Treatment and Prevention of Dysfunctional Behavior in Adolescents

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Treatment and Prevention of Dysfunctional Behavior in Adolescents Diagnosed within the Category of Pervasive Developmental Delay.* Raymond W. DuCharme, Ph. D.

The Learning Clinic, Inc., Brooklyn, CT. USA Kathleen A. McGrady, Psy.D., ABDA The Learning Clinic, Inc., Brooklyn, CT.

USA Introduction What is a pervasive developmental delay? Is a diagnostic description of Pervasive Development Delay, Not Otherwise Specified (PDD, NOS) helpful to the individual, his family and those responsible to provide treatment? The purposes of a diagnosis are to precisely describe a condition in need of treatment, and to determine from the described symptoms a preferred regimen of treatment.

Further, the diagnosis should state that if a treatment is provided, then a prediction may be made of a prognosis. The correctness of the diagnosis is critical to the identification of needed treatment resources that should be present in order to habilitate or rehabilitate the individual. Resource identification and allocation are expected consequences of a diagnosis.

The diagnosis of Pervasive Developmental Delay or Pervasive Developmental Delay, Not Otherwise Specified (DSM-IV PDD, NOS) is, in recent clinical experience, a more frequently observed diagnostic label in the literature, as well as present in the description of individuals referred for treatment to residential treatment settings and special education ... more. less.

classrooms. Individuals with a Pervasive Developmental Delay, Not Otherwise Specified diagnosis are those persons who do not fit all of the criteria for a cluster of diagnoses that are part of a spectrum of disorders that involve developmental delays (see Chart 1). * Chapter 14 excerpt from: Handbook Of Adolescent Behavioral Problems: Evidenced-Based Approaches to Prevention and Treatment , Edited by: Thomas P. Gullotta, C.E.O., Child and Family Agency of Southeastern Connecticut, New London, CT. Gerald Adams, Ph.D., Professor of Family Relations and Human Development, University Juelph, Ontario, Canada A new publication to be released in 2005. Diagnosis Onset of Symptoms Gender Social Skills Head Circumference Language Skills Cognitive Functioning Motor Skills Autism Prior to age 3 years. Symptoms in infancy are subtle. Males (8 times greater than females) Social skill deficits Delay, or lack of development 75% have mental retardation Repetitive and Stereotyped Rett's Disorder Five months normal development; diagnosed between 5-48 months Females Loss of social interaction early; may develop later Decelerates between 5 - 48 months Expressive and receptive language problems Severe to profound mental retardation "Hand-Wringing"; gait and truck coordination problems Childhood Disintegrative Disorder Two years normal development; diagnosed before age 10 Males - more common Loss of social skills (after age 2 years) Expressive or receptive (after age 2 years) Severe mental retardation (usually) Loss of motor skills after age 2 years Asperger Syndrome Recognition and diagnosis later (e.g., school age, between ages 7 - 11 years) Males (8 times greater than females) Social skill deficits No general delay in language; but pragmatic language deficits. Theory of Mind - Subvocal Speech Normal IQ Verbal Performance Deviation Motor delays and clumsiness: Absence of research PDD, NOS Does not meet criteria for any of the above, but has some of the behaviors Does not meet criteria for any of the above, but has some of the behaviors Does not meet criteria for any of the above, but has some of the behaviors Does not meet criteria for any of the above, but has some of the behaviors Does not meet criteria for any of the above, but has some of the behaviors Does not meet criteria for any of the above, but has some of the behaviors Does not meet criteria for any of the above, but has some of the behaviors The Learning Clinic, Inc. January 16, 2004 2 Chart 1 It is apparent from the comparison of the DSM-IV diagnostic classifications that describes Pervasive Developmental Delay sets of symptoms, that PDD, NOS does not fit within the symptom clusters of other diagnoses of different developmental delay profiles. A Pervasive Developmental Delay, Not Otherwise Specified description is more clearly what it is not than what it is. Pervasive Developmental Delay, Not Otherwise Specified is not Autism, Asperger Syndrome, Rett 9s Disorder or Childhood Disintegrative Disorder. It is sufficient to say that Rett 9s Disorder and Childhood Disintegrative Disorder have characteristics that are identifiable to distinguish each from the other, as well as from Autism and Asperger Syndrome. Autism and Asperger Syndrome are diagnostic classifications that are less clearly distinguishable (Schopler et al., 1998; Klin et al., 1995; Barnhill, 2000). It is argued by researchers that Autism is a separate diagnosis (Frith, 1991) and that Asperger Syndrome is clearly differentiated from other pervasive developmental profiles of delay (Gilchrist, 2001). There is a strong case made through various researches that Autism, and High Functioning Autism, and Asperger Syndrome are aspects of a continuum that reflect a spectrum of developmental delay (Volkmar et al., 1998; Rourke, 1995). The current DSM-IV and ICD-10 of the World Health Organization criteria for the diagnosis of Asperger Syndrome further illustrate that the differences in criteria for diagnosis threaten the external validity of a correct diagnosis (DuCharme & McGrady, 2004) (See chart 2). ASPERGER SYNDROME CRITERIA DSM-IV ICD-10 Qualitative impairment in social interaction X X Restricted repetitive and stereotyped patterns of behavior, interests and activities X X No general language delay X X No delay in cognitive development X X Normal general intelligence (most) X Markedly clumsy (common) X No delay in development of: " age appropriate self-help skills " adaptive behavior (excluding social interaction) " curiosity about environment X Chart 2 3 4 Determining a precise differential diagnosis of the pervasive developmental delays evident in the symptom profile of an individual currently remain problematic. The consequent ramifications are also evident: 1. unclear diagnostic criteria result in error and misdiagnosis 2. misdiagnosis causes error in the selection of type and duration of treatment 3. treatment misapplications yield poor prognosis and little evidence of efficacy There are risks in asserting data and evidence for rates of occurrence of types of developmental delays among children, adolescents and adults. Prevalence for Autistic Disorder based on epidemiological research suggests 2-5 per 10,000. Rett 9s Disorder is much less common and is reported to be only in females. Childhood Disintegrative Disorder is less frequent in occurrence than Autistic Disorder and is more frequently associated with males. The prevalence of Asperger Syndrome is limited by the validity measures associated with basic researches. Ehlers and GiIlberg (1993) report the prevalence of Asperger Syndrome to be 26-36 per 10,000 school age individuals. Asperger Syndrome is clearly the more numerous group of individuals among those under discussion. Paul Shattuck in his 2002 presentation at the Gatlinberg Conference for Research on Mental Retardation and Developmental Disabilities detailed prevalence data of Autism in public schools. He reports an increase of 24% between 1994 to 2000 (Blacher, 2002). Other researchers from Queens College and the Texas Center for Autism Research and Treatment report the same trends in prevalence data (Blacher, 2002) in Exceptional Parent Magazine , (2002), Oct., 94-97. Klin et al. (1995) conclude that Asperger Syndrome appears to be a cvery mild d form of Pervasive Developmental Disorder. The authors question the face value of creating the Asperger Syndrome grouping apart from the Pervasive Developmental Disorder, Not Otherwise Specified category. This idea of a broadband diagnostic grouping creates the need for criteria that are determinant of what constitutes a csignificant d delay and what combination of delayed performances indicate pervasiveness. Further, the status of a developmental delay does not imply that there will be continued future development toward the maturation of that measured delay. . Over the last decade, researchers have explored the basis for Asperger Syndrome. Some of that research yields evidence that resolves the question, Does Asperger Syndrome exist? A search of the literature using the keyword cAsperger d produced three hundred eighty-five studies, articles, and other references. One hundred sixty-six studies pertained to diagnosis. The researchers, whose purpose was to clarify issues related to the validity of Asperger Syndrome, are the primary sources for the following discussion. Their articles examine the requirements of a system that differentiates among Autism, Asperger Syndrome, High Functioning Autism, Pervasive Developmental Delay, Not Otherwise Specified and Non-Verbal Learning Disability. Raja and Anzzoni (2001) discuss the autistic condition described almost simultaneously by Dr. Asperger in Vienna (1944) and Dr. Kanner (1943) in Baltimore. Both men were medically trained in Vienna at about the same time. Dr. Kanner (1943) described the characteristics of children that he diagnosed as having infantile autism. Dr. Asperger (1944) made observations of children in his hospital unit in Vienna that he characterized as cautistic psychopathy d (Frith, 1991). Dr. Kanner 9s diagnosis of infantile autism is more severe than Dr. Asperger 9s label. Their work has inspired decades of research that attempts to clarify the differences and similarities between the two clinical descriptions. In recent years Asperger Syndrome (AS) was considered to be a Pervasive Developmental Disorder and was included as a new diagnosis in the World Health Organization (1992) International Classification of Diseases (ICD-10) and the United States (1994) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). For a comparison of factors included in the diagnoses, see chart 2. 5 Eisenmajer et al. (1996) point out that the DSM-IV criteria for Asperger 9s Disorder (AsD), (now called Asperger Syndrome), is the same as that for Autism Disorder (AD) with three exceptions: 1. Communication and imagination impairment criteria for Autism Disorder are not listed for AsD. 2. The child with an AsD diagnosis is described not to suffer from a clinically significant general delay in language; e.g.,single words by age 2 years and phrases by age 3. 3. The child with AsD does not have a clinically significant delay in cognitive development, the development of age appropriate self-help skills, adaptive behavior, or curiosity about the environment. Raja and Anzzoni (2001, p. 285-293) state that c . . . the syndrome Hans Asperger originally described may not be captured by the present DSM-IV or ICD-10 criteria. d There are differences between the diagnostic criteria provided by the DSM-IV and the ICD-10. While the ICD-10 endorses the traits of normal intelligence and clumsy behavior, the DSM-IV does not include those traits. Further, the DSM-IV lists that there is no delay in the development of age appropriate self-help skills, adaptive behavior (excluding social interaction), and curiosity about the environment. Note that the ICD-10 does not list these criteria. Behavior Patterns Fundamental differences in criteria produce a serious threat to the external validity of the diagnosis of Asperger Syndrome. The similarity between an Autistic Disorder diagnosis and a Pervasive Developmental Disorder, Not Otherwise Specified (PDD, NOS) diagnosis adds to the difficulty in interpreting diagnostic categories. Leekham et al. (2000) developed algorithms for a Diagnostic Interview for Social and Communication Disorders (DISCO). The interview models were used to compare the ICD-10 for AS with those developed by Gillberg in 1993. Two hundred (200) children and adults were studied, all of whom met the ICD-10 criteria for childhood autism or atypical autism. Only 1% met the ICD-10 criteria for Asperger Syndrome. Forty-five (45) percent of the sample met the Asperger Syndrome criteria defined by Gillberg. The study revealed that the discrepancy in diagnoses was due to the ICD-10 requirement for cnormal d development of cognitive skills. Gillberg 9s criteria showed that the participants diagnosed with Asperger Syndrome differed significantly from others on all but two Gillberg criteria. The authors question the benefit of defining a separate AS subgroup. They suggest, as do Klin et al. (1995), Volkmar et al. (1998), and Schopler et al. (1998) that a dimensional view of the autistic spectrum is more appropriate than a categorical one. The definition of a csyndrome d or pattern of symptoms along a continuum is more useful than the term cdisorder d. Gillberg 9s six criteria (Ehlers and Gillberg, 1993) comprise social impairments, narrow interests, repetitive routines, speech and language peculiarities, non-verbal communication problems and motor clumsiness. Gillberg includes Szatmari 9s et al. (1989) criteria and Tantam 9s (1988) five criteria. The ICD- 10 and DSM-IV note an absence of any clinical delay in language and cognitive development in the first 3 years of life. The DSM-IV adds no delay in the development of self-help skills, adaptive behavior, and curiosity about the environment. Gillberg 9s (Ehlers and Gillberg, 1993) broader criteria appears to differentiate between groups more reliably than do either the DSM-IV or ICD-10. It is also important to note that the developmental signpost of 3 years of age for evidence of delays may be too limiting, as critical functions may become deficient over time, through subsequent developmental stages. Also, the criterion of an IQ of 70 or above may place the lower level too low, given the normal range of IQ that other researchers use as the standard for an Asperger Syndrome characteristic. Other research (DuCharme, 2003) suggest that patterns of pragmatic skill deficits persist across ages for Asperger Syndrome individuals. These language patterns require further investigation. 6 Comparing Diagnoses Research suggests that a dimensional view of the autism spectrum is more appropriate than the categorical approach represented by the ICD-10 and DSM-IV. A dimensional view considers patterns of symptoms, or characteristics, and degrees of severity. Ozonoff et al. (2000) compared twenty-three (23) children with High Functioning Autism with twelve (12) children who were diagnosed with Asperger Syndrome. Both groups were matched for chronological age, gender and intellectual ability. The sources of difference between the groups are categorized as cognitive functions, current symptoms, and early history. The authors conclude that High Functioning Autism and Asperger Syndrome involve the same symptomatology and differ only in degree of severity. When comparing length of time in special education, the authors found that High Functioning Autism students remained in special education self-contained classes longer than Asperger Syndrome students. Klin et al. (1995) report on the validity of neuropsychological characterization of Asperger Syndrome and the convergence of Asperger Syndrome with Non-Verbal Learning Disability. Their research used the ICD-10 diagnostic criteria. The authors compared neuropsychological profiles of Asperger Syndrome (AS) and High Functioning Autism (HFA) and the assets and deficits described by the term cnon-verbal learning disability d (NLD) reported by Rourke (1995). The groups were described to differ significantly in eleven neuropsychological areas. The aspects of Non-verbal Learning Disorder, typical of child functioning, include deficits in tactile perception, psycho-motor coordination, visual-spatial organization, non-verbal problem solving, appreciation of incongruity, and humor. The Non-verbal Learning Disability child demonstrates poor pragmatic language skill and impaired prosody in speech, along with deficits in social perception, social judgment and social interaction skills. All of these examples of child functioning for Non-verbal Learning Disability are also typical of the Asperger Syndrome child. Both groups, Asperger Syndrome and Non- verbal Learning Disability, also share the tendency toward social withdrawal and mood disorder (Klin et al., 1995). Non-verbal Learning Disability is not part of the diagnostic nosology of either the ICD-10 or DSM-IV. Schopler and Mesibov (1998) identify the similar characteristics of High Functioning Autism and Asperger Syndrome. They support the notion of csymptom overlap d between Autism, High-Functioning Autism, and Asperger Sydrome. Manjiviona and Prior (1999) reported that higher IQ scores among Asperger Syndrome students account for the differences. Klin et al. (1995) reported that although the Asperger Syndrome and High Functioning Autism groups did not differ in full scale IQ, the verbal 3 performance differential (VIQ 3 PIQ) were significantly different. The Asperger Syndrome group demonstrated a higher verbal IQ and lower performance IQ in comparison to the High Functioning Autism group. The degree of overlap between the psychiatric diagnoses Asperger Syndrome, High Functioning Autism, and the neuropsychological characterization of Non-verbal Learning Disability (NLD), indicates a high degree of concordance between Asperger Syndrome and Non-verbal Learning Disability. The neuropsychological description of Non-verbal Learning Disability assets and deficits is a model for Asperger Syndrome, but not for High Functioning Autism. It is not useful then, to identify Non-verbal Learning Disability as a separate diagnostic group apart from Asperger Syndrome. 7 Characteristics of Asperger Syndrome: Motor Development It is reported that delayed motor milestones and the presence of motor clumsiness are Asperger Syndrome characteristics. But there is a paucity of research to corroborate a clear association between motor delay and other Asperger Syndrome characteristics (Ghaziuddin and Butler, 1998). Motor development and cclumsiness d were investigated by Ghaziuddin and Butler (1998), Ghaziuddin et al. (1994). The authors found no significant relationship between coordination scores and diagnostic category after adjusting scores for intelligence. Weimer et al. (2001) suggest that the motor clumsiness reported by Green, et al. (2002) and Miyahara et al. (1997) may be the result of the proprioceptive deficits that underlie the cases of uncoordination observed in some Asperger Syndrome cases. Motor delay and early language delay prior to age three are not predictive of other Asperger Syndrome characteristics or of later developmental problems. The definition of clanguage delay d may be too limited as this usually pertains to the child 9s saying single words or simple phases. Speech and Prosody Shriberg et al. (2001) investigated the speech and prosody characteristics of adolescents and adults with High Functioning Autism and AS. Prosody includes phrasing, variability in speech production, same word duration in sentences, and grammatical placement of stressed and unstressed syllables and words. Voice loudness, pitch and quality were also compared. There were minor differences between Asperger Syndrome and High Functioning Autism subjects in volubility differences and articulation errors. Asperger Syndrome subjects used higher volume, and there was a high prevalence of speech-sound distortion in both groups. Findings associated with prosody and voice analyses identified significant differences between clinical and control groups in the areas of phrasing, stress, and nasal resonance. Two-thirds of the Asperger Syndrome speakers were coded as having non-fluent phrasing on more than 20% of their utterances. It is speculated that Asperger Syndrome individuals use repetition and revision to compensate for formulation difficulties. There is also a suggestion that increasing length of utterance is associated with increased phrasing errors. Higher levels of grammatical complexity were also associated with increased phrasing errors and length of utterance. Gilchrist et al. (2001) compared adolescent Asperger Syndrome, High Functioning Autism, and Conduct Disorder (CD) diagnoses as to behavioral and speech abnormalities. The findings for the Asperger Syndrome group were as follows: 1) demonstrated less severe behavioral abnormalities than the autism group; 2) were unlikely to have speech abnormalities; 3) had other communication and social behavior difficulties similar to High Functioning Autism; 4) did better in structured one-to-one conversation than other groups. Language and Meaning Jolliffe and Baron-Cohen (2000) examined linguistic processing in high functioning adults with Autism or Asperger Syndrome. The ability to establish causal connections and to interrelate clocal chunks d (see footnote 1) into higher-order cchunks d so that most linguistic elements are linked together thematically is defined as cglobal coherence d. The authors hypothesized that adults on the Autism Spectrum, including Asperger Syndrome, would have difficulty integrating information so as to derive meaning. Results showed that the clinical groups were less able to arrange sentences coherently and to use context to make a global inference. The findings of the study on the abilities called cglobal coherence d are inconsistent with the classroom experience of adolescent High Functioning Autism and Asperger Syndrome student performance at TLC (DuCharme & McGrady, 2003). Thirty (30) students were assigned a task with directions for writing a news story. They were given seven statements of instruction and ten individual descriptive informational statements, six of which were relevant to a theme, and four, irrelevant. The 8 assignment was to create a news story that had a main point by selecting relevant information from the sentences provided. All thirty (30) students successfully completed the task set, but demonstrated an inability to select information less relevant or irrelevant to the main theme. 1 Chunking. The process of reorganizing materials in working memory to increase the number of items successfully recalled. Jolliffe and Baron-Cohen (2000) required an inference and use of connotative meaning to demonstrate comprehension. Global coherence may be different from inference. TLC student behavior demonstrated the ability to identify a main theme and related, supporting data that were ccoherent d. No inference was required. But students were not able to differentiate the relative importance of information provided. The cglobal coherence d requirement of the Jolliffe & Baron-Cohen (2000) study to interpret and infer within the context of a story is different from combining facts into a coherent statement or conclusion. The definition of their task has connotative implications. Connotative and denotative meaning derive from linguistic processes that may differ from the processes used to infer meaning from factual content. Frith (1994), and Minshew et al. (1995) describe linguistic difficulties present when an Asperger Syndrome person is given complex interpretive language tasks. Deficits were found in complex information processing abilities. However, linguistic basic skills were preserved. Channon et al. (2001) presented video taped real-life problems to thirty (30) pre-teen and adolescent youth. Fifteen (15) were diagnosed with Asperger Syndrome and fifteen (15) were placed in a control group. The Asperger Syndrome group differed in their ability to provide socially appropriate solutions to the problems as compared to the control group responses. The inability to draw inferences and to assign appropriate attribution to key factors present in social situations are also discussed by Barnhill (2001) and Barnhill and Myles (2001). Cognitive Processes Cognitive flexibility required to solve a novel problem, or a familiar problem in a novel situation is absent for Asperger Syndrome persons to a degree beyond what their normal to superior IQ scores should predict. Shulman et al. (1995) report that individuals on the Autism Spectrum have difficulties with tasks that necessitate internal manipulation of information. Theory of Mind (TOM) is defined as the ability to infer mental states, including beliefs, intentions and thoughts (Perner & Wimmer, 1985). Happe (1995) describes these internalized manipulations of information as mentalizing. How cmentalizing d is related to cglobal coherence d and Theory of Mind is unclear. But these processes suggest an interface among auditory processing, language, cognition, and the cload d of factors present in any situation. Dunn et al. (2002) support, with preliminary evidence, the view that clear differences exist in the sensory processing patterns of children with Asperger Syndrome when compared with non-clinical peers. Asperger Syndrome students are reported to have difficulty with auditory processing. They demonstrate poor ability to modulate their responses from one situation to another. The authors advocate for a student to receive a sensory measurement that will yield a profile that reflects the assessment of sensory processing, modulation of behavioral-emotional responses, and level of response to csensory events d. Sensory processing deficits may alter the ability to cognitively manipulate data accurately. The observations by Frith (1991) and Frith and Happe (1994) that Asperger Syndrome children are limited in their ability to demonstrate pretend play, imagination and creativity has some support in the research literature (Craig and Cohen, 1999). This apparent restricted ability to predict future events by manipulating past experience, as part of problem solving, may be related to measures of limited creativity and Theory of Mind factors identified early in Asperger Syndrome child development (Baron-Cohen et al. 1999) (Jolliffe & Baron-Cohen, 2000). 9 Ehlers, et al. (1997) compared the cognitive profiles of Asperger Syndrome, Autism Disorder, and Attention Deficit Disorder students 5 to 15 years old. The Swedish version of the WISC III Kaufman Factors of Verbal Comprehension, Perceptual Organization and Freedom from Distractibility measurements were compared for forty (40) students in each group. The Asperger Syndrome and Autism Disorder groups differed in respect to cfluid d and ccrystallized d cognitive ability, with the Asperger Syndrome group scoring higher in both areas. They also found that the Kaufman Factor scores accounted for more variance than WISC-III Verbal or Performance IQ scores. De Leon et al. (1986), Courchesne et al. (1994), Schultz et al. (2000), and Morris et al. (1999) investigated brain hemisphere function associated with developmental prosopagnosia and visual- perceptual functions involved in face recognition. There is inconclusive evidence that inability to perceive emotion in facial cues is a neurocognitive dysfunction of visual-perception (Grossman, et al. 2000). The conclusion does not imply that there is no evidence of cortical neuropathology present in Asperger Syndrome. Casanova, (2002), Rourke, et al. (1983), Aman, et al. (1998). Asperger Syndrome Profile Barnhill (2001) provides a synthesis of research conducted by the cAsperger Syndrome Project d. The Asperger Syndrome Project was designed to provide an cempirically valid profile of individuals with Asperger Syndrome d (p. 300). A series of studies is summarized to provide a description of Asperger Syndrome children and youth. The following characteristics are reported: 1. IQs similar to the general population, ranging from deficient to very superior. 2. Significantly less capable written than oral language skills. 3. Limited ability to problem solve in contrast to verbal fluency skill. 4. Measured emotional difficulties not endorsed by the Asperger Syndrome students themselves. 5. Problems with inferential comprehension. 6. Attributions that parallel a learned helplessness approach. 7. Sensory problems similar to a cognitively deficient person. It is helpful to separate the influence of intelligence quotient from each diagnostic classification, e.g., Autism IQ quotient in the deficient range and Asperger Syndrome IQ quotient in the normal to very superior range. Barnhill (2000) omits other characteristics such as eye gaze, pragmatic language deficiencies, poor speech characteristics of prosody, volume, phrasing, grammatical structure and word stress. The cluster of factors associated with socialization, social skill development and social reality testing are important discriminate variables associated with Asperger Syndrome. The tendency to prefer aloneness, to avoid peers in preference to adult interaction, other avoidant behaviors, and marginal independent living skills are also related to diagnosis and prognosis for Asperger Syndrome persons (Nesbitt, 2000); (Matthews, 1996); (Mawhood & Howlin, 1999); (Tantam, 2000); (Dewey, 1991); (Dyer, et al. 1996). The inability to draw inferences, to interpret connotative meaning, and to apprehend relationships between factual knowledge and higher order thinking also need to be included as Asperger Syndrome characteristics worthy of investigation. Evidence of over and under reactivity to ordinary stimuli, and attentional shift problems are important characteristics (Courchesne et al.,1994). Level of cognitive rigidity in the presence of anxiety-producing stimuli reported anecdotally has important heurestic value in future researches. Asperger Syndrome is a complex continuum of symptoms and these problematic symptoms of communication and language, cognition, adaptability, lack of generalization of skill, socialization and sensory processing are more evident in the interactions that are part of the daily activities in the natural environment than the testing room. The clarity of the diagnostic nosology that fits the child 9s environment is important. And the need to assess Asperger Syndrome persons as part of the natural daily routine is also important in order to obtain a valid assessment of their competencies. 10 Associated Co-morbid Conditions The method to obtain an accurate diagnosis and treatment for an Asperger child is usually not straightforward. Asperger Syndrome is a multi-faceted disorder with subtle manifestation of deficits (Mesibov et al. 2001). The diagnostic process is further complicated by co-morbid conditions, or other secondary problematic behaviors. These may include difficulties with attention and concentration, anxious behaviors, depression, motor or vocal tics, obsessive-compulsive behaviors, noncompliant or aggressive behaviors, or learning disabilities (Klin, Volkmar & Sparrow, 2000). Behaviors associated with these conditions tend to be disruptive, and therefore become the focus of treatment and diagnosis. Before it is recognized that a youngster has Asperger Syndrome, the child may be given one or more of the following diagnostic labels: Attention-Deficit/Hyperactivity Disorder (ADHD), Depression, Anxiety Disorder, Obsessive Compulsive Disorder (OCD), Oppositional-Defiant Disorder, or Schizophrenia. In some cases the child may have a co-morbid condition, which warrants the diagnosis. In other cases, the behaviors are a manifestation of one of the many features of Asperger Syndrome, and do not meet the criteria for a second diagnosis. Of twenty-four adolescent students at The Learning Clinic who were diagnosed with Asperger Syndrome or PDD, NOS, (using DSM-IV criteria) 54% were treated with three or more medications (R = 0-5) (mode = 3). The same group of 24 students revealed a pattern of co-morbid diagnoses: 54% were diagnosed with two or more conditions and 25% with three or more conditions (R = 0-4) (mode = 2) (DuCharme & McGrady, 2004). Attention-Deficit/Hyperactivity Disorder Difficulties with attention and concentration are not uncommon with Asperger Syndrome children, especially in younger children (Klin, Volkmar & Sparrow, 2000). According to Klin and Volkmar (1997) 28% of Asperger Syndrome children have a co-morbid diagnosis of Attention-Deficit/Hyperactivity Disorder. However, the Asperger Syndrome child can present with impaired attention without having Attention-Deficit/Hyperactivity Disorder. Some features of Asperger Syndrome that interfere with attention include sensory overload, and fixated attention. With sensory overload, the Asperger Syndrome child has difficulty filtering out irrelevant stimuli, and can become overloaded with sensory input. Instead of focusing attention on what is relevant, s/he is cdistracted d by too much sensory input, failing to attend to what is important. For example, cAlex d has a hypersensitivity to auditory input. He was so distracted by the sound of a bumblebee buzzing around a bush 30 feet from the house, that he couldn 9t stay on task to complete his chores. He repeatedly put his hands over his ears, trying to muffle the sound of the bumblebee. With fixated attention the Asperger Syndrome child becomes intensely preoccupied and selectively focused on an object or activity. Because of this fixated attention, they fail to attend to other stimuli (verbal information or interactions) in their environment. For example, cAlex 9s d teacher was reviewing plans for a class trip the next day. cAlex 9s d attention was so focused on the ducks printed on his teacher 9s tie that he failed to chear d what his teacher was saying, and did not respond to the teacher 9s questions. Anxiety Disorders and Depression Anxiety and depression are more common among older Asperger Syndrome children and adults (Klin, Volkmar & Sparrow, 2000). As Asperger Syndrome children mature, they become increasingly aware of how they differ from their peers, and the difficulty they have in social relationships. They are aware of cstandards d of behavior and achievement which are difficult for them to attain. Frequently, as a result of these differences, the Asperger Syndrome child becomes the victim of peer teasing or ostracizing. In response to these very real differences, taunting, and social consequences, the Asperger Syndrome child may become depressed. Adolescent depression tends to manifest differently than in adults. Instead of expressed sadness or withdrawn behaviors, it is manifested through acting-out or an irritable demeanor. 11 If the Asperger Syndrome child responds with anxious behaviors, it could manifest as nail-biting, tugging at clothing, hair pulling, avoidance of school or other social situations, etc. In some cases, the anxious behaviors may meet the criteria of an anxiety disorder such as social anxiety, or school phobia. Similarly, if the depression becomes chronic and significantly interferes with daily life, it may meet the criteria for a mood disorder. In a study by Klin et al. 2000, fifteen percent of Asperger Syndrome children had a co-existing mood disorder. Distinguishing between anxious and depressed behaviors, which meet the criteria for a disorder is not easy, and professional consultation is recommended. Generally, if the anxious or depressed behaviors are short-lasting, or are a normal response to an event, then the anxious or depressed behaviors should remit. If they are chronic, and significantly interfere with daily life, professional treatment may be needed. Obsessive-Compulsive Disorder Although Obsessive Compulsive Disorder does occur in some individuals with Asperger Syndrome, (nineteen percent according to Klin et al. 2000), some features of Asperger Syndrome can be mistaken for obsessive compulsive disorder: cognitive rigidity, rigid adherence to routines and schedules, and a restricted range of interests. For example, it is common for Asperger Syndrome children and adults to have a consuming interest in a specific limited topic, e.g., trains, elevators, dinosaurs, presidents of the United States, etc. They typically develop extensive knowledge about their specific area of interest. What distinguishes behaviors associated with these interests from Obsessive Compulsive Disorder, is that the Asperger Syndrome individual does not feel compelled to read about ctrains d or cride a train d as a means of reducing feelings of anxiety 3 they simply find pleasure in pursuing their area of interest. For example, cAlex d has a consuming interest in trains. He collects books, magazines, catalogues and videos about trains, train schedules, model trains, knows the history of trains, how they are built, and frequently rides trains. However, he is able to go through his day without train-related activities interfering with his daily routines. Given the opportunity, however, to read a book, or talk about something he likes, he will inevitably discuss/read about trains. Another feature of the Asperger Syndrome child 9s restricted range of interests is that they are ego-syntonic, i.e., the Asperger Syndrome youngster does not see anything wrong with engaging in the absorbing interest. An Obsessive Compulsive Disorder youngster is generally bothered by the obsessive thoughts and compulsive behaviors, and experiences them as intrusive and disruptive to his/her life, and is a source of anxiety. Not so for the Asperger Syndrome child. Oppositional-Defiant Disorder Asperger Syndrome children can be difficult to manage, and exhibit noncompliant behaviors. However, the reasons for the apparent noncompliance are different. An important difference between an Asperger Syndrome child and an oppositional-defiant child is volition. While the oppositional-defiant child will planfully disobey the crules d, the Asperger Syndrome child will generally make an effort to follow the rules, as he understands them. However, his understanding of the rule may be impaired either because of a miscommunication (comprehension or language pragmatics), sensory overload, misreading of contextual (nonverbal) cues, inattention, or because he acted impulsively. Additionally, when an Asperger Syndrome child learns a rule in one environment, the behavior will not generalize to a new setting. In the new setting the contextual cues are different, and the Asperger Syndrome child will perceive the similar setting/situation as entirely different. Schizophrenia Many aspects of Asperger Syndrome can be confused with psychotic behavior. An untreated Asperger Syndrome child can present as a solitary individual, uninterested in social interaction and intensely preoccupied with internal thoughts. Poor language pragmatic skills can contribute to a child verbalizing tangential thoughts that are loosely related to ongoing discussions. For example, when dAlex d was first enrolled in a therapeutic school, he had a history of many years of engaging in solitary activities. His parents reported that his behavior had become increasing unmanageable, and it became easier to allow him to entertain himself with his solitary activities, rather than endure his acting out behaviors when they tried to force him to interact with other family members. He spent many hours each day watching 12 television, playing computer games, or using other electronic game equipment. When first confronted with new routines and adult interactions from which he could not escape, Alex retreated into his private mental world of television and computer game characters. He expressed fear of one of these characters, and often imagined cseeing d the character in his room at night. He was provisionally diagnosed with a psychotic disorder. But as cAlex d adapted to his new environment and routines, learned age-appropriate social skills, and improved his pragmatic language skills, he became more interactive with others, and there were no more occurrences of his cpsychotic d behaviors. Individual Factors Children and youth who demonstrate significant and pervasive developmental delays are at risk of school failure, unemployment and increase in psychological and psychiatric symptoms of a debilitating nature over time. Asperger Syndrome individuals 9 college dropout rates and rates of failed employment are high. These high rates are due not to lack of intellectual capability or the inability to understand job performance and competency requirements. Failures are associated with a lack of social skill, pragmatic language skill, failed attendance and poor self- advocacy skills. Psychological and psychiatric symptoms increase over time and the corresponding medication therapy of increased levels of neuroleptic and other psychological medications tends to interfere with alertness, responsiveness, and other cognitive functions. Children and youth with an Asperger Syndrome diagnosis are within the normal to gifted range of intelligence. And children and youth with a diagnosis of Asperger Syndrome are the most prevalent group of individuals demonstrating developmental delay. The review of the almost four hundred researches, articles and books demonstrate a high degree of risk in all of the fifteen developmental indices identified (Chart 3). A primary contributing factor to risk for students on the Autistic spectrum is failure to clearly define diagnostic criteria, appropriate treatment cannot be applied, and prognosis is poor. The following chart (chart 3) defines 15 developmental indices to identify areas of strengths and deficits for Asperger and other Pervasive Developmental Disorder students. The conceptualization of Pervasive Developmental Disorder is a view of performance over time and in consideration of multi causal factors for delayed or impaired development. Each individual developmental index requires a defined criterion that illustrates a threshold index for impairment or delay. Conceptualization of PDD Assessment For Threshold of Impairment/Competence 1. IQ Level 2. Developmental Attention/ 3. Sensory 4. Visual-Perceptual Verbal Performance Perception Sensitivity: Skill Score Discriminant Stimulus: Kinesthetic Arousal-Recognition Auditory Identification-Classification Olfactory Full Scale Score Mediation-Utilization Light Retention: Discrepancy Profile: Short Term Memory (STM) Verbal/Performance Long Term Memory (LTM) (Sub Test) Scatter 5. Developmental Level 6. Motor Skill: 7. Developmental 8 . Social Skill: Assessment by Spatial Perception Fine-Gross Motor Ability Language: Settings: Coordination Verbal 3 NV Home Lateral Dominance Receptive Ability School Expressive Ability Community Pragmatics 9. Cognitive Skill: 10. Academic Readiness: 11. Independent 12. Moral Judgment Executive Function Achievement Grade Living Skills: Behavior: Bloom Levels Equivalent Skill Survey L. Kochberg Model of levels Imagination & Creativity Level of student-role J. Rest Model of Measurement Flexibility Behaviors Cognitive Load Limits 13. Medical Health 14. Civic Role Performance 15. Affective Developmental Mental and Physical Knowledge and Application Level influence on History Level perception and comprehension and self-regulation 14 If the fifteen developmental indices are chosen for assessment, thorough measurements of developmental function will provide a baseline of an individual 9s development. The dimensions of the developmental indices may be presented along a horizontal and vertical axis. Intelligence is one index. The intelligence quotient may be measured by the scores derived from the WISC-IV on cverbal d and cperformance d competencies indicated by the comparison of individual scores to normative data. The WISC-IV scores reflect an individual 9s relative competencies in two areas associated with learning potential. Cognitive functioning is inferred from the IQ score. Certainly the integration and interaction between levels of cognitive development within the measurement of intelligence, for example, is important as intelligence influences performance and competence in other developmental areas. Intelligence may not correlate with levels of moral judgment or levels of independent living skill or many other important areas. The following is a review of available assessment tools for nine skill areas: Attention and Mental Control, Intellectual Functioning, Visual-Spatial and Motor Skills, Auditory and Visual Perception and Memory and Social Skills. Attention and Mental Control The focus of the following task examples is to assess brief passive attention, short-term concentration skills, inhibition of routinized information, the ability to visualize and manipulate information in working memory, and the ability shift cognition and behavior as task demands change. These tasks include: reciting the alphabet, days of the week (forward and backwards), and months of the year (forward and backwards) (Bender, 1979), Serial Threes (counting forwards (from 1) and backwards (from 100) by threes, and spelling selected words forward and backwards, Visual Continuous Performance task (Mesulam, 1985), Trail Making Test (Reitan, 1958), Verbal Fluency (FAS), and Wisconsin Card Sorting Test (Grant & Berg, 1948). Intellectual Functioning IQ assessment not only provides an overall assessment of intellectual skills, but also differential assessment of verbal versus performance skills, processing speed, working memory. The Wechsler Intelligence Scale for Children, IV (Wechsler, 2003), or the Wechsler Adult Intelligence Scale, III (Wechsler, 1997), provides a comprehensive assessment of intellectual functioning. Analysis of the subtests provides information about other areas that are relevant to a diagnosis of Asperger Syndrome: knowledge of conventional social customs and social judgment, visual-motor skills versus visual problem-solving without a motor component, executive functions (e.g., organizing, planning, sequencing, attention), and visual and auditory memory. Visual-Spatial and Motor Skills These tests assess the brain 9s ability to process and integrate visual and motor information (e.g., eye-hand coordination), visual reasoning without a motor component, the ability to organize and execute a drawing strategy, and spatial organization. These tests include: IQ subtests (Block Design, Object Assembly, and Matrix Reasoning), Beery-Buktenica Developmental Test of Visual Motor Integration (Beery, 1989), Rey Osterrieth Complex Figure (Rey, 1941; Osterrieth, 1944; Meyers & Meyers, 1955), Benton Judgment of Line Orientation (Benton, Hannay, & Varnay, 1975), Rey Tangled Lines (Rey, 1964; Senior, Kelly & Salzman, 1999), Hooper Visual Organization Test (Hooper, 1958), and Draw a Clock (Goodglass & Kaplan, 1972). Auditory and Visual Perception and Memory These tests assess the brain 9s ability to process auditory information (language and non- language domains such as music) and visual information (written versus pictorial/abstract), and the ability to encode and recall it. The Wechsler Memory Scale, Third Edition (Wechsler, 1997) includes multiple subtests which provide a comprehensive assessment of auditory perception and memory, as well as visual perception and memory. The ability to chear d the prosodic quality of language is impaired in Asperger Syndrome individuals. The Seashore Rhythms Test (Halstead, 1947) assesses non-language auditory perception skills. In this test the individual must discriminate between pairs of musical beats, some of which are the same and others, which are different. . 15 Social Skill Assessment Deficits in social skills are one of the salient characteristics of Asperger Syndrome individuals. The Social Skills Rating Scale (Gresham & Elliott, 1990) has three forms (self, parent, and teacher) and assesses social skills in a variety of categories: cooperation, assertion, empathy, self-control, externalizing and internalizing behaviors, and academic competence. A comparison of the responses from student, parent and teacher provides an overview of the student's self-assessment skills. We need to improve the diagnostic clarity of the criteria used for Asperger Syndrome. We have a working knowledge for the basis for improvement. Level of language skill and prosody, social adaptability, social pragmatic language, cognition, sensory motor integration and maladaptive behavior are categorical aspects of Asperger Syndrome. These categories of behavior are most often referred to as component characteristics of a complete picture of the functioning of a person with an Asperger Syndrome diagnosis. The limitations of the diagnostic systems in current use complicate the process used to identify those in need of specialized services. It remains important to address the symptoms currently presented by individuals in need of services. And hopefully, the revision of the DSM-IV in 2010 will result in an improved system for the depiction of a person with Asperger Syndrome. If psychiatric conditions are left undiagnosed and untreated the prognosis for Asperger Syndrome individuals is poor over the course of their lifespan (see Chart 2). Children and young adults with the diagnosis of Asperger Syndrome, for example, are at a higher risk of demonstrating co-morbid psychiatric conditions. The most frequently associated conditions are attention deficit disorder, depression, anxiety disorder and oppositional defiant disorder. These conditions require a multi-modal approach to treatment, e.g., cognitive behavior therapy, psycho-educational interventions, medication therapy. Children referred for psychiatric illness corresponds to a rate of suicidal behavior of 63.0 per 100,000. The ratio of boys to girls is 53:73. Most girls are 13-14 years of age and the boys, 8-12 years. The population of children in a study by Ugeskr and Laegev (2002) suffered from psychosis, Pervasive Developmental Disorder, Attention-Deficit Disorder and Mixed Disorder of Conduct and Emotion. It is reported that individuals with an Asperger Syndrome diagnosis may follow the same trend. No formal research is reported, however, on suicide rates among Pervasive Developmental Disorder or Asperger Syndrome individuals. If left untreated and without early multi-modal intervention such as correct diagnosis, psycho-educational intervention, cognitive behavior therapy, and medication therapy, individuals become increasingly resistant to treatment. Asperger Syndrome individuals are observed to incorporate symptoms of dysfunctional behavior into their performance and these dysfunctional behaviors become ego-syntonic. The Asperger Syndrome individual perceives his behavior as cnormal d and not in need of change. Increased attention, focus and treatment attempts at intervention often result in greater the level of rigidity and resistance on the part of the AS individual. Pre-school and elementary age children are more maliable and responsive to treatment. This contrasts with adolescent individuals who demonstrate behavior patterns and preferences that are more resistant to modification. Adolescents are less able and willing to perceive their own patterns of behavior and specific symptoms as problematic and in need of change. Social and Community Factors A csyndrome d is defined as a group of signs and symptoms that occur together (Merriam- Webster, 1990) . The term Asperger 9s cDisorder d was changed to Asperger cSyndrome d to more accurately reflect the fact that it is characterized by a group of symptoms on a continuum. Many of these symptoms require specific interventions. Among the special services that may be needed are: social skills training, special education, occupational therapy, physical therapy, speech and language therapy, psychiatric and psychological interventions, neurological and neuropsychological assessments, and social and employment opportunities. The resiliency of children is enhanced when these resources are readily available through social networks and community services and preplanned transition services are provided after high school graduation. 16 Social Factors and Peer Groups Social skill training is essential for Asperger Syndrome and Pervasive Developmental Disorder children. However, the skills that are learned in a therapeutic setting must also be put into practice in daily life. The goal is for them to be able to self-initiate age-appropriate social skills in non-therapeutic settings. Asperger and Pervasive Developmental Disorder youth learn best when there is the opportunity for repeated practice in multiple settings. The concept of exposure to environmental social interaction as necessary for the development of social skills is well understood (Bandura, A., 1969); (Tharpe & Wetzel, 1969). Therefore, the availability of a peer group who can encourage, support, and role-model appropriate social skills 3 and provide the opportunity for social interaction 3 facilitates the development of these skills. cJeremy 9s d experience illustrates the power of a supportive peer group. Jeremy was fifteen when his family enrolled him at a residential school. He was an intelligent, kind-hearted young man, but had no friends. His prior school experiences became increasingly negative as he was not only excluded from social interactions but often ridiculed for his codd d behaviors and lack of social skills. Over time, he became depressed, increasingly isolative, and eventually refused to go to school. Upon arrival at the residential school, Jeremy was shy, and lacked age-appropriate social skills. However, he found that his peers at his residential house and at school were accepting and supportive. He learned that most of them had similar negative experiences of being targeted and ostracized. Along with some of his new peers, Jeremy participated in social skills training where he learned how to read nonverbal communication, participated in role-plays of social skills, and learned how to match the correct social behavior with the right social situation. Jeremy and his peers had to cpractice d their social skills in many settings: school, residential house, community, and home. With the support and encouragement of his peers, Jeremy joined in social activities and his self-confidence, as well as his social skills, gradually increased. His depression abated, and for the first time in his life, Jeremy obtained a community part-time job while completing his high school education. Today, his outlook is optimistic, he has a circle of friends, and he is proud of the independent living skills which he is developing. Social cClubs d One of the defining traits of Asperger and Pervasive Developmental Disorder children is their restricted areas of interest, topics in which they have an intense interest, and about which they tend to accumulate extensive knowledge. Teachers have learned that these children will become very attentive and motivated to learn when their area of special interest is incorporated into the concept being taught. Similarly, their area of special interest can be used to compete with the tendency to isolate: social clubs/activities in their area of special interest. For example, cAlan d had an intense interest in professional wrestling. He talked about wrestling with anyone who would listen, read magazines about the history of wrestling, acquired wrestling memorabilia, watched TV wrestling program, and attended wrestling events whenever there was an opportunity. Through his employment, Alan met a group of peers who shared his interest in professional wrestling, and he began getting together with them to watch TV wrestling programs together. What had been a solitary activity was now a social activity. Another student, cKaren d was particularly interested in health and nutrition, and would talk incessantly about these topics with anyone who would listen. She took college courses in biology and nutrition, and developed study groups with peers. Eventually, Karen 9s interest led her to become an EMT, and through her work at her local fire department, she has established friendships and social activities. Community Resources Children in general, and developmentally disabled children in particular, thrive and are resilient when their communities are able to provide the services they need. As mentioned above, the community- based services that may be needed include: special education, occupational therapy, physical therapy, speech and language therapy, psychiatric and psychological interventions, neurological and neuropsychological assessments, and social skill training, apprenticeship and employment opportunities and independent living skills and transition plans for post high school years. 17 Special Education Special education schools are better able to provide for the educational needs of developmentally handicapped children. Academic modifications which enhance learning for Asperger Syndrome and other Pervasive Developmental Disorder students include: multi-sensory learning, adaptations for dysgraphia and visual-motor processing problems, required extra processing time, self-paced program, frequent repetitions and cues, hands-on learning experiences for the concrete learner, distraction-free environments, structured and self-contained classrooms that minimize transitions, and modifications for sensory hypersensitivities, receptive-expressive language deficits, and other learning disabilities. Because of impaired nonverbal skills, and receptive/expressive language deficits, Asperger Syndrome and other Pervasive Developmental Disorder children learn better through multi-sensory approaches to learning. Special education teachers are skilled at using teaching techniques that involve use of multiple senses. One manifestation of visual-motor integration difficulties is poor handwriting (dysgraphia) necessitating a way of expressing themselves by other means than paper and pencil, such as computer keyboarding, or video and audio recording. These are common teaching modifications available at special education schools. Other teaching modifications available at special education schools include providing one-on-one instruction that incorporates the need for extra processing time, simplified (1-2 steps at a time) instruction, repetitive hands-on practice for the concrete learner, backwards chaining to address global coherence deficits, self-contained classrooms to minimize distractions and transitions. The degree to which these special education services are provided for Asperger Syndrome and Pervasive Developmental Disorder youngsters contributes to or detracts from their resiliency. Professionals knowledgeable in diagnosing and treating Asperger Syndrome and Pervasive Developmental Disorder, NOS Some students may also require occupational or physical therapy to improve visual-motor integration skills, and to minimize sensory hypo/hypersensitivities and self-stimulating behaviors. Speech and language therapists may be needed to remediate expressive and receptive language deficits. Psychologists, neuropsychologists, and psychiatrists are essential to diagnose and treat psychiatric and behavioral difficulties. This requires an understanding of the neurobiology of the Asperger/Pervasive Developmental Disorder brain, and the resulting individual patterns of strengths and weaknesses, to develop effective treatment interventions. Co-morbidity is common in Asperger Syndrome and Pervasive Developmental Delay children, and often interferes with accurate diagnosis. Children are accurately diagnosed at an earlier age when they are seen by medical and psychiatric professionals who are familiar with Pervasive Developmental Disorders. The resiliency of these children is enhanced when they receive an early, accurate diagnosis because they begin to receive needed services at an earlier age. Employment In general, Asperger Syndrome and Pervasive Developmental Disorder children have average to high-average intelligence and develop employable skills. However, because of their social skill deficits, they often cfail d the employment interview. Employers who are unfamiliar with the developmentally disabled sometimes interpret their poor social skills as lack of interest in the job, low intelligence, or rudeness. cAlan 9s d experience typifies the frustrating job search experience of many Asperger adolescents. Alan was bright, did well in school and was eager to get a part-time job. His cobsession d was baseball, and he wanted to save up to attend a baseball camp during summer vacation. However, his poor social skills, including tendency to avoid eye contact, and poor communication skills made it difficult for him to interview well. During interviews he spoke in a low volume, looked down or away from the interviewer, responded to questions with short answers, and was fidgety. Consequently, employers cread d his behavior as lack of interest in the job, and he was repeatedly rejected. 18 However, Alan was persistent, and continued to turn in job applications. One day he got a call for a job interview at a local fast food restaurant. Alan put on his dress pants and shirt, and showed up early for his interview. When he arrived he asked an employee where he should go for his meeting. She was impatient, interrupted Alan and hurriedly told him to enter an adjacent room where the meeting was getting underway. Alan was anxious and confused, but did not know how to ask for clarification. He entered the room, only to find it filled with people. He tried to ask about his interview, but was told just to sit down with the others and listen. So, Alan complied. It was an orientation meeting for new employees and they had mistakenly assumed Alan was there for the orientation. Before he left, he was given a uniform and training schedule to begin work 3 at his new job! Alan did well performing his duties 3 but would never had been hired if he had to cpass d the job interview first. Educating employers about the deficits 3 and strengths 3 of the developmentally disabled helps to overcome interview misunderstandings, and to provide an appropriate fit between employment opportunities and employee skills. Increasing employment opportunities for Asperger Syndrome and Pervasive Developmental Disorder youth increases the probability that they will be able to enter the job market, and work towards financial independence. Sufficient planning of transition programs that include invivo rehearsal, training and monitoring of employment skills is critically important to the Asperger Syndrome or PDD, NOS client. Family Factors Influencing Risk and Resiliency There is little research specific to risk and resiliency in families of Asperger Syndrome individuals. There is anecdotal evidence that Asperger Syndrome is linked to male family members. The evidence suggests that male Asperger Syndrome characteristics are genetically linked to male children and their fathers or paternal grandfathers. There are more male than female individuals identified with Asperger Syndrome (ratio 8:1). And, if one child is born with characteristics of autistic symptoms, then there is a higher probability of siblings being diagnosed as demonstrating symptoms on the Autism spectrum. There are genetic, hereditary risk factors. Genetic counseling is important to be made available for families identifie

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