CLINICAL PRACTICE
Asperger Syndrome in Children
Julie Schnur, RN, CPNP
Purpose
To review Asperger syndrome characteristics,
assessment tools, interventions, outcomes,
and the role of the nurse practitioner in
diagnosing and caring for children with
Asperger syndrome.
Data Sources
Review of published literature on and diag-
nostic criteria of the condition.
Conclusions
Asperger syndrome is a pervasive develop-
mental disorder or an autism spectrum disor-
der that is thought to have an incidence
higher than that of autism. Asperger syn-
drome is different from autism, with a lack
of delayed language as the most distinct dif-
ference between Asperger syndrome and
autism.
Implications for Practice
Because of the importance of early diagnosis
of Asperger syndrome for outcome improve-
ment, screening at all well-child visits from
infancy on is of utmost importance to pri-
mary care pediatric nurse practitioners. With
early diagnosis, timely intervention is possi-
ble, which is proven to show improvement
in outcomes.
Key Words
Pervasive developmental disorder, autistic
spectrum disorder, Asperger syndrome.
Author
Julie Schnur, RN, CPNP, is a graduate of
Columbia University School of Nursing,
New York, NY 10032. Contact Ms. Schnur
by e-mail at julie_schnur@hotmail.com
Acknowledgments
I thank Susan W. Ledlie, PhD, CPNP, for
her advice and support. A sincere thanks to
302
INTRODUCTION
In 1944, a pediatrician named Hans Asperger observed a condition in
a group of male children that he named autistic psychopathy; he named it
as such because these children had a stable personality disorder marked by
social isolation (Klin, 2003). However, others believe that ‘‘autistic personality
disorder’’ is a better translation of Asperger’s original description (Volkmar,
Klin, Schultz, Rubin, & Bronen, 2000). These children demonstrated prob-
lems with social integration and nonverbal communication associated with
idiosyncratic verbal communication and an egocentric preoccupation with
unusual and circumscribed interests. Asperger (1944) noted that these af-
fected individuals also had difficulties with empathy and intuition, as well as
a tendency to be clumsy with awkward motor skills. These were only the
observations of Asperger, and it was not until nearly 40 years later, in 1981,
when Lorna Wing introduced Asperger’s ‘‘autistic psychopathy’’ to the English
language and renamed the cluster of characteristics as Asperger syndrome.
Wing (1981) presented several additional difficulties, which afflicted chil-
dren demonstrated in the first 2 years of life. These difficulties included a lack
of normal interest and pleasure in people around them, a decreased quality
and quantity of babbling, a significant decrease in shared interests, a signifi-
cant decrease in the wish to communicate either verbally or nonverbally,
a delay in speech acquisition, and no imaginative play or play that is con-
fined to one or two rigid patterns (Fitzgerald & Corvin, 2001; Wing).
Wing’s group, a case series of observations of 34 children, included a small
number of female subjects, which differed from Asperger’s male-only popu-
lation (Klin, 2003; Wing). Ten years after Wing’s listing of general charac-
teristics, Gillberg (as cited in Fitzgerald & Corvin, 2001) presented six
diagnostic criteria: social impairments, narrow interests, repetitive routines,
speech and language peculiarities, nonverbal communication problems, and
motor clumsiness. His criteria are believed to be the closest to Asperger’s
characteristics.
Asperger syndrome is considered a pervasive developmental disorder
(PDD). PDD is an umbrella term referring to a spectrum of disorders that
differ with respect to either the number or type of symptoms present or the
age of onset of those symptoms (Szatmari et al., 2000). Others consider
Asperger syndrome as part of a group of disorders called autistic spectrum dis-
orders (ASD). However, Asperger syndrome is clinically differentiated from
autism and high-functioning autism by the absence of clinically delayed
speech (Rinehart, Bradshaw, Brereton, & Tonge, 2002; Volkmar et al.,
2000). It is characterized by social interaction impairments and restrictive or
repetitive interests with a lack of significant delays in language acquisition and
with normal intelligence (Schatz, Weimer, & Trauner, 2002). The incidence
of Asperger syndrome is believed to be much higher than that of autism, with
its prevalence believed to be about 26–36 out of 10,000 school-aged children
(Ehlers & Gillberg, 1993; Kadesjö, Gillberg, & Hagberg, 1999).
VOLUME 17, ISSUE 8, AUGUST 2005

Rita Marie John, CPNP, for her help and guidance at
every stage of preparation of this manuscript. I thank
Dr. Amy F. Cades, PhD, for her input and revisions of
the final version of this manuscript.
Asperger thought his syndrome to be different from Kanner’s
autism, often considered classic autism. This is still debated,
although most consider Asperger syndrome to be different from
autism but part of the autistic spectrum (Wing & Potter,
2002). Asperger believed that the main handicap of his disorder
was social in nature and was not due to delays or deficits in lan-
guage or intellect (Eisenmajer et al., 1996). Thus, although both
Asperger syndrome and autism are defined in terms of so-
cial deficits, early language skills are preserved in Asperger
syndrome.
The etiology of Asperger syndrome is not completely under-
stood. It is generally believed to have genetic causes combined
with environmental factors. Asperger (1944) noticed a familial
nature of the characteristics, with a primarily male pattern of
transmission, as he often noted the traits in the fathers of the
children he observed and is typically seen in a male-to-female
ratio of 4:1 (Klin, 2003; Wing & Potter, 2002). Multiple genes
have been linked to Asperger syndrome in children. However,
although no specific gene has been identified as a cause of
Asperger syndrome, it has been proposed that genetic factors
play a greater role in Asperger syndrome than in autism (Foster
& King, 2003; Rinehart et al., 2002). There have also been
many suggestions surrounding other possible nongenetic causes
of autism and ASDs, including dietary components, environ-
mental pollutants, antibiotic use, allergies, vaccines, and traces of
neurotoxins found in some preservatives (Wing & Potter). None
of these have been scientifically validated (Wing & Potter).
Findings suggest that in the majority of cases, the underlying
pathology of ASDs is present prenatally (Wing & Potter).
Genetics play a major role in the development of autism and
ASDs as there is a male preponderance, with a ratio of approx-
imately four men to one woman in autism (Rapin, 2001). Asperger’s
original group consisted solely of men, and he noticed similar char-
acteristics in their fathers. Toward the end of the 1970s and early
1980s, male-to-female ratios for Asperger syndrome varied from
four men to one woman to nine to one (Marshall, 2002). Kadesjö
et al. (1999) conducted a population study of 826 children born
in Karlstad, Sweden, in 1985, who were aged 6.7–7.7 years at the
time of the study. Eight of the children were in special classes.
The authors chose to use a 50% sample of the remaining children,
containing 224 boys and 185 girls. Twenty-one of the children had
at least one parent who had entered from outside the Nordic coun-
tries. The authors found four children with Asperger syndrome––all
male––which is comparable to Asperger’s original population and
adds credence to the belief that this condition is highly genetic in
etiology. The four boys with Asperger syndrome constituted
0.48% of their population––a rate of 48 in 10,000––compared to
earlier studies that found a rate of 26–36 per 10,000.
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
The purpose of this article is to review the diagnostic criteria
of Asperger syndrome, describe the characteristic behaviors of
children with this diagnosis, examine screening tools and inter-
ventions, review outcomes of patients with Asperger syndrome,
and discuss the role of the nurse practitioner (NP) in the care
of patients with Asperger syndrome.
DIAGNOSTIC CRITERIA
Several studies have attempted to validate Asperger syn-
drome as a distinct diagnosis from that of autism without
mental retardation (Klin, 2003). Eisenmajer et al. (1996) noted
three major differences: (a) there is no communication and
imagination impairment criteria for Asperger syndrome, (b)
people with Asperger syndrome do not suffer from a significant
delay in language, and (c) children with Asperger syndrome do
not have a clinically significant delay in development of cogni-
tion or age-appropriate self-help skills, adaptive behavior, and
curiosity about the environment. Thus, lack of language delays
is the major differentiating factor between Asperger syndrome
and autism.
The ‘‘Diagnostic and Statistical Manual of Mental Disorders’’,
fourth edition (American Psychiatric Association [APA], 1994),
known as the DSM-IV, and the ‘‘International Statistical Classifi-
cation of Diseases’’, 10th edition (World Health Organization,
1992), known as the ICD-10, both have diagnostic criteria
for Asperger syndrome. Some of the criteria presented by the
DSM-IV differ from both Asperger’s original description and
Gillberg’s subsequent criteria (Fitzgerald & Corvin, 2001). The
ICD-10 diagnostic criteria are similar to those of the DSM-IV,
although they are closer to Gillberg’s. According to the DSM-IV
(APA), if diagnostic criteria of both autism and Asperger dis-
order are present, the diagnosis of autism takes priority.
Diagnostic criteria from the DSM-IV are divided into two
broad categories of qualitative impairment in social interaction
and restricted repetitive and stereotyped patterns of behavior,
interests, and activities; patients must possess two or more of
the listed qualitative impairments and at least one of the listed
repetitive and stereotyped patterns. Qualitative impairments
include marked impairment in the use of multiple nonverbal
behaviors, failure to develop peer relationships appropriate for
their developmental age, lack of spontaneous seeking to share
with others, and a lack of social or emotional reciprocity (APA,
1994). Restricted repetitive and stereotyped patterns include an
encompassing preoccupation with one or more stereotyped and
restricted patterns of interest that is abnormal in either intensity
or focus, apparently inflexible adherence to specific nonfunc-
tional routines or rituals, stereotyped and repetitive motor man-
nerisms, and persistent preoccupation with parts of objects
(APA). In order for diagnosis, these criteria must present before
3 years of age, the impairment must be clinically significant,
and must exclude a clinically significant delay in language,
cognition, or other skills (APA).
The ICD-10 (World Health Organization, 1992) criteria for
Asperger syndrome include no clinically significant delays in
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Table 1 Summary of Assessment Tools for Autism, Autism Spectrum Disorders, and Asperger Syndrome
General Tests for Autism and Autism Spectrum Disorders
Screening tests
Checklist for Autism in Toddlers (CHAT)—for
children aged 18 months
Pervasive Developmental Disorder Screening Test—a
parent-completed survey
Autism Screening Questionnaire (1999)
Autism Diagnostic Interview-Revised (1999)
Diagnostic tests
Behavior Rating Scale for Autistic and Atypical
Children (1966)
Childhood Autism Rating Scale (1988)
Autism Behavior Checklist (1980)
a
Found in Howlin (2000).
b
Ehlers et al. (1999).
spoken or receptive language or development, with single words
spoken at or before 2 years of age, and communicative phrase
use at the latest 3 years; qualitative abnormalities in reciprocal
social interaction; the affected person exhibits an unusually
intense and circumscribed interest or restrictive and repetitive
behaviors; and the disorder is not attributable to another PDD.
For the diagnosis of Asperger syndrome, the patient must
demonstrate qualitative impairments in social interaction and
restricted patterns of interest. Of utmost importance is that
there are no language and communication criteria for diagnosis
of Asperger syndrome; there should be no clinically significant
delay in language acquisition, cognition, and self-help skills
(Klin, 2003). Differential diagnoses for Asperger syndrome
include other ASDs or PDDs, attention deficit hyperactivity dis-
order (ADHD), affective disorders, developmental disabilities,
childhood onset schizophrenia, selective mutism, separation anxi-
ety, stereotypic movement disorders, obsessive compulsive dis-
order, and bipolar disorder (Fitzgerald & Corvin, 2001; Foster
& King, 2003). While ADHD is on the list of differentials,
attention deficits are not a part of the diagnostic criteria for
Asperger syndrome.
Although attentional difficulties are not a part of the diag-
nostic criteria, the article by Schatz et al. (2002) ‘‘Brief report:
Attention differences in Asperger syndrome’’ studied attentional
differences between eight male children and young adults
with Asperger syndrome (mean age of 16.00 years) and eight
matched male control subjects (mean age of 16.05 years). The
subjects’ ethnicity was not specified. The authors found evi-
dence of attention deficits in most of the Asperger group and,
while these deficits and hyperactivity are not included in the
diagnostic criteria, they have been observed in conjunction with
Asperger syndrome in other instances (Eisenmajer et al., 1996).
304
Specific Screening Tests for Asperger Syndrome
The Australian Scale for Asperger Syndromea
The Screening Questionnaire for Asperger syndrome and
other high-functioning Autism Spectrum Disorders in
school-aged children (1999)a,b
Pervasive Developmental Disorders Questionnairea
Autism Spectrum Disorder Tests that have been successfully
used to recognize children with Asperger syndrome
Autism Diagnostic Interview
Autism Behavior Checklist (1980)
Gilliam Asperger’s Disorder Scale
Yeargin-Allsopp et al. (2003) found an equal prevalence of
autism––which they defined as autism, Asperger syndrome, and
PDD not otherwise specified––in black and white children, a
rate of 3.4/1000 children. However, they found that the male-
to-female ratio varied within different racial and ethnic groups.
The authors sought to determine the prevalence of autism in
a U.S. metropolitan area by using the area surrounding Atlanta,
Georgia. All the 289,456 children aged 3–10 years residing in
a five-county metropolitan area were screened for autism (as
previously defined), with a gender split of 51% males, 49%
females and a racial split of 58% white people, 38% black peo-
ple, and 4% other. The authors found that 987 of the children
had autism (3.4/1000) and that while the rates were similar
between racial groups, the sex ratios varied between the groups,
with the highest male-to-female ratio seen in black people. The
authors also found that the prevalence rates of autism varied
between age groups, with the highest prevalence seen in 8-year-
old children.
CHARACTERISTICS OF ASPERGER SYNDROME
Some characteristics of Asperger syndrome are social, devel-
opmental, and attentional warning signs that alert the NP dur-
ing well-child care visits that the development is abnormal.
Other characteristics are more discrete because language devel-
opment usually is not delayed in these children; yet, other char-
acteristics, such as genetic factors, are even further concealed as
they cannot be seen or noted by the naked eye when observing
the patient.
The typical age of diagnosis for Asperger syndrome is 11
years. However, parents can usually trace their concerns regarding
VOLUME 17, ISSUE 8, AUGUST 2005
their child’s development to as early as 30 months (Foster &
King, 2003; Wing & Potter, 2002). This is in accordance with
the DSM-IV diagnostic criteria that state that symptoms must
be present before 3 years of age, although diagnosis occurs on
average several years later. Therefore, it is important during
well-child visits that pediatric nurse practitioners (PNPs) screen
children from infancy on, and if concerns arise, to make the
proper referrals so that timely intervention and therefore better
outcomes can occur.
Social Skills
Children with Asperger syndrome display a similar clinical
picture. They often speak at the expected age and have an IQ
that is above 70, which may extend into the gifted range, but
they tend to be socially inept with narrow interests (Rapin,
2001). Some children are clumsy or have poor motor skills.
Although it is not part of the DSM-IV description of Asperger
syndrome, children often exhibit hyperactivity (Schatz et al.,
2002). Some propose that children with Asperger syndrome bet-
ter relate to adults than to their same age peers (Marshall, 2002).
Szatmari et al. (2000) studied 68 children aged 4–6 years
diagnosed with autism or Asperger syndrome. Forty-seven chil-
dren were diagnosed with autism and 21 with Asperger syn-
drome. Two years later, at follow-up, one subject from each
group had left the study, and three (6.5%) of the autism and
four (20%) of the Asperger group were women. It is important
to note that in this study, the DSM-IV hierarchy rule was
reversed, allowing Asperger syndrome to take priority. In com-
paring the two groups, the authors found that children with
Asperger syndrome had better social skills at follow-up and that
the outcome could not be attributed to initial differences in
intelligence and language. Both groups scored low on the social-
ization assessment, but children in the Asperger group scored at
least 1 standard deviation (SD) better than those in the autism
group (p = 0.001). The authors felt that these differences may
have been due to initial differences (Szatmari et al., 2000). On
language and communication scales, the children in the
Asperger group usually scored within 1 SD of the normal popu-
lation, whereas those with autism usually fell at least 2 SDs
below. Last, the authors propose that some findings suggest that
the differences between Asperger syndrome and autism may
largely be a function of timing, meaning that both groups may
follow parallel paths but with different start and end ages.
Characteristics that may lead an NP to entertain a diagnosis
of Asperger syndrome include abnormal eye contact, a state of
aloofness, failure to orient to name or to use gestures to point
out or show objects, a lack of interactive play, and a lack of
interest in peers (Foster & King, 2003). Children with Asperger
syndrome often possess an extensive knowledge of factual infor-
mation about a single, narrow topic in an intensive manner and
are often able to recite that information and have discussions of
great depth on that topic.
Those with Asperger syndrome ‘‘may be able to describe cor-
rectly, in a cognitive and often formalistic fashion, other peo-
ple’s emotions, expected intentions and social conventions; yet,
they are unable to act upon this knowledge in an intuitive, and
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
spontaneous fashion, thus losing the tempo of the interaction’’
(Klin, 2003, p. 104). These children are inclined to engage in
long-winded, often one-sided, and sometimes incoherent,
although grammatically correct, speech (Klin). These children
tend to have problematic nonverbal communication, including
limited gesturing, limited or inappropriate facial expression,
and a stiff and peculiar gaze; they also have characteristic pedan-
tic speech, with normal expressive language but impaired com-
prehension (Foster & King, 2003). They are usually socially
isolated but tend not to be withdrawn when around other peo-
ple. However, their approach toward others is often inappropri-
ate or eccentric in manner. They may have a history of delayed
motor acquisition, poor coordination, bouncy gait patterns, or
odd posture (Klin).
Attentional Characteristics
Eisenmajer et al. (1996) compared interviews of parents
of 117 children with autism and Asperger syndrome in two
Australian cities. The mean age of the autism group was 10.5
years and the male-to-female ratio was 39:9; the Asperger group
had a ratio of 61:8, with a mean age of 10.7 years. Although
the DSM-IV states that ADHD is not to be diagnosed in peo-
ple with a PDD, the authors found an increased likelihood of
a comorbid diagnosis of ADHD. The increase in ADHD is in
agreement with Schatz et al.’s (2002) study. Eisenmajer et al.
also found that children in the Asperger group were more likely
to engage in more prosocial behaviors. They had less severe eye
contact avoidance at younger ages, more willingness and ability
to play with others as they got older, they were less likely to use
echolalic speech, and more likely to engage in long-winded
pedantic speech patterns (Eisenmajer et al.). Diagnosis of
Asperger syndrome usually occurs at an older age than autism,
and the authors suggest that this is because the level of impair-
ment of Asperger syndrome is less. However, the age at which
parents first recognized problems in their child’s development
occurred at the same age for both. Foster and King (2003)
reported that recent studies have also linked certain other char-
acteristics to children with Asperger syndrome, such as macro-
cephaly, abnormal motor coordination, and low birthweight.
ASSESSMENT TOOLS
There are currently several autism and Asperger syndrome
assessment and screening tools available. Some are completed
by parents, while others are completed either by lay personnel
or trained professionals. A summary of screening tests can be
found in Table 1. Some of the tests, such as the Childhood
Autism Rating Scale and the Autism Behavior Checklist, have
acceptable levels of reliability and validity (Howlin, 2000).
The ‘‘Screening questionnaire for Asperger syndrome and
other high functioning autism spectrum disorders in school
aged children’’, by Ehlers, Gillberg, and Wing (1999), is a ques-
tionnaire to be completed by lay informants. It is intended to
identify children in need of further evaluation, not as a diagnos-
tic tool. The questionnaire consists of 27 items encompassing
305
elements of communication, social interaction, uncoordinated
motor skills, and other associated symptoms, rated on a 3-point
scale with 0 indicating normalcy and 2 indicating definite
abnormality. Possible scores range from 0 to 54 (Ehlers et al.),
and it has been noted to be a useful screening device. The ques-
tionnaire is used for children who are high functioning with
normal to above-normal intelligence. However, it does not differ-
entiate between Asperger syndrome and other high-functioning
autistic disorders (Ehlers et al.).
According to Foster and King (2003), caution must be used
in screening children, especially those under 3, who possess fea-
tures of general ASDs as they may attract a diagnosis of PDD
possibly due to the presence of a significant developmental
delay. A potential benefit of screening is that there may be
earlier diagnosis. However, in high-functioning children, who
often lack a language delay and have average or above-average
cognition, diagnosis often is not made until school age or later
(Baird et al., 2001). About 25% of children in any given pri-
mary care practice exhibit some level of developmental prob-
lems, but less than 30% of primary care providers perform
screening tests at well-child visits (Filipek et al., 2000). Many
tools are good, but some primary care providers may prefer
screening tools that are quick to administer or that are parent
completed as time for primary care visits are limited, and these
types of tools may decrease the amount of time for test adminis-
tration, therefore increasing the time to discuss the test results
with parents.
INTERVENTIONS
Clinical assessment is more effectively accomplished by an
interdisciplinary team and should include a developmental and
health history, an assessment of communication and psychol-
ogy, and a diagnostic exam that should be able to rule out dif-
ferential diagnoses (Klin, 2003). Treatment methods are more
beneficial if they are multimodal and strategies vary for children
of different ages. In creating interventions, it is important to
remember that they should be customized to the individual
child. Interventions should be tailored to the child’s develop-
mental and behavioral needs and to the family’s coping style
and available resources (American Academy of Pediatrics, Com-
mittee on Children with Disabilities, 2001).
Because of the various clinical presentations of children with
Asperger syndrome, individualized therapy is very important.
Evidence has shown that intensive and early individualized edu-
cation alters outcomes for all children with Asperger syndrome
and autism (Rapin, 2001). In older children, who are well func-
tioning and intelligent, the major goal is integration into a regu-
lar classroom. Mainstreaming can be for part of or for the whole
day, often with the help of an individual or shared aide to keep
the child focused on the assignments or activities (Rapin).
Adolescents may benefit from social skills training programs
and groups, which could aid them in coping more effectively
with the changing social goals encountered during adolescence
(Rapin).
306
Pharmacologic interventions have recently been gaining
attention for their use in children with Asperger syndrome and
autism. Medications, including selective serotonin reuptake
inhibitors and other antidepressants, atypical antipsychotics,
and anticonvulsants, may alleviate troublesome behaviors and
symptoms but do not cure the underlying Asperger syndrome
(Foster & King, 2003; Rapin, 2001).
THE ROLE OF THE NURSE PRACTITIONER
No data are available for a large U.S. population, but even if
conservative rates of Asperger syndrome, autism, and other ASDs
apply, NPs can expect to care for at least one child with these
disorders during their careers (American Academy of Pediatrics,
Committee on Children with Disabilities, 2001). The roles of
the NP include early diagnosis, providing anticipatory guidance,
preparation for medical procedures, continuity of care, and fam-
ily or parental counseling.
Early Diagnosis
It can be argued that the most important role of the NP is
early diagnosis of Asperger syndrome. Parental concerns regard-
ing their child’s development should be of the utmost impor-
tance and, if found, should lead to additional assessment. The
increasing importance of early diagnosis is supported by
research showing that patients who have early, consistent, and
appropriate intervention have improved outcomes (American
Academy of Pediatrics, Committee on Children with Disabil-
ities, 2001). Continual developmental surveillance and screen-
ing at serial well-child visits is important. Only using very early
screening methods may miss later onset autism and Asperger
syndrome (Baird et al., 2001), whereas only using later screen-
ing methods may cause children to be diagnosed later and thus
miss out on much needed early interventions. The NP’s ability
to note behaviors typical of Asperger syndrome and a reliance
on key elements of history, such as parental reports, is impor-
tant in providing proper early diagnosis (American Academy of
Pediatrics, Committee on Children with Disabilities). Outcome
improvement for the child is possible with early diagnosis and
timely intervention.
Research has indicated that there is an extremely high occur-
rence risk for Asperger syndrome and other ASDs in subsequent
siblings of an affected child. The American Academy of Pediat-
rics, Committee on Children with Disabilities (2001) states that
early diagnosis is important to ensure that parents can get
timely genetic counseling before the conception of other chil-
dren. Early diagnosis is also important if subsequent siblings
have already been born so that they may receive timely assess-
ment and, if present, may receive the proper diagnosis. The
reverse is also true: this information may be helpful in a younger
child who has been diagnosed whose older sibling has a sus-
pected ASD.
According to the American Academy of Pediatrics, Com-
mittee on Children with Disabilities (2001), early manage-
ment strategies include parental education and support, early
VOLUME 17, ISSUE 8, AUGUST 2005
intervention for children under 3 years or school-based special
education for children over 3, behavior management, commu-
nity services, medical treatments, and alternative therapies.
Referrals for, and implementation of, occupational therapy and
physical therapy services are also part of the role of the NP and
contribute to the multimodal treatment.
Anticipatory Guidance
Anticipatory guidance geared toward both parents and the
patient is important. Vocational counseling may be helpful for
older children and adolescents in order to find careers for which
they can make the most of their strengths and in which they
will not be disqualified because of their poor social skills
(Rapin, 2001). Patients should also be taught about their diag-
nosis, with emphasis placed on maintaining self-esteem and
facilitating acceptance of interventions (Rapin). Anticipatory
guidance for parents includes providing training in behavior
management, such as teaching them how to manage problem-
atic behaviors and helping to foster their child’s positive social
skills (Rapin). Providing parents with other resources, such as
local mental health agencies and credible Internet sites, is also
very helpful (Marshall, 2002). One resource for parents and
healthcare providers is Act Early, a Web site from the Centers
for Disease Control and Prevention, National Center on Birth
Defects and Developmental Disabilities (n.d.), that includes
information about ASDs and developmental milestones in chil-
dren of different ages. The information is available in both
Spanish and English (www.cdc.gov/actearly).
While NPs and other primary care providers are not capable
of determining a child’s outcome at the time of diagnosis, they
are able to provide anticipatory guidance in terms of a possible
trajectory and the child’s potential ability for development.
Parents can use this information as a guideline for plotting and
assessing their child’s progress over time because a child with a
milder ASD and normal intelligence tends to undergo a predict-
able progression as he or she gets older (Coplan, 2000). Children
with Asperger syndrome improve with maturity and age as they
progress into adulthood and are able to hold jobs and live inde-
pendently (Marshall, 2002; Szatmari, Bremner, & Nagy, 1989).
Coplan (2000) suggests that children or adolescents who
may accidentally or innocently participate in socially unaccept-
able behaviors should wear a MediAlert identification to pro-
vide them protection. Marshall (2002) states that at school,
because of social isolation, these children may feel alone and
may even be the focus of ridicule from classmates, at times so
severe as to drive them to suicidal ideation, anxiety, depression,
and possibly suicide. Therefore, extra attention should be paid
when a child with Asperger syndrome presents with depression
or extreme sadness. Because of the significant delays in social
skills, and the often lacking ability to read others’ nonverbal
cues, adolescents are at risk for being victims of sexual assault
(Marshall).
Preparation for Procedures and Continuity of Care
The American Academy of Pediatrics’ Committee on Chil-
dren with Disabilities (2001) has provided recommendations
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
for pediatric primary care providers who treat children with
Asperger syndrome and ASDs. Some of the recommendations
have already been covered, but a summary includes monitoring
all areas of development at each well-child visit, genetic counsel-
ing for families, becoming familiar with alternative therapies,
providing comprehensive care to the child, and providing the
opportunity for age-appropriate interventions (American Acad-
emy of Pediatrics, Committee on Children with Disabilities).
In terms of continuity of care and medical procedures, it is
important to avoid rapid changes of caregivers and to opt for
a more gradual method of transferring care such as introduction
of new people, places, and procedures over time. This decreases
the anxiety and is less disruptive to the child’s rigid routines.
Counseling
Strategies to increase the overall functional status of a
school-aged child with Asperger syndrome includes decreasing
maladaptive and repetitive behaviors and helping the family
manage the stress associated with raising a child with Asperger
syndrome (American Academy of Pediatrics, Committee on
Children with Disabilities, 2001). Brothers and sisters of diag-
nosed children need an honest and truthful explanation of their
sibling’s disorder because they may not receive as much parental
attention due to a focus on the child with Asperger syndrome.
The whole family also needs support, counseling, in-home help,
and respite care (Rapin, 2001). Coplan (2000) discusses a model
for parental counseling that is based on what he believes to be
four commonly accepted premises: (a) atypical development
occurs on a spectrum from mild to severe, (b) the phenotypic
expression of ASDs varies with age, (c) an ASD of any degree
can occur in combination with any degree of intelligence, and
(d) long-term prognosis for an individual child is representative
of the impact of both the ASD and the child’s level of cognitive
ability or delay. Some suggestions for helpful coping strategies
for children with Asperger syndrome and their families include
keeping a schedule, using clear communication, gradually intro-
ducing change, planning for physical activity, providing encour-
agement to the child via positive feedback, and working with
the child’s particular interests and strengths (Marshall, 2002;
Olney, 2000).
CONCLUSION
While some people consider Asperger syndrome and high-
functioning autism to be one and the same, they are in fact
different entities. Clinically delayed language is the most dis-
tinguishable difference between autism and Asperger syndrome.
Those with Asperger syndrome tend to have normal or above-
normal intelligence. School-aged children with Asperger syn-
drome also tend to have more circumscribed interests and are
capable of possessing a large amount of factual information
about isolated topics.
Screening and surveillance methods are important to identify
children who are in need of further evaluation and testing.
307
Developmental surveillance and screening should be performed
at all well-child visits for children ranging from infancy to
school aged, and even later if there are concerns surround-
ing social interactions, learning, or behavior problems. While
early diagnosis is important, screening methods should continue
until well into school age as Asperger syndrome is more often
diagnosed in school-aged children and less frequently in
infancy.
Several possibilities exist for future research for Asperger syn-
drome. These include clarification of its etiology that could
potentially help in other realms, such as prenatal diagnosis and
genetic counseling, avoidance of environmental triggers (if pres-
ent), and better comprehension of the underlying pathophys-
iology of Asperger syndrome for the future development of
specific pharmacologic treatments (Rapin, 2001). Identification
of the chromosome(s) involved in Asperger syndrome may also
influence treatments.
Continuing studies of the validity, reliability, specificity, and
sensitivity of Asperger syndrome tests and the creation of other
tests, if necessary, are another realm of research that could
benefit Asperger syndrome. While screening tests do exist, the
potential for development of a diagnostic tool specific for diag-
nosis of Asperger syndrome is needed to test those children who
are referred for further evaluation.
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VOLUME 17, ISSUE 8, AUGUST 2005