Early diagnosis of Asperger's disorder: lessons from a large clinical practice

The inclusion of Asperger’s disorder (AD) in the DSMIV (American Psychiatric Association, 1994) has, as one could predict, led to a great increase in its diagnosis and interest in those so diagnosed. It is my impression, and that of others (Filipek et al., 1999), that, similar to autistic disorder, it has shared the same fate as being misdiagnosed and/or diagnosed months or years after its appearance. Delayed diagnosis can have disastrous effects on the mental state and academic progress in AD. In most cases of AD, parents report being mystified and frustrated with their children’s lack of social tact and intense interests that preoccupy them to the exclusion of peer relations. As their children age, poor relatedness, odd preoccupations, and sometimes a lack of motivation are noted as well at school. The children need expert help to remain academically challenged while their social and behavioral problems are addressed. I have, over the past 25 years, evaluated and treated hundreds of children, adolescents, and adults diagnosed with AD or other pervasive developmental disorders (PDDs) in both a hospital and private practice setting. In a paper (Perry, 1998), I described five children and adolescents, previously diagnosed with attention deficit disorder or attention-deficit/hyperactivity disorder (ADHD), who met criteria for AD. I participated in a multidisciplinary panel, convened by the New York State Department of Health, that published guidelines for the early assessment and treatment of autism/PDD (New York State Department of Health, 1999). Children referred to rule in or out AD are generally older than those referred for evaluation of autistic disorder. Presenting problems in AD are much more likely to be social or behavioral in nature, whereas in autistic disorder, the presenting problem is more often abnormal language development. In some cases, children who are subsequently diagnosed with AD, meet criteria for autistic disorder or PDD not otherwise specified in their first years, and their clinical pictures evolve into that of AD. These children show early, significant delays in language. The issue and controversy concerning significant language delay in AD, which is an exclusion criterion in the DSM-IV, is addressed by Attwood (1998) and Volkmar and Klin (2000). The Gillberg and Gillberg (1989) criteria for AD includes possible language delay, and I have found them to be useful in diagnosis. Parent questionnaires, such as those of Attwood (1998) and Ehlers et al. (1999) can aid diagnosis. Suspicion of AD should be heightened if a close family member has been diagnosed with a PDD or has traits of AD (Volkmar and Klin, 2000). However, in my experience, many diagnosed with AD report no family history of AD or another PDD. In AD, many children do not concern their parents until later in childhood when social difficulties in group settings become clear. In milder cases, problems with socializing become more evident in late childhood or even adolescence when increasingly greater expectations for socializing and independence are not met. The problem behaviors in AD overlap with those of children diagnosed with other psychiatric disorders. Presenting problems often include inattention, impulsivity, sensory issues, learning problems, oppositional behavior, obsessive-compulsive disorder (OCD)–like preoccupations, and affective storms. The examiner can end up focusing on one or more of the behaviors and draw the wrong diagnostic conclusions if he or she is not sufficiently familiar with AD. Examinations must Accepted May 27, 2004. Dr. Perry is with New York University School of Medicine and the Bellevue Hospital Center Pediatric Consultation-Liaison Unit, New York. Reprint requests to Dr. Perry, 55 West 74th Street, New York, NY 10023; e-mail: PerryR3@aol.com. 0890-8567/04/4311–1445©2004 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000140451.43582.f8