Asperger Syndrome or ADHD?
by: Lynda Thompson, Ph.D.
For a comprehensive overview of Asperger's Syndrome, neuroanatomical underpinnings and interventions, please see a new publication:
Thompson, L., (2009) Chapter 15: Asperger's Syndrome Intervention: Combining Neurofeedback, Biofeedback and Metacognition in: Budzynski, Thomas, Budzynski, Helen Kogan, Evans, James R., Abarbanel, Andrew, (eds.), Introduction to Quantitative EEG and Neurofeedback: Advanced Theory and Applications (second edition), Academic Press, Elsevier, NY, 365-415.
Also: see our Recently published article (Click link beside to view) - Functional Neuroanatomy
Schools and parents are wondering how to cope with increasing numbers of children who present with Asperger Syndrome, a constellation of traits first described by the Viennese paediatrician Hans Asperger in 1944. In 1994 this diagnosis finally made it into the DSM-IV, the diagnostic manual used by psychiatrists. Knowledgeable professionals were using the term much earlier, especially Lorna Wing, a British autism expert who introduced Asperger’s into the English literature in 1981.
The traits of someone with Asperger Syndrome overlap with ADHD in terms of poor attention and impulsive behaviour so these children are often diagnosed as ADHD. As the social difficulties are more obvious as they get older, the correct diagnosis is made. There is also overlap with anxiety disorders and with non-verbal learning disabilities. Language skills nearly always exceed visual motor skills in this group of children. A British study found the average age of diagnosis was eleven and there had been three assessments/diagnoses before Asperger’s was recognized.
What are the distinguishing characteristics? The main thing that hampers progress is lack of smooth social interactions due to difficulty reading social cues. They seem unable to interpret the rules of social interaction; for example, boring other children by talking exclusively about their own special interest area or being bossy. Often they seem like little professors and very high IQ scores are common in those with Asperger’s. They may dress differently both because they do not care about social conventions and because they want to wear what is comfortable. There is sensitivity to stimulation (loud noises, clothing labels, having a hair cut) yet they seem to tune out life around them at times and be in their own world. Unlike those with autism, they do want to interact with other children and may even try to buy friends since they do not know how to make and keep friends in the usual way. Often they are more comfortable with adults or with younger children and they may be teased, bullied or rejected by peers. If people yell at them or show anger they can get very confused and may do something inappropriate. There is a good portrayal of a boy with Asperger’s in the film entitled “About A Boy”. Think of them as being socially naïve.
Language is usually an area of strength and this further distinguishes the child with Asperger syndrome from one with autism (now termed PDD, pervasive developmental disorder). Vocabulary will be well developed and they are logical, but they are also literal: if a coach tells a group of players to pull up their socks, the boy with Asperger’s will reach down to do so. He might be wearing shoes with Velcro closures because they have a tendency to be awkward in motor skills and are often late learning to tie their shoes. Though highly verbal, there may be something a little different about the intonation of their speech and they can sound pedantic, using phrases that are more adult than their years. (A 7-year-old boy I saw recently began an anecdote about school saying, “The comical thing about it was…”) They may have trouble labeling emotions and their own emotions run to extremes. If angry or upset they are hard to reason with and hard to soothe. Escaping into a special interest reduces anxiety and they will have extensive knowledge about their particular current love, be it weather, hockey statistics, electronics, computer games or animals. Routines are desired and they do not adapt easily to change or surprises. They are stubborn. In adolescence they often seem depressed. There is an endearing honesty, but even that can get them in trouble as they do not understand social lies and may say something that seems insensitive or say something about family life that others would keep private.
How do you help these honest, well-meaning, naïve children navigate the complex social scene so that their talents can be utilized? Above all, they need to be treated with kindness. They need to be coached in social skills and taught to observe and imitate good role models. They need protection from bullies and also from impatient adults who might get frustrated and yell at them. One should encourage any special interests that could be turned into later career opportunities. If they test in the top two per cent on an intelligence test (IQ 130 or above) then they would qualify for a Gifted class in most jurisdictions. This can be an excellent placement since eccentricities will be better tolerated and the peer group is usually more accepting.
Computer-based training that has been used successfully for those with ADD for more than thirty years also looks promising. Since brainwave patterns in those with Asperger syndrome differ from those of same age peers, it makes sense to try and normalize those patterns. (The patterns look somewhat like ADD patterns but are more extreme and there are other distinguishing EEG characteristics.) We have seen many people with Asperger’s syndrome at our ADD Centre over the past decade and have found that they respond well to neurofeedback training. This training, which lets them practice brainwave patterns that indicate they are paying attention to the outside world and not drifting off in their own world quite as much, also allows them to get more out of the other educational and social interventions that are put in place.
At the ADD Centre we have recently submitted a review study on 150 consecutive clients with Asperger's. The abstract for that study is as follows:
Neurofeedback Outcomes in Clients with Asperger's Syndrome
Lynda Thompson - Michael Thompson - Andrea Reid
Applied Pyschophysiology and Biofeedback, Volume 35, Number 1, March 2010, pp 63-81
This paper presents data from a case review and summarizes the results of neurofeedback (NFB) training with 150 clients with Asperger's Syndrome (AS) and 9 clients with autistic spectrum disorder (ASD) seen over a 15 year period (1993 – 2008) in a clinical setting. The main objective of the study was to investigate whether electroncephalographic (EEG) biofeedback, also called neurofeedback (NFB), made a significant difference in clients diagnosed with AS. An earlier paper (Thompson & Thompson, 2008) reviews the symptoms of AS, highlights research findings and theories concerning this disorder, discusses QEEG patterns in AS (both single and 19-channel), and details a hypothesis, based on functional neuroanatomy, concerning how NFB, often paired with biofeedback (BFB), might produce a change in symptoms. A further aim of the current study is to provide practitioners with a detailed description of the method used to ameliorate some of the key symptoms of AS in order to encourage further research and clinical work to refine the use of NFB plus BFB in the treatment of AS. All charts were included for review where there was a diagnosis of AS or ASD and pre- and post-training testing results were available for one or more of the standardized tests used. Clients received 40 – 60 sessions of NFB, which was combined with training in metacognitive strategies and, for most older adolescent and adult clients, with BFB of respiration, electrodermal response, and, more recently, heart rate variability. For the majority of clients, feedback was contingent on decreasing slow wave activity (usually 3-7 Hz), decreasing beta spindling if it were present (usually between 23 and 35 Hz), and increasing fast wave activity termed sensorimotor rhythm (SMR) (12–15 Hz or 13-15 Hz depending on assessment findings). The most common initial montage was referential placement at the vertex (CZ) for children and at FCz (midway between FZ and CZ) for adults, referenced to the right ear. Metacognitive strategies relevant to social understanding, spatial reasoning, reading comprehension, and math were taught when the feedback indicated that the client was relaxed, calm, and focused. Significant improvements were found on computerized measures of attention (T.O.V.A. and IVA), on questionnaires (Australian Scale for Asperger's Syndrome, Conners' Global Index, SNAP version of the DSM-IV criteria for ADHD, and the ADD-Q), on achievement tests (Wide Range Achievement Test), and on intelligence measures (Wechsler Intelligence Scales). The average gain for the full-scale IQ score was 9 points. A decrease in relevant EEG ratios was also observed. The ratios measured were (4-8 Hz)2 / (13-21 Hz)2, (4-8 Hz) / (16-20 Hz), and (3-7 Hz) / (12–15 Hz). The positive outcomes of decreased Asperger's and ADHD symptoms (including a decrease in difficulties with attention, anxiety, aprosodias, and social functioning) plus improved academic and intellectual functioning, support the use of neurofeedback as a helpful component of effective intervention in people with AS.