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Chapter 31: Child Psychiatry
Differential Diagnosis.
The differential diagnosis includes
social anxiety disorder, obsessive-compulsive disorder, and
schizoid personality disorder. According to the previous DSM-
IV-TR, the most obvious characteristics of Asperger’s disorder
compared to autistic disorder are the absence of language delay
and dysfunction. The lack of language delay and impaired use
of language were previous requirements for Asperger’s disorder;
however, social and communication deficits are present. Studies
comparing children with Asperger’s disorder and autistic dis-
order found that children with Asperger’s disorder were more
likely to seek social interaction, and due to their awareness
of their impairment sought more vigorously to make friends.
Although in this subgroup within autism spectrum disorder sig-
nificant delay in language is not a feature, some delay in the
acquisition of language, and some impairment in verbal com-
munication has been noted in more than one third of clinical
samples.
Course and Prognosis.
The factors associated with a good
prognosis in this subgroup within autism spectrum disorder are
a normal IQ and more competencies in social skills. Reports
of some adults diagnosed with Asperger’s disorder indicate that
their social and communication deficits remain and they con-
tinue to relate in an awkward way and appear socially uncom-
fortable.
Treatment.
Treatment of individuals who meet the criteria
for the previous Asperger’s disorder diagnosis aims to promote
social communication and peer relationships. Interventions are
initiated with the goal of shaping interactions so that they better
match those of peers. Very often children with Asperger’s disor-
der are highly verbal and have excellent academic achievement.
The tendency of children and adolescents with Asperger’s dis-
order to rely on rigid rules and routines can become a source of
difficulty for them and be an area that requires therapeutic inter-
vention. A comfort with routines, however, can be utilized to
foster positive habits that may enhance the social life of a child
with Asperger’s disorder. Self-sufficiency and problem-solving
techniques are often helpful for these individuals in social situ-
ations and work settings. Some of the same techniques used for
autistic disorder are likely to benefit patients with Asperger’s
disorder with severe social impairment.
Pervasive Developmental Disorder Not
Otherwise Specified
Whereas the DSM-IV-TR defines pervasive disorder not other-
wise specified as a condition with severe, pervasive impairment
in communication skills or the presence of restricted and repeti-
tive activities and associated impairment in social interactions,
DSM-5 conceives of this as encompassed within a diagnosis of
autism spectrum disorder.
Jared was an only child. Birth, medical, and family histories
were unremarkable. His motor development was slightly delayed,
but language milestones were within normal limits. His parents
became concerned about him at age 4 when he was enrolled in a
nursery school and was noted to have difficulties in peer interaction,
joining activities, and following the rules that were so pronounced
that he could not continue in the program. In grade school, he was
enrolled in regular education classes and was noted to have difficul-
ties making friends and playing sports with the other students, and
he often played alone and spent time alone at lunch and recess.
His greatest difficulties arose in peer interactions—he was viewed
as eccentric and did not seem to understand how to interact with
peers. At home, he seemed captivated by watching the weather
channel on television, which he insisted on watching and pursued
with great interest and intensity. On examination at age 13, Jared
had markedly restricted and intense interests and exhibited pedantic
and odd patterns of communication with a monotonic voice quality.
Psychological testing revealed an IQ within the normal range. For-
mal communication examination revealed age-appropriate skills in
receptive and expressive language but marked impairment in prag-
matic language skills. (Adapted from Fred Volkmar, M.D.)
Anna was the older of two children. She had been a difficult
baby who was not easy to console but her motor and communica-
tive development seemed appropriate. She was socially related and
sometimes enjoyed interaction, but she was easily overstimulated.
She exhibited some hand flapping behavior, especially when she
was excited. Anna’s parents sought evaluation when she was 4 years
of age because of problems with getting along with other children.
At evaluation Anna was found to have language and cognitive func-
tion within the normal range. Anna had difficulty relating to her
parents as sources of support and comfort. She displayed behav-
ioral rigidity and a tendency to impose routines on social skills.
Anna was placed in a special education kindergarten and did well
academically, although problems in peer interactions and unusual
affective responses persisted. As an adolescent, Anna describes her-
self as a “loner,” who often retreats from others and avoids social
interaction and tends to be comfortable with solitary activities.
(Adapted from Fred Volkmar, M.D.)
Treatment.
The treatment approach is identical to that of
other autism spectrum disorder. Mainstreaming in school may
be possible. Compared with previously diagnosed autistic chil-
dren, those with the former pervasive developmental disorder
not otherwise specified generally have less impairment in lan-
guage skills and more self-awareness.
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