Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 31: Child Psychiatry

with Asperger’s disorder. Self-sufficiency and problem-solving techniques are often helpful for these individuals in social situ- ations and work settings. Some of the same techniques used for autistic disorder are likely to benefit patients with Asperger’s disorder with severe social impairment.

Differential Diagnosis.  The differential diagnosis includes social anxiety disorder, obsessive-compulsive disorder, and schizoid personality disorder. According to the previous DSM- IV-TR, the most obvious characteristics of Asperger’s disorder compared to autistic disorder are the absence of language delay and dysfunction. The lack of language delay and impaired use of language were previous requirements for Asperger’s disorder; however, social and communication deficits are present. Studies comparing children with Asperger’s disorder and autistic dis- order found that children with Asperger’s disorder were more likely to seek social interaction, and due to their awareness of their impairment sought more vigorously to make friends. Although in this subgroup within autism spectrum disorder sig- nificant delay in language is not a feature, some delay in the acquisition of language, and some impairment in verbal com- munication has been noted in more than one third of clinical samples. Course and Prognosis.  The factors associated with a good prognosis in this subgroup within autism spectrum disorder are a normal IQ and more competencies in social skills. Reports of some adults diagnosed with Asperger’s disorder indicate that their social and communication deficits remain and they con- tinue to relate in an awkward way and appear socially uncom- fortable. Treatment.  Treatment of individuals who meet the criteria for the previous Asperger’s disorder diagnosis aims to promote social communication and peer relationships. Interventions are initiated with the goal of shaping interactions so that they better match those of peers. Very often children with Asperger’s disor- der are highly verbal and have excellent academic achievement. The tendency of children and adolescents with Asperger’s dis- order to rely on rigid rules and routines can become a source of difficulty for them and be an area that requires therapeutic inter- vention. A comfort with routines, however, can be utilized to foster positive habits that may enhance the social life of a child Jared was an only child. Birth, medical, and family histories were unremarkable. His motor development was slightly delayed, but language milestones were within normal limits. His parents became concerned about him at age 4 when he was enrolled in a nursery school and was noted to have difficulties in peer interaction, joining activities, and following the rules that were so pronounced that he could not continue in the program. In grade school, he was enrolled in regular education classes and was noted to have difficul- ties making friends and playing sports with the other students, and he often played alone and spent time alone at lunch and recess. His greatest difficulties arose in peer interactions—he was viewed as eccentric and did not seem to understand how to interact with peers. At home, he seemed captivated by watching the weather channel on television, which he insisted on watching and pursued with great interest and intensity. On examination at age 13, Jared had markedly restricted and intense interests and exhibited pedantic and odd patterns of communication with a monotonic voice quality. Psychological testing revealed an IQ within the normal range. For- mal communication examination revealed age-appropriate skills in receptive and expressive language but marked impairment in prag- matic language skills. (Adapted from Fred Volkmar, M.D.)

Pervasive Developmental Disorder Not Otherwise Specified

Whereas the DSM-IV-TR defines pervasive disorder not other- wise specified as a condition with severe, pervasive impairment in communication skills or the presence of restricted and repeti- tive activities and associated impairment in social interactions, DSM-5 conceives of this as encompassed within a diagnosis of autism spectrum disorder. Anna was the older of two children. She had been a difficult baby who was not easy to console but her motor and communica- tive development seemed appropriate. She was socially related and sometimes enjoyed interaction, but she was easily overstimulated. She exhibited some hand flapping behavior, especially when she was excited. Anna’s parents sought evaluation when she was 4 years of age because of problems with getting along with other children. At evaluation Anna was found to have language and cognitive func- tion within the normal range. Anna had difficulty relating to her parents as sources of support and comfort. She displayed behav- ioral rigidity and a tendency to impose routines on social skills. Anna was placed in a special education kindergarten and did well academically, although problems in peer interactions and unusual affective responses persisted. As an adolescent, Anna describes her- self as a “loner,” who often retreats from others and avoids social interaction and tends to be comfortable with solitary activities. (Adapted from Fred Volkmar, M.D.) Treatment.  The treatment approach is identical to that of other autism spectrum disorder. Mainstreaming in school may be possible. Compared with previously diagnosed autistic chil- dren, those with the former pervasive developmental disorder not otherwise specified generally have less impairment in lan- guage skills and more self-awareness. R eferences Akins RS, Angkustiri K, Hansen RL. Complementary and alternative medicine in autism: An evidence-based approach to negotiating safe and efficacious inter- ventions with families. Neurotherapeutics. 2010;7:307–319. Aman MG, Arnold MKLE, McDougle CJ, Vitiello B, Scahill L, Davies M, McCracken JT, Tierney E, Nash PL, Posey DJ, Chuang S, Martin A, Shah B, Gonzalez HM, Swiezy NB, Ritz L, Koenig K, McGough J, Ghuman JK, Lind- say RL. Acute and long-term safety and tolerability of risperidone in children with autism. J Child Adolesc Psychopharmacol. 2005;15:869. Autism and Developmental Disabilities Monitoring Network Surveillance Year 2006 Principal Investigators; Centers for Disease Control and Prevention (CDC). Prevalence of autism spectrum disorders—Autism and Developmental Disabilities Monitoring Network, United States, 2006. MMWR Surveill Summ. 2009,58:1–20. Baron-Cohen S, Knickmeyer RC, Belmonte MK. Sex differences in the brain: Implications for explaining autism. Science. 2005;310:819. Bishop DV, Mayberry M, Wong D, Maley A, Hallmayer J. Characteristics of the broader phenotype in autism: A study of siblings using the children’s communi- cation checklist-2. Am J Med Genet B Neuropsychiatr Genet. 2006;141B:117– 122. Boyd BA, McDonough SG, Bodfish JW. Evidence-based behavioral interventions for repetitive behaviors in autism. J Autism Dev Disord. 2011;1284–1294.