The Complete Guide to Asperger's Syndrome

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[说明:我们把自闭症/爱斯柏格症的一本经典著作扫描了贴了上来,这本书的初版本已经有台湾的中文本了,部分已经贴在本栏目,但是作者的这本"全版本"的内容更全面,目前还没有任何中文版.我们先把英文内容贴上来,有机会我们可以选择翻译一些.

这一大本书由WANGMAOMI一人扫描出来,特此感谢!


CHAPTER I

What is Asperger's Syndrome?

Not everything that steps out of line, and thus ‘abnormal’, must necessarily be 'inferior'.
- Hans Asperger (1938)

The door bell rang, heralding the arrival of another guest for Alicia's birthday party. Her mother opened the door and looked down to see Jack, the last guest to arrive. It was her daughter's ninth birthday and the invitation list had been for ten girls and one boy. Alicia's mother had been surprised at this inclusion, thinking that girls her daughter's
age usually consider boys to be smelly and stupid, and not worthy of an invitation to a girl's birthday party. But Alicia had said that Jack was different. His family had recently moved to Birmingham and Jack had been in her class for only a few weeks. Although he tried to. join in with the other children, he hadn't made any friends. The other boys teased him and wouldn't let him join in any of their games. Last week he had sat next to
Alicia while she was eating her lunch, and as she listened to him, she thought he was a kind and lonely boy who seemed bewildered by the noise and hectic activity of the playground. He looked cute, a younger Harry Potter, and he knew so much about so many things. Her heart went out to him and, despite the perplexed looks other friends when she said he was invited to her party, she was determined he should come.
And here he was, a solitary figure clutching a birthday card and present which he immediately gave to Alicia's mother. She noticed he had written Alicia's name on the envelope, but the writing was strangely illegible for an eight-year-old. "You must be Jack,' she said and he simply replied with a blank face, 'Yes'. She smiled at him, and was about to suggest he went into the garden to join Alicia and her friends when he said,’Alicia's birthday present is one of those special dolls that my mum says every girl wants,and she chose it, but what I really wanted to get her was some batteries. Do you like batteries? I do, I have a hundred and ninety-seven batteries. Batteries are really useful. What batteries do you have in your remote controllers?' Without waiting for a reply, he con-
tinued, ‘I have a special battery from Russia. My dad’s an engineer and he was working on an oil pipeline in Russia and he came home with six triple-A batteries for me with Russian writing on them. They are my favourite. When I go to bed I like to look at my box of batteries and sort them in alphabetical order before I go to sleep. I always hold one of my Russian batteries as I fall asleep. My mum says I should hug my teddy bear but I prefer a battery. How many batteries do you have?'
She replied, 'Well, I don't know, but we must have quite a few...', and felt unsure what to say next. Her daughter was a very gentle, caring and maternal girl and she could understand why she had 'adopted' this strange little boy as one other friends. Jack continued to provide a monologue on batteries, how they are made and what to do with them when the power is exhausted. Alicia's mother felt exhausted too, listening to a lecture that lasted about ten minutes. Despite her subtle signals of needing to be somewhere else, and eventually saying, 'I must go and get the party food ready,' he continued to talk, following her into the kitchen. She noticed that when he talked, he rarely looked at her and his vocabulary was very unusual for an eight-year-old boy. It was more like listening to an adult than a child, and he spoke very eloquently, although he didn't seem to want to listen.
Eventually she said, 'Jack, you must go into the garden to say hi to Alicia and you must go now.' Her facial expression clearly indicated there was no alternative. He gazed at her face for a few seconds, as if trying to read the expression, and then off he went. She looked out of the kitchen window and watched him run across the grass towards Alicia. As he ran through a group of four girls, she noticed one of them deliberately put
out her foot to trip him up. As he fell awkwardly to the ground, the girls all laughed. But Alicia had seen what happened and went over to help him get to his feet.
This fictitious scene is typical of an encounter with a child with Asperger's syndrome. A lack of social understanding, limited ability to have a reciprocal conversation and an intense interest in a particular subject are the core features of this syndrome. Perhaps the simplest way to understand Asperger's syndrome is to think of it as describing someone who perceives and thinks about the world differently to other people.
Although clinicians have only recently described these differences, the unusual profile of abilities that we define as Asperger's syndrome has probably been an important and valuable characteristic of our species throughout evolution. It was not until the late twentieth century that we had a name to describe such individuals. We currently use the diagnostic term Asperger's syndrome, based on the remarkably perceptive descriptions of Dr Hans Asperger, a Viennese paediatrician, who, in 1944, noticed that some of the children referred to his clinic had very similar personality characteristics and behaviour. By the mid-1940s, the psychological study of childhood in Europe and America had become a recognized and growing area of science with significant advances in descriptions, theoretical models and assessment instruments, but Asperger could not find a description and explanation for the small group of similar and unusual children that he found intriguing. He suggested the term Autistische Psychopathen im Kindesalter. A modern translation of the original German psychological term 'psychopathy' into current English terminology would be personality disorder - that is, a description of someone's personality rather than a mental illness such as schizophrenia.
Asperger was clearly entranced by children with autistic personality disorder and he wrote a remarkably perceptive description of the children's difficulties and abilities (Asperger 1944). He observed that the children's social maturity and social reasoning were delayed and some aspects of their social abilities were quite unusual at any stage of
development. The children had difficulty making friends and they were often teased by other children. There were impairments in verbal and non-verbal communication, especially the conversational aspects of language. The children's use of language was pedantic, and some children had an unusual prosody that affected the tone, pitch and rhythm of speech. The grammar and vocabulary may have been relatively advanced but, at the end of the conversation, one had the impression that there was something unusual
about their ability to have the typical conversation that would be expected with children of that age. Asperger also observed and described conspicuous impairments in the communication and control of emotions, and a tendency to intellectualize feelings. Empathy was not as mature as one would expect, considering the children's intellectual abilities. The children also had an egocentric preoccupation with a specific topic or interest that would dominate their thoughts and time. Some of the children had difficulty maintaining attention in class and had specific learning problems. Asperger noted that they often needed more assistance with self-help and organizational skills from their mothers than one would expect. He described conspicuous clumsiness in terms of gait and coordination. He also noted that some children were extremely sensitive to particular sounds,
aromas, textures and touch.
Asperger considered that the characteristics could be identified in some children as young as two to three years, although for other children, the characteristics only became conspicuous some years later. He also noticed that some of the parents, especially the fathers of such children, appeared to share some of the personality characteristics of their child. He wrote that the condition was probably due to genetic or neurological,
rather than psychological or environmental, factors. In his initial and subsequent publications and a recent analysis of his patient records for children he saw over three decades, it is apparent that he considered autistic personality disorder as part of a natural continuum of abilities that merges into the normal range (Asperger 1944, 1952, 1979; Hippler and Klicpera 2004). He conceptualized the disorder as a life-long and stable
personality type, and did not observe the disintegration and fragmentation that occurs in schizophrenia. He also noted that some of the children had specific talents that could lead to successful employment and some could develop life-long relationships.

(待续)

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PATHWAYS TO A DIAGNOSIS
Today, when a child or adult is referred for a diagnostic assessment, they may have travelled along one of several different diagnostic pathways. The child referred for a diagnostic assessment would have had an unusual developmental history and profile of abilities from early childhood, though the average age for a diagnosis of a child with Asperger's syndrome is between 8 and 11 years (Eisenmajer et al. 1996; Howlin and Asgharian 1999). I have identified several pathways to that diagnosis, which may
commence when the child is an infant, or at other stages of development, or even at specific times in the adult's life history.

Diagnosis of autism in infancy or early childhood
Lorna Wing, who first used the term Asperger's syndrome, considered that there was a need for a new diagnostic category. She had observed that some children who had the clear signs of severe autism in infancy and early childhood could achieve remarkable progress and move along the autism continuum as a result of early diagnosis and intensive and effective early intervention programs (Wing 1981). The previously socially aloof and silent child now wants to play with children and can talk using complex sentences. Where previously there was motivation for isolation, the child is now motivated to be included in social activities. After many hours in intensive programs to encourage communication abilities, the problem is no longer encouraging the child to speak, but encouraging him or her to talk less, listen and be more aware of the social context. As a younger child, there may have been a preoccupation with sensory experiences - the
spinning wheel of a toy car or bicycle may have mesmerized the child - but now he or she is fascinated by a specific topic, such as the orbits of the planets. Previous assessments and observations of play would have indicated the possibility of significant intellectual impairment, but now the child is confirmed as having an Intelligence Quotient (IQ) within the normal range.
Peter Szatmari has suggested that those children with autism who develop functional language in early childhood eventually join the developmental trajectory and have a profile of abilities typical of a child with Asperger's syndrome (Szatmari 2000). At one point in a child's early development, autism is the correct diagnosis, but a distinct subgroup of children with autism can show a remarkable improvement in language, play
and motivation to socialize with their peers between the ages of four and six years. The developmental trajectory for such children has changed and their profile of abilities in the primary or elementary school years is consistent with the characteristics of Asperger's syndrome (Attwood 1998; Dissanayake 2004; Gillberg 1998; Wing 1981). These children, who may subsequently be diagnosed as having High Functioning Autism or Asperger's syndrome, will benefit from the strategies and services designed for children with Asperger's syndrome rather than autism.

Recognition of Asperger's syndrome in the early school years
During the diagnostic assessment of adults, I usually ask when the person first recognized that he or she was different to other people. Many adults who are diagnosed in their mature years say that the first time they felt different to others was when they started school. They describe being able to understand and relate to family members, including playing socially with brothers and sisters, but when they were expected to play with their peers at school and relate to a teacher, they recognized themselves as being very different from children their age. When I ask these adults to describe those
differences, the replies usually refer to not being interested in the social activities of their peers, not wanting to include others in their own activities, and not understanding the social conventions in the playground or classroom.
The diagnostic pathway commences when an experienced teacher observes a child who has no obvious history of characteristics associated with autism, but who is very unusual in terms of his or her ability to understand social situations and conventions. The child is also recognized as immature in the ability to manage emotions and to express empathy. There can be an unusual learning style with remarkable knowledge in an area of interest to the child, but significant learning or attention problems for other
academic skills. The teacher may also notice problems with motor coordination such as handwriting, running, and catching a ball. The child may also cover his or her ears in response to sounds that are not perceived as unpleasant by other children.
When in the playground, the child may actively avoid social play with peers or be socially naive, intrusive or dominating. In class, the teacher recognizes that the child does not seem to notice or understand the non-verbal signals that convey messages such as 'not now' or 'I am starting to feel annoyed.' The child can become notorious for interrupting or not responding to the social context in ways that would be expected of a child of that age and intellectual ability. The teacher may also notice that the child becomes extremely anxious if routines are changed or he or she cannot solve a problem.
The child is obviously not intellectually impaired but appears to lack the social understanding of his or her peers. The teacher knows that the child would benefit from programs to help in his or her understanding of the social conventions of the classroom and school playground. The teacher also needs access to training, in-class support, resources and expertise in Asperger's syndrome to facilitate successful social integration and academic success. The child needs help and the teacher needs help.
My clinical experience suggests that the majority of children with Asperger's syndrome achieve a diagnosis using this pathway. The child's unusual profile of abilities and behaviour are not conspicuous at home but a teacher recognizes qualitative differences in abilities and behaviour in the classroom and playground. At a subsequent meeting of parents and representatives of the school, parents are encouraged to seek a diagnostic assessment both to explain the unusual behaviour and profile of abilities, and for the parents and school to achieve access to appropriate programs and resources.

The previous diagnosis of another developmental disorder
Another diagnostic pathway is that a child's developmental history includes a developmental disorder that can be associated with Asperger's syndrome. The diagnosis of a disorder of attention, language, movement, mood, eating or learning ability can be the start of the formal assessment process that eventually leads to a diagnosis of Asperger's syndrome.

Attention Deficit Hyperactivity Disorder
The general population is reasonably knowledgeable about Attention Deficit Hyperactivity Disorder (ADHD) and the child may be of concern to parents and teacher because of problems with sustained attention, impulsivity and hyperactivity. This diagnosis may account for the child's difficulties in these areas but not explain the child's unusual profile of social, linguistic and cognitive abilities, which are more accurately described
by the diagnostic criteria for Asperger's syndrome. The ADHD was accurately diagnosed first but was not the end of the diagnostic trail.
Clinicians have recognized for some time that children with Asperger's syndrome can also have signs of ADHD, which has been confirmed by several research studies and case descriptions (Ehlers and Gillberg 1993; Fein et al. 2005; Ghaziuddin, Weider-Mikhail and Ghaziuddin 1998; Klin and Volkmar 1997; Perry 1998; Tani et al. 2006). The two diagnoses are not mutually exclusive and a child may benefit from the medical treatment and strategies used for both disorders.
I have observed young children with Asperger's syndrome who have been hyperactive but not necessarily due to having ADHD. The hyperactivity can be a response to a high level of stress and anxiety, particularly in new social situations, making the child unable to sit still and relax. It is important to distinguish between a range of factors that can influence attention span (such as motivation) and hyperactivity before confirming
the diagnosis of ADHD.

A language disorder
A young child who has Asperger's syndrome may first be recognized as having a delay in the development of speech and be referred to a speech/language pathologist for assessment and therapy. Formal testing of communication skills may identify both delay in language development and specific characteristics that are not typical of any of the stages in language development. The assessment would indicate language delay and deviance with a pattern of linguistic abilities that resembles Semantic Pragmatic
Language Disorder (SPLD). Children with SPLD have relatively good language skills in the areas of syntax, vocabulary and phonology but poor use of language in a social context, i.e. the art of conversation or the pragmatic aspects of language (Rapin 1982). Semantic abilities are affected such that the child tends to make a literal interpretation of what someone says. The diagnosis of SPLD explains the child's language skills but a

comprehensive assessment of abilities and behaviour indicates that the broader clinical picture is explained by a diagnosis of Asperger's syndrome.
The diagnostic boundaries between Asperger's syndrome and specific language disorders such as SPLD are not clear cut (Bishop 2000). Receptive language delay in young children is often associated with problems with socialization (Paul, Spangle-Looney and Dahm 1991). A child who has difficulties understanding someone's language and being understood could become anxious and withdrawn in social situations. The reason for the social withdrawal is then due to language impairment rather than the impaired social reasoning that occurs in Asperger's syndrome. During the diagnostic assessment it is important to distinguish between the secondary consequences of a language disorder and Asperger's syndrome. Nevertheless, the child with Asperger's syndrome who also has signs of SPLD will benefit from programs designed for children who have SPLD.

A movement disorder
A young child may be identified by parents and teachers as being clumsy, with problems with coordination and dexterity. The child may have problems with tying shoelaces, learning to ride a bicycle, handwriting and catching a ball, and an unusual or immature gait when running or walking. The child is referred to an occupational therapist or physiotherapist for assessment and therapy.  The assessment may confirm a delay in movement skills or a specific movement disorder but the therapist may note other unusual characteristics in the child's developmental history and profile of abilities and be the first professional to suspect that the child has Asperger's syndrome. Although the coordination problems were the start of the diagnostic pathway to Asperger's syndrome, the child will still obviously benefit from programs to improve motor skills.
Some children with Asperger's syndrome can develop involuntary, rapid and sudden body movements (motor tics) and uncontrollable vocalizations (vocal tics) that resemble signs of Tourette's syndrome (Ehlers and Gillberg 1993; Gillberg and Billstedt 2000; Kadesjo and Gillberg 2000; Ringman and Jankovic 2000). A diagnostic assessment for Tourette's syndrome due to the recognition of motor and vocal tics could be a pathway
to the further diagnosis of Asperger's syndrome.

A mood disorder
We know that young children with Asperger's syndrome are prone to develop mood disorders (Attwood 2003a), and some children seem to be almost constantly anxious, which might indicate a Generalised Anxiety Disorder (GAD). One of the problems faced by children with Asperger's syndrome who use their intellect rather than intuition to succeed in some social situations is that they may be in an almost constant state of alertness and anxiety, leading to a risk of mental and physical exhaustion.
The child may have developed compensatory mechanisms to avoid anxiety-
provoking situations such as school, by refusing to go to school or being mute at school

(Kopp and Gillberg 1997). There may be intense anxiety or a phobic reaction to certain social situations, or to sensory experiences such as a dog barking, or to a change in expectations such as an alteration to the daily school routine. A referral to a clinical psychologist, psychiatrist or mental health service for children with a mood disorder may lead to a diagnosis of Asperger's syndrome when a detailed and comprehensive developmental history is completed (Towbin et al. 2005).
Some children with Asperger's syndrome can become clinically depressed as a reaction to their realization of having considerable difficulties with social integration. The depressive reaction can be internalized, leading to self-criticism and even thoughts of suicide; or externalized, resulting in criticism of others and an expression of frustration or anger, especially when the child has difficulty understanding a social situation.
Blame is directed at oneself: T am stupid'; or others: 'It's your fault.' The signs of a clinical depression or problems with anger management could be the first indicators of a developmental disorder such as Asperger's syndrome.

An eating disorder
Eating disorders can include refusal to eat foods of a specified texture, smell or taste due to a sensory hypersensitivity (Ahearn et al. 2001). There can also be unusual food preferences, and routines regarding meals and food presentation (Nieminen-von Wendt 2004). Referral to a paediatrician for problems with food intake, diet or weight can lead to a diagnosis of Asperger's syndrome. Several studies have also suggested an overrepresentation of low body weight in Asperger's syndrome that may be due to anxiety or sensory sensitivity associated with food (Bolte, Ozkara and Poustka 2002; Hebebrand et al. 1997; Sobanski et al. 1999).
Serious eating disorders such as anorexia nervosa can be associated with Asperger's syndrome, with approximately 18 to 23 per cent of adolescent girls with anorexia nervosa also having signs of Asperger's syndrome (Gillberg and Billstedt 2000; Gillberg and Rastam 1992; Gillberg et al. 1996; Rastam, Gillberg and Wentz 2003; Wentz et al. 2005; Wentz Nilsson et al. 1999). Thus, concerns about food intake or the diagnosis of an eating disorder could be the starting point for a diagnostic assessment for Asperger's syndrome.

Non-verbal Learning Disability
A young child may be recognized as having an unusual profile of intellectual and academic abilities, and formal testing by a neuropsychologist indicates a significant discrepancy between verbal reasoning abilities (Verbal IQ) and visual-spatial reasoning (Performance IQ). If the discrepancy is a significantly higher Verbal IQ, a subsequent and more detailed assessment of cognitive abilities may indicate a diagnosis of
Non-verbal Learning Disability (NLD).

The main characteristics of NLD are deficits in the following: visual-perceptual-organizational abilities; complex psychomotor skills and tactile perception; adapting to novel situations; time perception; mechanical arithmetic; and social perception and social interaction skills. There are relative assets in auditory perception, word recognition, rote verbal learning and spelling. This pattern of abilities suggests right-hemisphere dysfunction and white matter damage to the brain (Rourke and Tsatsanis 2000). The overlap between NLD and Asperger's syndrome is an area of continuing study and discussion among clinicians (Volkmar and Klin 2000). If the child with NLD is subsequently diagnosed as having Asperger's syndrome, information on the child's unusual profile of cognitive skills can be invaluable for a teacher in terms of how to adapt the school curriculum for a distinct learning style.

First recognition of the clinical signs in adolescence
As a child matures into adolescence, the social and academic worlds become more complex and there is an expectation that the child should become more independent and self-reliant. In the early school years, social play tends to be more action than conversation, with friendships being transitory and social games relatively simple with clear rules. In adolescence, friendships are based on more complex interpersonal rather than practical needs, someone to confide in rather than someone to play ball with.
In the early school years, the child has one teacher for the whole year and both teacher and child learn how to read each other's signals and develop a working relationship. There is also more guidance, flexibility and leniency with regard to the school curriculum and expected social and emotional maturity. Life is relatively simple and the child may be less aware of being different to other children, and his or her difficulties
may not be conspicuous in the classroom or playground.
During adolescence, a teenager with Asperger's syndrome is likely to have increasingly conspicuous difficulties with planning and organizational skills, and completing assignments on time. This can lead to a deterioration in school grades that comes to the attention of teachers and parents. The teenager's intellectual abilities have not deteriorated, but the methods of assessment used by teachers have changed. Knowledge of
history is no longer remembering dates and facts but organizing a coherent essay. The study of English requires abilities with characterization and to 'read between the lines'. A group of students may be expected to submit a science project and the teenager with Asperger's syndrome is not easily assimilated into a working group of students. The deterioration in grades and subsequent stress can lead the adolescent to be referred to the school psychologist who recognizes signs of Asperger's syndrome.
I have noted that the signs of Asperger's syndrome are more conspicuous at times of stress and change, and during the teenage years there are major changes in expectations and circumstances. The child may have coped well during his or her pre-adolescent years, but changes in the nature of friendship, body shape, school routines and support

may precipitate a crisis that alerts the relevant diagnostic authorities to the discovery of Asperger's syndrome in a child who was previously coping so well.
Adolescence is also a time of re-appraisal of who one is and wants to be. The influence of parents in an adolescent's life diminishes and the power of and identification with the peer group increases. The teenager is expected to relate to many teachers, each with his or her own personality and teaching style, and to engage in academic assessment that relies on abstract thinking rather than facts. Problems with social inclusion,
acceptance and academic success can precipitate a clinical depression, or anger directed to others or the 'system'.
The adolescent may be referred to adolescent psychiatric services for the treatment of depression, an anxiety disorder - which at this age can include Obsessive Compulsive Disorder (Bejerot, Nylanderand Lindstrom 2001)-an eating disorder such as anorexia nervosa, problems with anger, or a conduct disorder. I have also seen some children who have various levels of expression of four disorders which can form a cluster, namely
Attention Deficit Hyperactivity Disorder, Asperger's syndrome, Tourette's disorder and an Obsessive Compulsive Disorder. Each diagnosis is correct and the child or adult will need treatment for all four disorders.

The suggestion of a conduct or personality disorder
Asperger described a subgroup of children with a tendency to have conduct problems, leading to their being suspended from school - one of the main reasons the children who were subsequently diagnosed as having autistic personality disorder were referred to his clinic in Vienna. Sometimes children with Asperger's syndrome perceive themselves as more adult than child. Indeed, such children may act in the classroom as an assistant to the teacher, correcting and disciplining the other children. In situations of conflict, they are less likely to refer to an adult to act as an adjudicator, and are liable to 'take the law into their own hands'. These children may also learn that acts of aggression can repel other children, ensuring uninterrupted solitude. Conflict and confrontation with adults can be made worse by non-compliance, negativism, and a difficulty in perceiving the differences in social status or hierarchy, resulting in a failure to respect authority or maturity.
The child with Asperger's syndrome is often immature in the art of negotiation and compromise and may not know when to back down and apologize. He or she will not accept a particular school rule if it appears to be illogical, and will pursue a point or argument as a matter of principle. This can lead to a history of significant conflict with teachers and school authorities.
We know that the child with Asperger's syndrome has difficulty with social integration with his or her peers. If that child also has superior intellectual ability, difficulties in social integration may be compounded. Those children who have exceptionally high IQs may compensate by becoming arrogant and egocentric, and have considerable difficulty acknowledging that they have made a mistake. Such children can be hypersensitive to any suggestion of criticism, yet overly critical of others, including teachers,parents or authority figures. The school or parents may turn to professional help with regard to the attitude and conduct of such children, leading to a diagnosis of Asperger's syndrome. Referral to a behaviour management specialist may be the starting point of the pathway to a diagnosis of Asperger's syndrome.

Diagnosis of a relative with autism or Asperger's syndrome
When a child or adult is diagnosed as having autism or Asperger's syndrome, parents and relatives will soon become aware of the different forms of expression of autism, and review their own family history and the characteristics of their relatives for signs of autism spectrum disorder, in particular Asperger's syndrome. Recent research has indicated that 46 per cent of the first-degree relatives of a child with Asperger's syndrome have a similar profile of abilities and behaviour (Volkmar, Klin and Pauls 1998),although usually to a degree that is sub-clinical, i.e. more a description of personality than a syndrome or disorder.
After a child has a diagnosis of Asperger's syndrome confirmed, the clinician may then receive another referral for the diagnostic assessment of a sibling or relative of the child. The diagnosis may be confirmed and clinical experience has indicated that some families have children and adults with Asperger's syndrome within and between generations. This has been confirmed in some of the autobiographies of adults with Asperger's syndrome (Willey 1999). However, the subsequent diagnostic assessment may indicate that the level of expression of the characteristics is too ‘mild’ for a diagnosis, or the person has a number of ‘fragments’ of Asperger's syndrome that are insufficient for a diagnosis. Nevertheless, the person may benefit from some of the strategies that are designed for the characteristics or fragments that are present in his or her profile of abilities.

Recognition of the signs of Asperger's syndrome from the media
Watching a television programme or news item that explains Asperger's syndrome, or reading a magazine article or popular autobiography by an adult with Asperger's syndrome, may be the starting point for some people to seek a diagnostic assessment for themselves or a family member, colleague or friend. In Australia, I recently explained the nature of Asperger's syndrome on a national 'live' television programme, and the switch-board of the television company was subsequently inundated with calls from parents who recognized the signs of  Asperger's syndrome in their adult son or daughter who, due to their age, had never had access to the diagnostic knowledge that is available for children today. In the next few years there is likely to be a deluge of referrals of adults for a diagnostic assessment for Asperger's syndrome.

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Sometimes partners in a relationship may acquire information from the media, and consider that a diagnosis of Asperger's syndrome may explain their husband's (or wife's) unusual hobby and difficulties with empathy and social skills. It is important to remember that many typical women feel that their partner does not understand what they are thinking or feeling, and that many natural characteristics of males could be perceived as signs of Asperger's syndrome. Nevertheless, I have noted an increase in referrals from relationship counsellors who are becoming aware of how to recognize genuine signs of Asperger's syndrome in couples who are seeking relationship counseling (Aston 2003).

Employment problems
Although the person with Asperger's syndrome may achieve academic success, difficulties with social skills may affect his or her performance at a job interview, the social or team aspects of employment, or the understanding of social conventions such as standing too close or looking at someone too long. Getting and keeping a job may be a problem. An assessment by a careers guidance agency, government employment agency or the personnel department of a company may be the first step down the pathway to recognition of Asperger's syndrome. There is probably a high rate of Asperger's syndrome among the chronically unemployed.
Another diagnostic pathway in the area of employment is a change in job expectations. This can be, for example, a promotion to management, requiring interpersonal skills, and conferring responsibilities [hat demand planning and organizational abilities which can be elusive in some adults with Asperger's syndrome. There can also be issues of not accepting conventional procedures, and difficulties with time management, and recognizing and accepting the organizational hierarchy.

WHY PURSUE A DIAGNOSIS?
The very young child with Asperger's syndrome may not be aware of being different from other children of his or her age. However, adults and other children will become increasingly aware that the child does not behave, think or play like other children. The initial opinion of adults within the extended family and school may be that the child is rude and selfish, while peers may think that the child is just weird. If there is no diagnosis and explanation, others will make moral judgements that will inevitably have a detrimental effect on the child's self-esteem and lead to inappropriate attitudes and consequences.
Gradually the child will recognize that he or she is perceiving and experiencing the world in an unusual way and will become concerned about being different from other children. This is not only in terms of different interests, priorities and social knowledge but also in terms of frequent criticisms by peers and adults. The realization of being different to other children usually occurs when the child with Asperger's syndrome is between six and eight years old.
Claire Sainsbury was about eight years old:

Here is one of my most vivid memories of school; I am standing in a corner of
the playground as usual, as far away as possible from people who might bump into
me or shout, gazing into the sky and absorbed in my own thoughts. I am eight or
nine years old and have begun to realize that I am different in some nameless
but all-pervasive way.
I don't understand the children around me. They frighten and confuse me. They don't want to talk about things that are interesting. I used to think that they were silly, but now I am beginning to understand that I am the one who is all wrong. (Sainsbury 2000, p.8)

The child can then develop compensatory thoughts and attitudes for feeling alienated, socially isolated and not understood.

COMPENSATORY AND ADJUSTMENT STRATEGIES TO BEING DIFFERENT
I have identified four compensatory or adjustment strategies developed by young children with Asperger's syndrome as a response to the realization that they are different from other children. The strategy used will depend on the child's personality, experiences and circumstances. Those children who tend to internalize thoughts and feelings may develop signs of self-blame and depression, or alternatively use imagination and a fantasy life to create another world in which they are more successful. Those children who tend to externalize thoughts and feelings can either become arrogant and blame others for their difficulties, or view others not as the cause but the solution to their problems and develop an ability to imitate other children or characters. Thus some psychological reactions can be constructive while others can lead to significant psychological problems.

A reactive depression
Social ability and friendship skills are highly valued by peers and adults and not being successful in these areas can lead some children with Asperger's syndrome to internalize their thoughts and feelings by being overly apologetic, self-critical and increasingly socially withdrawn. The child, sometimes as young as seven years old, may develop a clinical depression as a result of insight into being different and perceiving him- or herself as socially defective.
Intellectually, the child has the ability to recognize his or her social isolation, but lacks social skills in comparison to intellectual and age peers, and does not know intuitively what to do to achieve social success. Brave attempts by the child to improve social integration with other children may be ridiculed and the child deliberately shunned. Teachers and parents may not be providing the necessary level of guidance and especially encouragement. The child desperately wants to be included and to have friends but does not know what to do. The result can be a crisis of confidence, as described in the following quotation from an unpublished autobiography by my sister-in-law, who has Asperger's syndrome.

The fact is, no one likes others to know their weaknesses, but with
an affliction like mine, it's impossible to always avoid making a fool
of yourself or looking indignant/undignified. Because I never knew
when the next 'fall' is going to occur, I avoid climbing up on to a
'confidence horse' so to speak.

There can be increased social withdrawal due to a lack of social competence that decreases the opportunities to develop social maturity and ability. The depression can also affect motivation and energy for other previously enjoyable activities in the classroom and at home. There can be changes in sleep patterns and appetite, and a negative attitude that pervades all aspects of life and, in extreme cases, talk of suicide, or impulsive or planned suicide attempts.

Escape into imagination
A more constructive internalization of thoughts and feelings of being socially defective can be to escape into imagination. Children with Asperger's syndrome can develop vivid and complex imaginary worlds, sometimes with make-believe friends.
Thomas has Asperger's syndrome and considerable intellectual ability. In his biography written by his mother, she describes one of the reasons why her son escaped into his imagination:

During a speech session at school, Thomas was asked by his speech
teacher, 'So who do you play with at recess?'
'My imagination. What do you think?' he informed her.
'Who do you think you should play with at recess?' she enquired.
'Anyone that understands me; but that's nobody but you adults and you don't have time for me,' he said bluntly. (Barber 2006, p. 103)

In their imaginary worlds with imaginary friends, children with Asperger's syndrome are understood, and successful socially and academically. Another advantage is the responses of the imaginary friends are under the child's control and the friends are instantly available. Imaginary friends can prevent the child from feeling lonely. Liane Holliday Willey explained that:

When I think of my earliest years, I recall an overwhelming desire to be away from my peers. I much preferred the company of my imaginary friends. Penny and her brother Johnna were my best friends, though no one saw them but me. My mother
tells me I used to insist that we set them a place at the table, include them in our car trips, and treat them like they were real beings. (Willey 1999, p. 16)

In a personal communication to me, Liane explained that having imaginary friends 'is not pretend play, so much as the only play that works'.
Having an imaginary friend is typical of the play of many young children and is not necessarily of clinical significance. However, the child with Asperger's syndrome may only have friends who are imaginary, and the intensity and duration of the imaginary interactions can be qualitatively unusual.
Searching for an alternative world can lead some children to develop an interest in another country, culture, period of history or the world of animals, as described in the following passage by my sister-in-law.

When I was about seven, I probably saw something in a book, which fascinated me and still does. Because it was like nothing I had ever seen before and totally unrelated and far removed from our world and our culture. That was Scandinavia and its people. Because of its foreignness it was totally alien and opposite to any one and any thing known to me. That was my escape, a dream world where nothing would remind me of daily life and all it had to throw at me. The people from this wonderful place look totally unlike any people in the 'real world'.Looking at these faces, I could not be reminded of anyone who might have humiliated, frightened or rebuked me. The bottom line is I was turning my back on real life and its ability to hurt, and escaping. (Unpublished autobiography)

The interest in other cultures and worlds can explain the development of a special interest in geography, astronomy and science fiction, such that the child discovers a place where his or her knowledge and abilities are recognized and valued.
Sometimes the degree of imaginative thought can lead to an interest in fiction, both as a reader and author. Some children, especially girls, with Asperger's syndrome can develop the ability to use imaginary friends, characters and worlds to write quite remarkable fiction. This could lead to success as an author of fiction for children or adults.
The escape into imagination can be a psychologically constructive adaptation, but there are risks of other people misinterpreting the child's intentions or state of mind. Hans Asperger wrote, with regard to one of the four children who became the basis of his thesis on autistic personality disorder, that:

He was said to be an inveterate 'liar'. He did not lie in order to get out of something that he had done - this was certainly not his problem, as he always told the truth very brazenly - but he told long, fantastic stories, his confabulations becoming ever more strange and incoherent. He liked to tell fantastic stories, in which he always appeared as the hero. He would tell his mother how he was praised by the teacher in front of the class, and other similar tales. (Asperger [1944] 1991, p.51)
Under conditions of extreme stress or loneliness the propensity to escape into an imaginary world and imaginary friends can lead to an internal fantasy becoming a 'reality' for the person with Asperger's syndrome. The person may be considered as developing delusions and being out of touch with reality (Adamo 2004). This could result in a referral for a diagnostic assessment for schizophrenia, as described in the biography of Ben by his mother, Barbara LaSalle (2003).

Denial and arrogance
An alternative to internalizing negative thoughts and feelings is to externalize the cause and solution to feeling different. The child can develop a form of over-compensation for feeling defective in social situations by denying that there is any problem, and by developing a sense of arrogance such that the 'fault' or problem is in other people and that the child is 'above the rules' that he or she finds so difficult to understand. The child or adult goes into what I describe as 'God mode', an omnipotent person who never makes a mistake, cannot be wrong and whose intelligence must be worshipped. Such children can deny that they have any difficulties making friends, or reading social situations or someone's thoughts and intentions. They consider they do not need any programs or to be treated differently from other children. They vehemently do not want to be referred to a psychologist or psychiatrist, and are convinced that they are not mad or stupid.
Nevertheless, the child does know, but will not publicly acknowledge, that he or she has limited social competence, and is desperate to conceal any difficulties in order not to appear stupid. A lack of ability in social play with peers and in interactions with adults can result in the development of behaviours to achieve dominance and control in a social
context; these include the use of intimidation, and an arrogant and inflexible attitude. Other children and parents are likely to capitulate to avoid yet another confrontation. The child can become 'intoxicated' by such power and dominance, which may lead to conduct problems.
When such children are confused as to the intentions of others or what to do in a social situation, or have made a conspicuous error, the resulting 'negative' emotion can lead to the misperception that the other person's actions were deliberately malicious. The response is to inflict equal discomfort, sometimes by physical retaliation: 'He hurt my feelings so I will hurt him.' Such children and some adults may ruminate for many years over past slights and injustices and seek resolution and revenge (Tantam 2000a).
The compensatory mechanism of arrogance can also affect other aspects of social interaction. The child may have difficulty admitting being wrong and be notorious for arguing. Hans Asperger advised that:

There is a great danger of getting involved in endless arguments with these children, be it in order to prove that they are wrong or to bring them towards some insight. This is especially true for parents, who frequently find themselves trapped in endless discussion. (Asperger [1944] 1991, p.48)

There can be a remarkably accurate recall of what was said or done to prove a point, and no concession, or acceptance of a compromise or a different perspective. Parents may consider that this characteristic could lead to a successful career as a defence lawyer in an adversarial court. Certainly the child has had a great deal of practice arguing his or her point.
Unfortunately, the arrogant attitude can further alienate the child from natural friendships, and denial and resistance to accepting programs to improve social understanding can increase the gap between the child's social abilities and that of his or her peers. We can understand why the child would develop these compensatory and adjustment strategies. Unfortunately, the long-term consequences of these compensatory mechanisms can have a significant effect on friendships and prospects for relationships and employment as an adult.

Imitation
An intelligent and constructive compensatory mechanism used by some children is to observe and absorb the persona of those who are socially successful. Such children initially remain on the periphery of social play, watching and noting what to do. They may then re-enact the activities that they have observed in their own solitary play, using dolls, figures or imaginary friends at home. They are rehearsing, practising the script and their role, to achieve fluency and confidence before attempting to be included in real social situations. Some children can be remarkably astute in their observation abilities, copying gestures, tone of voice and mannerisms. They are developing the ability to be a natural actor. For example, in her autobiography, Liane Holliday Willey describes her technique:

I could take part in the world as an observer. I was an avid observer. I was enthralled with the nuances of people's actions. In fact, I often found it desirable to become the other person. Not that I consciously set out to do that, rather it came as something I simply did. As if I had no choice in the matter. My mother tells me I was very good at capturing the essence and persona of people. (Willey 1999,p.22)

I was uncanny in my ability to copy accents, vocal inflections, facial expressions, hand movements, gaits, and tiny gestures. It was as if I became the person I was emulating. (Willey 1999, p.23)

Becoming an expert mimic can have other advantages. The child may become popular for imitating the voice and persona of a teacher or character from television. The adolescent with Asperger's syndrome may apply knowledge acquired in drama classes to everyday situations, determining who would be successful in this situation and adopting the persona of that person. The child or adult may remember the words and body postures of someone in a similar situation in real life or in a television programme or film. He or she then re-enacts the scene using 'borrowed' dialogue and body language. There is a veneer of social success but, on closer examination, the apparent social

competence is not spontaneous or original but artificial and contrived. However, practice and success may improve the person's acting abilities such that acting becomes a possible career option.
An adult with Asperger's syndrome who is a retired actor wrote to me and explained that, 'As an actor, I find the scripts in theatre far more real than everyday life. The role playing comes naturally to me.' The ability to act a role in daily life is explained by Donna Williams:

I found it impossible to talk to her in a normal voice. I began to put on a strong American accent, making up a history and identity for myself to go with it. As always, I actually convinced myself that I was this new character and consistently kept this up for six months. (Williams 1998, p.73)

There are several possible disadvantages. The first is observing and imitating popular but notorious models, for example the school 'bad guys'. This group may accept the adolescent with Asperger's syndrome, who wears the group's 'uniform', speaks their language and knows their gestures and moral code; but this in turn may alienate the adolescent from more appropriate models. The group will probably recognize that the person with Asperger's syndrome is a fake, desperate to be accepted, who is probably
not aware that he or she is being covertly ridiculed and 'set up'. Another disadvantage is that some psychologists and psychiatrists may consider that the person has signs of multiple personality disorder, and fail to recognize that this is a constructive adaptation to having Asperger's syndrome.
Some children with Asperger's syndrome dislike who they are and would like to be someone other than themselves, someone who would be socially able and have friends. A boy with Asperger's syndrome may notice how popular his sister is with her peers. He may also recognize that girls and women, especially his mother, are naturally socially intuitive; so to acquire social abilities, he starts to imitate girls. This can include dressing like a girl. There are several published case reports and, in my clinical experience, I have seen several males and females with Asperger's syndrome who have issues with gender identity (Gallucci, Hackerman and Schmidt 2005; Kraemer et al. 2005). This can also include girls with Asperger's syndrome who have self-loathing and want to become someone else. Sometimes such girls want to be male, especially when they cannot identify with the interests and ambitions of other girls, and the action activities of boys seem more interesting. However, changing gender will not automatically lead to a change in social acceptance and self-acceptance.
When adults with Asperger's syndrome have used imitation and acting to achieve superficial social competence, they can have considerable difficulty convincing people that they have a real problem with social understanding and empathy; they have become too plausible in their role to be believed.

binfeng2000

WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF HAVING A DIAGNOSIS?
The advantage to the child of having a diagnosis is not only in preventing or reducing the effects of some compensatory or adjustment strategies, but also to remove worries about other diagnoses, such as being insane. The child can be recognized as having genuine difficulties coping with experiences that others find easy and enjoyable. When an adult has problems with the non-verbal aspects of communication, especially eye contact, there can be <in assumption made by the general public that he or she has a mental illness or malicious intent. Once the characteristics of Asperger's syndrome are explained, such assumptions can be corrected.
Children with Asperger's syndrome have no physical characteristics to indicate that they are different, and having intellectual ability may lead others to have high expectations with regard to their social knowledge. Once the diagnosis is confirmed and understood, there can be a significant positive change in other people's expectations, acceptance and support. The child is now understood and more likely to be respected. There should be compliments rather than criticism with regard to social competence, and acknowledgement of the child's confusion and exhaustion from learning two curricula at school: the academic curriculum and the social curriculum.
The advantage of acknowledging and understanding the diagnosis for parents is that, at last, they have an explanation for their son's or daughter's unusual behaviours and abilities, and knowledge that the condition is not caused by faulty parenting. The family may then have access to knowledge on Asperger's syndrome from literature and the Internet, resources from government agencies and support groups, as well as access to programs to improve social inclusion and emotion management that will greatly benefit the whole family. There may also be greater acceptance of the child within the extended family and family friends. The parents can now provide an acceptable explanation to other people regarding the child's unusual behaviour. It is also important that parents explain to the child that having Asperger's syndrome is not an excuse to avoid chores and responsibilities.
Siblings may have known for some time that their brother or sister is unusual and may have been either compassionate, tolerant and concerned about any difficulties, or embarrassed, intolerant and antagonistic. Each sibling will make his or her own accommodations towards the sibling with Asperger's syndrome. Parents can now explain to their children why their brother or sister is unusual, and how the family has had to, and will need to, adjust and work cooperatively and constructively to implement the strategies. Parents and professionals can provide the siblings with age-appropriate explanations about their brother or sister, to give their friends, without jeopardizing their own social networks. Siblings will also need to know how to help their brother or sister at home when friends visit, and be made aware of their role and responsibilities at school and in the neighbourhood.

The advantages for school services, especially teachers, is that the child's unusual behaviour and profile of social, cognitive, linguistic and motor skills are recognized as a legitimate disorder that should provide access to resources to help the teacher. Confirmation of the diagnosis should also have a positive effect on the altitudes of other children in the classroom and other staff who have contact with the child. The teacher can access information from textbooks and resource programs specifically developed for teachers of children with Asperger's syndrome. The teacher can also explain to other children and staff who teach or supervise the child why he or she behaves and thinks in a different way.
The advantages of the diagnosis for the adolescent or adult with Asperger's syndrome can be in terms of support while a student at college or university or in employment. Acknowledgement of the diagnosis can lead to greater self-understanding, self-advocacy and better decision making with regard to careers, friendships and relationships (Shore 2004). An employer is then more likely to understand the profile of abilities and needs of an employee with Asperger's syndrome: for example, the problems that may arise if an employee with visual sensitivity is assigned a work cubicle lit with fluorescent lights.
An adult with a diagnosis of Asperger's syndrome may benefit from joining an adult support group that has local meetings, or an Internet support group or chat room. This can provide a sense of belonging to a distinct and valued culture and enable the person to consult members of the culture for advice. We also know that acceptance of the diagnosis can be an important stage in the development of successful adult relationships with a partner, and invaluable when seeking counselling and therapy from relationship counsellors (Aston 2003).
I have noted chat when an adult is diagnosed with Asperger's syndrome there can be a range of emotional reactions. Most adults report that having the diagnosis has been an extremely positive experience (Gresley 2000). There can be intense relief: 'I am not going mad'; euphoria at ending a nomadic wandering from specialist to specialist, at last discovering why they feel and think differently to others; and excitement as to how their lives may now change for the better. A young man with Asperger's syndrome sent me an e-mail which stated, T know I have Asperger's, because nothing else comes even close to describing my weirdness as flawlessly and perfectly as Asperger's syndrome does.'
There can also be moments of anger at the delay in being diagnosed and at 'The System' for not recognizing the signs for so many years. There can be feelings of despair regarding how their lives would have been much easier if the diagnosis had been confirmed decades ago. Other emotional reactions can be a sense of grief for all the suffering in trying to be as socially successful as others, and the years of feeling misunderstood, inadequate and rejected.
Nita Jackson provides sound advice for fellow people with Asperger's syndrome:

Because Asperger people can be exceptionally stubborn when they get the chance, denial can pose a big problem. The less they acknowledge their condition, the less they can improve upon their social skills, and consequently the higher the probability of them being friendless and/or victimized. Don't think that acknowledgement solves everything (it doesn't), but at least it brings a certain amount of self-awareness, which can be built upon. Once the person has this acknowledgement, learning the tricks of the trade - or the rules of the game, as some people refer to it-will be feasible, providing they are advised and directed by people who have at least a basic understanding of the syndrome. (N. Jackson 2002, p.28)

There can be a new sense of personal validation and optimism, at last not feeling stupid, defective or insane. As Liane Holliday Willey said exuberantly on learning of her diagnosis, 'That's why I'm different; I'm not a freak or mad' (Attwood and Willey 2000).There can be benefits in terms of self-esteem and moral support in identifying with other adults with Asperger's syndrome by using the Internet and support groups specifically for and organized by adults with Asperger's syndrome. The group meetings can initially be organized by a local parent support group or by disability support staff at a large university or college that has several students registered with Asperger's syndrome (Harpur, Lawlor and Fitzgerald 2004). Some support groups have formed spontaneously in large cities as occurred in Los Angeles when Jerry Newport, a man with Asperger's syndrome, formed and coordinated the support group AGUA (Adult Gathering, United and Autistic). There can be an affinity, empathy and support network with fellow members of the same 'tribe' or clan who share the same experiences, thinking and perception of the world.
When talking to adults with Asperger's syndrome about the diagnosis, I often refer to the self-affirmation pledge of those with Asperger's syndrome written by Liane Holliday Willey

.I am not defective. I am different.

.I will not sacrifice my self-worth for peer acceptance.

.I am a good and interesting person.

.I will take pride in myself.

.I am capable of getting along with society.

.I will ask for help when I need it.

.I am a person who is worthy of others' respect and acceptance.

.I will find a career interest that is well suited to my abilities and interests.

   .I will be patient with those who need time to understand me.

.I am never going to give up on myself.

.I will accept myself for who I am. (Willey 2001, p. 164)


I consider the last pledge, 'I will accept myself for who I am,' as a major goal when conducting psychotherapy with an adolescent or adult with Asperger's syndrome.
One reaction, although rare, is for some people to deny that they have Asperger's syndrome, insisting there is nothing wrong with or different about them. Despite acknowledging that the clinical descriptions match their developmental history and profile of abilities, they may question the validity of the syndrome and reject any programs or services. However, this may only be an initial reaction and, given time to reflect, they may eventually accept that their personality and profile of abilities includes the characteristics of Asperger's syndrome, and that this is invaluable information when making major decisions in aspects of life such as employment and relationships.
There could be disadvantages in having a diagnosis in terms of how the person and others perceive the characteristics. If the diagnostic news is broadcast widely, there will inevitably be some children or adults who misuse this disclosure to torment and despise the person with Asperger's syndrome. Care must be taken when using the diagnostic term Asperger's syndrome as some children may consider the condition is infectious (or tease the child that it is), or corrupt the term in a variety of ways - Asparagus syndrome, Sparrow syndrome, Hamburger syndrome or Arseburger syndrome, among others. Children can be quite inventive in stigmatizing differences, but more compassionate people may be able to repair some of the damage to the self-esteem of someone with Asperger's syndrome who has been ridiculed for being different.
One of the concerns of adults with Asperger's syndrome is whether they should include reference to the diagnosis on a job application. If there is considerable competition for a particular vacancy, an applicant having a diagnosis that is unknown to the employer might lead to the application being rejected. A potential solution is for the adult to write a brief, perhaps one-page, description of Asperger's syndrome and the qualities and difficulties that would be relevant to the job. This personalized brochure could also be used to explain Asperger's syndrome to colleagues, juniors and line managers. A shorter version can be reduced to a business card that can be given to anyone who needs to know about the person's diagnosis.
Having a diagnosis of Asperger's syndrome could limit the expectations of others, who may assume that the person will never be able to achieve as well as his or her peers with regard to social, academic and personal success. The diagnosis should facilitate realistic expectations but not dictate the upper limits of ability. I have known adults with Asperger's syndrome whose successful careers have ranged from professor of mathemat- ics to social worker; and those whose ability in the area of relationships ranges from enjoying a fulfilling but celibate life, to having a life-long partner and being a much-loved parent.
As a society, we need to recognize the value of having people with Asperger's syndrome in our multi-cultural and diverse community. In summary, maybe we should consider the comment from an adult with Asperger's syndrome who suggested to me that perhaps Asperger's syndrome is the next stage of human evolution.



KEY POINTS AND STRATEGIES

.Children with Asperger's syndrome have the following characteristics:
。delayed social maturity and social reasoning
。immature empathy
。difficulty making friends and often teased by other children
。 difficulty with the communication and control of emotions
。unusual language abilities that include advanced vocabulary and syntax
but delayed conversation skills, unusual prosody and a tendency to be pedantic
。a fascination with a topic that is unusual in intensity or focus
。 difficulty maintaining attention in class
。 an unusual profile of learning abilities
。 a need for assistance with some self-help and organizational skills
。 clumsiness in terms of gait and coordination
。 sensitivity to specific sounds, aromas, textures or touch.

.There are several pathways to a diagnosis:
。Diagnosis of autism in early childhood and progression by the middle
school years to High Functioning Autism or Asperger's syndrome.
。 A teacher's recognition of Asperger's syndrome when the child starts
primary school.
。 Previous diagnosis of another developmental disorder such as Attention
Deficit Hyperactivity Disorder, a language or movement delay or disorder, a mood disorder, eating disorder or Non-verbal Learning Disability.
。The signs of Asperger's syndrome only becoming conspicuous during adolescence, when the social and academic expectations become more complex.
。The development of behaviour problems and conflict with parents, teachers and school authorities.
。 The identification of signs of Asperger's syndrome in a relative, where a review of the child's family history identifies other family members
who have similar characteristics.
。 Descriptions of Asperger's syndrome in the media and literature may
lead someone to seek a diagnosis for him- or herself or a family
member.
。 Employment problems, especially achieving and keeping a job appropriate to the person's qualifications and abilities.


. There are four compensatory or adjustment strategies when the child
realizes he or she is different to other children:
。self-blame and depression
。escape into imagination
。 denial and arrogance
。imitation of other children and characters.

. The advantages of a diagnosis can be:
。Preventing or reducing the effects of some of the compensatory or
adjustment strategies.
。Removing worries about other diagnoses and being insane.
。Being recognized as having genuine difficulties coping with  experiences that others find easy and enjoyable.
。A positive change in other people's expectations, acceptance and
support.
。Compliments rather than criticism with regard to social competence.
。Acknowledgement of confusion and exhaustion in social situations.
。Schools can access resources to help the child and class teacher.
。An adult can access specialized support services for employment and
further education.
。Greater self-understanding, self-advocacy and better decision making
with regard to careers, friendships and relationships.
。A sense of identification with a valued 'culture'.
。The person no longer feels stupid, defective or insane.

. The disadvantages of a diagnosis can be;
。Some children or adults could torment and despise the person for
having a disorder diagnosed by a psychologist or psychiatrist.
。The diagnosis could limit the expectations of others who erroneously
assume the person with Asperger's syndrome will never be able to
achieve as well as his or her peers with regard to social, academic and personal success.

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CHAPTER 2

The Diagnosis

One can spot such children instantly. They are recognizable from small details, for instance, the way they enter the consulting room at their first visit, their behaviour in the first few moments and the first words they utter.
-Hans Asperger ([1944] 1991)

At the same time as Hans Asperger described autistic personality disorder in the 1940s, another Austrian physician, Leo Kanner, then living in Baltimore in the United States, described another part of what we now call the autism spectrum. Leo Kanner, who was apparently unaware ofAsperger's studies, described an expression of autism that is characterized as having very severe impairments in language, socialization and cognition: the silent, aloof child with intellectual disability (Kanner 1943). It was this expression of autism, originally considered a form of childhood psychosis, that dominated the subsequent research and therapy literature in the English-speaking countries for the next 40 years. As far as I am aware, Hans Asperger and Leo Kanner never exchanged correspondence regarding the children they were describing, although both used the term autism.
It was not until after Asperger's death in 1980 that we first used the term Asperger's syndrome. Lorna Wing, a renowned British psychiatrist specializing in autism spectrum disorders, became increasingly aware that the descriptions of Leo Kanner that formed the basis of our understanding and diagnosis of autism in America and Britain did not accurately describe some of the children and adults within her considerable clinical and research experience. In her paper, published in 1981, she described 34 cases of children and adults with autism, ranging in age from 5 to 3 5 years, whose profile of abilities had a greater resemblance to the descriptions of Asperger than Kanner, and did not easily match the diagnostic criteria for autism that were being used by academics and clinicians at the time. Lorna Wing first used the term Asperger's syndrome to provide a new diagnostic category within the autism spectrum (Wing 1981).

Her case examples and conclusions were very convincing, and a group of British and Swedish psychologists and psychiatrists began a closer study of the descriptions of Hans Asperger and the profile of abilities of Asperger's syndrome. Although the original descriptions of Asperger were extremely detailed, he did not provide clear diagnostic criteria. In London, in 1988, a small international conference was held on Asperger's syndrome, with speakers who had begun exploring this newly discovered area of the autism spectrum. One of the results of the discussions and papers was the publication of the first diagnostic criteria in 1989, revised in 1991 (Gillberg 1991; Gillberg and Gillberg 1989). Despite subsequent criteria being published in the two principal diagnostic manuals, and by child psychiatrist Peter Szatmari and colleagues from Canada (Szatmari, Bremner and Nagy 1989b), the criteria of Christopher Gillberg, who is based in Sweden and London, remain those that most closely resemble the original descriptions of Asperger. Thus, these are the criteria of first choice for me and many experienced clinicians. The criteria of Christopher Gillberg are provided in Table 2.1. In clinical practice, a diagnosis of Asperger's syndrome is made if the social impairment criterion is met along with at least four of the five other criteria (Gillberg 2002).
In 1993, the World Health Organization (WHO) published the tenth edition of the International Classification  of Diseases (ICD-10), and in 1994, the American Psychiatric Association published the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-1V). For the first time, both diagnostic textbooks included Asperger's syndrome, or to be more precise Asperger's disorder, as one of several Pervasive
Developmental Disorders (American Psychiatric Association 1994; World Health Organization 1993). Both criteria are remarkably similar. There was a recognition in both diagnostic manuals that autism, or Pervasive Developmental Disorder, is a heterogeneous disorder and that there appear to be several subtypes, one of which is Asperger's syndrome.
When a new syndrome is confirmed, there is a search of the international clinical literature to determine whether another author has described the same profile of abilities. We now know that it was probably a Russian neurology scientific assistant, Dr Ewa Ssucharewa, who first published a description of children that we would describe today as having Asperger's syndrome (Ssucharewa 1926; Ssucharewa and Wolff 1996). Ssucharewa's description became known as Schizoid Personality Disorder (SPD). Sula
Wolff (1995, 1998) has reviewed our knowledge of Schizoid Personality Disorder and suggested that SPD closely resembles the characteristics of Asperger's syndrome. I am relieved that we currently use the term Asperger's syndrome because it is easier for English-speaking people to pronounce (the 'g' is pronounced as in 'get') and spell than Ssucharewa's syndrome.
Hans Asperger died in 19 80 and was unable to comment on the interpretation of his seminal study by English-speaking psychologists and psychiatrists. It was only relatively recently, in 1991, that his original paper on autistic personality disorder was finally translated into English by Uta Frith (Asperger [1944] 1991). However, we now have

Table 2.1 The Gillberg diagnostic criteria
for Asperger's syndrome (Gillberg 1991)

1. Social impairment (extreme egocentricity)(at least two of the following):

.  difficulties interacting with peers

. indifference to peer contacts

.  difficulties interpreting social cues

. socially and emotionally inappropriate behaviour.

2. Narrow interest (at least one of the following):

.  exclusion of other activities

. repetitive adherence

. more rote than meaning.

3. Compulsive need for introducing routines and interests (at least one of the following):

. which affect the individual's every aspect of everyday life

. which affect others.

4. Speech and language peculiarities (at least three of the following):

.delayed speech development

. superficially perfect expressive language

.formal pedantic language

. odd prosody, peculiar voice characteristics

. impairment of comprehension including misinterpretations of literal/implied meanings.

5. Non-verbal communication problems (at least one of the following):

. limited use of gestures

.clumsy/gauche body language

. limited facial expression

. inappropriate facial expression

. peculiar, stiff gaze.

6. Motor clumsiness:

.poor performance in neurodevelopmental test.



over 2000 studies that have been published on Asperger's syndrome, and over 100 books. Since the mid-1990s, clinicians throughout the world have reported an increasing referral rate for a diagnostic assessment of Asperger's syndrome.

QUESTIONNAIRES AND SCALES FOR ASPERGER'S SYNDROME
When a school, therapist, relative, organization or the person him- or herself has identified abilities that could indicate a diagnosis of Asperger's syndrome, the next stage is usually the completion of a questionnaire or rating scale to substantiate a referral to a specialist in Asperger's syndrome. Completing the questionnaire can identify other abilities and behaviour that could be indicative of Asperger's syndrome and confirm whether the person completing the questionnaire is 'on the right track'. We currently have eight screening questionnaires that can be used with children, and six that can be used with adults. There has been a recent review of assessment scales and questionnaires for Asperger's syndrome that concluded that there are problems with validity, reliability, specificity and sensitivity with all the instruments (Howlin 2000). There is, as yet, no questionnaire or scale of first choice. The following are the questionnaires and scales for children, in alphabetical order rather than merit:

. ASAS or Australian Scale for Asperger's Syndrome (Garnett and Attwood
1998)
. ASDI or Asperger Syndrome Diagnostic Interview (Gillberg et al. 2001)
. ASDS or Asperger Syndrome Diagnostic Scale (Myles, Bock and Simpson
2001)
. ASSQ_pr Autism Spectrum Screening Questionnaire (Ehlers, Gillberg and Wing 1999)
. CAST or Childhood Asperger Syndrome Test (Scott et al. 2002; Williams et al. 2005)
. GADS or Gilliam Asperger Disorder Scale (Gilliam 2002)
. KADI or Krug Asperger's Disorder Index (Krug and Arick 2002).

A recent review of the ASDS, ASSQ, CAST, GADS and KADI suggests that these five published rating scales all had significant psychometric weaknesses, particularly in the use of normative samples, but the KADI showed the strongest psychometric properties while the ASDS had the weakest (Campbell 2005).
The following are questionnaires designed for adults who may have Asperger's syndrome. Most of the current assessment instruments have been developed by Simon Baron-Cohen and Sally Wheelwright and have been published in the appendix of the book The Essential Difference: Men, Women and the Extreme Male Brain by Simon Baron-Cohen (2003):

.ASQ_or Autism Spectrum Quotient (Baron-Cohen etdl. 2001b; Woodbury
Smith et al. 2005)

.EQ_or Empathy Quotient (Baron-Cohen and Wheelwright 2004)

.The Reading the Mind in the Eyes Test (Baron-Cohen et al. 2001a)

.The Reading the Mind in the Voice Test (Rutherford, Baron-Cohen and
Wheelwright 2002)

.FQ_or Friendship Questionnaire (Baron-Cohen and Wheelwright 2003)

.ASDASQ_or Autism Spectrum Disorders in Adults Screening Questionnaire (Nylander and Gillberg 2001).

Michelle Garnett and I are currently revising the original Australian Scale for Asperger's Syndrome for children and adolescents between the ages of 5 and 18 years. The results of the evaluation of the ASAS-R should be published in 2007.

THE DIAGNOSTIC ASSESSMENT
Screening instruments are usually designed to be over-inclusive so that any potential cases of Asperger's syndrome are identified, but they cannot be a substitute for a thorough diagnostic assessment, which provides an objective validation of the profile of behaviour and abilities identified by the screening instruments. An experienced clinician needs to conduct an assessment of the domains of social reasoning, the communication of emotions, language and cognitive abilities, interests, and movement and coordination skills, as well as examine aspects of sensory perception and self-care skills. Invaluable information can be obtained from reading and highlighting previous reports and assessments that identify characteristics associated with Asperger's syndrome, which can then be examined and confirmed during the diagnostic assessment. The diagnostic assessment will also include a review of the person's medical, developmental and family history (Klin et al. 2000). The family history should include questions about any family members who may have a similar profile of abilities, but not necessarily a diagnosis of Asperger's syndrome.
There are two diagnostic tests that have been designed for children with autism: the Autism Diagnostic Interview - Revised or ADI-R (Lord, Rutter and Le Couteur 1994) and the Autism Diagnostic Observation Schedule - Generic or ADOS-G (Lord et al.2000). The ADI-R uses a semi-structured interview with information provided by a parent or caregiver and provides a dimensional measure of the severity of the signs of autism. The ADOS-G is a protocol for the observation of the social and communication abilities associated with autism, with a rating of the quality of behaviours and abilities. However, these diagnostic assessment instruments were primarily designed for the diagnosis of autism, not Asperger's syndrome, and are not sensitive to the more subtle characteristics of Asperger's syndrome (Gillberg 2002; Klin et al. 2000).

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The diagnostic assessment for Asperger's syndrome requires a protocol (often developed by individual clinicians) that uses a 'script' or sequence of activities and tests that determine whether the pattern of abilities in a particular domain are typical for a child of that age, or adult, or indicative of developmental delay or deviance. The clinician may refer to a checklist: this can include the characteristics of Asperger's syndrome that are included in the diagnostic criteria, and characteristics identified in the research literature or through extensive personal clinical experience as being typical of children or adults with Asperger's syndrome.

Some children and adults are relatively easy to diagnose. A clinician may suspect a positive diagnosis within a matter of minutes, but the full diagnostic assessment will need to be conducted to confirm the initial clinical impression. Some girls and women with Asperger's syndrome, and adults of considerable intellectual ability, can be more difficult to diagnose due to an ability to camouflage their difficulties. The full diagnostic assessment can take an hour or more depending on the number and depth of the assessments of specific abilities. More experienced clinicians can significantly shorten the duration of the diagnostic assessment. Subsequent chapters will include some of the diagnostic assessment procedures that I use to examine specific abilities and behaviour.

The diagnostic assessment should not only examine areas of difficulties, but also areas of ability that may be attributable to the characteristics of Asperger's syndrome. For example, the child may have achieved prizes and certificates for his or her knowledge regarding a special interest, or demonstrated academic skills by winning a mathematics or art competition. The person may draw with photographic realism or invent computer games. Parents can be asked for the endearing personality qualities of their son or daughter, for example being kind, having a strong sense of social justice, and caring for animals.

The Diagnostic Interview for Social and Communication Disorders (DISCO) is a guide for clinicians to enable them to collect, systematically, detailed information on developmental history and current state needed to diagnose autistic spectrum disorders and related developmental disorders in children and adults of all ages (Wing et al. 2002). It is available only to those who have been trained in its use.

THE CURRENT DIAGNOSTIC CRITERIA
Clinicians would usually expect to use the DSM-IV criteria of the American Psychiatric Association when conducting a diagnostic assessment for developmental disorders such as Asperger's syndrome. The criteria for Asperger's syndrome or Asperger's disorder in DSM-IV, which were revised for the edition published in 2000, are provided in Table 2.2.
The text in DSM-IV, intended to supplement the criteria, provides only cursory guidelines for the diagnostic process and a superficial description of the disorder. Just reading the DSM-IV criteria as the only source of information from which to make a diagnosis, a clinician would have insufficient knowledge about Asperger's syndrome to

Table 2.2 Diagnostic criteria for Asperger's disorder according to DSM-IV (TR) (American Psychiatric Association 2000)
                                                                     
A. Qualitative impairment in social interaction, as manifested by at least two of the following:
1. marked impairment in the use of multiple non-verbal behaviours such as eye-to-eye gaze, facial expression, body postures, 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.

B. Restricted repetitive and 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, non-functional routines or rituals

3. stereotyped and repetitive motor mannerisms (e.g. hand or ringer flapping or twisting, or complex whole-body movements)

4. persistent preoccupation with parts of objects.

C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.

D. There is no clinically significant general delay in language (e.g. single words used by age two years, communicative phrases used by age three years).

E. 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.

F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.
                                                                     

make a reliable diagnosis. Training, supervision and extensive clinical experience in the nature of Asperger's syndrome are essential before a clinician and client can be confident of the diagnosis.

Problems associated with the current DSM-IV diagnostic criteria
The original inclusion of Asperger's disorder within the DSM-IV was welcomed by clinicians as a wise decision, as was the decision to move the Pervasive Developmental Disorders, including autism and Asperger's syndrome, from Axis II (an axis for long-term, stable disorders with a relatively poor prognosis for improvement) to Axis I (which implies that the signs can improve with early intervention and treatment).

However, there are problems with the diagnostic criteria in DSM-IV, and especially the differential criteria in the manual that distinguish between a diagnosis of autism or Asperger's syndrome.

Language delay
The current criteria in DSM-IV have been criticized by speech/language pathologists with regard to the statement that for children and adults to achieve a diagnosis of Asperger's syndrome, 'There is no clinically significant general delay in language (e.g. single words used by age two years, communicative phrases used by age three years).' In other words, if there have been signs of early language delay, then the diagnosis should not be Asperger's syndrome, but autism, even if all the other criteria, developmental history (apart from language acquisition) and the current profile of abilities are met for Asperger's syndrome. Diane Twachtman-Cullen (1998), a speech/language pathologist with considerable experience of autism spectrum disorders, has criticized this exclusion criterion on the grounds that the term clinically significant is neither scientific nor precise and left to the judgement of clinicians without an operational definition. A further criticism is that research on the stages of early language acquisition has established that single words emerge around the child's first birthday, communicative phrases at about 18 months of age and short sentences around two years. In fact, the DSM-IV criteria describe a child who actually has a significant language delay.
Does the development of early language skills actually differentiate between adolescents with autism and an IQ_within the normal range (i.e. High Functioning Autism) and Asperger's syndrome? Research has now been conducted on whether delayed language in children with autism can accurately predict later clinical symptoms. Four studies have cast considerable doubt over the use of early language delay as a differential criterion between High Functioning Autism and Asperger's syndrome (Eisenmajer et al. 1998; Howlin 2003; Manjiviona and Prior 1999; Mayes and Calhoun 2001). Any differences in language ability that are apparent in the pre-school years between children with autism and an IQ within the normal range, and those with Asperger's syndrome, have largely disappeared by early adolescence.
Delayed development of language is actually one of the Gillberg and Gillberg diagnostic criteria for Asperger's syndrome (Gillberg 1991; Gillberg and Gillberg 1989). Young children with typical autism who subsequently develop fluent language eventually have a profile of abilities that resembles the profile of children with Asperger's syndrome who did not have early language delay. In my opinion, and that of many clini-
cians, early language delay is not an exclusion criterion for Asperger's syndrome and may actually be an inclusion criterion, as in the Gillberg criteria. The focus during the diagnostic assessment should be on current language use (the pragmatic aspects of language) rather than the history of language development.

Self-help skills and adaptive behaviour
The DSM-IV criteria refer to children with Asperger's syndrome as having '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'. Clinical experience and research indicate that parents, especially mothers, of children and adolescents with Asperger's syndrome often have to provide verbal reminders and advice regarding self-help and daily living skills. This can range from help with problems with dexterity affecting activities such as using cutlery, to reminders regarding personal hygiene and dress sense, and encouragement with planning and time-management skills. When parents complete a standardized assessment of self-care skills and adaptive functioning, such abilities in children with Asperger's syndrome are below the level expected for their age and intellectual ability (Smyrnios 2002). Clinicians have also recognized significant problems with adaptive behaviour, especially with regard to anger management, anxiety and depression (Attwood 2003 a).

The inclusion of other important or transitory characteristics
The diagnostic criteria of the DSM-IV do not include a description of the unusual characteristics in the pragmatic aspects of language originally described by Asperger and portrayed in the clinical literature, namely the pedantic use of language and unusual prosody. The DSM-IV criteria also fail to make adequate reference to problems with sensory perception and integration, especially auditory sensitivity and hypersensitivity to light intensity, tactile experiences and aromas. These aspects of Asperger's syndrome can have a profound effect on the person's quality of life. The criteria also exclude reference to motor clumsiness, which was described by Asperger and has been substantiated in the research literature (Green et al. 2002).
The diagnostic criteria in the DSM-IV can also be criticized for emphasizing characteristics that can be rare or transitory. The criteria refer to 'stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements)', yet clinical experience indicates that many children with Asperger's syndrome never display such characteristics and, for those who do, research indicates that these characteristics have disappeared by the age of nine years (Church, Alisanski and Amanullah 2000).

A hierarchical approach
The DSM-IV guidelines are that if the criteria for autism are confirmed in a diagnostic assessment, then despite the child's cognitive, social, linguistic, motor and sensory abilities and interests being consistent with the descriptions of a child with Asperger's syndrome, a diagnosis of autism should take precedence over a diagnosis of Asperger's syndrome.

The issue of precedence has been examined by several research studies (Dickerson Mayes, Calhoun and Crites 2001; Eisenmajer et al. 1996; Ghaziuddin, Tsai and Ghaziuddin 1992; Manjiviona and Prior 1995; Miller and Ozonoff 1997; Szatmari et al. 1995). The general conclusion of these studies is that a diagnosis of Asperger's syndrome is almost impossible using current DSM-IV criteria.
Many clinicians, including myself, have rejected the hierarchical rule. The general consensus among clinicians at present is that if the current profile of abilities of the child is consistent with the descriptions of Asperger's syndrome, then the diagnosis of Asperger's syndrome takes precedence over a diagnosis of autism. Thus, contrary to the DSM-IV, if a child meets criteria for both autism and Asperger's syndrome, the child is usually given a diagnosis of Asperger's syndrome by clinicians (Mahoney et al. 1998). It is important to recognize that the diagnostic criteria are still a work in progress.

ASPERGER'S SYNDROME OR HIGH FUNCTIONING AUTISM?
DeMyer, Hingtgen and Jackson first used the term High Functioning Autism in 1981, the same year in which the term Asperger's syndrome was first used by Lorna Wing (1981). The term High Functioning Autism (HFA) has been used in the past to describe children who had the classic signs of autism in early childhood but who, as they developed, were shown in formal testing of cognitive skills to have a greater degree of intellectual ability, with greater social and adaptive behaviour skills and communication skills, than is usual with children with autism (DeMyer et al. 1981). The child's clinical outcome was much better than expected. However, we currently have no explicit diagnostic guidelines for the diagnosis of HFA.
The cognitive abilities of this group of children have been compared to the cognitive profile of children with Asperger's syndrome, who did not have a history of early cognitive or language delay. The results of the research have not established a distinct and consistent profile for each group. Ehlers et al. (1997) found that only a minority of each diagnostic group showed a characteristic cognitive profile. One group of researchers, based at Yale University in the United States, has suggested that the neuropsychological profiles of children with Asperger's syndrome and High Functioning Autism are different (Klin et al. 1995). However, other research examining diagnostic differentiation using neuropsychological testing has not identified a distinct profile that discriminates between the two groups (Manjiviona and Prior 1999; Miller and Ozonoff 2000; Ozonoff, South and Miller 2000). A recent study of the past and present behavioural profiles of children with High Functioning Autism and Asperger's syndrome using the Autism Behaviour Checklist concluded that the two groups were indistinguishable in their current behavioural profiles (Dissanayake 2004).
A diagnosis of Asperger's syndrome is usually given if the person has an Intelligence Quotient within the average range. However, children and adults with the clinical features of Asperger's syndrome often have a profile of abilities on a standardized test of intelligence that is remarkably uneven. Some scores may be within the normal range or even superior range, but other scores, within the same profile, may be in the mildly retarded range. Asperger originally included children with some level of intellectual impairment within his description of autistic personality disorder, although mental retardation, according to the DSM-IV, would exclude a diagnosis of Asperger's syndrome. I would view an overall IQ_score with some caution and may include those cases with a borderline intellectual impairment when some cognitive skills are within the normal range.
A recent review of the research literature comparing the abilities of children with Asperger's syndrome with those with High Functioning Autism concluded that the number of studies that found a difference in cognitive, social, motor or neuropsychological tasks probably equal those indicating no difference (Howlin 2000). Clinicians in Europe and Australia are taking a dimensional or spectrum view of autism and Asperger's syndrome rather than a categorical approach (Leekham et al. 2000). At present, both terms (Asperger's syndrome and High Functioning Autism) can be used interchangeably in clinical practice. To date, there is no convincing argument or data that unequivocally confirm that High Functioning Autism and Asperger's syndrome are two separate and distinct disorders. As a clinician, I do not think that academics should try to force a dichotomy when the profiles of social and behavioural abilities are so similar and the treatment is the same.
Unfortunately, a dilemma for the clinician is whether a particular diagnosis – autism or Asperger's syndrome - enables the child or adult to have access to the government services and benefits that he or she needs. In some countries, states or provinces, a child may only have support in the classroom, or the parents automatically receive government allowances or medical insurance coverage, if the child has a diagnosis of autism, such services not being available if the child has a diagnosis of Asperger's syndrome. Some clinicians may write reports with a diagnosis of autism or High Functioning Autism rather than the more accurate diagnosis of Asperger's syndrome so that the child has access to resources and the parents do not have to resort to litigation.

HOW PREVALENT IS ASPERGER'S SYNDROME?
The prevalence rates for Asperger's syndrome vary according to the choice of diagnostic criteria. The DSM-IV criteria of the American Psychiatric Association, which are almost identical to the criteria in the International Classification of Diseases, or ICD-10, are the most restrictive criteria, and have been the subject of considerable criticism as a result of research studies, and deemed by clinicians as unworkable in clinical practice. The prevalence of Asperger's syndrome using DSM-IV or ICD criteria varies in each study with reported rates of between 0.3 per 10,000 children to 8.4 per 10,000 children (Baird et al. 2000; Chakrabarti and Fombonne 2001; Sponheim and Skjeldal 1998; Taylor et al.

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1999). The expected prevalence rate for Asperger's syndrome, therefore, according to these criteria, would vary between 1 in 33,000 and 1 in 1200 children.
The diagnostic criteria of choice by many clinicians, especially in Europe and Australia, are those of Gillberg and Gillberg (1989) which represent more accurately the original descriptions of Asperger and the profile of abilities of children referred for a diagnostic assessment for Asperger's syndrome. According to the Gillberg criteria, the prevalence rate is between 36 and 48 per 10,000 children, or between 1 in 280 or 210 children (Ehlers and Gillberg 1993; Kadesjo, Gillberg and Hagberg 1999).
There is a difference between the scientific terms of prevalence and incidence. Prevalence figures indicate how many individuals have the condition at a specific point in time, while incidence is the number of new cases occuring in a specified time period, such as one year. Using the Gillberg criteria, it is my clinical opinion that we are currently detecting and diagnosing about 50 per cent of children who have Asperger's syndrome. Those who are not referred for a diagnostic assessment for Asperger's syndrome are able to camouflage their difficulties and avoid detection, or a clinician fails to see Asperger's syndrome and focuses on another diagnosis.

THE DIAGNOSTIC ASSESSMENT OF GIRLS
The majority of children referred for a diagnostic assessment for Asperger's syndrome are boys. Since 1992, I have conducted a regular diagnostic assessment clinic for children and adults with Asperger's syndrome in Brisbane, Australia. A recent analysis of over 1000 diagnostic assessments over 12 years established a ratio of males to females of four to one. From my clinical experience, I have noted that girls with Asperger's syndrome may be more difficult to recognize and diagnose due to coping and camouflaging mechanisms, which can also be used by some boys. One of the coping mechanisms is to learn how to act in a social setting, as described by Liane Holliday Willey in her autobiography, Pretending to be Normal (Willey 1999). The clinician perceives someone who appears able to develop a reciprocal conversation and use appropriate affect and gestures during the interaction. However, further investigation and observation at school may determine that the child adopts a social role and script, basing her persona on the characteristics of someone who would be reasonably socially skilled in the situation, and using intellectual abilities rather than intuition to determine what to say or do. An example of a camouflaging strategy is to conceal confusion when playing with peers by politely declining invitations to join in until sure of what to do, so as not to make a conspicuous social error. The strategy is to wait, observe carefully, and only participate when sure what to do by imitating what the children have done previously. If the rules or nature of the game suddenly change, the child is lost.
Girls with Asperger's syndrome can develop the ability to 'disappear' in a large group, being on the periphery of social interaction. One woman with Asperger's syndrome said, when recalling her childhood, that she felt as though she was 'on the outside looking in'. There can be other strategies to avoid active participation in class proceedings, such as being well behaved and polite, thus being left alone by teachers and peers; or tactics to passively avoid cooperation and social inclusion at school and at home, as described in a condition known as Pathological Demand Avoidance (Newsom 1983).
A girl with Asperger's syndrome is less likely to be fickle' or 'bitchy' in friendships in comparison to other girls, and is more likely than boys to develop a close friendship with someone who demonstrates a maternal attachment to this socially naive but 'safe' girl. These characteristics reduce the likelihood of being identified as having one of the main diagnostic criteria for Asperger's syndrome, namely a failure to develop peer relationships. With girls, it is not a failure but a qualitative difference in this ability. The girl's problems with social understanding may only become conspicuous when her friend and mentor moves to another school.
The language and cognitive profile of girls with Asperger's syndrome may be the same as those of boys, but the special interests may not be as idiosyncratic or eccentric as can occur with some boys. Adults may consider there is nothing unusual about a girl who has an interest in horses, but the problem may be the intensity and dominance of the interest in her daily life: the young girl may have moved her mattress into the stable so that she can sleep next to the horse. If her interest is dolls, she may have over 50 Barbie dolls arranged in alphabetical order, but she would rarely include other girls in her doll play.
While in conversation with a boy with Asperger's syndrome, the listener is likely to consider the child a 'little professor' who uses an advanced vocabulary for a child of that age, and is able to provide many interesting (or boring) facts. Girls with Asperger's syndrome can sound like 'little philosophers', with an ability to think deeply about social situations. From an early age, girls with Asperger's syndrome have applied their cognitive skills to analyse social interactions and are more likely than boys with Asperger's syndrome to discuss the inconsistencies in social conventions and their thoughts on social events.
The motor coordination problems of girls may not be so conspicuous in the playground, and they are less likely to have developed the conduct problems that can prompt a referral for a diagnostic assessment for a boy. Thus, where a girl has developed the ability to conceal her signs of Asperger's syndrome in the playground and classroom, and even in the diagnostic assessment, then parents, teachers and clinicians may fail to see any conspicuous characteristics of Asperger's syndrome.
At my clinic I see people with Asperger's syndrome of all ages, and although the sample of adults with Asperger's syndrome is small in comparison to the number of children, I have noticed that the ratio of men to women with Asperger's syndrome is almost two to one. Many of the women who seek a diagnostic assessment have previously not had the self-confidence or a reason to seek a diagnostic assessment. With increasing maturity, they are prepared to seek help, especially when there have been long-term and unresolved problems with emotions, employment and relationships. Another 'pathway' is that of a woman having a child with Asperger's syndrome and recognizing that she had similar characteristics as a child. We need to explore more of what Ruth Baker, a woman with Asperger's syndrome, describes as 'the invisible end of the spectrum' (personal communication).

THE DIAGNOSTIC ASSESSMENT OF ADULTS
The diagnostic assessment of adults will present the clinician with several problems. It may be many years since the adult was a child, and recollections of childhood by the adult and any relatives interviewed during the diagnostic assessment may be affected by the accuracy of long-term memory. An aid to memory and discussion may be the perusal of photographs of the adult as a child. Family photographs are usually taken during a social occasion, and this can provide an opportunity to notice if the child appears to be participating in the social interaction. Conversation during the diagnostic assessment can be about the event in the photograph and the person's competence and confidence in the situation. School reports can be useful in indicating any problems with both peer relationships, and learning abilities and behaviour at school.
We now have questionnaires to identify the ability and personality characteristics of adults with Asperger's syndrome, and the analysis of the responses and scores on these questionnaires can be extremely useful for the clinician. I have found that it can be an advantage to have the person's questionnaire responses validated by a family member such as the person's mother or partner. The adult referred for a diagnostic assessment may provide a response based on personal perception of his or her social abilities, while someone who knows him or her well and does not have Asperger's syndrome may have a different opinion. For example, a man was asked about his friends when he was a child and whether other children would come to his home. He replied that children did come to his house, which would suggest some degree of popularity and friendship. His mother affirmed that other children would visit, but not to play with her son, rather to play with his toys. He preferred to play with his Lego on his own in the bedroom.
It is possible that the adult or adolescent will deliberately mislead the clinician for reasons of maintaining self-esteem or to avoid a diagnosis that may be perceived as a mental illness. For example, Ben described how:
I was always ashamed of who I was, so I never told the truth about anything that would embarrass me. If you had asked me if I have trouble understanding others, I would have said no, even though the true answer was yes. If you had asked me if I avoided social contact, I would have said no, because I wouldn't want you to think I was weird. If you had asked me if I lacked empathy, I would have been insulted, because everyone knows good people have empathy and bad people don't. I would have denied that I'm afraid of loud noises, that I have a narrow range of interests, and that I get upset by changes in routine. The only questions I would have answered yes to would have been the ones about having unusually long-term
memory for events and facts; reading books for information; and being like a walking encyclopaedia. That's because I liked those things about me. I thought they made me look smart. If I thought it was good, I would have said yes, and if I thought it was bad, I would have said no. (LaSalle 2003, pp.242-3)

During the diagnostic assessment the adult client may provide responses that appear to indicate empathy and ability with social reasoning, but on a more careful examination it may be clear that these responses, given after a fractional delay, were achieved by intellectual analysis rather than intuition. The cognitive processing required gives the impression of a thoughtful rather than spontaneous response.
Some adults with clear signs ofAsperger's syndrome may consider that their abilities are quite normal, using the characteristics of a parent as the model of normal interaction skills. If the person had a dominant parent with the characteristics of Asperger's syndrome, this may have influenced the person's perception of normality.

The Adult Asperger Assessment (AAA)
We now have an assessment instrument and diagnostic criteria specifically for adults (Baron-Cohen et al. 2005). The Adult Asperger Assessment, or AAA, uses two screening instruments, the Autism Spectrum Quotient (ASQ) and the Empathy Quotient (EQ) and new diagnostic criteria specifically for adults. These criteria include the DSM-IV criteria and several additional criteria. The original research for the AAA was conducted by Simon Baron-Cohen and colleagues at the Cambridge Lifespan Asperger Syndrome
Service (CLASS) in the United Kingdom. The clinician asks the client to complete the ASQ and EQ, then validates the answers during the diagnostic assessment and makes his or her own opinion on the diagnosis based on the new diagnostic criteria.

Diagnostic criteria for adults
The diagnostic criteria in the AAA are the same as in the DSM-IV (see page 41), with the addition often criteria based on our understanding of the characteristics of Asperger's syndrome in adults rather than children. In section A of the DSM-IV criteria (qualitative impairment in social interaction) there is the additional criterion:

Difficulties in understanding social situations and other people's thoughts and feelings.

In section B of the DSM-IV criteria (restricted repetitive and stereotyped patterns of behaviour, interests and activities) there is the additional criterion:

Tendency to think of issues as being black and white (e.g. in politics or morality), rather than considering multiple perspectives in a flexible way.

In the AAA diagnostic criteria there are two sections that are in the DSM-IV criteria for autism but not the DSM-IV criteria for Asperger's syndrome. These two sections are justifiably included in the AAA criteria, being based on the profile of communication and imagination abilities identified in research studies and from clinical experience, as being characteristic of adults with Asperger's syndrome, namely:

Qualitative impairments in verbal or non-verbal communication:
1.   Tendency to turn any conversation back to self or own topic of interest.

2.   Marked impairment in the ability to initiate or sustain a conversation with others. Cannot see the point of superficial social contact, niceties, or passing time with others, unless there is a clear discussion point/debate or activity.

3.   Pedantic style of speaking, or inclusion of too much detail.

4.   Inability to recognize when the listener is interested or bored. Even if the person has been told not to talk about their particular obsessive topic for too long, this difficulty may be evident if other topics arise.

5.  Frequent tendency to say things without considering the emotional impact on the listener (faux pas).

The diagnostic criteria of the AAA require three or more symptoms of qualitative impairment in verbal or non-verbal communication, and at least one symptom from the following impairments in imagination:

Impairments in imagination:

1.   Lack of varied, spontaneous make believe play appropriate to
developmental level.

2.   Inability to tell, write or generate spontaneous, unscripted or unplagiarised fiction.

3.  Either lack of interest in fiction (written, or drama) appropriate to developmental level or interest in fiction is restricted to its possible basis in fact (e.g. science fiction, history, technical aspects of film).

The adult's response to specific questions in the ASQ_and EQ_provides examples of the symptoms in the five sections of the AAA. Future studies will examine the test sensitivity and specificity of the AAA, but at last we have an assessment instrument and diagnostic criteria that a clinician can use in the diagnostic assessment of adults.

CLOSURE OF THE DIAGNOSTIC ASSESSMENT
At the end of the diagnostic assessment, the clinician provides a summary and review of those characteristics in the person's developmental history, profile of abilities and behaviour consistent with a diagnosis of Asperger's syndrome, and concludes whether the signs are sufficient for a diagnosis. I explain to the client and family the concept of a 100-piece diagnostic jigsaw puzzle. Some pieces of the puzzle (or characteristics of Asperger's syndrome) are essential, the corner and edge pieces. When more than 80 pieces are connected, the puzzle is solved and the diagnosis confirmed. None of the characteristics are unique to Asperger's syndrome, however, and a typical child or adult may have perhaps 10 to 20 pieces or characteristics. The person referred for a diagnostic assessment may have more pieces than occur in the typical population, but sometimes not enough, or the key or corner pieces, to complete the puzzle or receive a diagnosis of Asperger's syndrome.
The conceptualization of a diagnostic jigsaw puzzle can help explain the diagnostic term Pervasive Developmental Disorder Not Otherwise Specified or PDDNOS. This term describes someone who has many of the fragments or pieces of the diagnostic jigsaw but some pieces are described as atypical or sub-threshold. However, there are sufficient pieces or fragments of Asperger's syndrome to warrant recognition that the person is 'almost there' and needs access to services for the pieces that are there.
Should a diagnosis of Asperger's syndrome be confirmed (the diagnostic puzzle is completed), the summary at the end of the diagnostic assessment needs to acknowledge the positive characteristics of Asperger's syndrome such as being an expert in a particular field, the degree of expression of each of the main characteristics, the overall degree of expression, and which characteristics in the profile of abilities and behaviour are not due to Asperger's syndrome. The clinician may also need to comment on the signs of any secondary or dual disorders such as depression, anxiety or conduct disorder, and whether another disorder is currently the dominant factor affecting the person's quality of life and, as a matter of expediency, should be the priority for treatment.
I make an audio recording for the client or his or her family of the summary stage of the diagnostic assessment, so that participants can listen to the explanation several times to absorb all the information and implications. Other family members and teachers who were not able to attend the diagnostic assessment can listen to the recording to aid their understanding of the rationale for the diagnosis. I have also noted that recording the summary can lessen the likelihood of being misunderstood or misquoted when others are informed of the diagnosis and degree of expression. The next stage is to discuss the known causes of Asperger's syndrome, recommended specific programs, government support services, support groups, relevant publications, the likely prognosis and the monitoring of progress. However, this would be achieved in subsequent appointments once the significance of the diagnosis has been understood and acknowledged.

'dissolve' over time; however, the very young child who could be a false positive may still benefit from the programs designed for children with Asperger's syndrome to improve social reasoning and conversation skills. Over time the clinical or diagnostic picture becomes clearer. However, we are developing diagnostic assessment procedures that can be used with pre-school children (Perry 2004). Clinicians can include some of the descriptions of the characteristics of very young children with Asperger's syndrome that are described in subsequent chapters, as part of their assessment procedures for very young children who could be developing the early signs of Asperger's syndrome.
The confidence in the diagnostic assessment of adults can also be affected by the honesty and accuracy in the responses of the client. The person may be able to 'fake it' in terms of denying difficulties with social competence, and using intellect in the artificial circumstances of a clinic room to provide the response of a typical adult, but may in fact have conspicuous difficulties in everyday social interaction. There is a difference between knowledge at an intellectual level and actual practice in real life.
Some adults referred for a diagnostic assessment may have the signs but not the clinically significant impairment in functioning necessary for a diagnosis using the DSM-IV criteria of the American Psychiatric Association. Problems with social understanding may be reduced to a sub-clinical level with the help of a supportive partner who provides the necessary guidance in the codes of conduct and explains or repairs comments or actions that may appear confusing or inappropriate to other people.
Work circumstances may be successful due to sympathetic colleagues and line managers. In such circumstances, the clinician may have to consider whether the person, who appears to be coping reasonably well, perhaps with a high-status profession and having a partner, would benefit from receiving a diagnosis of Asperger's syndrome (Szatmari 2004). At the time of the diagnostic assessment, the person may not need treatment from a psychiatrist or services from government agencies (one of the principal justifications for a diagnosis), although he or she may well benefit from relationship or career counselling. However, should the person experience a divorce or unemployment, the signs may become more conspicuous and then warrant a diagnosis. It is perhaps not the severity of expression that is important, but the circumstances, expectations, and coping and support mechanisms.
The final decision on where you draw the artificial line, namely whether a person has a diagnosis of Asperger's syndrome, is a subjective decision made by the clinician on the basis of the results of the assessment of specific abilities, social interaction, and descriptions and reports from parents, teachers etc. The qualitative impairment in social interaction or social relatedness is central to the diagnosis, but there is no weighting system for the other characteristics to help decide whether, on balance, a borderline case should have the diagnosis. The ultimate decision on whether to confirm a diagnosis is based on the clinician's clinical experience, the current diagnostic criteria and the effect of the unusual profile of abilities on the person's quality of life. Jerry Newport, who has Asperger's syndrome, said to me that the diagnosis occurs when 'human characteristics are at an impractical extreme.'

KEY POINTS AND STRATEGIES

.There are currently eight diagnostic screening questionnaires that can be used with children and six that can be used with adults.

.Girls and women, and children and adults of considerable intellectual ability, can be more difficult to diagnose with Asperger's syndrome due to an ability to camouflage their difficulties.

.The diagnostic assessment should examine not only areas of difficulties, but also areas of ability that may be attributable to the characteristics of Asperger's syndrome.

.There are significant problems with the diagnostic criteria in DSM-IV:

。The criteria state there should be no clinically significant general delay in language, but the criteria for inclusion actually describe a child who has language delay.

。 Any differences in language ability that are apparent in the pre-school years between children with autism and an IQ_within the normal range, and those with Asperger's syndrome, have largely disappeared by early adolescence.

。 The criteria state there should be no clinically significant delay in the development of age-appropriate self-help skills, but clinical experience and research indicate that parents often have to provide verbal reminders and advice regarding self-help and daily living skills.

。The DSM criteria do not include a description of the unusual language characteristics originally described by Hans Asperger, or make reference to problems with sensory perception, but include characteristics that are rare or transitory.

。The guidelines state that if the criteria for autism are confirmed, a diagnosis of autism should take precedence over a diagnosis of Asperger's syndrome. Many clinicians have rejected this hierarchical rule.

。 The DSM diagnostic criteria are still a work in progress.

.The diagnostic criteria of Christopher Gillberg most closely resemble the original descriptions of Hans Asperger and are the criteria of first choice by many experienced clinicians.

.There is currently no convincing argument or data that unequivocally confirm that High Functioning Autism and Asperger's syndrome are two separate and distinct disorders.

.Using the Gillberg diagnostic criteria, the prevalence rate for Asperger's syndrome is about 1 in 250 children.
. We are currently detecting and diagnosing only about 50 per cent of children who have Asperger's syndrome.

. A diagnosis can be made with some confidence for a child after the age of five years, but cannot yet be made with sufficient confidence in pre-school children.

. We now have an assessment instrument and diagnostic criteria specifically for adults.

. The confidence in the diagnostic assessment of adults can be affected by the honesty and accuracy in the responses to questions and questionnaires.

. Some adults referred for a diagnostic assessment may have the signs but not the clinically significant impairment in functioning necessary for a diagnosis.

. It is not the severity of expression that is important but the circumstances, expectations and coping and support mechanisms.

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Social Understanding and Friendship

The nature of these children is revealed most clearly in their
behaviour towards other people. Indeed their behaviour in the social
group is the clearest sign of their disorder.
- Hans Asperger ([1944] 1991)

The reader will be interested to know that I have discovered a means of removing almost all of the characteristics that define Asperger's syndrome in any child or adult. This simple procedure does not require expensive and prolonged therapy, surgery or medication, and has already been secretly discovered by those who have Asperger's syndrome. The procedure is actually rather simple. If you are a parent, take your child with Asperger's syndrome to his or her bedroom. Leave the child alone in the bedroom and close the door behind you as you walk out of the room. The signs of Asperger's syndrome in your son or daughter have now disappeared.

SOLITUDE
In solitude, the child does not have a qualitative impairment in social interaction. At least two people are needed for there to be a social interaction, and if the child is alone, there will be no evidence of any social impairment. In solitude, there is no one to talk to, so there are no speech and language peculiarities; and the child can enjoy time engaged in a special interest for as long as he or she desires, without anyone else judging whether the activity is abnormal either in intensity or focus.
In Chapter 6 I will explain how solitude is also one of the most effective emotional restoratives for someone with Asperger's syndrome. Being alone can be a very effective way of calming down and is also enjoyable, especially if engaged in a special interest, one of the greatest pleasures in life for someone with Asperger's syndrome.
Solitude can facilitate learning. The acquisition of knowledge in a classroom requires considerable social and linguistic skills. The difficulties experienced in these areas by children with Asperger's syndrome can impede the understanding of academic concepts. I have observed that some children with Asperger's syndrome acquire academic skills such as basic literacy and numeracy before they attend school, often by looking at books, watching television or playing educational games on a computer.
They have successfully taught themselves, in solitude.
When alone, especially in a bedroom, the hypersensitivity for some sensory experiences is reduced as the environment can be relatively quiet, particularly in comparison to a school playground or classroom. The child with Asperger's syndrome may also be sensitive to change and be anxious if things are not where they have been or should be. Furniture and objects in the bedroom will be a known configuration, and family members will have learned not to move anything. The child's bedroom is a refuge that is sacrosanct.
When someone is alone, relaxed and enjoying a special interest, the characteristics of Asperger's syndrome do not cause clinically significant impairment in social, occupational, w other important areas of functioning. For the child with Asperger's syndrome, being alone has many advantages; problems only occur when someone enters the room, or when he or she has to leave the bedroom and interact with other people.
I have noted that people with Asperger's syndrome may function reasonably well in one-to-one interactions, using their intellectual capacity to process social cues and non-verbal communication, and using memory of similar social situations to determine what to say and do. The phrase 'two's company, three's a crowd' is very appropriate for someone with Asperger's syndrome. In a group setting, the person's intellectual capacity may not be sufficient to cope with the social interaction of several participants, and the person may take longer to process social information that is normally communicated more quickly in a group than individually. If a one-to-one conversation is a game of tennis, a group interaction is a game of football.
The delay in social processing means the person can become out of synchronization with the conversation and is liable to make a conspicuous social error or have to withdraw. There have been occasions when I have been involved in a reciprocal conversation with an adult with Asperger's syndrome, and noted that when another person or several others join in, the person with Asperger's syndrome becomes quiet and does not participate as actively and fluently as when the conversation was between just the two of us.
When I explained to a teenager with Asperger's syndrome that the degree of stress is proportional to the number of people present, he started to work on a mathematical formula and geometric representation of the number of potential connections between individuals that can occur as more people join a conversation. With two people there is only one link; with three people, three links; with four people, six links; five people, ten links; and so on. This is one of the explanations as to why people with Asperger's syndrome do not like large gatherings of people.

THE ASSESSMENT OF SOCIAL INTERACTION SKILLS
The essential feature of Asperger's syndrome is a qualitative impairment in social interaction, which is acknowledged in all diagnostic criteria. The criteria also refer to a lack of social or emotional reciprocity and failure to develop peer relationships appropriate to developmental level. To date we do not have standardized tests of social interaction and social reasoning for typical children that can be used to produce a 'social quotient' for a child with Asperger's syndrome. The interpretation of aspects of social skills and social understanding such as reciprocity and peer relationships is currently a subjective clinical judgement. The clinician therefore needs to have considerable experience of the social development of typical children to act as a comparison for the child who is referred for a diagnostic assessment for Asperger's syndrome.
To assess social interaction and social reasoning skills, the clinician must socialize with the child, adolescent or adult. With young children, this can be achieved by playing with the child using toys and play equipment in the clinic room. Of clinical significance will be the degree of reciprocity, the child's recognition and 'reading* of social cues expressed by the clinician, and his or her knowledge of how to respond to those cues. The clinician will examine whether the child displays developmentally appropriate social behaviour, and his or her use of eye contact, methods of regulating the interaction, and the degree of spontaneity and flexibility when playing with the clinician. This part of the assessment should be achieved in both structured and unstructured play. For adolescents and adults, the assessment of social interaction skills will be achieved using a conversation that includes a range of topics that explore aspects of friendship, social experiences and social abilities. Some of the topics and conversation questions can be taken from the screening instruments for Asperger's syndrome to provide more information on the person's social maturity and social competence.
An examination of peer relationships or friendships can be achieved by identifying the person's friends, the quality, stability and maturity of the friendships, and his or her thoughts regarding the attributes of friendship. The questions can include:

. Who are your friends?

. Why is _________ your friend?

. What are the things that someone does to be friendly?

. How do you make friends?

. Why do we have friends?

. What makes you a good friend?

I have noted that the child with Asperger's syndrome usually has a concept of friendship that is immature and at lease two years behind that of his or her age peers (Attwood 2003a; Botroff et al. 1995). The child with Asperger's syndrome typically has fewer friends, playing with other children less often and for a shorter duration in comparison to peers (Bauminger and Kasari 2000; Bauminger and Shulman 2003; Bauminger, Shulman and Agam 2003). This can also occur during adolescence. Liane Holliday
Willey explained in her autobiography that at college, '1 was accustomed to defining friendship in very simplistic terms. To me, friends were people 1 enjoyed passing a few minutes or a few hours with' (Willey 1999. p.43).
Friendships may be unusual in that the child chooses to play with younger children or prefers the company of adults. One child with Asperger's syndrome described to me the friend he regularly met at school during lunch recess. His mother then explained that his 'friend' was the school groundsman, and every lunch recess he helped the groundsman with his chores. My wife's sister, who is an adult with Asperger's syndrome, wrote to me that, 'As a child, a teenager and a young adult, 1 seldom got along well with my peers, preferring the company of older adults. Probably because they are likely to be more mellow in temperament and of course quieter.' Stephen Shore, who also has Asperger's syndrome, has explained that adults tend to have more patience to listen to special interests and 'scaffold' a conversation.
A child or adult with Asperger's syndrome can mistake friendliness for friendship and conceptualize friends as though they should be reliable machines. Jamie, a young child with Asperger's syndrome, said of the child he used to play with, 'He can't play with me one day and then other friends another day, he wouldn't be a true friend,' A child with Asperger's syndrome may conceptualize friendship to be about possession, and is intolerant of anyone who breaks his or her personal rules about friendship. Teenagers and adults with Asperger's syndrome may have problems understanding that friendliness is not necessarily a sign of romantic interest.
The clinician also examines the person's motivation for friendships, ability to make and keep friends and the value and nature of friends in that person's life. Adolescents and adults with Asperger's syndrome can express feelings of loneliness, sometimes being acutely aware and miserable about having so few, if any, friends. As Therese Jolliffe wrote in her personal account of autism, 'contrary to what people may think, it is possible for an autistic person to feel lonely and to love somebody' (Jolliffe. Lansdown and Robinson 1992, p.16).
Young children with Asperger's syndrome can be described by parents and teachers as socially clumsy, such that other children often consider that the child with Asperger's syndrome is not fun to play with, and does not conform with the usual rules of friendship, such as sharing, reciprocity and cooperation. As Jerry Newport, a man with Asperger's syndrome, said to me, 'To share, you have to give up control,' and as Holly said to me during her diagnostic assessment, 'My friends don't let me do what I want to do.'

The child with Asperger's syndrome often plays in an unconventional or idiosyncratic way with different priorities and interests to his or her peers, who tend to be bored by monologues or lectures on the child's special interests. In Jean-Paul's reflections on his childhood, he explained, 'I was not very good playing in typical ways or with other children and I rarely got enjoyment from it' (Donnelly and Bovee 2003).
The imaginative play can be qualitatively different to that of other children. In the same reflections on childhood, Jean-Paul described his unusual imaginative play; 'Imagination is something that is different in each person. For me, it was making my lists, creating fictional genealogies of characters, planning imaginary ball games with players on baseball cards, creating different languages, and the list goes on.' Children with Asperger's syndrome can develop imaginative play but usually as a solitary and idiosyncratic activity.
The child with Asperger's syndrome can be on the periphery of the playground, sometimes socially isolated by choice, or actively among the other children and seeking inclusion but being perceived by peers as intrusive and irritating. Such behaviour is often described by teachers as silly, immature, rude and uncooperative (Church et al. 2000).
When adolescents are included in the activities and conversations of their peers, there can still be feelings of not being included or popular. This is illustrated by two comments from adults with Asperger's syndrome describing their teenage years: 'I wasn't rejected but did not feel completely included,' and T was supported and tolerated but not liked,' A lack of genuine social acceptance by peers will obviously adversely affect the development of self-esteem.
The diagnostic assessment includes an examination of the child's abilities in a range of social situations, such as when playing with friends, parents, siblings or peers, and in new social situations. The signs of Asperger's syndrome are more apparent when the child is playing with peers rather than parents or an adult such as the examining clinician, an important point to remember in a diagnostic assessment. The clinician may supplement the assessment of social interaction skills by observing the child in unstructured play with peers, or obtaining reports on social play from a teacher.
There should be an examination of the child's awareness of the codes of social conduct in a range of situations, particularly the child's recognition of the concept of personal space, and his or her ability to modify greetings, touch and topics of conversation according to the context and cultural expectations. Other valuable information needs to be collected and evaluated with regard to the child's response to peer pressure, the duration and enjoyment of solitary play, the enforcement of social rules, degree of honesty, sense of humour and susceptibility and reaction to teasing and bullying.
To assess social reasoning ability, I show the child a series of pictures of children engaged in various solitary or social activities with associated emotions - for example, a child who has fallen from her bicycle and is crying, a child who appears to be trying to 'steal' a cookie while another child stands guard, and a girl who appears to have lost her

parents in the shopping mall. The child is asked to describe what is happening in the pictures. Children with Asperger's syndrome tend to notice and describe objects and physical actions with a relative lack (in comparison to their peers) of reference to the thoughts, feelings and intentions of the participants in the picture. When assessing teenagers and adults, I will ask them to describe events in their personal lives, noting any predominance of descriptions of actions compared to descriptions and interpretations of thoughts, feelings and intentions of themselves and others.
The diagnostic assessment includes an evaluation of the person's social interaction and social reasoning skills from observation, interaction and self-report that can be used to confirm or reject the diagnosis. This evaluation can also be used as the baseline to measure the progress of programs in each of those areas of social understanding that may be delayed or unusual (the 'hallmarks' of Asperger's syndrome). This chapter will now describe strategies to improve social understanding and friendship skills.

THE MOTIVATION TO HAVE FRIENDS
I have observed the social development of children and adults with Asperger's syndrome over several decades and identified five stages in their motivation to have friends.

An interest in the physical world
Very young children with Asperger's syndrome in their pre-school or kindergarten years may not be interested in the activities of their peers or making friends. They are usually more interested in understanding the physical rather than the social world, and may enter the pre-school playground to explore the drainage or plumbing system of the school, or to search for insects and reptiles, or to gaze at the different cloud formations. The social activities of the child's peers are perceived as boring, with incomprehensible social rules. The child is content with solitude, but may be motivated to interact with adults who can answer questions beyond the knowledge of the child's peers, or seek refuge from the noisy and chaotic playground in the quiet sanctuary of the school library to read about topics such as volcanoes, meteorology and transport systems.

Wanting to play with other children
In the early primary or elementary school years, children with Asperger's syndrome notice that other children are having fun socializing and want to be included in the social activities to experience the obvious enjoyment of their peers. However, despite intellectual ability, their level of social maturity is usually at least two years behind that of their peers, and they may have conspicuous difficulties with the degree of reciprocal and cooperative play expected by other children.
At this stage in the motivation to have friends, the child with Asperger's syndrome may long for successful social inclusion and a friend to play with. This is the time when

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the child can become acutely aware of being different to his or her peers, giving rise to the adjustment and compensation strategies described in Chapter 1, namely depression, escape into imagination, denial and arrogance, or imitation.
The initial optimism about friendship can turn to paranoia, especially if the child fails to make the distinction between accidental and deliberate acts. Children with Asperger's syndrome have difficulty with Theory of Mind tasks - that is, conceptualizing the thoughts, feelings, knowledge and beliefs of others (see Chapter 5). Other children may recognize from the context, and often knowledge of the character of the other person, whether a particular comment or action had benevolent or malicious intent. For example, other children know when someone is teasing with friendly or unfriendly intentions. This knowledge may not be available to the child with Asperger's syndrome.
I have noted that children with Asperger's syndrome are often limited in their ability to make character judgements. Other children will know which children are not good role models and should be avoided; children with Asperger's syndrome can be somewhat naive in their judgements, and prone to be attracted to and imitate children who may not demonstrate good friendship skills.

Making first friendships
In the middle school years, children with Asperger's syndrome may achieve genuine friendships but have a tendency to be too dominant or to have too rigid a view of friendship. Such children may 'wear out their welcome'. However, some typical children, who are naturally kind, understanding and 'maternal', may find children with Asperger's syndrome appealing, and can be tolerant of their behaviour, becoming genuine friends for several years or more.
Sometimes the friendship is not with a compassionate, typical child, but with a similar, socially isolated child, who shares the same interests, but not necessarily the diagnosis. The friendship tends to be functional and practical, exchanging items and knowledge of mutual interest, and may extend beyond a dyad to a small group of like-minded children with a similar level of social competence and popularity.

Searching for a partner
In late adolescence, teenagers with Asperger's syndrome may seek more than a platonic friendship with like-minded individuals, and express a longing for a boyfriend or girlfriend, and eventually a partner. The partner they seek is someone who understands them and provides emotional support and guidance in the social world - someone to be a 'mother figure' and mentor.
Adolescent peers are usually much more mature and knowledgeable in identifying a potential partner and developing and practising relationships skills. The adolescent boy with Asperger's syndrome may ask forlornly, 'How do I get a girlfriend?' Attempts to develop a relationship beyond platonic friendship can lead to rejection, ridicule and a misinterpreration of intentions. The adolescent with Asperger's syndrome can feel even more socially confused, immature and isolated.

Becoming a partner
Eventually, perhaps when emotionally and socially more mature, the adult with Asperger's syndrome can find a lifetime partner. However, both partners would probably benefit from relationship counselling to identify and encourage the adjustments needed to make an unconventional relationship successful for both. We now have literature on relationship counselling for couples where one partner has Asperger's syndrome. The Resources section towards the end of the book provides a list of recommended books, Internet resources and agencies.

THE IMPORTANCE OF FRIENDSHIP
There must be advantages in having friends. The research evidence suggests that children without friends may be at risk for later difficulties and delay in social and emotional development, low self-esteem and the development of anxiety and depression as an adult (Hay, Payne and Chadwick 2004). Having friends can be a preventative measure for mood disorders.
Another advantage can be an improvement in problem solving (Rubin 2002), If a group of children are engaged cooperatively in a task, they have the benefit of different perspectives and ideas, and greater physical abilities. Another child may literally be in a position to see something of importance, have previous experience of what to do, or can generate an original solution, A group of friends provides greater physical and intellectual strength for problem solving.
Chee is a young man with Asperger's syndrome and he wrote that:

The worst problem for me in my life is socializing. I cannot make friends and I need friends badly. When you have friends you get more support and you can ask a lot of things from them and they'll help because they're your friends. You also gain a lot of knowledge and experience from your friends. And because I don'l have friends it means that I'm cut off from help. Whenever I have a problem I have to handle it on my own. I don't know how to socialize and that means I don't know how to use people to my advantage. To me that is the biggest problem with having Asperger Syndrome. (Molloy and Vasil 2004, p.77)

Being isolated and not having friends also makes the child vulnerable to being teased and bullied- The 'predators' at school target someone who is alone, vulnerable and less likely to be protected by peers. Having more friends can mean having fewer enemies.
Peer acceptance and friendships can benefit the child in terms of providing a second opinion with regard to the motives and intentions of others, preventing a sense of paranoia. Friends can provide an effective emotional monitoring and repair mechanism, especially for emotions such as anxiety, anger and depression. Friends can offer guidance on what is appropriate social behaviour, help develop self-image and self-confidence, and can act as personal counsellors and psychologists. Deborah is an adult with Asperger's syndrome who, in an e-mail to me, stated that in her opinion, 'The best cure for low self esteem...friendship.' This is particularly true during adolescence.
All the qualities of a good friend are the qualities of a good team member, and important attributes for later employment as an adult. I have known of adults with Asperger's syndrome who have impressive academic qualifications, but their lack of teamwork skills has contributed to problems with gaining or maintaining employment or achieving an income appropriate to their impressive qualifications. Having friends and developing friendships skills can determine whether the person acquires the interpersonal abilities for successful employment.
The development of interpersonal skills with friends is also the basis of later success in a relationship with a partner. Concepts of empathy, trust, repairing emotions and sharing responsibilities, developed throughout childhood with friends, are essential in adult relationships.

ENCOURAGING FRIENDSHIPS
In typical children, the acquisition of friendship skills is based on an innate ability that develops throughout childhood in association with progressive changes in cognitive ability, and modified and matured through social experiences. Unfortunately, children with Asperger's syndrome are not able to rely on intuitive abilities in social settings as well as their peers and must rely more on their cognitive abilities and experiences.
Children and adults with Asperger's syndrome have difficulty in social situations that have not been rehearsed or prepared for. Thus, it is essential that such children receive tuition and guided practice in the ability to make and keep friends and that their friendship experiences are constructive and encouraging (Attwood 2000). A failure to experience friendship will lead to an inability to grasp the very concept of'friend' (Lee and Hobson 1998). If you do not have friends, how can you know how to become a friend?
Parents can try to facilitate social play at home with siblings and another child invited to their home on a play date, but will have difficulty providing the range of experiences and degree of supervision and tuition required for a child with Asperger's syndrome. The optimum environment to develop reciprocal play with peers is at school. Education services will need to be aware of the importance of a social curriculum as well as an educational curriculum for a child with Asperger's syndrome. The social curriculum must have an emphasis on friendship skills, and include appropriate staff training and relevant resources. The following suggestions are designed for implementation by teachers and parents for each of the developmental stages of friendship that occur in typical children and can be applied to children with Asperger's syndrome.

The developmental stages in the concept of friendship for typical Children Before the age of three years, typical children will interact and play with members of their family, but their conceptualization of their peers is often one of rivalry for possessions and adult attention rather than friendship. If another child comes to the home, the typical child may hide a favourite toy. However, some basic sharing, helping and comforting can occur after the first year: the first building blocks of friendship. There may be parallel play and curiosity about what is interesting to other children and subsequent copying of what other children are doing, but primarily because it may be interesting, enjoyable and likely to impress a parent. We know that typical children in this age group do have preferred companions and may choose to play alongside a particular child. As children with Asperger's syndrome are usually diagnosed after the age of five years, they have usually progressed beyond the level of friendships associated with very young children when first diagnosed.

Stage one of friendship - three to six years
Typical children from the ages of three to six years have a functional and egocentric conceptualization of friendship. When asked why a particular child is his or her friend, a typical child's reply is usually based on proximity (lives next door, sits at same table) or possessions (the other child has toys that the child admires or wants to use). Toys and play activities are the focus of friendship and the child gradually moves from engaging primarily in parallel play to recognizing that some games and activities cannot happen unless there is an element of sharing and turn-taking. However, cooperative skills are limited, the main characteristics that define a friend being one-way and egocentric (he helps me or she likes me). Conflict is usually associated with the possession and use of equipment and the violation of personal space, but in the last year or two of stage one, conflict can be over the rules of games and who wins. Conflict resolution, from the child's perspective, is often achieved by ultimatums and use of physical force. An adult may not be asked to adjudicate. Children may have some suggestions to comfort or help a distressed friend, but consider emotional repair as the function of a parent or teacher rather than themselves.
If children from three to four years are asked what they did today, they tend to describe what they played with, while over the age of about four years they start to include whom they played with. Social play gradually becomes more than just the construction and completion of the activity. However, friendships are transitory and the child has a personal agenda of what to do and how to do it.
Very young children with Asperger's syndrome have a clear end-product structure, and be extremely agitated when another child places a brick where, according to the mental image, there shouldn't be a brick. The typical child, meanwhile, does not understand why his or her act of cooperation is rejected.
The young child with Asperger's syndrome often seeks predictability and control in play activities while typical peers seek spontaneity and collaboration. In her autobiography, Liane Holliday Willey explains about her early childhood:

Like with my tea parties, the fun came from setting up and arranging things. Maybe this desire to organize things rather than play with things, is the reason I never had a great interest in my peers. They always wanted to use the things I had so carefully arranged. They would want to rearrange and redo. They did not let me control the environment. They did not act the way I thought they should act. Children needed more freedom than I could provide them. (Willey 1999, pp. 16-17)

Other children often consider that the child with Asperger's syndrome, who often prefers to play alone, does not welcome them. When other children are included, the child with Asperger's syndrome may be dictatorial, tending not to play by conventional rules and considering the other child as subordinate. Such behaviour is perceived by other children as being bossy and sounding and behaving more like a teacher than a friend. Thus, the child with Asperger's syndrome, who is eventually avoided by other children, inadvertently becomes unpopular. Opportunities are then lost to use and develop friendship skills.

Programs for stage one
An adult acting as a friend
For the young child with Asperger's syndrome, who is probably not interested in playing with peers, but who may be motivated to interact with adults, social play can be taught by an adult who 'plays the part' of an age peer. In much the same way that actors in a theatre play learn how to act, and rehearse their roles, the child can be taught how to engage in reciprocal play. The adult 'friend' in this situation will need to adjust his or her abilities and language to resemble that of the child's peers. The intention is to encourage reciprocal play between equals with neither 'friend' being dominant.
A class teacher has a designated and relatively fixed role, being an adult not a friend. However, an adult who provides support to facilitate integration into the kindergarten or pre-school can sometimes act the role of 'friend'. This adult 'friend' can act as a mentor, or stage director, giving guidance and encouragement to the child in social situations. Games or equipment that are used at school and are popular with other children of the same age may be borrowed or bought to assist in making the interactions more comparable with real social situations with peers.
It is important that adults, especially parents, observe the natural play of the child's peers, noting the games, equipment, rules and language. The strategy is for the parent to play with the child using 'child speak' - the typical utterances of children of that age-and to be equal and reciprocal in terms of ability, interests and cooperation. The adult can demonstrate specific social cues, and momentarily stop and encourage the child to see or listen to the cue, explaining what the cue means and how he or she is expected to respond.
The adult can vocalize his or her thoughts when playing with the child - a commentary of thoughts. This will enable the child with Asperger's syndrome to actually listen to the other person's thoughts rather than be expected to know what the other person is thinking from the context, or by having to interpret facial expressions and body language.
It is important that the adult role-plays examples of being a good friend, and also situations that illustrate unfriendly actions, dominance, teasing and disagreements. Appropriate and inappropriate responses can be enacted by the adult, to provide the child with a range of responses and the ability to determine which response is appropriate and why.

Taking turns and asking for help
In stage one of friendship, a good friend is someone who takes turns and helps. It is important that when the adult is acting as a friend, he or she models and encourages turn-taking. For example, when completing an inset board, the adult and the child should take turns in placing each of the pieces in the puzzle; if looking at a book, the adult first points to one of the pictures and makes a comment or asks a question, and on the next page the child points and asks the adult a question. If the child enjoys being pushed on the swing, the next activity is for the child to push the adult on the swing. The two 'friends' take turns in each activity and in being the leader.
To encourage helping someone, the adult will need to deliberately make a mistake or not be sure what to do in order to solve a problem. The adult then asks the child for help, with the comment that asking for help is the smart and friendly thing to do when you have a problem. The adult will need to ensure that his or her own ability on a task is comparable to that of the child with Asperger's syndrome. Such children may perceive themselves as small adults, and become extremely disappointed or agitated if their level of ability is obviously less than that of their playmate. The adult is also modelling that it is okay to make mistakes.

A dress rehearsal with another child
An adult can easily modify the pace of play and amount of instruction and feedback. After sufficient practice in such a setting, the child can progress to a 'dress rehearsal' with another child. This might be an older sibling, or perhaps a mature child in the class, who can act as a friend A video recording of children playing
Children with Aspcrger's syndrome often enjoy watching the same movie many times. This is a common preferred activity of typical children but the child with Asperger's syndrome may be unusual in terms of the number of times the film or programme is watched. This is not necessarily a self-stimulatory behaviour, as suggested in some of the behaviourist literature on autism, but in my opinion a constructive way of learning without the confusion and effort of having to socialize or talk. Parents can be concerned that watching the same programme so many times is a waste of time; however, the problem may not be what the child with Asperger's syndrome is doing, but what he or she is watching.
I recommend that video recordings be made of the social experiences of the child with Asperger's syndrome - for example, the child and peers playing in the sandpit, 'show and tell' time in class, or playing with cousins at home. The child can then replay, perhaps many times, the 'social documentary' to better understand the social cues, responses, sequence of activities, actions of peers and the child's role as a friend. An adult can use [he freeze-frame or pause facility to focus on a specific social cue, identify friendly behaviour and point out what the child with Asperger's syndrome did that was appropriate.

Pretend games
Typical children in stage one of friendship often play make-believe or pretend games based on popular characters and stories from books, television programmes and films. The play of the child with Asperger's syndrome can also be based on characters and events in fiction, but may be qualitatively different in that it is usually a solitary rather than shared activity. It may be an exact re-enactment with little variation or creativity, and may include other children, but only if they follow [he directions of the child with Asperger's syndrome and do not change the script. The interaction is not as creative, cooperative or reciprocal as would occur with typical peers- However, the child with ' Asperger's syndrome can have a remarkable memory and knowledge of popular characters and films, and happily replay scenes for many hours. The child will need to be encouraged to be more flexible in his or her'imaginative' play, especially when playing with other children. The principle is to learn that something is not wrong if it is different.
Activities to encourage flexible thinking and the ability to engage in pretend play can include games where the objective is to invent as many uses as possible for a given object - that is, to think beyond the most obvious, functional use of that object. For example, how many uses can be thought of for a brick, a paper clip, a section of toy train track, and so on? The section of train track could become the wings of an aeroplane, a sword or a ladder, for example. This will encourage the ability to 'break set' when problem solving and be more comfortable when involved in pretend play with other children.

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The adult can act a friend in make-believe games, using the phrase 'let’s pretend that...', thus encouraging flexible thinking and creativity. Children with Asperger's syndrome can be very rule-bound and need to learn that, when playing with a friend, it is possible sometimes to change the rules and be inventive, yet still have an enjoyable experience, and that this is not necessarily a cause for anxiety. The child may benefit from a Social Story™ (see page 69) that explains that in friendships, and when solving a practical or intellectual problem, trying another way can lead to an important discovery. Trying to find a quicker way to sail to India led to the European discovery of America.
Once the child with Asperger's syndrome is more comfortable with flexible thinking, the adult and peers can encourage him or her to engage in reciprocal imaginative social play. I have found that when the child discovers the intellectual and social value of being imaginative, the level of creativity can be astounding.

Encouragement for being friendly
When discussing childhood social experiences with young adults with Asperger's syndrome, I have listened to many descriptions of social confusion, and how, very often, the response of adults was criticism of social mistakes but rarely praise for what was appropriate. The child often assumed that at the end of an interaction, a lack of criticism, sarcasm or derisory laughter meant the interaction was successful but had no idea what he or she had done that was socially appropriate- As one young adult said of his childhood, 'The only comments I had were when I did it wrong but no one told me what I was doing right' (personal commuication}.
If the child were completing a mathematics activity, the teacher's tick or cross would indicate what was right or wrong. When completing a jigsaw puzzle or construction with building blocks, the child knows he or she has achieved success when all the pieces fit together or the construction is complete and robust. The problem in social situations is that success may not be obvious, and there may be a relative lack of positive feedback.
I strongly recommend that when an adult, peer or friend is interacting with a young child with Asperger's syndrome, a conscious effort should be made to point out and ' comment on what the child did that was appropriate.
For example, if the child was observed playing soccer with other children during the lunch recess, he or she could be informed at the end of the game which actions were friendly and why Positive feedback could be: 'I noticed that when the ball got lost in the tall grass, you helped to find the ball. Excellent! Helping to find something is a friendly thing to do'; or 'When Joshua fell over and you came up to him and asked if he was okay, that was a caring and friendly thing to do'; or 'When Jessica scored a goal and you went up to her and said "Great goal", that was a nice compliment, and a friendly thing to do.'
The child can have a friendship diary, which records the times during the day or week when he or she demonstrated friendship abilities. The diary can take the form of a 'boasting book* or provide a means of recording friendship 'points' for a particular act of friendship. The diary can record what was done or said and why it was an example of friendship. Memorable acts of friendship could achieve public recognition and an appropriate reward.

Social Stones™
Another strategy to learn the relevant social cues, thoughts, feelings and behavioural script is to write Social Stories? which were originally developed by Carol Gray in 1991, not from the academic application of a theoretical model of social cognition, but from Carol working directly and collaboratively with children with autism and Asperger's syndrome (Gray 1998). Preparing Social Stories™ also enables other people (adults and peers) to understand the perspective of the child with Asperger's syndrome, and why his or her social behaviour can appear confused, anxious, aggressive or disobedient. Carol Gray (2004b) has recently revised the criteria and guidelines for writing a Social Story™ and the following is a brief summary of the guidelines.
A Social Story™ describes a situation, skill or concept in terms of relevant social cues, perspectives and common responses in a specifically defined style and format. The intention is to share accurate social and emotional information in a reassuring and informative manner that is easily understood by the child (or adult) with Asperger's syndrome. The first Social Story™ and at least 50 per cent of subsequent Social Stories™  should describe, affirm and consolidate existing abilities and knowledge and what the child does well, which avoids the problem of a Social Story™ being associated only with ignorance or failure. Social Stories™ can also be written as a means of recording achievements in using new knowledge and strategies. It is important that Social Stories™ are viewed as a means of recording social knowledge and social success.
One of the essential aspects of writing a Social Story™ is to determine collaboratively how a particular situation is perceived by the child with Asperger's syndrome, abandoning the assumption that the adult knows all the facts, thoughts, emotions and intentions of the child- The structure of the story comprises an introduction that clearly identifies the topic, a body that adds detail and knowledge and a conclusion that summarizes and reinforces the information and any new suggestions.
For younger children, the story is written in the first-person perspective, using the personal pronoun 'I', or the child's name if that is how the child refers to himself or herself, and should provide the child with information that can be personalized and internalized (Gray 2002a). For teenagers and adults, the Social Story™ can be written in the third-person perspective, 'he' or 'she', with a style resembling an age-appropriate magazine article. The term Social Story™ could then be changed to Social Article. For example, one of the expectations of friendship and teamwork abilities for employment as a young adult is the ability to give and receive compliments. A magazine-style article of 16 pages, with cartoon illustrations, was written by Carol Gray to explain to adults with Asperger's syndrome why compliments are expected in friendships, in the relationship with your partner, and with colleagues or customers at work (Gray 1999).

If the person has a special interest, this interest can be incorporated in the text. For example, if the child's special interest is the sinking of the Titanic, then scenes from the film or personal recollections in history books or documentaries can be used to illustrate and emphasize some of the key information in the Social Story™ (Gagnon 2001).
Social Stories™ use positive language and a constructive approach. The suggestions are what to do rather than what not to do. The text will include descriptive sentences that provide factual information or statements, and perspective sentences, which are written to explain a person's perception of the physical and mental world. Perspective sentences, which are one of the reasons for the success of Social Stories™ describe thoughts, emotions, beliefs, opinions, motivation and knowledge. They are specifically included to improve Theory of Mind abilities. Carol Gray recommends including cooperative sentences to identify who can be of assistance, and directive sentences that suggest a response or choice of responses in a particular situation. Affirmative sentences explain a commonly shared value, opinion or rule, the reason why specific codes of conduct have been established and why there is the expectation of conformity. Control sentences are written by the child to identify personal strategies to help remember what to do. Carol Gray has developed a Social Story™ formula such that the text describes more than directs. The Social Story™ will also need a title, which should reflect the essential characteristics of the story.
Carol Gray's original work on Social Stories™ has now been examined by many research studies and found to be remarkably effective in improving social understanding and social behaviour in children with autism and Asperger's syndrome (Hagiwara and Myles 1999; Ivey, Heflin and Alberto 2004; Lorimer 2002; Norris and Dattilo 1999; Rogers and Myles 2001; Rowe 1999; Santosi, Powell Smith and Kincaid 2004;Scattone et al. 2002; Smith 2001; Swaggart et al. 1995; Thiemann and Goldstein 2001).
Social Stories™ can be an extremely effective means of learning the relevant social cues at all stages of friendship, but particularly at stage one. Young children will need guidance to understand the thoughts and feelings of the other person and the role or actions expected in a particular situation. For example, the following is part of an unpublished Social Story™ on gestures of reassurance:

Sometimes children hug me. They do this to be friendly. Yesterday, I made three spelling mistakes in the class test. When my friend Amy saw my rest paper and three mistakes, she thought 1 would be sad and I was sad. Amy put her arm around me and said, 'It's okay Juanita.' Amy is my friend. She gave me a hug to help me feel better. For some people, having a hug makes them feel better. Having a hug can make Amy feel better. When 1 have a hug from Amy it is because she knows I am sad and she wants me to feel better. I can say thank you after she has given me a hug.
In the situation described above, the reason for the behaviour of Amy, namely putting her arm around Juanita. may need to be explained to a child with Asperger's syndrome. Such children have difficulty understanding the thoughts, feelings and intentions of others, which can make the behaviour of other people appear illogical and confusing. A gesture of reassurance can repair feelings, not spelling mistakes. Only when the child understands that the action was a gesture of reassurance, intended to repair her feelings of distress, will the behaviour of Amy seem logical and not a cause for confusion and rejection.
After the Social Story™ is written, other people in the child's everyday world will need to know how they can help the child successfully implement the new knowledge and strategies. The child may create a Social Stories™ folder to keep the stories as a reference book at home or school, and have copies of some stories that may be kept in a pocket or a wallet to read again in order to refresh his or her memory just before or during a time when the Social Story™ is relevant.
Other topics for Social Stories™ in stage one of friendship include entry and exit skills (i.e. how to join in and leave an activity), when and how to provide help, and the importance of sharing and accepting play activities suggested by another child. The ability to join a group of children successfully is a particularly difficult skill for children with Asperger's syndrome. The general advice for typical children is to watch, listen, move closer and then ease in (Rubin 2002). Each stage in the entry process may need a Social Story™  for example, the child may need help to recognize and understand the entry signals to ease into a group, such as a welcome look or gesture, the natural pause in conversation or the transition between activities - the 'green-light' signals.

The Social Signals activity
I use a metaphor of a car driver to explain the consequences of not noticing or knowing the social signals. We have developed road signs and driving codes to prevent injuries and damage. A teacher or parent is asked to imagine a driver who does not see or understand the road signs and goes through a red light, exceeds the speed limit or drives too close to another vehicle, any of which can cause an accident.
The child with Asperger's syndrome has difficulty recognizing and knowing how to respond to the social signals that prevent social accidents. When the teacher utters a loud 'Ahem' sound as though clearing his throat, a typical child will know this could be a warning sign similar to the road sign that informs the driver there are traffic lights ahead. The child needs to look at the teachers' face as though looking at traffic lights – if he or she is smiling, a 'green-light' expression, it means you can carry on with whatever you are doing. If the teacher has a frown, but is staring at someone else, this is an 'amber-light' face, meaning be careful, you may have to stop. If he or she is staring at you with an angry expression, a 'red-light' face, it is the clear signal to stop what you are doing or there will be consequences. The child with Asperger's syndrome, however, may interpret the 'Ahem' simply as indicating that the teacher has a dry throat and needs a throat lozenge or a drink.
Children with Asperger's syndrome may not understand the 'no tailgating' signs and encroach on someone's personal space; the 'road closed' sign that indicates 'this will lead nowhere'; or the 'men working' sign that signals 'do not disturb'. In not responding as expected to these social signs, the child with Asperger's syndrome is not being deliberately reckless and provocative, but demonstrating his or her lack of understanding, and will thus be prone to social accidents that damage feelings.
The Social Signals activity uses Social Stories™ to explain the reason for a particular 'rule of the road', and provides clear examples of the signals, and practice in how to respond. The concept of facial expressions as traffic lights can be explored by having a large picture of traffic lights and some pictures of facial expressions. The child with Asperger's syndrome sorts through the pictures and decides which traffic light is associated with each expression. Is this a green-light face, an amber face or a red-light face? The activity includes explaining appropriate comments or questions that the child can use when he or she sees a particular amber or red-light facial expression, such as 'I'm sorry', 'Are you angry with me?', or 'What should I do?'; or when confused as to what the social signal means, questions and comments to prevent further social accidents, such as 'Did I do something wrong?' or 'I am confused.'

Stage two of friendship - six to nine years
At this stage in the development of friendships, typical children start to recognize that they need a friend to play certain games and that their friend must also like those games. Children accept and incorporate the influences, preferences and goals of their friends in their play. Typical children become more aware of the thoughts and feelings of their peers and how their actions and comments can hurt, physically and emotionally. The child is prepared to inhibit some actions and thoughts, to 'think it, not say it', or to tell a 'white lie' in order not to hurt someone's feelings. There is a greater reciprocity and mutual assistance expected in friendships at this stage.
A friendship may develop because both children have similar interests. Aspects of a friend's character rather than possessions are recognized (he's fun to be with, we laugh together). The concept of reciprocity (she comes to my party and I go to hers) and the genuine sharing of resources and being fair in games become increasingly important. When managing conflict the child's view is that the offender must retract the action and a satisfactory resolution is to administer equal discomfort, or 'an eye for an eye'. The concept of responsibility and justice is based on who started the conflict, not what was subsequently done or how it ended. Around the age of eight years the child can develop the concept of a best friend as not only his or her first choice for social play but also as someone who helps in practical terms (he knows how to fix the computer) and in times of emotional stress (she cheers me up when I'm feeling sad). However, not every child has a 'best friend' at this stage.

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Programs for stage two
Role-play activities
In stage two of friendship, children develop greater cooperation when playing with their peers and develop more constructive means of dealing with conflict. It is important that the child with Asperger's syndrome learns the theory of, and gains practice in, various aspects of cooperative play using Social Stories™ and role-play activities. These can provide practice in aspects of cooperative play such as giving and receiving compliments, accepting suggestions, working towards a common goal, being aware of personal body space, proximity and touch, coping with and giving criticism, and recognizing signs of boredom, embarrassment and frustration and when and how to interrupt. The role-play and modelling of aspects of social interaction such as giving compliments can be recorded on video to provide practice and constructive feedback (Apple, Billingsley and Schwartz 2005).
In situations of conflict or disagreement, the child with Asperger's syndrome will need encouragement to seek an adult as an adjudicator, rather than act as the person to determine who is at fault and administer the consequences. Social Stories™ and role-play activities can focus on aspects such as the benefits of negotiation and compromise, being fair and the importance of an apology. Issues of control can be a problem. If the child has a tendency to be autocratic or dominant, or to use threats and aggression to achieve his or her goal, other approaches can be explained and encouraged. You are more likely to get what you want by being nice to someone.

A teacher assistant in the classroom and playground
To facilitate successful social inclusion in the classroom and playground, the child will probably need support staff at school. A teacher assistant can observe the child's social behaviour, particularly behaviours indicative of age-appropriate friendship skills, and provide immediate positive feedback and guidance. The teacher assistant has a number of functions including:

. helping the child identify the relevant social cues and responses

. providing individual tuition using specific activities or games, role-play, rehearsal and writing Social Stories™ with the child

. encouraging other children to successfully include the child with Asperger's syndrome in their play

. providing guidance in managing potential conflict between the child with Asperger's syndrome and peers

. providing positive feedback for the child.
The number of hours in the school day that a child with Asperger's syndrome needs a teacher assistant will vary according to the abilities of the child, the social context and abilities of the peer group.

Playing, with dolls or figures and reading fiction
In stage two of friendship, I have noted that there can be different coping mechanisms used by girls with Asperger's syndrome in comparison to boys. Girls with Asperger's syndrome are more likely to be interested observers of the social play of other girls and to imitate their play at home using dolls and imaginary friends, or adopt the persona of a socially able girl. These activities can be a valuable opportunity to analyse and rehearse friendship skills.
Girls with Asperger's syndrome can develop a special interest in reading fiction. This also provides an insight into thoughts, emotions and social relationships. A boy with Asperger's syndrome can be encouraged to play with figures, usually masculine action heroes, but to re-enact everyday experiences rather than movies, and to read fiction, perhaps based on a special interest - for example, a book such as The Railway Children if the child is interested in trains.

Shared interests
One of the common replies of typical children at this stage in the development of friendship to the question 'What makes a good friend?' is 'We like the same things.' Shared interests are a basis for friendship. I know a child with Asperger's syndrome who had a remarkable interest in and knowledge of insects, especially ants. His peers tolerated his enthusiasm and monologues on ants, but he was not regarded as a potential friend as there was a limit to their enthusiasm for the topic. He was learning friendship skills such as how to have a reciprocal conversation, waiting for the other person to finish what he or she was saying, and how to give and receive compliments and show empathy. When he used these social skills with his class peers, they were achieved by intellectual effort and guidance and perceived by other children as somewhat contrived and artificial. He had few genuine friends.
By chance, another child with Asperger's syndrome lived close by, and also had an interest in ants. Their parents arranged a meeting of the two young entomologists; when they met, the social rapport between the new friends was remarkable. The two boys became regular companions on ant safaris, shared knowledge and resources on insects, made a joint ant study and regularly contacted each other with long and genuinely reciprocal conversations about their latest ant-related discoveries. When observing their interactions, it was clear that there was a natural balance to the conversation, with both children being able to wait patiently, listen attentively, show empathy and give compliments at a level not observed when they were with their typical peers.
Parents and teachers can consider friendship matchmaking, based on the child's special interest. Local parent support groups for families with a child with Asperger's syndrome can provide the names and addresses of families, along with the special interests of the children, in order to arrange a potentially successful friendship. However, I have noted that when the shared interest ends for one partner, the friendship may also end.
The interest can also be used to facilitate friendship with typical peers. My wife's sister has Asperger's syndrome and an outstanding ability in art. She wrote that at school:

Longing to make friends, when someone complimented a drawing I had done, I started giving people drawings until someone accused me of bragging - a rebuke I never forgot. I was only trying to win friendship. (Personal communication)

If the child with Asperger's syndrome has a particular talent such as drawing, a teacher can arrange for the child to form a working partnership with another child whose abilities are complementary. For example, the artist may become the illustrator for a child whose talent is writing stories. This can demonstrate the value of collaboration and teamwork.

Sense of humour
Another reply to the question 'What makes a good friend?' can be 'Someone with a sense of humour'. Children with Asperger's syndrome tend to make a literal interpretation of what someone says and may not understand when someone is joking; however, there can be a wonderful, though sometimes idiosyncratic, sense of humour (Darlington 2001). The very young child may laugh at the way a word is spoken and repeat the word to himself as a very private Joke, but the reason for the humour is not explained or shared. The development of humour can progress to the creation of inventive puns, word associations and word play (Werth, Perkins and Boucher 2001). The next developmental stage of humour can be visual slapstick as occurs in the comedy programmes of Mr Bean and subsequently, at an earlier age than expected, an interest in surreal humour such as the comedy style of Monty Python.
Among peers, the jokes of children between the ages six and nine years can start to include laughter associated with rude words and actions. Other children will be aware of the nature of the Joke, an appropriate context for it, and who would appreciate it. The child with Asperger's syndrome may repeat a rude joke to be popular in circumstances when other children would realize it would not be funny. The joke that causes uproarious laughter among children in the playground is not necessarily the joke to tell your grandmother at the lunch table on Sunday The child may need a Social Story™ to explain why some jokes are funny for some people and not others.
Hans Asperger wrote that children with Asperger's syndrome lack a sense of humour but this is not consistent with my experience of several thousand children with Asperger's syndrome. Many have a unique or alternative perspective on life that can be the basis of comments that are perceptive and clearly humorous. I agree with Claire Sainsbury when she writes, 'It is not a sense of humour we lack, but rather the social skills to recognize when others are joking, signal that we ourselves are joking, or appreciate jokes which rely on an understanding of social conventions' (Sainsbury 2000, p.80).
Some adolescents with Asperger's syndrome can be remarkably imaginative in creating original humour and jokes but the topic is often related to the special interest and may not be created to share the laughter with others (Lyons and Fitzgerald 2004; Werth et al. 2001). I know many teenagers with Asperger's syndrome who create abundant jokes, although sometimes I am not sure what I am supposed to be laughing at. However, the laughter of the person with Asperger's syndrome in response to an idiosyncratic joke is very infectious.

Concentric circles
The child with Asperger's syndrome will probably need guidance in the understanding of the different social hierarchies and social conventions for humour, topics of conversation, touch and personal body space, greetings and gestures of affection. I use an activity where a series of concentric circles are drawn on a very large sheet of paper. In the inner circle is written the name of the child and immediate family members. In the surrounding circle are written the names of people well known to the child but not immediate family, such as his or her teacher, aunts and uncles, neighbours and the child's friends. The next circle, closer to the perimeter, can include the names of family friends and acquaintances, distant relatives and children who are known to the child but are not friends. The next circle can include people known but seen only occasionally, such as a doctor or the person who delivers the mail. The outer circle can include people who are initially strangers or seen rarely, such as the distant relative.
Once the circles and occupants of the circles have been agreed, the topic of conversation is an aspect of social behaviour such as different types of greetings. The adult facilitating the activity can work with the child on finding and cutting out pictures of different types of greetings from magazines. The discussion centres around deciding in which circle to place each greeting. A handshake may be an appropriate greeting for the doctor but not the expected greeting for a grandma. The child may really like and admire his or her teachers but giving them a hug and kiss each morning would not be an age-appropriate greeting for a seven-year-old to give a teacher. An alternative affectionate but verbal greeting can be suggested. The concentric circles activity can become more intriguing for older children when considering the greetings of people from different cultures. In northern Europe, the greeting of female friends can be just a smile, but in France, the expectation is a kiss on each cheek. In New Zealand Maori culture, sticking out one's tongue at a respected guest is a traditional form of welcome. However, a parent may have to explain that if the family do not live in New Zealand, sticking out one's tongue is generally not an acceptable greeting.
The concentric circles activity can also be used with programs on friendship to illustrate many of the rules and different aspects of friendship. For example, it is a very clear way of explaining how someone may 'cross the boundaries' and move from being an acquaintance to being a close friend. The great advantage of the concentric circles activity is that it enables the child to visualize a range of complex social conventions and to know what to say and do when socializing with someone within one of the designated circles,

What not to say
Children with Asperger's syndrome are usually brutally honest and speak their mind. Their allegiance is to the truth, not people's feelings. They may have to learn not to tell the truth all the time. While honesty is a virtue, peers at this stage are starling to tell white lies so as not to hurt friends' feelings, or to express solidarity and allegiance to friendship by not informing an adult of the misbehaviour of a friend. Such behaviour may appear immoral and illogical for a child with Asperger's syndrome, who is willing to inform the teacher 'who did it' and that a friend has made a stupid mistake. This is not a recommended way to make or keep friends - The child with Asperger's syndrome may benefit from Social Stories™ to understand why it is appropriate at times to say something that is not the truth, and when to stay quiet.

An anthropologist in the classroom
One way to describe a person with Asperger's syndrome is someone who comes from a different culture and has a different way of perceiving and thinking about the world. Some adults with Asperger's syndrome have suggested that the term Asperger's syndrome should be replaced with 'wrong planet' syndrome- Clare Sainsbury, an Oxford university graduate who has Asperger's syndrome, has written a book entitled Martian in the Playground (2000) to help parents and teachers understand Asperger's syndrome. The conceptualization of someone with Asperger's syndrome as being from a different culture or planet can help change the attitudes of adults and peers, but can also be used to substantiate an intervention strategy.
The child with Asperger's syndrome is trying to understand our social customs in much the same way as an anthropologist who has discovered a new tribe will want to study its people and customs. The anthropologist will need someone from that culture to explain the culture, customs and language. A teacher or teaching assistant assigned to the child with Asperger's syndrome can take the role of a guide to explain this new culture or civilization. The process is one of discovery and explanation of the reason for particular customs. A visitor to a new culture will need a guidebook, and writing Social Stories™  is a collaboration between the guide (teacher) and anthropologist (child). Teenagers and adults with Asperger's syndrome would certainly benefit from writing or reading a travel guide to understanding and living with typical people, or, to use a term created by adults with Asperger's syndrome, neurotypicals.
The representative of the culture, or personal guide, can sit with the anthropologist in a corner of the classroom or playground and both watch, comment and make notes on the social interactions of the children, with the guide providing an explanatory commentary. Another activity is the game of 'spot the friendly act', taking turns to identify an act of friendship. The guide comments on why the particular behaviour is considered friendly or not friendly. A people-watching game, with a guide, can provide information on friendship without the child with Asperger's syndrome feeling that he or she is the centre of attention, or the person who inevitably makes mistakes.

After-school social experiences
Children with Asperger's syndrome work twice as hard at school as their peers, as they are learning both the academic and the social curriculum. Unlike other children, they are using cognitive abilities rather than intuition to socialize and make friends. As explained by Stephen, Tt takes all my brain power to be a friend.' At the end of the school day, the child has usually had enough social experiences and desperately needs to relax in solitude. As far as the child with Asperger's syndrome is concerned, friendships end at the school gate. The child can therefore resist parents' suggestions to contact friends from school or play with neighbourhood children. He or she has had enough socializing at school, and parents may need to accept that the child does not have the energy or motivation to socialize any more. If parents arrange social experiences, it is important that the experiences are brief, structured, supervised, successful and voluntary.

Social skills groups
There has been some success reported in the research literature for social skills groups for children, adolescents and young adults with Asperger's syndrome (Andron and Weber 1998; Barnhill et al. 2002; Barry et al. 2003; Bauminger 2002; Broderick et al. 2002; Howlin and Yates 1999; Marriage, Gordon and Brand 1995; Mesibov 1984; Ozonoff and Miller 1995; Soloman, Goodlin-Jones and Anders 2004; Williams 1989). The group members receive information on why certain skills are important, and practise applying those skills using modelling, role-play, reviewing video recordings and receiving constructive feedback from the group leader and fellow participants. The programs have focused on conversation skills, reading and interpreting body language, understanding the perspective of others and friendship skills. A variation on this approach, focusing on the development of emotional intelligence, has been conducted by Andron and Weber (1998), who have coordinated social skills groups using family members, especially siblings, as participants. Their curriculum emphasizes the development of appropriate affect or emotions in social situations.
At present it is extremely difficult to determine whether social skills groups are an effective means of improving the social integration skills of children with Asperger's syndrome. Outcome measures have primarily been qualitative and we do not know if this technique can change specific skills in natural settings. Nevertheless, experience has shown that the groups are perceived as valuable by parents, teachers and participants- In particular, the participants have appreciated the opportunity to meet people similar to themselves who share the same confusion and experiences. This can be the basis of subsequent friendships and self-help groups.

Programs for peers
The other children in the class of the child with Asperger's syndrome will need explanations and guidance in understanding and encouraging the friendship abilities of their classmate. Such children will know that the child with Asperger's syndrome does not play or interact with them in the same way as other children. Without guidance and support from the teacher, the reaction to the child with Asperger's syndrome can be rejection and ridicule rather than acceptance and inclusion in their activities. As much as we have programs to help the child with Asperger's syndrome integrate with his or her peers, the other children need their own programs. They will need to know how to respond to behaviours that appear unfriendly and how to encourage abilities that facilitate friendships - A successful interaction requires a constructive commitment from both parties, and a teacher will need to be a good role model of what to do, and should commend other children who adapt to, welcome and support the child with Asperger's syndrome.The peer group may need their own equivalent of Social Stories™ to improve mutual understanding and to be encouraged to provide guidance for the child with Asperger's syndrome when the teacher is not present or available.

Stage three of friendship - 9 to 13 years
In the third stage in the development of friendships there is a distinct gender split in the choice of friends and companions, and a friend is defined not simply as someone who helps but as someone who is carefully chosen because of special personality attributes. A friend is someone who genuinely cares with complementary attitudes, ideas and values. There is a growing need for companionship and greater selectivity and durability in the friendship alliances. There is a strong desire to be liked by peers and a mutual sharing of experiences and thoughts rather than toys.
With an increase in self-disclosure there is the recognition of the importance of being trustworthy and a tendency to seek advice not only for practical problems but also for interpersonal issues. Friends support each other in terms of repairing each other's emotions. If children are sad, close friends will cheer them up, or if angry, calm them down, to prevent them from getting into trouble.
Friends and the peer group become increasingly important in strengthening or destroying self-esteem and determining what is appropriate social behaviour. Peer-group acceptance and values can override the opinion of parents. The power of the peer group can become greater than the power of adults.
When conflicts occur, friends will now use more effective repair mechanisms. Arguments can be less 'heated', with reduced confrontation and more disengagement, admission of mistakes and recognition that it is not simply a matter of winner and loser. A satisfactory resolution of interpersonal conflict between friends can actually strengthen the relationship. The friend is forgiven and the conflict is put in perspective. These qualities of interpersonal skills that are played out in friendships are the foundation of interpersonal skills for adult relationships.

Programs for stage three
Same-gender friendships
In stage three of friendship, there is usually a clear gender preference in the choice of friends and associates. The activities and interests of boys, who may be playing team games or seasonal sports, may be considered of little interest to boys with Asperger's syndrome. They are also likely to be less able than male peers to understand team games, and clumsy with regard to ball skills, dexterity and coordination. Will Hadcroft explained in his autobiography that:

I was frightened of the other boys, and this was very apparent to them. Tackling was a nightmare, and I let the ball go without much of a fight, to the fury of my fellow team members. (Hadcroft 2005, p.62)

The boy with Asperger's syndrome knows that he is usually the last person chosen for a team and can be actively shunned and alienated from potential male friends.
When the boy with Asperger's syndrome is alone in the playground, he is likely to be approached by one of two groups: the predatory males who seek someone socially isolated, vulnerable and gullible to tease and torment (see Chapter 4); or girls, who feel sorry for the boy because of his apparent loneliness, and offer inclusion and support in their activities and games. While other boys at this age would usually shun girls, using derogatory and sexist remarks, he can be recruited into the play of girls and actively welcomed. If the boy with Asperger's syndrome is unsure what to do when socializing with girls, his female friends are more likely to be supportive than critical - 'He's a boy so he wouldn't understand, so I'll help him.' There can be the development of genuine 'opposite-gender' friendships.
Having opposite-gender friends at this stage of friendship can have two consequences for boys with Asperger's syndrome; further alienation from boys who consider he is 'fraternizing with the enemy', and absorption within the female culture through imitation, resulting in the development of feminine body language, vocal characteristics and interests. The child may enjoy and benefit from the friendships with girls, but other boys may taunt him as being more like a girl, often using the description 'gay' as an insult. The boy may feel that the only gender to accept and understand him is female - his mother, perhaps his sisters, and his female friends, which could contribute to gender-identity problems.

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I have noted that some girls with Asperger's syndrome at this stage of friendship development can reject the companionship of same-gender friends. They may be critical of their peers for enjoying affection and feeling games, and for talking about whom they like or dislike for reasons that seem to be illogical or untrue. The in- and out-group members and rapidly changing friendship cliques are confusing. So too is peer pressure, which can often centre around what is viewed as 'cool' in the way of clothing and accessories. The girl with Asperger's syndrome can have considerable difficulty understanding these new dimensions to friendships, and tends to prioritize logic, truth and comfort over peer pressure. The choice of clothing is likely to be what is comfortable rather than popular or fashionable, and very often this is male clothing, as it is the most comfortable and practical. Hair may be worn very long to create a curtain or wall behind which the girl can 'hide', or very short for convenience, with no desire to appear 'feminine'.
While the activities of other girls can be confusing and illogical to the girl with Asperger's syndrome, the activities of boys can be interesting and based on physical activities rather than emotions. She may be interested in, and then 'adopted' or recruited by, a group of boys. She becomes known as a 'tomboy', with male friends who are more tolerant of someone who has 'come over to their side'; and once again, if she is unsure what to do in a social situation, she is likely to experience support, not ridicule - 'She's a girl, she wouldn't understand. But that's OK, we don't mind.'
The child with Asperger's syndrome needs a balance of same- and opposite-gender friends, and some social engineering could be necessary to ensure acceptance by both gender groups. Teachers will need to monitor group inclusion and exclusion and actively encourage children of the same gender to allow and support the acceptance and integration of the child with Asperger's syndrome.

A mentor or buddy
During stage three of friendship there is a strong desire for companionship rather than functional play, and children with Asperger's syndrome can feel lonely and sad if their attempts at friendship are unsuccessful (Bauminger and Kasari 2000; Carrington and Graham 2001). They will need programs and guidance in friendship, but this may now be achieved by discussion with supportive peers as well as adults. Some typical children who have a natural rapport with children with Asperger's syndrome can be identified and encouraged to be 'buddies' or mentors in the classroom, playground and in social situations. A buddy's advice may be accepted as having greater value than that of parents or teachers, especially if the buddy is socially skilled and popular. A mentor at school, or a sibling, may provide advice and guidance on what is up-to-the-minute from the perspective of the child's peers in terms of what to wear and talk about, so that the child is less conspicuous and less likely to be subjected to ridicule for not being 'cool'.
From the perspective of their peers, children with Asperger's syndrome are 'poor' in terms of the currency of friendship. They may not wear fashionable clothes or be interested in the popular television programmes or merchandise. In return, children with Asperger's syndrome perceive peers as having limited currency for the Asperger's syndrome culture, namely knowledge. Peta, a girl with Asperger's syndrome who has an encyclopaedic knowledge of the weather, finds other girls her age boring, as they only want to talk about magazines and make-up. She wants to talk about meteorology, which is perceived as equally boring by her peers.

An alternative friendship group
The child with Asperger's syndrome may not easily identify with the new social groups forming during this stage of friendship. The child may be shunned by groups that value sporting abilities due to being clumsy, by academic groups if he or she has a different learning style, and by the groups of socialites because of limited social skills. Unfortunately, there is one group, the disreputable characters, who may accept and include the person with Asperger's syndrome. This group always has an open door, but admission and acceptance is by engaging in inappropriate, anti-social behaviour - not the most appropriate model for children with Asperger's syndrome. A teacher may need to arrange for entry into a more socially acceptable group by encouraging a popular member of that group to act as a mentor or buddy.
Equally, a teacher may consider arranging an alternative group based on the attributes of children with Asperger's syndrome. This group comprises the collectors, scientists or computer experts. Every school will have a few such children who have similar abilities and interests but not the other characteristics needed for a diagnosis. The new group can meet at recess and lunchtime to compare and exchange items of mutual interest (often merchandise based on Japanese animated cartoon characters), undertake a project set by a science teacher, or learn computer-programming techniques from the school information technology teacher. The friendships can be relatively safe from criticism and based on shared interests.
A parent support group may consider publishing a regular newsletter for children and young adolescents with Asperger's syndrome. The contributions can be written by the children and include information on special interests that may be shared by readers and editorial staff, news of group members and examples of their work, reviews of interesting films and books, including books on Asperger's syndrome, and cartoons, editorials, correspondence and advice columns. One teenager considered that his graduation from a social understanding group gave him the qualifications to be a mentor to other adolescents with Asperger's syndrome and provide advice on friendship in the advice column of a school newsletter.

Developing teamwork skills
In early adolescence, children with Asperger's syndrome can become increasingly self-conscious about being different, and resent any suggestion that they might have difficulties making friends or should accept programs. They do not want their social difficulties to be in the 'spotlight' or to be considered a social retard. One option that can enable the pre-adolescent or adolescent to accept programs to improve social and friendship abilities is to change the name of the programs from friendship skills to teamwork skills. All the attributes of a good friend are the same as for a good team member. Class programs on teamwork skills are socially acceptable among peers. Success in sport is valued very highly at this age, especially team sports, and the most successful team does not necessarily comprise the best players, but the most cohesive members. Programs to develop teamwork skills are also relevant to successful employment. Companies often require an applicant to have the ability to be a 'team player', and guidance in teamwork can be accepted by the adolescent with Asperger's syndrome as necessary to achieve his or her career choice. There is then likely to be greater cooperation and motivation.

Drama classes
Another option to help the adolescent who is sensitive to being publicly identified as having few friends and socially naive is to adapt drama classes. Hans Asperger's nursing sister, Viktorine Zak, at the Vienna Children's Hospital, developed the first programs in the 1940s for children with Asperger's syndrome. She used drama activities to teach the children social skills (Asperger [1944] 1991). When I met Hans Asperger's daughter,
Maria, she was able to describe the programs developed by Sister Zak at the children's hospital. Unfortunately, she was killed during an allied bombing raid on Vienna and buried with the child she was clutching and trying to save.
Liane Holliday Willey, in her book Pretending to be Normal, describes how she improved her social skills by observation, imitation and acting (Willey 1999). This is an appropriate and effective strategy, especially in stage three of friendship development. The teenager with Asperger's syndrome can learn and practise aspects of adolescent interaction such as suitable conversation topics, the art of being a good listener, expressing affection for someone, and when and how much personal information to disclose. Drama activities can teach appropriate body language, facial expressions and tone of voice, and provide an opportunity for the young person with Asperger's syndrome to act and rehearse responses to specific situations, such as being teased.

Television programmes
Popular television programmes can be used to explain and teach aspects of social behaviour. The Mr Bean series in particular can identify the consequences of not being fully aware of someone's thoughts and feelings and of breaking the social codes. The character of Mr Bean and his experiences can be particularly entertaining and informative for children with Asperger's syndrome. The illogical aspects of humans and social conventions can be explored in programmes such as Third Rock from the Sun; and science-fiction series such as Star Trek provide us with characters (for example, Mr Spock and Data) whose perception, experiences and wisdom are enlightening.

Resources
Towards the end of the book I have provided a list of resources and books that desc ribe and explore aspects of friendship in this age group (and other age groups) for typical children, and are quite informative and entertaining. For example, Judge Judy Sheindlin (2001) has written You Can't Judge a. Book by it's Cover: Cool Rules for School which includes scenarios associated with friendship that require the child to make social judgements. For example, next to a drawing of a child who has opened his lunch box and looks at his companion with a quizzical expression, there is a description of the situation and a choice of options:

The salami sandwich that your mother prepared for you is missing from your lunch box. You suspect one of your friends took it because he smells like salami.
You should:
A.  Ask him if he saw your sandwich
B.  Take his lunch box and search it
C.  Steal his lunch
D.  Tell him your sandwich smells like salami but really is dog food.
(Sheindlin 2001,p.51)

A similar style is used in the book I Did It, I'm Sorry by Caralyn Buehner (1998), to explain that there can be more than one correct response to social situations. Unlike the world of science (especially mathematics), there is rarely only one correct solution to a social problem. Children with Asperger's syndrome often seek certainty and the correct and simple solution to a problem. However, the appropriate response or solution in the social world may be based on an evaluation of the merits and consequences of a particular solution for all participants. This requires quite complex reasoning and the ability to make a judgement on the balance of probability and equity, and not certainty. My clinical experience suggests that children with Asperger's syndrome have a limited range of options or solutions for social problems. Some suggestions can be immature, provocative or impulsive, but with encouragement and careful thought, the child can suggest or learn alternative appropriate and more effective solutions.
I also strongly recommend the advice of fellow teenagers with Asperger's syndrome. Luke Jackson, a remarkable and talented young man with Asperger's syndrome, has written a self-help guide for fellow adolescents with Asperger's syndrome (L. Jackson 2002). He provides the following analysis of peer interactions and offers astute advice.

On the subject of rules, I am sure that all of you AS teenagers have been given some rules on how to behave appropriately. Have you heard of these?

.Don't 'invade people's space' - that means get too close to them.

.Don't stare at someone for whatever reason (however fit they are!).

.Don't make comments about people's bodies, good or bad.

.Don't tell dirty, sexist or racist jokes or make sexual innuendos.

.Don't hug or touch people unless they are part of your family or they have agreed to be your boyfriend or girlfriend and you have both agreed to do it.

If you haven't heard any of those rules, then now you have! Here comes the but... you Just watch and listen to a group of teenage boys or girls. First, they will either huddle up together really close or tower over someone in a threatening way. Next they make all sorts of rude comments about the size of people's uh hum ...what can I say?! They tell dirty jokes and make sexual innuendos at every opportunity and they will often touch someone or put their arm around them, when they are not a member of their family, their boyfriend or girlfriend.
If these are the rules, then it seems that when boys and girls are in their teenage packs, performing their adolescent rituals, then these rules go out of the window. What a strange world we live in! All in all I would say to stick to the rules and ignore the fact chat others seem to be breaking them. (L. Jackson 2002, pp. 104-5)

Pre-teens and teenagers with Asperger's syndrome will need advice on puberty and how this will affect their bodies and thinking, but they will also need information and advice on the changing nature of friendship and sexuality. We now have programs and literature developed by Isabelle Henault to explain puberty and sexuality that have been specifically designed for teenagers with Asperger's syndrome (Henault 2005).

Stage four of friendship - 13 years to adult
In the previous stage of friendship there may be a small core of close friends but in stage four the number of friends and breadth and depth of friendship increases. There can be different friends for different needs, such as comfort, humour or practical advice. A friend is defined as someone who 'accepts me for who I am' or 'thinks the same way as me about things'. A friend provides a sense of personal identity and is compatible with one's own personality . It is important at this stage that one is able to accept the self before being able to relate to others at an adult level - otherwise friendships may be manipulated as a means of resolving personal issues. There are less concrete and more abstract definitions of friendship, with what may be described as autonomous inter-dependence. The friendships are less possessive and exclusive, and conflict is resolved with self-reflection, compromise and negotiation. During adolescence, friendships are often based on shared interests such as academic achievements, mutual participation in sports and recreational activities and passion for causes such as eradicating world poverty .The person increasingly spends more time with friends than parents, and allegiance can be to friends rather than family.

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Young adults with Aspcrger's syndrome can have a remarkable insight into the difficulties they face in social situations. Scott has Asperger's syndrome and in a college essay wrote:

Social skills are a foreign language to me. Most of my peer interactions are awkward and unintuitive. I have to guess whether a behaviour is appropriate or not, unlike my friends, who rely on instinct seemingly without effort. These difficulties with navigating life's daily social challenges are the main disadvantage of my neurological disorder, a high-functioning form of autism called Asperger's syndrome that makes it harder for me to lead a normal life- Yet while I get discouraged at times, I do not believe Asperger's syndrome is anything to be ashamed of; it is simply another way of looking at the world. Most people I encounter do not know about Asperger's syndrome and therefore misunderstand my behaviours. My efforts to make friends, for example, have often driven people away. (Personal communication)

Programs for stage four
One of the characteristics of a good friend at stage four is someone 'who accepts me for who I am'. Some adults with Asperger's syndrome have commented to me that no one seemed to accept them for who they were; ‘They always wanted me to be different, a copy of themselves.' Eventually the person may find a friend who really does accept him or her - a friend who is not constantly trying to impose change, and who genuinely admires some of the characteristics of Asperger's syndrome.
However, acceptance may come from another source of 'friendship': animals.

Animals as friends

Animals provide unconditional acceptance. The dog is always delighted to see you, despite the day's disappointments and exhaustion. The horse seems to understand you, and wants to be your companion. The cat Jumps on your lap, and purrs in your company. I have suggested that cats are autistic dogs, so there may be a natural affinity between cats and people with autism and Asperger's syndrome. Ronald, a mature adult with Asperger's syndrome, wrote to me in an e-mail that 'I only start to be alive and truly natural when alone or with my cats'. Thus, pets, and animals in general, can be effective and successful substitutes for human friends, and a menagerie becomes a substitute 'family'- Animals identify with, and feel relaxed in the company of, a non-predator (the person with Asperger's syndrome), and pets can be a source of comfort and reassurance. A special interest in and natural understanding of animals can become the basis of a successful career (Grandin 1995). And I have found that children and adults with
Asperger's syndrome are sometimes more able to perceive and have compassion for the perspective of animals than humans.
Internet friends
The Internet has become the modern equivalent of the dance hall in terms of an opportunity for young people to meet. The great advantage of this form ofcommunicarion to the person with Aspergers syndrome is that he or she often has a greater eloquence in disclosing and expressing thoughts and feelings through typing rather than face-to-face conversation. In social gatherings the person is expected to be able to listen to and process the other person's speech, often against a background of other conversations, to reply immediately, and simultaneously analyse non-verbal cues such as gestures, facial expression and tone of voice. When using the computer, the person can concentrate on social exchange without being overwhelmed by so many sensory experiences and social signals.
As in any social situation, the person with Aspergers syndrome may be vulnerable to others taking advantage of his or her social naivety and desire to have a friend. The person with Asperger's syndrome needs to be taught caution and not to provide personal information until he or she has discussed the Internet friendship with someone who can be trusted. However, genuine and long-lasting friendships can develop over the Internet based on shared experiences, interests and mutual support. The Internet provides an opportunity to meet like-minded individuals who accept the person because of his or her knowledge rather than his or her social persona and appearance. Internet 'friends' can share experiences, thoughts and knowledge using chat lines, web pages and message boards dedicated to people with Asperger's syndrome.

Support groups
An interesting recent development is the formation of support groups for adults with Asperger's syndrome, with regular meetings to discuss topics that range from employment issues to personal relationships, and social occasions for the participants, such as excursions to the train museum, or the cinema to see the latest science-fiction film. Friendships can develop between like-minded individuals who share similar experiences and circumstances. There is a variety of ways that support groups can begin. For example, a group can initially be formed by parents of young adults with Asperger's syndrome; or by individuals with Asperger's syndrome who originally met each other in group counselling or therapy sessions and wanted to maintain contact- Older adults with Asperger's syndrome who want to help others who share the same diagnosis and difficulties may form support groups. Groups can be started by final-year college students wanting to help newly enrolled students with Asperger's syndrome; or by someone who used to belong to and benefit from being a member of a support group, who moves to another town and wants to start a support group locally.

In Los Angeles, Jerry Newport founded AGUA, a support group for adults with
Asperger's syndrome, and it was at one of the support group meetings that he met Mary, a woman with Asperger's syndrome. The relationship gradually became less platonic and more romantic and eventually Jerry and Mary married each other. Their romance and relationship are portrayed in the film Mozart and the Whale.

Information on relationships
Teenagers with Asperger's syndrome'may be keen to understand and experience the social and relationship world of their peers, including sexual experiences, but there can be some concerns regarding the source of information on relationships. If the teenager with Asperger's syndrome has few friends with whom she or he can discuss personal topics, such as romantic or sexual feelings for someone, the source of information on relationships may be television programmes ('soap operas' and situation comedies in particular) or pornography. The television dramas and situation comedies often portray intense and dramatic emotions and relationships. The teenager with Asperger's syndrome may remember and apply the actions and script in an inappropriate context, For example, Tim watched a popular situation comedy in which the line '1 want to have sex with you' resulted in considerable laughter from the audience, Tim did not consider the context, only the request, and could not understand why his peers did not laugh when he said the same line to a girl in class. Reading or watching pornography, the teenager with Asperger's syndrome may presume intimate acts occur very quickly in a relationship and will be less aware of any concerns regarding consent.
The source of information on relationships can be same-age peers who may recognize that the person with Asperger's syndrome is naive, gullible and vulnerable. Peer advisors with cruel intent can provide information and make suggestions that cause the person with Asperger's syndrome to be ridiculed, or encourage others to assume malevolent intentions. The person with Asperger's syndrome can easily be 'set up' and suffer the consequences of deliberately misleading suggestions. It is important that the teenager with Asperger's syndrome has access to accurate information on relationships, especially the early stages in a relationship that goes beyond friendship, and to have someone he or she trusts to provide guidance.
I have known previously socially isolated teenage girls with Asperger's syndrome who, after the physical changes that occur at puberty have become flattered by the attention of boys. Due to their naivety, they have not realized that the interest was sexual, and not simply to enjoy their conversation and company. When the teenage girl lacks female friends to provide advice on dating and intimacy there can be concern with regard to promiscuity and sexual experiences- Teenage girls with Asperger's syndrome are often not 'street wise' or able to identify sexual predators, and may become vulnerable to sexual exploitation when desperate to be popular with peers.

Social anxiety
Adolescents, especially girls, with Asperger's syndrome can be increasingly aware of being socially naive and making a social mistake. The worry about social incompetence and conspicuous errors can lead to the development of a social phobia and increased social withdrawal. Carrie said to me that 'I live in a constant state of performance anxiety over day-to-day social encounters.'
The anxiety can be especially acute at the end of the day, and before falling asleep, when the teenager reviews the social experiences of the day. He or she may now be very aware of what other people may think and this can be a significant cause of anxiety ('I probably made a fool of myself) or depression ('I always make mistakes and always will').
It is essential that teenagers and young adults with Asperger's syndrome receive positive feedback on social competence from parents and peers, and guidance and preparation for what to do and say in social situations. The intention is to change a negative self-perception to a positive or optimistic self-perception, to focus on achievements, not errors. Strategies to change attitudes and self-perception will be explained in the Cognitive Behaviour Therapy section of Chapter 6 and in Chapter 14 on psychotherapy

Maintaining the friendship
When a friendship does occur, one of the difficulties for people with Asperger's syndrome is knowing how to maintain it. At this stage, the issues are those of knowing how often to make contact, appropriate topics of conversation, what might be suitable gifts, empathic comments and gestures, as well as how to be generous or tolerant with regard to disagreements. There can be a tendency to be 'black or white', such that when a friend makes a transgression the friendship is ended rather than reconciliation sought. A useful strategy is to encourage the person to seek advice from other friends or family members before making a precipitous decision.

Providing a reason/or the characteristics of Asperger's syndrome
If a young child is diagnosed with Asperger's syndrome, early intervention designed to improve social abilities in primary or elementary school and continued up to the end of high school can achieve remarkable success. Although so far we do not have any longitudinal research data to substantiate the progress in social understanding and peer relationships, clinical experience can testify to the benefits of social understanding programs for individual children. When someone first acquires the diagnosis in his or her adolescent or adult years, the person has missed the opportunity to benefit from early intervention and, as an adult, is less likely to have access to programs and resources.
An option for such adults is not to seek elusive programs that may take decades to achieve success, but simply to acquire a means of explaining why an attribute of Asperger's syndrome is confusing to friends, colleagues or acquaintances. For example, the person with Asperger's syndrome may not look at the other person as much as would be expected in a conversation, and especially when answering a question. Rather than undertake a program to know when to look at someone and read facial expressions, I recommend explaining the avoidance of eye contact: for example, 'I need to look away to help me concentrate on answering your question. I am not being rude, dishonest or disrespectful.' When talking about a special interest that is likely to be perceived as boring, the person with Asperger's syndrome may say, before starting the monologue, 'Sometimes I talk too much about my interests. If I am boring you, please ask me to stop. I will not think you are being rude.' The person creates a spoken Social Story™ or typical people to explain what appears to be eccentric or rude behaviour.
When given a succinct and accurate explanation, the typical person can be less confused by and more tolerant of the characteristics of Asperger's syndrome. The person with Asperger's syndrome may need some guidance in thinking of an explanation. However, I have noted that the parent or partner of an adult with Asperger's syndrome may have been providing such explanations to other people for many years.

Moving to another culture
I frequently give presentations on Asperger's syndrome in many countries throughout the world. When in countries with a very different culture to my own, I am amazed at the number of people from English-speaking countries who have Asperger's syndrome in the audience. When I was last in Japan, I met Richard, a charming man from England, who has lived in the Far East for several years. Richard explained that if he makes a social error in Japan, his behaviour is acknowledged as being due to cultural differences, not a deliberate attempt to offend or confuse. The Japanese are remarkably tolerant of his social clumsiness, especially as he is very keen to speak Japanese and clearly admires the culture. Stephen Shore explained to me in an e-mail that 'some people (me included) with Asperger's syndrome enjoy visiting and even living in foreign countries for extended periods of time. Their differences and "social blindness" are then attributed to being in a foreign country rather than a mistaken assumption of wilful behaviour.'
The person with Asperger's syndrome may also make friends with visitors to his or her culture. Visitors sometimes share the same challenges integrating into a new culture as the 'native' with Asperger's syndrome.

Friendships with colleagues
Due to a developmental delay in the conceptualization of friendship, when the person with Asperger's syndrome reaches stage four of friendship development, he or she may have left high school and be seeking friends through work, college and recreational pursuits. Attempts to change a relationship from colleague or workmate to friend can present some challenges to the young adult with Asperger's syndrome. A mentor at work who understands his or her unusual personality and friendship skills can provide guidance and act as a confidant and advocate.
The mentor can also help determine the degree of genuine interest in friendship from the colleague. Sometimes people with Asperger's syndrome assume that a friendly act, smile or gesture has greater implications than was intended, and this may lead to the development of an intense interest or infatuation with a person who appears kind and friendly.
The duration of socializing
We each have a limited capacity for the duration of social contact. I use the metaphor of filling a 'social bucket'. Some typical individuals have a large social bucket that can take some time to fill, while the person with Asperger's syndrome has a small bucket, or cup, that reaches capacity relatively quickly Conventional social occasions can last too long for someone with Asperger's syndrome, especially as social success is achieved by intellectual effort rather than natural intuition. Socializing is exhausting.
The person with Asperger's syndrome is more comfortable if social interactions are brief and purposeful, and when complete, he or she is able to end the interaction or participation. It is important that others are not offended by an abrupt ending to a conversation or social gathering, as offence was not intended. The person must leave due to exhaustion and is not being inconsiderate,
Another characteristic that can affect the duration of social contact is the difficulty people with Asperger's syndrome have in finding someone that they want to talk to and spend time with. As Darren said to me, 'It's not that I'm anti-social, it's that I don't meet many people that I like.'

THE PROGNOSIS FOR THE DEVELOPMENT OF SOCIAL
UNDERSTANDING
Hans Asperger considered that:

Normal children acquire the necessary social habits without being consciously aware of them, they learn instinctively. It is these instinctive relations that are disturbed in autistic children. Social adaptation has to proceed via the intellect, (Asperger[1944] 1991, p.58)

There may be two ways to acquire a skill - intuition or instruction. Children and adults with Asperger's syndrome will need tuition in specific social skills. I recommend that the learning process include an explanation of the rationale for the specific social rule. The child with Asperger's syndrome will not change his or her behaviour unless the reason is logical. The teaching style is that of making a mutual discovery in the social world. The person with Asperger's syndrome is almost an anthropologist, conducting research on a newly discovered culture; and [he 'teacher' or representative of the culture will need to discover and appreciate the perspective, different way of thinking and culture of the person with Asperger's syndrome. It is important not to make a value judgement that one culture is superior to the other.
Those with Asperger's syndrome can perceive typical people as social zealots who assume that everyone can and should socialize without effort, and that anyone who does not prioritize and excel at socializing must be defective, ridiculed and corrected. There needs to be a compromise between the two cultures. Those in the typical culture communicate in 'social telegrams' assuming the other person can fill in the gaps.
Such assumptions should not be made when engaged in a social interaction with someone with Asperger's syndrome. Also, typical people may complain that the person with Asperger's syndrome is not good at explaining why he or she did something that appeared to contravene the social codes; but, equally, typical people are not good at explaining the exceptions to the codes and reasons for their social behaviour.
When considering the prognosis for social interaction skills, Hans Asperger (1938) wrote that;

These children can take note of 'rules of etiquette' given to them in a down-to-earth kind of way, which then they can fulfil-like they would a sum. The more 'objective' such a law is - maybe in a form of schedule, which includes all possible variations of daily routines, and which must be stuck to by both parties in the most pedantic kind of way - the better it will be. So it is not through a habit, which unconsciously and instinctively grows by itself, but through conscious, intellectual training, in years of difficult and conflict-ridden work, that one will achieve the best possible assimilation to the community, which will be more and more successful with growing intellectual maturity. (Asperger 1938, p. 10)

Gradually the person with Asperger's syndrome can build a mental library of social experiences and social rules. The process is similar to learning a foreign language with all the problems of exceptions to the rule for pronunciation and grammar. Some adults with Asperger's syndrome consider that social conversations appear to use a completely different language, for which they have no translation and which no one has explained to them.
I use the metaphor of a social jigsaw puzzle of 5 000 pieces. Typical people have the picture on the box of the completed puzzle, the innate ability to know how to relate or connect to fellow humans. The social puzzle is completed in childhood relatively easily .The picture on the box, or intuition, can generally be relied on to solve a social problem. The child with Asperger's syndrome does not have the picture, and tries to identify the connections and pattern from experience and, one would hope, some guidance. Eventually, some pieces of the social puzzle fit together in small groups of disconnected 'islands', and after three or four decades, a pattern is recognized and the completion of the puzzle accelerates. Some people with Asperger's syndrome are eventually able to socialize reasonably well, with typical people unaware of the mental energy, support, understanding and education that is required to achieve such success. Perhaps the final words in this chapter should be from Liane Holliday Willey who, in her autobiography Pretending to be Normal, wrote:

Looking far over my shoulder, I can call to mind people who must have been interested in friendship. I can see a boy I knew as if it was yesterday. I can remember his -face and the expressions he made as we talked. Today if he looked at me like he did then, I believe I would have seen the kindness and gentleness that was his. I never did much with this boy when 1 had the chance. I missed his offer of friendship. I would not miss that offer if it were made today. His face would make sense to me today. (Willey 1999, pp.61-2)
KEY POINTS AND STRATEGIES

Stage 1

.An adult can act as a friend to the child.
.Teach the child to take turns and ask for help.
.Organize a dress rehearsal with another child.
.Encourage the child to watch a video recording of children playing.
.Play pretend games with the child.
.Give encouragement to the child for being friendly.
.Write Social Stories™ to help the child understand specific social
situations.
.Use 'social signals' activity to teach the social signs to prevent social accidents.

Stage 2
.Use role-play activities to provide practice in aspects of cooperative
play.
.Provide a teacher assistant in the classroom and playground to offer
guidance and feedback for the child and his or her friends.
.Encourage boys and girls to play with figures or dolls and read fiction.
.Seek shared interests with like-minded children,
.Help the child to develop a sense of humour.
.Use concentric circles to help the child to learn social conventions for greetings, topics of conversation, touch and personal body space and gestures of affection.
.Teach the child what not to say.
.Be the guide to the child as 'anthropologist' in the classroom to explain social customs.
.Ensure that after-school social experiences are brief, structured,
supervised, successful and voluntary.
.Enrol the child in social skills groups.
.Provide programs for peers on how to play with and be a friend of someone with Aspcrger's syndrome.
Stage 3

.Encourage same-gender and opposite-gender friendships.
.Encourage a peer to become a mentor or buddy to the child.
.Help the child to find and join an alternative group of friends who have
similar interests and values.
.Introduce programs to develop teamwork skills as a way to teach friendship skills.
.Encourage the child to attend drama classes.
.Use television programmes, especially situation comedies and science
fiction, to illustrate aspects of social behaviour.
.Use books and resources to teach friendship skills.

Stage 4
.Encourage the person to view animals as potential friends.
.Encourage the person to use the Internet as a source of friendship.
.Suggest the value of support groups for young adults with Asperger's
syndrome.
.Provide information on relationships.
.Explore different strategies to reduce performance anxiety in social
situations.
.Provide guidance on how to maintain a friendship.
.Teach the person how to explain the characteristics of Asperger's
syndrome to someone.
.Explore the advantages of moving to another culture.
.Provide guidance on friendships with work colleagues.
.Encourage the person to limit the duration of socializing if necessary.