighters. I'd probably be really good too because of my abilty to block out pain which seems to shut off competly when fighting or enraged.

Aggression is a very common thing for those with AS.

The rest of it doesn't look any less accurate than any other clinical observation of displayed symptoms.

I wonder how this "increased aggression" compares with other people with communication difficulties? (Including, especially, non-verbal communication.)

I'm not able to generate the non-verbal signals that say "you're making me angry and you need to back off NOW," and have had people push and push (looking for some "push back." It's as if they're automations or possed when they do that...) Anyway, I've always been overly self-controlled (and probably lucky), but I can see how people could get pushed into "acting out."

Luckily, I eventually figured out how to generate a scary look that works, and the push-push problem mostly went away. I'm sure some autistic people may simply be really aggressive, but the article assumes an internal POV that's IMO full of false assumptions and projections.

For most of "Challenge 8", there are no citations. The author seems to be making this stuff up. Note also that the author is not an autism expert, but an expert in conflict.

Personally, I definitely get upset by the reasons he states, but I direct the hurt inwards by doing things to harm myself. The most aggressive I've gotten towards others is yelling.

I fear that stuff like this that gets published will make us even more marginalized.

Some Aspies are probably aggressive, but certainly not all. I'm the least aggressive person I know.

I got in fight with kids when I was little because they were bullying me.

Tony Attwood is of the opinion that the reason why girls are missed more often than boys is because they aren't as disruptive and aggressive. There was also a documentary that showed children and teenagers with Asperger's as quite aggressive. Also, Hans Asperger noted aggressive and violent behaviour from some of his children. There's so many reasons why individuals with AS can display aggression; trouble understanding emotions, trouble in recognizing said emotions until they hit boiling point, bullying and teasing; frustration at social failings, etcetera.

I'd say that there's a higher incidence of violent behaviour amongst those with AS compared to the "normal" population; not everyone displays this, but add the difficulties that AS induces over people who're prone to aggressive behaviour due to innate differences amongst the population, and it'll be more frequent in those with AS.

There's also those with AS who're extremely passive, the opposite side of the coin.

There's a few good points in the article that are unrelated to the heading:

On impairment:

And AS:

Note that he actually states (in the Complete Guide, chapter 2) that girls are 'missed' more frequently because (a)they develop different methods to cope with their differences and (b)girls face different expectations (being aloof or shy and non-physical is more accepted). He also mentions that he sees a 1:2 ration in adults in his practice and that would make your interpretation somewhat implausible as it implies adult women being more disruptive and aggressive ...

Good catch though on Tantams remark to not see - or assume - impairments and deficits (rather then traits) on the basis of a (suspected) diagnosis.

It's from a paper. It speaks of school aged children (primary/elementary), and a lack of aggressive behaviour as one of the main causes.

There are definitely positive aspects to the article, including the fact that somebody is actually writing about adults on the spectrum, which is poorly understood.

However, I still maintain that he is overgeneralizing from a few incidents in children, to adolescents and adults (the topic of the paper). He makes us sound like we all are fire-starters. He talks about "explosive aggression", talks about lack of any empathy, that targets of our aggression is directed towards our mothers or spouses, how we become "suddenly and unexpectedly aggressive", "lacking empathy for others’ reactions to their violence, may continue to feel that they were justified" (in their aggressive behavior).

And how do you feel about this quote: "The level of aggression so far described is frightening and may lead to social
isolation because parents are ashamed for friends and family to call at the house and see broken furniture or walls with holes punched in them." Is there anybody here that can relate to that statement?

Maybe it's because I'm female that I resent these statements - I just don't see it in myself and I haven't read tales of aggression here in this forum.

Another quote, and again, no reference for his statement: "A young adolescent may just need to refuse to obey school rules,
swear at the teacher, or knock down school furniture. As the person gets older, more serious acts may be necessary to produce outrage and these can involve aggression, although they are more likely to be sexual or to involve arson."

Maybe I'm really on the wrong planet.

I can't really speak for anyone else, since I haven't exactly been immersed in an all-aspergian environment for any period of my life...

... but in my personal case, I couldn't really say for sure whether I'm aggressive or not. I mean, my typical coping strategy basically involves omniobjectification. I just treat people like animate obstacles... and while I can be physically or verbally violent to them, there is nothing personal in it... and no anger required.


I noticed something about the article though.... especially the bolded part.
The guy kept going on about behaviour that "they thought was justified".... and the funny thing is, in pretty much every example it sounded entirely justifiable to me. Apparently the writer didn't think so, but I expect that is just because he is a morally shackled, socially dependant mundie.

ya same here newer want experience that again though i was hell of figther
anyways these would be mainreasons why my meltdown ocurs
2. Outrage -maybe getting upset of someting
4. A special interest-like not being able to do my spesial indrest a week in row
5. Defensive-got lot of this when i was figthing..usually endet to "timeout" though i werent staying long if i had chance to run away so after hard trying they started to use leash so i cant run away from time out area this was days when i was in kindergarden and it was only for me defencing my self though got somefictories whith out punishment like when one kid runned to my fist himself

I get it. Explosive and out of frustration.

Most frequent ( several times ) in last few years is hitting the father of my son usually on the top of his head, ( when he is sitting down being particularly insensitive to some issue, often about changes in plans, or promises made and not kept, or not understanding how he has profoundly confused,or even insulted/undermined , me by some reply ), and throwing things, breaking crockery, throwing work files out of a 13 floor window, liquids onto work papers of his.

In serious post-natal depression I had 3 violent moments with my son, of "throwing"/flinging him when infant/baby/toddler onto soft armchairs, cushions or bed, never on to a hard surface though, aswell as on 2 or 3 occasions baring my teeth and roaring-growling at him and almost ( but not quite) biting, when he was very little and another nappy had exploded all over his clothes, or when I desperately wanted time alone and after falling asleep in my lap after breastfeeding my putting him in his bed woke him up; then I was close to murder.

We, both the father and I, went through a short phase of mismanaged and stressed, thoughtless, irritable slapping, but I actually stopped that because I saw it was counter-productive and bound to escalate.

The worst have always been the meltdown moments, like last summer when I lost it on holiday because son wouldn't leave a playground area, and I roughly dragged, and painfully gripped, and screamed.

I bullied my sister ( 18 months younger than me), for many years; from suffocation with pillows, to teasing, persuading her to drink horrible mixture i had concocted, and other things.

Rare explosions when younger , things like sweeping stuff off the family tea-table out of frustration with my father's pedanticism about meanings of words which made made discussion/argument impossible.

And my AS son does it too. Tendency to lash out, thump, kick, growl/scream, but perhaps only because he has seen me do it, and not only me. His father often gets angry/irritated and yells, and barks, and occasionally pushes me, and shouts and swears, and sometimes breaks down and sobs ( like I do too). So far son's violence doesn't seem explosive exactly , more frustrated. But I didn't get the explosive-rage thing until I was in my late teens.

I have definitely become more prone to explosive violence since becoming a mother. Child-rearing has been an enormous strain on my AS tolerance for noise, company and responsibility.

Baby-crying was hell. Noise has produced violent or hysterical defensive reactions in me.The desire to kill. I can remember wanting a gun to shoot at cars whose car-alarm went off over and over again.

I posted an article by Tantam on this forum a few months ago, relating to "maliciousness/malice" and AS, after Paolo quoted him in In-Depth Adult Discussion, because I found his description so refreshingly honest about the darker sides, aswell as wonderfully clear about so many aspects of AS.

For instance elsewhere in the above article, which I think should go into the AS Resources thread it is so good, I was so glad, and grateful, to find several recognitions of things that I find difficult to describe/express but which are so true for me; the issue of "accountability" for instance!

I have read posts by others on wp about being violent.

PS: And someone I knew who I now suspect was definitely AS did indeed knock a hole in a door with their fist.

Last edited by ouinon on 20 May 2008, 3:58 am, edited 6 times in total.

aylissa,

I doubt he's talking about everyone with Asperger's, just a subset that he sees in his clinical experience; whilst it may look sobering, there are individuals out there who're like he describes, and it is directly related to the disorder [in how it manifests in these young adults]. Many sites tend to gloss over certain challenging aspects of the disorder how it is in a noted percentage of individuals.