Course:RSOT513/2010W2/pervasive developmental

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Asperger Syndrome

Asperger Syndrome (AS) is a chronic neurodevelopmental disorder [1] that includes the social and behavioural symptoms observed in other Autistic Spectrum Disorders (ASDs), but does not include the delays in cognition, language, and adaptive functions associated with other ASDs.[2] AS is named for Hans Asperger, an Austrian paediatrician, who first described AS in 1944.[1]

Etiology

The etiology of AS is currently unknown and is still under debate.[2] Numerous studies have looked at the etiology of Autism, but very few have looked exclusively at the AS population.[1] AS has been linked to genetic factors and abnormalities in brain structure and function.[2]

Genetic factors

Many studies suggest a link between AS and genetic factors. In a study of 100 boys with AS, 71 had one or more family members who were suspected of having some form of ASD.[3] Studies by Volkmar and colleagues, and Ghaziuddin also support this finding: both found a high prevalence of AS between first-degree relatives. [1]

Male specific genes may be involved in the expression of AS, as shown by the male to female ratio of 9:1. [1] In a study of 100 boys with AS, about 50% had a paternal family history of ASD.[3] Stone et al's [4] study also found a link between AS and abnormalities of chromosome 17 in male subjects.

Neurobiology

Numerous neuroimaging studies have identified a wide range of structural and physiological abnormalities in the brains of subject with AS and ASD. [1][5] Common affected areas of the brain include the limbic system, frontal lobe and temporal lobe.[1] There have also been reports of right hemisphere atrophy in subjects with AS.[5]

Megalencephaly, an abnormally large brain, is often observed in people with ASD. There have been no specific studies on brain size for the AS population, but it has been suggested that because male brains are typically larger than female brains, that AS is caused by the expression of “'extreme male brain.'” [1]

Other Factors

While AS has been linked to genetic factors, not all individuals with a family history of AS show characteristics of the disorder. In a study of 100 boys with AS, Gillberg and Cederlund [3] found that pre- and perinatal risk factors such as brain damage appeared to be relevant in about 25% of the cases.[3]

Prevalence

There is debate as to whether AS is a mild form of autism and should be included as part of the ASD, or if it is, instead, a disinct type of Pervasive Developmental Disorder (PDD) and should be classified separately. Numerous labels have been given to individuals with normal intellectual ability who have with difficulties in social interaction and communication (symptoms typical of AS), including nonverbal learning disability, schizoid personality, right hemisphere learning disability and high functioning autism. This inconsistency in classification causes epidemiological data regarding AS to vary. Data collected from numerous studies found a median prevalence of 2.6/10 000.[1] AS is more prevalent in males: the male to female ratio ranges from 4:1 to 9:1. [6] Chakrabarti and Fombonne [7] suggest that the prevalence of AS is on the rise. Fombonne et al[8] suggest that the increased prevalence of PDD (including AS) is accounted for by a broadening of diagnostic concepts and criteria as well as an increased awareness of PDD. Despite increased awareness, roughly 50% of children with AS enter adulthood without receiving a diagnosis. [6]

Co-morbid psychiatric disorders are common among those with AS. Matilla et al[9] found a prevalence of 74%/84% (current/lifetime) of co-morbid psychiatric disorders in community based and clinic based samples with AS. The most common disorders include: behavioural (44%/50%), anxiety (42%/56%), tic (26%/38%), mood (6%/14%) and insomnia (36%-current).

Common signs and symptoms

AS and Autistic Disorder (AD) are both distinct categories of PDD, though there is debate regarding whether this distinction should persist. [5] AD is characterized by impairment in reciprocal interaction; restricted repertoire of interests and activities; and impairment in verbal and nonverbal communication. AS is characterized by social dysfunction and idiosyncratic interests, without significant delay in language acquisition. [5] AS shares characteristics with AD, but differs in regards to language and cognitive functioning, which are unaffected at earlier stages in AS. AS and AD are mutually exclusive; an individual cannot be diagnosed with both AS and AD. Diagnosis of AD is favoured. AS is only diagnosed if the individual's symptoms do not fit a diagnosis of AD.[1] Due to the relationship between AS and AD, it is necessary to include both diagnostic criteria here.

Diagnostic Criteria for Asperger’s Disorder in the DSM-IV[10]:

  1. Qualitative impairment in social interaction, as manifested by at least two of the following:
    1. marked impairments in the use of multiple nonverbal behaviours such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction
    2. failure to develop peer relationships appropriate to developmental level
    3. a lack of spontaneous seeking to share enjoyment, interest or achievements with other people, (e.g.. by a lack of showing, bringing, or pointing out objects of interest to other people)
    4. lack of social or emotional reciprocity
  2. Restricted repetitive & stereotyped patterns of behaviour, interests and activities, as manifested by at least one of the following:
    1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
    2. apparently inflexible adherence to specific, nonfunctional routines or rituals
    3. stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements)
    4. persistent preoccupation with parts of objects
  3. The disturbance causes clinically significant impairments in social, occupational, or other important areas of functioning.
  4. There is no clinically significant general delay in language (E.G. single words used by age 2 years, communicative phrases used by age 3 years)
  5. There is no clinically significant delay in cognitive development or in the development of age-appropriate self help skills, adaptive behaviour (other than in social interaction) and curiosity about the environment in childhood.
  6. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.

Diagnostic Criteria for Autistic Disorder in the DSM-IV[10]:

  1. A total of six (or more) items from (A), (B), and (C), with at least two from (A), and one each from (B) and (C)
    1. qualitative impairment in social interaction, as manifested by at least two of the following:
      1. marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction
      2. failure to develop peer relationships appropriate to developmental level
      3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people, (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
      4. lack of social or emotional reciprocity
    2. qualitative impairments in communication as manifested by at least one of the following:
      1. delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
      2. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
      3. stereotyped and repetitive use of language or idiosyncratic language
      4. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
    3. restricted repetitive and stereotyped patterns of behaviour, interests and activities, as manifested by at least two of the following:
      1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
      2. apparently inflexible adherence to specific, non-functional routines or rituals
      3. stereotyped and repetitive motor mannerisms (e.g hand or finger flapping or twisting, or complex whole-body movements)
      4. persistent preoccupation with parts of objects
  2. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:
    1. social interaction
    2. language as used in social communication
    3. symbolic or imaginative play
  3. The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder

While not a requirement for diagnosis, individuals with AS often exhibit a peculiar communication style. For example, they may be overly formal, focused on a topic of special interest, verbose, or tangential. [1] The volume, rate, or rhythm of their speech may deviate from the social norm.[1] Individuals with AS may also experience pauses in their speech resulting from their communication difficulties.[1] Individuals with AS may also experience difficulties in any, or all, of the following areas: sensory processing, sensory modulation, fine and gross motor skills .[11]

Implications for occupation

In Canada, OTs divide occupations into three categories: self-care (eating, bathing, dressing, toileting), productivity (paid or unpaid work, volunteering, academic pursuits, or play (for children)) and leisure (activities done for pleasure, socializing, and recreational activities such as games, hobbies or sports). [12] For older children, the categories of productivity and leisure are more differentiated, as academic pursuits become increasingly important. That being said, play remains an important part of an older child's life. Children and adults with AS are known to experience occupational performance challenges at home, in the community, and at school or work. [11][13][14][15][16]

Occupational Challenges

Self-care

Individuals with AS have difficulties with self-care tasks. For instance, sensory modulation is often impaired. This impairment causes hyper-responsiveness to stimuli such as touch and sound, [2][11][15][17] and results in rigid behaviours [15]. For example, sensitivity of the head, upper arms, and palms may lead to difficult behaviours when an individual with AS has their hair washed, combed, or cut. [16] Individuals with AS may also experience stress when their nails are cut. [17] Due to the texture of the fabric, presence of seams, or tags, individuals with AS may only find a narrow selection of clothing comfortable when dressing. [16] Because of rigid preferences for certain clothes, parents of children with AS may need to launder preferred clothes frequently. Because individuals with AS may prefer or avoid different textures of food or certain aromas, [2][11][17] they may experience challenges while eating at both at home or in restaurants. For example, Asperger in 1944 described children with AS having a strong preference for certain flavors, such as sour and spicy foods. [2][18] Heightened auditory awareness, especially to specific sounds, [16] may cause distress for the individual, and result in avoidance behaviours, [15] or a catastrophic reaction. [19] A catastrophic reaction is an emotional response that includes behaviours such as shouting, screaming, swearing, destroying objects, disrupting others’ activities, and injury to self and/or others. [19] Hypersensitivity to light can cause the distress when venturing into the sunlight. [17] These reactions may result in the choice to avoid environments with overwhelming stimuli, and this avoidance limits occupational participation.

Productivity

For an older child with AS, who has entered the school system, social and academic performance becomes difficult. [2][20][15] Parents and teachers often report that children are inattentive, have difficulty remaining focussed and completing homework. [21] Poor fine motor skills, [17] poor visual motor skills[17] and at times distorted visual perceptual skills [11] contribute to difficulties with school-based occupations such as handwriting, cutting and copying from the board.[16][22][17][23][24]

Children with AS have poor imitative skills that make it difficult to learn new games, [15] possibly leading to decreased participation in physical education classes. Children with AS, often described as “[m]otorically-awkward” [22] or clumsy, [16][13][25] may have difficulties with coordinated physical activities, such as running, jumping, climbing, and catching. Though initial observations of a child with AS may suggest a child's language use and intelligence are typical, further observation may reveal memorized behaviours with little flexibility. [22][15][21] This initial assumption of normalcy may lead teachers to overestimate the child’s ability, or to see inflexibility as an anti-social behaviour, rather than a product of AS. [15]

Transitions may be difficult for individual with AS, because of an extreme need for routine and their propensity to focus their attention on a particular topic.[17][15] A child with AS may have trouble completing, or miss the intent of, school-related tasks because of rigid behaviour patterns or the tendency to focus on one part of the task. [15]

Though a child with AS may appear to use age-appropriate language, the use of a patterned and inflexible repertoire of language skills may result in peers and teachers misunderstanding the child's intent. [15] Impaired communication, despite intact language skills, affects social interactions with peers (misunderstanding jokes), and reduces their ability to comprehend abstract interpretations of written material (especially fiction, or words with multiple meanings). [26] Circumscribed interests [27] result in inflexibility, when changing from topic to topic, and pose difficulties in the classroom when multiple subjects must be covered.

Play

Through play, children develop skills for participation and communication; physical mastery; coping mechanisms for anxiety; a basic understanding of social rules; and develop self-control. [28][29] A child with AS may experience difficulties in the area of play. For instance, they tend to avoid social play. [17] They have difficulty interpreting social and nonverbal cues leading to limited participation in childhood games. This may result in social isolation. [22][25][15] Individuals with AS often speak pedantically: give too much information; use formal sentence structure, a non-reciprocal or monologue style, and sophisticated language; and are more formal or precise.[1] As a result of these factors, individuals may appear socially impolite and lacking in sensitivity and awareness of other’s feelings. [17][22] The inability to perceive others' facial expressions of pain, annoyance, or boredom may cause others to avoid the individual with AS. Peers may become a victim of what is interpreted to be misbehaviour (e.g. refusing to share toys or playing oddly with them; playing alone). [15] Making and keeping friends is more difficult for boys with with AS, than it is for girls with the syndrome. [30] Female peers may be more forgiving: the child with AS, who does not attend well to social cues, may be assisted by girls who model the socially acceptable mode of responding for the child with AS. [30]

Secondary schooling

As the child with AS reaches adolescence, difficulties with continued social inclusion in the classroom become more apparent, [20] though research in this area is limited. Acceptance of individuals with AS, by normally developing peers, tends to decrease with age. [31] Many adolescents with AS receive less attention and individualized instruction in secondary school resulting in poor performance at school. [20] The transition between secondary school and college can be particularly difficult, because of increased demands on teachers may decrease their inclination or ability to provide individualized assistance to the student with AS. [20]

Employment

Several factors effect employability of individuals with AS: including social skills, communication, [20][17] and sensory issues. [17] One qualitative study interviewed adults with AS and high functioning autism, and found that several difficulties with employment emerged. [32] The participant described experiences of frequent unemployment and underemployment, and difficulties with social aspects, rather than duties, of their jobs. For instance, they experienced increased levels of stress and anxiety in their attempt to manage alongside neurotypicals; misunderstanding of social rules and appropriate or taboo conversation topics. The adults with AS expressed difficulty asking for help, and felt exhausted by efforts to understand neurotypical behaviour. The authors describe clear descriptions of responsibilities and expectations, and providing rules in advance as a key factor in successful employment for individuals with AS. [32] In contrast, individuals with AS often excel in areas that interest them. [27] If this interest relates to a career, this intense focus can be beneficial, and may warrant further exploration. [20]

Occupapational Therapy Interventions for AS

Approximately 80% of children with AS receive services from an occupational therapist (OT) in some form. [11] OTs work collaboratively with the client, family, educators, clinicians, and community to enable participation in meaningful occupations. OT services for AS include assessment, intervention, and evaluation. OT focuses on achieving outcomes such as engagement in activities, adaptation, individual satisfaction, role competence, and quality of life. Occupational therapy interventions for AS often address “areas of attention, behaviour, social skills, sensory processing, motor function, play, and self-care skills.” [14] OT services may also be solicited when impairments in social interaction (such as restricted or repetitive patterns of behaviour, interests, and activities) interfere with function.

Two methods are typically used to deliver occupational therapy services: consultative and direct delivery. Consultative delivery for individuals with AS does not involve direct therapist intervention. Instead, the therapist spends time discussing the child's needs with parents, and/or teachers – the therapist designs, monitors and evaluates an intervention that will be implemented by others. [33] For example, the OT may teach a parent strategies for managing behaviours to promote occupational performance, such as ways to encourage alternative behaviours, or ways to modify the environment to change negative patterns. Consultative service delivery has been found to be an effective method for facilitating the achievement of goals. [33] When providing direct service, the OT will spend the majority of their time directly interacting with the client to solve occupational performance issues. [33]

Individuals with AS often have difficulty understanding social norms and establishing satisfying relationships with family and peers. As individuals with AS do not 'outgrow' these difficulties, they may experience difficulties securing employment and relational difficulties in adulthood. [34] A variety of social skills interventions may be facilitated by OTs, either directly or on a consultative basis. Social skills interventions may be administered in school classrooms as a part of the curriculum, in mixed groups with typically developing peers, or in groups consisting of only individuals with AS. Social skills programs aim to teach children and adolescents the skills necessary to navigate their social environment – to interact with peers, familiar and unfamiliar adults - through interventions such as role play, direct instruction, providing feedback on interactions, practicing learning during free play, social scripts and social stories, and systems of rewards, and teaching Theory of Mind. [34] Topics covered include: greetings, eye contact, initiating, responding to, and maintaining social interactions, turn taking, sharing, giving and receiving compliments, awareness and expression of feelings, non-verbal communication, politeness, conversational skills, negotiation, dealing with bullying, and hygiene. [34] Research suggests promising teaching strategies include involving parents, using 'homework,' providing people to practice with, making teaching predictable and structured, modeling, reinforcing attempts, making social rules concrete, developing a fun and nurturing environment, and starting with simple skills. [35]

An array of different social skills programs, which demonstrate varying levels of success, are offered by occupational therapists. In a systematic review, seven of ten studies reported some positive results, but because social skills are both difficult to define and measure objectively, it is difficult to isolate what part of the interventions was successful. Further, generalization of skills beyond the therapeutic milieu, especially in more complex areas of social interaction, appears to be somewhat limited (based on the available measures). That being said, interventions where skill generalization was facilitated resulted in wider application of learned skills. Though social skills training programs are common clinical interventions, more research is necessary to design and evaluate programs that are specifically targeted at subgroups within the Autism Spectrum, as programs that are targeted toward children's levels of functioning are more successful. [34]

Social Stories™ is a specific type of social skills intervention used by occupational therapists that aims to improve social interaction. This intervention involves short stories that are written for a child, and provide a description of a social situation with accurate information about the event, a description of how others may react, and instruction for appropriate action or response in that social situation. [36] These stories are typically formatted as short books, written from the child's perspective. Social Stories are a common intervention used with children with ASD. There is evidence that using Social Stories may decrease disruptive behaviour, enhance greetings, and teach appropriate play. [36] There is also evidence that social stories increase eye contact and smiling behaviours. [37] Overall, the evidence indicates that Social Stories are a promising practice, however further research is required to increase evidence supporting this intervention for children with AS. [38]

Like other ASDs, some individuals with AS experience difficulties with processing and coping with sensory stimuli. Two general categories of OT interventions have been developed that seek to improve activity and participation issues resulting from impairments related to sensation: impairment-oriented therapies focus on body function and structure, while performance-oriented therapies focus on performance of specific tasks. [33] Sensory Integration and sensory based approaches aim to reduce impairment by targeting an impaired body system, in this case sensory integration and processing systems, to remediate impairments to increase performance in other areas. [33] Sensory based approaches are widely used, but supported with limited evidence. For example, one survey found that more than fifty percent of therapists who responded used weighted vests for clients with autism and other disorders. Though this sensory based intervention claims many positive outcomes, including remediation of inattentiveness, stereotypic behaviour, clumsiness, and hyperactivity, these positive effects have not been demonstrated in reliable research studies. [39] Other sensory based interventions include sound therapy, therapeutic riding, using therapy balls or other equipment, and movement therapy. The later four therapies are aimed at improving motor coordination, based on the assumption that motor systems cannot operate successfully without processing and integrating sensory information. [33]

Cognitive Orientation to Occupational Performance (CO-OP) is a performance-oriented approach to intervention that utilizes the power of cognition to drive successful performance, and to solve daily occupational performance problems. [40] CO-OP is an individualized, client-centred approach, focused on strategy-based skill acquisition. [40] CO-OP interventions enable the child to select a skill that will be the focus of treatment. Depending on the skill that is selected, OT intervention addresses issues in the areas of self care, productivity, or leisure. An OT would then help the child with his/her selected occupations by guiding them in the use of global problem solving strategies, as well as the identification of domain-specific strategies that will enable new and effective ways to achieve their goals. [41]

The CO-OP approach was designed by OTs for use with children who have occupational performance deficits, specifically Developmental Coordination Disorder (DCD). [40] However, evidence that supports the use of the CO-OP approach for children with AS is accumulating. [42][43] OTs can use the CO-OP approach to assist children with AS in the acquisition of social and organizational skills. [42] Some OTs use the CO-OP approach to assist children in acquiring new skills, and, theoretically, to enable them to generalize and transfer learned strategies to new materials, contexts, and situations. [43] As the use of the CO-OP approach with children with AS is still a fairly new area of practice, further research is required to assess the effectiveness of the CO-OP with this population.

Animal assisted therapy for children with AS is an emerging OT intervention. [44] Animal assisted therapy integrates animals, in a goal oriented setting, while treatment is implemented. Animal assisted therapy has significant benefits in terms of increasing cognitive, psychological, and social function. Evidence also suggests that animal assisted therapy influences physiological factors, and can lower blood pressure, heart rate, and decrease levels of anxiety. [44] There is evidence that OT treatment for children with ASD that incorporates animals can promotes a greater use of language and increased social interaction, when compared to standard techniques.[44]

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Woodbury-Smith MR, Volkmar FR. Asperger Syndrome. Eur Child Adolesc Psychiatry. 2009 Jan; 18(1):2-11.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Shangraw K, Autism Spectrum Disorders. In: Atchison BJ, Dirette DK, editors. Conditions in Occupational Therapy. 3rd ed. Baltimore, Philadelphia: Lippincott, Williams & Wilkins; 2007. p. 23-49.
  3. ↑ 3.0 3.1 3.2 3.3 Gillberg C, Cederlund M. Asperger Syndrome: Familial and Pre- and Perinatal Factors. J Autism Dev Disord. 2005 Apr; 35(2):159-166.
  4. ↑ Stone J, Merriman B, Cantor RY, Gilliam T, Geshwind D, Nelson S. Evidence for sex specific risk alleles in autism spectrum disorder. Am J Hum Genet. 2004 Dec; 75(6):1117–1123.
  5. ↑ 5.0 5.1 5.2 5.3 Lyons V, Fitzgerald M. Asperger Syndrome: A gift or a curse? New York: Nova Biomedical Books; 2005.
  6. ↑ 6.0 6.1 Khouzam HR, Gabalawi FE, Pirwani N, Priest F. Asperger’s disorder: A review of its diagnosis and treatment. Compr Psychiatry. 2004 May-Jun; 45(3): 184-91.
  7. ↑ Chakrabarti S, Fombonne E. Pervasive Developmental Disorders in Preschool Children: Confirmation of High Prevalence. Am J Psychiatry. 2005 Jun; 162(6):133-141.
  8. ↑ Fombonne E, Zakarian R, Bennet A, Meng L, Mclean-Heywood D. Pervasive Developmental Disorders in Montreal, Quebec, Canada: Prevalence. Pediatrics. 2006 Jul; 118(1):139-150.
  9. ↑ Mattila ML, Hurtig T, Haapsamo H, Jussila K, Kuusikko-Gauffin S, Kleinen M, Linna SL, Ebeling H, Blouigu R, Joskitt L, Pauls DL, Moilanen I. Comorbid Psychiatric Disorders Associated with Asperger Syndrome/High-functioning Autism: A Community and Clinic-based Study. J Autism Dev Disord. 2010 Sep; 40(9):1080-93.
  10. ↑ 10.0 10.1 Tucker GJ, Popkin M, Caine ED, Folstein M, Gottlieb GL, Grant I, Liptzin B. Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Text Revision. Washington DC: The American Psychiatric Association; 2000.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 Dunn W, Smith Myles B, Orr S. Sensory processing issues associated with Asperger’s Syndrome: A preliminary investigation. American Journal of Occupational Therapy. 2002 Feb; 56(1):97-102.
  12. ↑ Canadian Association of Occupational Therapists. Enabling occupation: An occupational therapy perspective. Ottawa, ON: CAOT Publications ACE; 2002.
  13. ↑ 13.0 13.1 Polatajko HJ, Cantin N. Developmental coordination disorder (Dyspraxia): An overview of the state of the art. Semin Pediatr Neurol. 2005 Dec; 12(4):250-258.
  14. ↑ 14.0 14.1 Watling R, Tomchek S, La Vesser P. The scope of occupational therapy services for individuals with autism spectrum disorders across the lifespan. Am J Occup Ther. 2005 Nov/Dec; 59(6):680-683.
  15. ↑ 15.00 15.01 15.02 15.03 15.04 15.05 15.06 15.07 15.08 15.09 15.10 15.11 15.12 Miller Porr S. Chapter 9: The psychological system. In: Miller Porr S, Berger Rainville E, editors. Pediatric therapy: A systems approach. Philadelphia, PA: FA Davis Company; 1999. p. 297-300.
  16. ↑ 16.0 16.1 16.2 16.3 16.4 16.5 Kurtz LA. The development of motor skills. In: Kurtz LA, editor. How to help a clumsy child: Strategies for young children with developmental motor concerns. London: Jessica Kingsley Publishers; 2003. p. 15-29.
  17. ↑ 17.00 17.01 17.02 17.03 17.04 17.05 17.06 17.07 17.08 17.09 17.10 17.11 Attwood T. The complete guide to Asperger’s syndrome. [Internet]. Philadelphia, PA: Jessica Kingsley Publishers; 2007 [cited 2011 March 24]. Available from Google books: http://tinyurl.com/4hor8cx
  18. ↑ Asperger H. Autistic psychopathology in childhood [U Frith, trans]. In Frith U, editor. Autism and Asperger syndrome. Cambridge, UK: Cambridge University Press. 1991/1944.
  19. ↑ 19.0 19.1 Tantam D. Assessment and treatment of comorbid emotional and behavior problems. In: Prior M, editor. Learning and behavior problems in Asperger’s syndrome. New York, NY: Guildford Press; 2003. p. 148-174.
  20. ↑ 20.0 20.1 20.2 20.3 20.4 20.5 Howlin P. Longer term educational and employment outcomes. In: Prior M, editor. Learning and behavior problems in Asperger’s syndrome. New York, NY: Guildford Press; 2003. p. 269-293.
  21. ↑ 21.0 21.1 Reitzel J, Szatmari P. Cognitive and academic problems. In: Prior M, editor. Learning and behavior problems in Asperger’s syndrome. New York, NY: Guildford Press; 2003. p. 35-54.
  22. ↑ 22.0 22.1 22.2 22.3 22.4 Klin A. Diagnostic Issues in Asperger Syndrome [Internet]. New York: Guilford Press; 2000 [cited 2011 March 21]. Available from Google books: http://tinyurl.com/4qegjhs
  23. ↑ Green D, Baird G, Barnett A, Henderson L, Huber J, Henderson S. The severity and nature of motor impairment in Asperger’s disorder: A comparison with specific developmental disorder of motor function. J Child Psychol Psychiatr. 2003; 43:655-668.
  24. ↑ Rodger S, Brandenberg J. Cognitive orientation to (daily) occupational performance with children (CO-OP) with Asperger Syndrome with motor based occupational performance goals. Aust Occup Ther J. 2009; 56:41-50.
  25. ↑ 25.0 25.1 Ghaziuddin M. Mental health aspects of autism and Asperger’s syndrome. Philadelphia, PA: Jessica Kingsley Publishers; 2005.
  26. ↑ Tager Flushberg H. Effects of language and communicative deficits on learning and behavior. In: Prior M, editor. Learning and behavior problems in Asperger syndrome. New York, NY: Guildford Press; 2003. p. 85-103.
  27. ↑ 27.0 27.1 Attwood T. Understanding and managing circumscribed interests. In: Prior M, editor. Learning and behavior problems in Asperger’s syndrome. New York, NY: Guildford Press; 2003. p. 126-147.
  28. ↑ Burke JP. Chapter 8: Play: The life role of the infant and young child. In: Case-Smith J. editor. Pediatric occupational therapy and early intervention, 2nd ed. Boston, MA: Butterworth Heinemann, 1998. p. 189-205.
  29. ↑ Olson L. Psychosocial frame of reference. In: Kramer P, Hinojosa J, editors. Pediatric Occupational Therapy: Frames of Reference. Baltimore, MD: Williams & Wilkins, 2009. p. 351-394.
  30. ↑ 30.0 30.1 Attwood T, Grandin T, Bolick T. Asperger’s and girls [Internet]. Arlington, TX: Future Horizons; 2006 [cited 2011 March 25]. Available from Google books; http://tinyurl.com/4vpr2dm
  31. ↑ Beveridge S. Experiences of an integration link scheme: The perspectives of pupils with severe learning difficulties and their mainstream peers. Europ J Learn Disab. 1996; 26:87-101.
  32. ↑ 32.0 32.1 Hurlbutt K, Chalmers L. Employment and Adults with Asperger Syndrome. Focus Autism Other Dev Disabl. 2004; 19(4):215-222Polatajko HJ, Cantin N. Exploring the effectiveness of occupational therapy interventions other than sensory integration therapy with children and adolescents experiencing sensory processing difficulties. Am J Occup Ther. 2010; 64(3):415-429.
  33. ↑ 33.0 33.1 33.2 33.3 33.4 33.5 Rao PA, Beidel DC, Murray MJ. Social skills interventions for children with asperger's syndrome or high-functioning autism: A review and recommendations. J Autism Dev Disord. 2008 02;38(2):353-61.
  34. ↑ 34.0 34.1 34.2 34.3 Williams White S, Keonig K, Scahill L. Social skills development in children with autism spectrum disorders: A review of the intervention research. J Autism Dev Disord. 2007 10/15;37(10):1858-68.
  35. ↑ Scattone D. Enhancing the conversation skills of a boy with asperger’s disorder through social stories and videomodeling. J Autism Dev Disord. 2008 Jun; 38(4):395-400.
  36. ↑ 36.0 36.1 Crozier S, Tincani M. Effects of social stories on prosocial behaviour of preschool children with autism spectrum disorders. J Autism Dev Disord. 2006 Dec; 37(5):1803-1814.
  37. ↑ Hess KL, Morrier MJ, Heflin LJ, Ivey ML. Autism treatment survey: Services received by children with autism spectrum disorders in public school classrooms. J Autism Dev Disord. 2008 Oct; 38(4):961-971.
  38. ↑ Stephenson J, Carter M. The use of weighted vests with children with autism spectrum disorders and other disabilities. J Autism Dev Disord. 2009;39(1):105-14.
  39. ↑ Polatajko HJ, Mandich AD, Missiuna C, Miller LT, Macnab JJ, Malloy-Miller T, Kinsella EA. Cognitive orientation to daily occupation performance (CO-OP): Part 3 – The protocol in brief. Phys Occup Ther Pediatr. 2001; 20(3):107 – 123.
  40. ↑ 40.0 40.1 40.2 Polatajko HJ, Mandich AD, Miller L, Macnab J. Cognitive orientation to daily occupational performance (CO-OP): Part 2- The evidence. Phys Occup Ther Pediatr. 2001; 20(3):83-106.
  41. ↑ Rodger S, Vishram A. Mastering social and organization goals: Strategy use by two children with asperger syndrome during cognitive orientation to daily occupational performance. Phys Occup Ther Pediatr. 2010; 30(4):264-276.
  42. ↑ 42.0 42.1 Rodger S, Springfield E, Polatajko HJ. Cognitive orientation for daily occupational performance approach for children with asperger’s syndrome: A case report. Phys Occup Ther Pediatr. 2007; 27(4):7-22.
  43. ↑ 43.0 43.1 Bass M, Duchowny CA, Llabre MM. The effect of therapeutic horseback riding on social functioning in children with autism. J Autism Dev Disord. 2009 April; 39(4):1261-1267.
  44. ↑ 44.0 44.1 44.2 Sams MJ, Fortney EV, Willenbring S. Occupational therapy incorporating animals for children with autism: A pilot investigation. Am J Occup Ther. 2006 May; 60(3):268-274.
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