Pervasive Developmental Disorder: Asperger Syndrome Last Updated

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Developmental And Behavioral 

Pervasive Developmental Disorder: 

Asperger Syndrome

Last Updated: April 10, 2006 

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Synonyms and related keywords: Asperger syndrome, Asperger disorder, 

autistic psychopathy, high-functioning autism, HFA, hyperlexia, 

nonverbal learning 


, NLD, personality disorder—not otherwise specified, pervasive

developmental disorder—not otherwise specified, PDD-NOS, pragmatic language

disorder, right hemisphere dysfunction, schizoid personality, semantic pragmatic

disorder, sensory integration disorder, persistent impairment in social interactions,

repetitive behavior patterns, restricted interests, pedantic speech, early childhood

motor delays, clumsiness, 

fine motor difficulty

, gait anomalies, odd movements, 

social insensitivity, severe social impairment, 


mood disorders

obsessive-compulsive disorder

Tourette disorder

, socially inappropriate behavior, 

abnormalities in speech, abnormalities in language, oddities in pitch, abnormalities 

in intonation, abnormalities in prosody, abnormalities in rhythm, 

selective mutism

lax joints, anomalies of locomotion, anomalies of balance, anomalies of manual 

dexterity, anomalies of handwriting, anomalies of rapid movements, anomalies of 

rhythm, anomalies of imitation of movements, impaired ball-playing skills, doll-play 

paradigm, miscomprehension of language nuance, inability to use language in 

social contexts, lack of sensitivity about interrupting others, irrelevant commentary,

absent facial expressions, inappropriate facial expressions, peer relation difficulties



Section 1 of 10   



Author Information



















James Robert Brasic, MD, MPH

, Adjunct Assistant Professor, Department of 

Psychiatry, New York University School of Medicine; Fellow in Nuclear Medicine, Russell H 

Morgan Department of Radiology and Radiological Science, 

Johns Hopkins University School 

of Medicine

James Robert Brasic, MD, MPH, is a member of the following medical societies: 


Academy of Child and Adolescent Psychiatry

American Academy of Neurology

, and

Movement Disorders Society

Editor(s): Carol Diane Berkowitz, MD, Executive Vice Chair, Professor, Department of 

Pediatrics, Harbor-University of California at Los Angeles Medical CenterMary L Windle, 

PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of 

Pharmacy, Pharmacy Editor,, Inc; Caroly Pataki, MD, Associate Program 

Director, Clinical Associate Professor, Department of Psychiatry and Biobehavioral Sciences, 

Division of Child and Adolescent Psychiatry, Neuropsychiatric Institute and Hospital, UCLA;

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, 

Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical 

School; and Murray M Kappelman, MD, Professor, Departments of Pediatrics and 

Psychiatry, University of Maryland School of Medicine




Section 2 of 10   



Author Information


















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Background: Asperger disorder is a form of pervasive developmental disorder characterized 

by severe persistent impairment in social interactions, repetitive behavior patterns, and 

restricted interests. Unlike an autistic disorder, no significant delay occurs in language 

development or cognitive development. Asperger disorder is generally evident in children older 

than 3 years and primarily occurs in boys.

Children with this disorder often exhibit a limited capacity for empathy, a failure to develop 

friendships, and a limited number of intense and highly focused interests. While people with

Asperger disorder may have certain communication problems, including poor nonverbal 

communication and pedantic speech, many individuals have good cognitive and verbal skills.

Physical symptoms may include early childhood motor delays, clumsiness, fine motor 

difficulty, gait anomalies, and odd movements.

Individuals with Asperger disorder have normal or even superior intelligence, and they may 

make great intellectual contributions, while demonstrating social insensitivity or even apparent 

indifference toward loved ones. Published case reports of men with Asperger disorder suggest 

an association with the capacity to accomplish cutting-edge research in computer science, 

mathematics, and physics. While the deficits manifested by those with Asperger disorder are 

often debilitating, many individuals experience positive outcomes, especially those who excel 

in areas not dependent on social interaction. Persons with Asperger disorder have exhibited

outstanding skills in mathematics, music, and computer sciences. Many are highly creative,

and many prominent individuals demonstrate traits suggesting Asperger syndrome. As an

example, biographers describe Albert Einstein as a person with highly developed 

mathematical skills who was unaware of social norms and insensitive to the emotional needs 

of family and friends.

Although normal language and cognitive development differentiate Asperger disorder from 

other developmental disorders, the severe social impairment associated with this condition 

overlaps disorders such as high-functioning autism (HFA). For clinical management purposes,

Asperger disorder and HFA may be considered together. Impaired social skills are associated

with several other conditions (eg, developmental learning disability of the right hemisphere, 

nonverbal learning disability, schizoid personality disorder, semantic-pragmatic processing 

disorder, social-emotional learning disabilities).

For further information about conditions characterized by social impairments, restricted 

interests, and mental retardation, see 

Pervasive Developmental Disorder: Autism


Pathophysiology: The pathophysiology of Asperger disorder is unknown.

Some individuals with Asperger disorder have a history of problems in the prenatal and 

neonatal periods and during delivery. The relationship between obstetric complications and 

Asperger disorder is unclear. Events in early development may play a role in the pathogenesis 

of Asperger disorder.

Neuroimaging of individuals with Asperger disorder and related conditions is described in 


Scanning in Autism Spectrum Disorders

, an article that also includes hypotheses about the 

possible pathophysiology of Asperger disorder.


In the US: Because of the divergent diagnostic criteria used in the United States and 

Canada, estimates of Asperger disorder frequency vary widely. Various studies indicate

rates ranging from 1 case in 250-10,000 children. Additional epidemiologic studies are

needed, using widely accepted criteria and a screening instrument that targets these 


Internationally: A population study in Sweden estimates the prevalence of Asperger 

disorder as 1 case in 300 children. While this estimate is convincing for Sweden, the

findings may not apply elsewhere because they are based on a homogeneous 

population. Extrapolating from this study, Asperger disorder may be more common than

clinicians once thought; pediatricians, family physicians, general practitioners, and other

health professionals may underdiagnose this disorder.

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Mortality/Morbidity: Individuals with Asperger disorder appear to have normal lifespans, but 

they seem to endure an increased prevalence of comorbid psychiatric maladies (eg, 

depression, mood disorders, obsessive-compulsive disorder, Tourette disorder).

Race: Asperger disorder has no racial predilection.

Sex: The estimated male-to-female ratio is approximately 4:1.

Age: Asperger disorder is commonly diagnosed in the early school years and less frequently 

during early childhood or even adulthood. 



Section 3 of 10   



Author Information



















Developmental history

Interview parents about prenatal history and maternal health factors that may 

have affected the pregnancy.

Include a thorough evaluation of social behaviors, language, interests, routines, 

physical coordination, and sensory sensitivity, starting from birth.

Social problems

Children with Asperger disorder may have difficulties with peer relations and may 

be rejected by other children.

Outside the realm of immediate family members, the affected child may exhibit 

inappropriate attempts to initiate social interaction and to make friends. Within the

immediate family, the child is often loving and affectionate.

Alternatively, an affected child may not display affection to parents or other family 

members. A lack of bonding and warmth with parents and other guardians may

seem apparent, typically resulting from the child's lack of social skills.

Separations from parents because of work and divorce may be particularly 

stressful for these children. Changing homes, communities, and neighborhoods

may also exacerbate symptoms.

Individuals with Asperger disorder may have particular difficulty in dating and 

marriage. Boys and men with Asperger disorder may decide to marry suddenly 

without the dating and courtship that typically precede a union. Individuals with 

Asperger disorder may want to marry despite the lack of awareness of the many 

social interactions that usually lead up to matrimony. For example, in the movie 

Roger Dodger, an inexperienced youth with traits suggesting Asperger disorder 

encounters difficulty in relations with women (Chaisson and Kidd, 2002). Such 

problems may continue into adulthood.

Case vignette: A 50-year-old surgeon, who is an accomplished 

amateur musician with a PhD in mathematics and who has traits 

consistent with Asperger disorder, decides that it is time to marry 

and have children. He has always lived at home with his parents. 

Because he has trouble establishing relationships with women in his 

ethnic group locally, he goes overseas to marry a cousin less than 

half his age. He leaves his parents home for the first time to rent an 

apartment with his wife. They have no sexual relationship. She finds 

no career for herself in her new country, so she requests a divorce. 

Immediately after the divorce the patient wants to marry another 

woman. He complains that he is unable to find a suitable woman in 

his ethnic group.

People with Asperger disorder may benefit from counseling and social skills 

training. Attwood (1998) provides exercises for parents to use to foster social 

skills in their children. These activities can be modified for the needs of adults 

with Asperger disorder. Psychotherapy is often helpful for individuals to recognize 

their deficits in social skills.

People with Asperger disorder are vulnerable to depression, even suicide, after a 

perceived rejection in a social situation such as dating and marriage. Clinicians 

must be aware of the risk of depression and institute prompt interventions when 

major depression occurs.

Socially inappropriate behavior and failure to understand social cues may be 


The child may not understand why people become upset when he or she breaks 

social rules.

Communication abnormalities

Use of gestures is frequently limited.

Body language or nonverbal communication may be awkward and inappropriate.

Facial expressions may be absent or inappropriate.

Speech and hearing

Affected children demonstrate several abnormalities in speech and language, 

including pedantic speech and oddities in pitch, intonation, prosody, and rhythm.

Miscomprehension of language nuance (eg, literal interpretations of figures of 

speech) is common.

Individuals often exhibit practical speech problems, including inability to use 

language in social contexts, lack of sensitivity about interrupting others, and 

irrelevant commentary.

Speech may be unusually formal or used in idiosyncratic ways that others do not 


Individuals may vocalize their thoughts without censoring. Personal remarks

inappropriate to most social environments may be uttered routinely.

The amount of speech may also vary greatly and reflect the individual's current 

emotional state more than the communication requirements of the social setting.

Some individuals may be verbose and others taciturn. Furthermore, the same

individual may demonstrate excesses and paucity of speech intermittently.

Some individuals may display selective mutism, speaking not at all to most 

people and excessively to specific people. Some may choose to talk only to

people they like. Thus, speech may reflect idiosyncratic interests and preferences 

of the individual.

The form of language chosen may include metaphors meaningful only to the 

speaker. The message meant by the speaker may not be understood by those

who hear it, or the message may be meaningful only to a few people who 

understand the private language of the speaker.

Children often exhibit auditory discrimination and distortion, particularly when the 

child encounters 2 or more people speaking simultaneously.


Children exhibit peculiar and narrow interests, excluding other activities.

These interests may be so important that the children do not develop typical 

relationships with their family, school, and community.

Sensory sensitivity

Children may show sensitivity to sound, touch, taste, sight, smell, pain, and 

temperature. For example, a child may demonstrate either extreme or diminished

sensitivity to pain.

Children may be particularly sensitive to the texture of foods.

Children may exhibit synesthesia, including a sensory response to an 

environmental stimulus in a different sensory modality.


Screening for a theory of mind

Key features of the deficit manifested in people with Asperger syndrome pertain to their 

inability to understand the thoughts of other people and themselves. A typical child can 

recognize the thoughts of other children and himself or herself and hypothesize how other 

people are likely to respond to life occurrences. The lack of this comprehension in a person 

with Asperger syndrome is termed a deficiency in the formation of a theory of the mind.

A theory of the mind can be thought of as a form of intuition in which young children learn how 

other children respond to common situations. Children usually develop the skill to predict other 

children's responses to common occurrences before they begin school. Some people with 

Asperger syndrome appear never to develop a theory of mind.

Because most children have the ability to understand the mental processes of themselves and 

others since early childhood, pediatricians and other clinicians need to recognize that children 

with Asperger syndrome often lack abilities to intuit the thoughts of others and themselves. 

Pediatricians and other clinicians may be shocked to recognize that otherwise intelligent 

children with Asperger syndrome lack simple mental abilities to grasp situations that appear 

obvious to even typical preschool children. Therefore, screening for a theory of mind is an 

important process a pediatrician can use to identify some of the core behavioral symptoms of 

Asperger syndrome.

Clinicians can screen for a theory of mind in a few minutes in offices, homes, and other 

everyday settings with minimal props. Screening for a theory of mind involves a doll-play 

paradigm and an imagination task.

The two components of the doll-play paradigm constitute a fundamental procedure to 

demonstrate the presence of a theory of mind. The clinician and the patient are seated at 

opposite ends of a table. The clinician shows the patient two dolls and names them by saying, 

"This is Sally. This is Anne" (Baron-Cohen, 1985).

For the first procedure in the doll-play paradigm, the clinician tells and shows Sally placing a

marble in a basket. The clinician then removes Sally from the room and closes the door,

leaving her outside. The clinician then tells and shows Anne removing the marble from the

basket and placing it in a box. The clinician then brings Sally back into the room. The clinician

asks the patient, "Where will Sally look for the marble?” (Baron-Cohen, 1985)

Typical children, adolescents, and adults with a theory of mind will indicate that Sally will look 

for the marble in the basket where she placed it before leaving the room. If this response is 

elicited, the child passes the doll-play paradigm, and the subsequent sections and the clinician 

may then proceed to the imagination task.

If the patient does not indicate that Sally will look for the marble in the basket where she 

placed it before leaving the room, the clinician proceeds with questions to clarify the patient's 

understanding of the situation. The clinician asks the patient, "Where is the marble really?" 

(Baron-Cohen, 1985) Both typical and atypical children, adolescents, and adults will usually 

state that the marble is in the box. The clinician then asks the patient, "Where was the marble 

in the beginning?" (Baron-Cohen, 1985) Both typical and atypical children, adolescents, and 

adults will usually state that the marble was originally in the basket.

The first procedure of the doll-play paradigm identifies the absence of a theory of mind when 

an affected child, adolescent, or adult indicates that Sally will look for the marble in the box. 

The patient thereby indicates an assumption that Sally, like the patient, will look for the marble 

in the box because the patient knows that the marble is in the box. The ability to recognize that 

Sally, unlike the patient, was absent and does not know that the marble was moved from the 

basket into the box is an example of a theory of mind of Sally as distinct from that of the 


For the second procedure of the doll-play paradigm, the clinician tells and shows Sally placing 

a marble in a basket. The clinician then removes Sally from the room and closes the door, 

leaving Sally outside. The clinician then tells and shows Anne removing the marble from the 

basket and placing it in the clinician's pocket. The clinician then brings Sally back into the 

room. The clinician then asks the patient, "Where will Sally look for the marble?" 

(Baron-Cohen, 1985)

Typical children, adolescents, and adults with a theory of mind will respond that Sally will look

in the basket because Sally last placed it in the basket. If this response is elicited, then the

patient passes the doll play paradigm so the clinician may proceed to the imagination task.

Otherwise, the clinician then asks the patient, "Where is the marble really?” (Baron-Cohen,


Both typical and atypical children, adolescents, and adults respond that the marble is in the

clinician's pocket. The clinician next asks the patient, "Where was the marble in the

beginning?” (Baron-Cohen, 1985) Both typical and atypical children, adolescents, and adults

respond that the marble was in the basket originally.

As for the first step in the doll-play paradigm, an absence of a theory of mind is identified when 

an affected child, adolescent, or adult indicates that Sally will look for the marble in the 

clinician's pocket. Affected children, adolescents, and adults repeatedly incorrectly think that 

Sally will know the location of the marble because they do. Affected individuals do not 

recognize that Sally's understanding of the placement of the marble is different from theirs 

because she was absent when it was moved. This is evidence of deficits in the ability to 

formulate a theory of mind in the affected person.

The final activity in the screen for a theory of mind is the imagination task. In this procedure, 

the clinician tells the patient, "Now, I want you to close your eyes and think about a big white 

teddy bear. Make a picture in your head of a big white teddy bear. Can you see the white 

teddy?" (Baron-Cohen, Psychiatric Clin North Am, 1991) Typical children, adolescents, and 

adults report the visualization of a big white teddy bear. If the patient does not report the 

image of a big white teddy bear, then the clinician asks, "What can you see when you close 

your eyes?" (Baron-Cohen, Psychiatric Clin North Am, 1991) If the patient reports any mental 

image, then the clinician asks, "What are you thinking of?" (Baron-Cohen, Psychiatric Clin 

North Am, 1991) Typical children, adolescents, and adults readily report the visualization of a 

big white teddy bear with these stimuli.

The next activity of the imagination task is a repetition of the first part with the substitution of a 

big red balloon for the white teddy bear. Typical children, adolescents, and adults readily 

report the visualization of a big red balloon.

For the final activity of the imagination task, the clinician asks the patient to identify the first 

picture of the task. Typical children, adolescents, and adults readily report that they first 

imagined a big white teddy bear. The ability to remember an earlier mental image is evidence 

of a theory of mind. The inability to recognize one's own prior mental images suggests the lack 

of a theory of mind; therefore, the report that a big red balloon was first item imagined is 

evidence of the absence of a theory of mind.

Typical children show evidence of having a theory of the mind before beginning school. Thus, 

inability to correctly perform any of the theory of mind screening procedures in a school-aged 

child suggests the need to refer the child for additional evaluation.

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