Asperger syndrome: an
By Ami Klin
Child Psychology and
Psychiatry Yale Child Study Center. New Haven, CT, USA
This article provides an overview of the
history and clinical features of Asperger syndrome, and considers guidelines
for clinical assessment and treatment. A review of issues related to
external validity is provided, which points out the limitations of current
research, and lists several potentially beneficial areas of investigation
into the nosologic status of the condition. It concludes with a discussion
of the unequivocal need of individuals with severe social disabilities for.orgprehensive and adequate educational services and other treatments
irrespective of the fact that the validity and the utility of this specific
diagnostic concept is far from resolved.
Keywords: Asperger syndrome.
Pervasive developmental disorder.
Asperger syndrome (AS) is one of the
pervasive developmental disorders (PDD), which are a family of congenital
conditions characterized by marked social impairment,.orgmunication
difficulties, play and imagination deficits, and a range of repetitive
behaviors or interests.1 The prototypical PDD is autism, which
was first described by Leo Kanner at Johns Hopkins in 1943.2
Autism occurs in 1 out of every 1,000 births,3 is a
neurobiological disorder with a strong genetic.orgponent (a 2% to 5%
recurrence rate in siblings, which is a 50 fold increase relative to the
general population),4 and some, as yet tentative biological
markers involving brain structure (e.g., some individuals may have larger
brains) and brain function (e.g., the typical brain specialization to
recognize faces is not present).5 About 70% of individuals with
autism have a degree of mental retardation, and the typical cognitive
profile includes great variability of skills (e.g., usually higher level
nonverbal problem-solving skills and lower level language and conceptual
skills).6 Universally, there is a considerable discrepancy
between a person's cognitive potential (i.e., their IQ s) and their ability
to meet the demands of everyday life (or adaptive skills).7 The
diagnosis of autism is entirely behavioral, through clinical examination of
a child's history and current presentation in the areas of social,.orgmunicative, and play/imagination behaviors.8 In the past
decade, there has been progress in research of the biological origins of
autism, particularly in the areas of genetics and brain function, but there
is no biological test as yet (e.g., through blood analysis) to identify
individuals with this condition.
In 1944, Hans Asperger, an Austrian
pediatrician with interest in special education, described four children who
had difficulty integrating socially into groups.10 Unaware of
Kanner's description of early infantile published just the year before,
Asperger called the condition he described "autistic psychopathy",
indicating a stable personality disorder marked by social isolation. Despite
preserved intellectual skills, the children showed marked paucity of
nonverbal.orgmunication involving both gestures and affective tone of voice,
poor empathy and a tendency to intellectualize emotions, an inclination to
engage in long winded, one-sided, sometimes incoherent and rather
formalistic speech (he called them "little professors"), all-absorbing
interests involving unusual topics that dominated their conversation, and
motoric clumsiness. Unlike Kanner's patients, these children were not as
withdrawn or aloof. They also developed, sometimes precociously, highly
grammatical speech, and in fact could not be diagnosed in the first years of
life. Discarding the possibility of a psychogenetic origin, Asperger
highlighted the familial nature of the condition, and even hypothesized that
the personality traits were primarily male-transmitted. Asperger's work,
originally published in German, became widely known to the English speaking
world only in 1981, when Lorna Wing published a series of cases showing
similar symptoms.11 Her codification of the condition, which she
called Asperger's syndrome (AS), blurred somewhat the differences between
Kanner's and Asperger's descriptions, as she included a small number of
girls and mildly mentally retarded children, as well as some children who
had presented with some language delays in their first years of life. Since
then, several studies have attempted to validate Asperger's syndrome as
distinct from autism without mental retardation, although.orgparability of
findings has been difficult due to the lack of consensual diagnostic
criteria for the condition.12 Although AS was first granted
official recognition in ICD-10,13 and appears as Asperger's
disorder in DSM-IV,1 its nosological status is still uncertain.
The diagnosis of AS requires the
demonstration of qualitative impairments in social interaction and
restricted patterns of interest, criteria which are identical to autism. In
contrast to autism, there are no criteria in the cluster of language and.orgmunication symptoms, and onset criteria differ in that there should be no
clinically significant delay in language acquisition, cognitive and
self-help skills. Those symptoms result in significant impairment in social
and occupational functioning.1
In some contrast to the social presentation
in autism, individuals with AS find themselves socially isolated but are not
usually withdrawn in the presence of other people, typically approaching
others but in an inappropriate or eccentric fashion. For example, they may
engage the interlocutor, usually an adult, in one-sided conversation
characterized by long-winded, pedantic speech, about a favorite and often
unusual and narrow topic. They may express interest in friendships and in
meeting people, but their wishes are invariably thwarted by their awkward
approaches and insensitivity to the other person's feelings, intentions, and
nonliteral and implied.orgmunications (e.g., signs of boredom, haste to
leave, and need for privacy). Chronically frustrated by their repeated
failures to engage others and form friendships, some individuals with
Asperger's syndrome develop symptoms of a mood disorder that may require
treatment, including medication. They also may react inappropriately to, or
fail to interpret the valence of the context of the affective interaction,
often conveying a sense of insensitivity, formality, or disregard to the
other person's emotional expressions. They may be able to describe
correctly, in a cognitive and often formalistic fashion, other people's
emotions, expected intentions and social conventions; yet, they are unable
to act upon this knowledge in an intuitive and spontaneous fashion, thus
losing the tempo of the interaction. Their poor intuition and lack of
spontaneous adaptation are a.orgpanied by marked reliance on formalistic
rules of behavior and rigid social conventions. This presentation is largely
responsible for the impression of social naiveté and behavioral rigidity
that is so forcefully conveyed by these individuals.12
Although significant abnormalities of
speech are not typical of individuals with AS, there are at least three
aspects of these individuals'.orgmunication patterns that are of clinical
interest.14 First, speech may be marked by poor prosody, although
inflection and intonation may not be as rigid and monotonic as in autism.
They often exhibit a constricted range of intonation patterns that is used
with little regard to the.orgmunicative functioning of the utterance
(assertions of fact, humorous remarks, etc.). Rate of speech may be unusual
(e.g., too fast) or may lack in fluency (e.g., jerky speech), and there is
often poor modulation of volume (e.g., voice is too loud despite physical
proximity to the conversational partner). The latter feature may be
particularly noticeable in the context of a lack of adjustment to the given
social setting (e.g., in a library, in a noisy crowd). Second, speech may
often be tangential and circumstantial, conveying a sense of looseness of
associations and incoherence. Even though in a very small number of cases
this symptom may be an indicator of a possible thought disorder, the lack of
contingency in speech is a result of the one-sided, egocentric
conversational style (e.g., unrelenting monologues about the names, codes,
and attributes of innumerable TV stations in the country), failure to
provide the background for.orgments and to clearly demarcate changes in
topic, and failure to suppress the vocal output a.orgpanying internal
thoughts. Third, the.orgmunication style of individuals with AS is often
characterized by marked verbosity. The child or adult may talk incessantly,
usually about a favorite subject, often in.orgplete disregard to whether the
listener might be interested, engaged, or attempting to interject a.orgment,
or change the subject of conversation. Despite such long-winded monologues,
the individual may never.orge to a point or conclusion. Attempts by the
interlocutor to elaborate on issues of content or logic, or to shift the
interchange to related topics, are often unsuccessful.
Individuals with AS typically amass a large
amount of factual information about a topic in a very intense fashion.12
The actual topic may change from time to time, but often dominates the
content of social interchange. Frequently the entire family may be immersed
in the subject for long periods of time. This behavior is peculiar in the
sense that oftentimes extraordinary amounts of factual information are
learned about very circumscribed topics (e.g., snakes, names of stars, TV
guides, deep fat fryers, weather information, personal information on
members of congress) without a genuine understanding of the broader
phenomena involved. This symptom may not always be easily recognized in
childhood since strong interests in certain topics, such as dinosaurs or
fashionable fictional characters, are so ubiquitous. However, in both
younger and older children typically the special interests interfere with
learning in general because they absorb some much of the child's attention
and motivation, and also interfere with the child's ability to engage in
more reciprocal forms of conversation with others.
Individuals with AS may have a history of
delayed acquisition of motor skills such as pedalling a bike, catching a
ball, opening jars, and climbing outdoor play equipment. They are often
visibly awkward and poorly coordinated and may exhibitid stilted or bouncy
gait patterns and odd posture. Neuropsychologically, there may be a pattern
of relative strengths in auditory and verbal skills and rote learning, and
significant deficits in visual-motor and visual-perceptual skills and
conceptual learning.15 Many children exhibit high levels of
activity in early childhood, and the.orgmonest reported.orgorbid symptoms in
adolescence and young adulthood are anxiety, and particularly depression.16
AS, like the other pervasive developmental
disorders, involves delays and deviant patterns of behavior in multiple
areas of functioning. To thoroughly evaluate all relevant domains, different
areas of expertise, including overall developmental functioning,
neuropsychological features, and behavioral status are required. Hence the
clinical assessment of individuals with this disorder is most effectively
conducted by an experienced interdisciplinary team. In the majority of
cases, a.orgprehensive interdisciplinary assessment will involve the
following.orgponents: a thorough developmental and health history,
psychological and.orgmunication assessments, and a diagnostic examination
including differential diagnosis.17 Further consultation
regarding behavioral management, motor disabilities, possible neurological
concerns, psychopharmacology, and assessment related to advanced studies or
vocational training may also be needed. Given the prevailing difficulties in
the definition of AS, and the great heterogeneity of the condition, it is
crucial that the aim of the clinical assessment be a.orgprehensive and
detailed profile of the individual's assets, deficits, and challenges,
rather than simply a diagnostic label. Effective educational and treatment
programs can only devised on the basis of such profile, given the need to
address specific deficits while capitalizing on the person's various
resources and strengths.
The psychological assessment aims at
establishing the overall level of intellectual functioning, profiles of
psychomotor functioning, verbal and nonverbal cognitive strengths and
weaknesses, style of learning, and independent living skills. At a minimum,
the psychological assessment should include assessments of intelligence and
adaptive functioning, although the assessment of more detailed
neuropsychological skills can be of great help to further delineate the
child's profiles of strengths and deficits (e.g., organizational skills). A
description of results should include not only quantified information but
also a judgment as to how representative the child's performance was during
the assessment procedure, and a description of the conditions that are
likely to foster optimal and diminished perfor mance. For example, the
child's responses to the amount of structure imposed by the adult, the
optimal pace for presentation of tasks, successful strategies to facilitate
learning form modeling and demonstrations, effective ways of containing
off-task and maladaptive behaviors such as cognitive and behavioral
rigididty (e.g., perseverations, perfectionism, rituralized behavior),
distractibility (e.g., difficulty inhibiting irrelevant responses,
tangentiality), and anxiety, are all important observations that can be
extremely useful for designing an appropriate intervention program. Within
the psychological assessment, particular attention should be place on
adaptive functioning, which refers to capacities for personal and social
self-sufficiency in real-life situations. The importance of this.orgponent
of the clinical assessment cannot be overemphasized. Its aim is to obtain a
measure of the child's typical patterns of functioning in familiar and
representative environments such as the home and the school, which may
contrast markedly with the demonstrated level of performance and
presentation in the clinic. It provides the clinician with an essential
indicator of the extent to which the child is able to utilize his or her
potential (as measured in the assessment) in the process of adaptation to
environmental demands. A large discrepancy between intellectual level and
adaptive level signifies that a priority should be made of instruction
within the context of naturally occurring situations in order to foster and
facilitate the use of skills to enhance quality of life.
The.orgmunication assessment should examine
nonverbal forms of.orgmunication (e.g., gaze, gestures), nonliteral language
(e.g., metaphor, irony, absurdities, and humor), suprasegmental aspects of
speech (e.g., patterns of inflection, stress and volume modulation),
pragmatics (e.g., turn-taking, sensitivity to cues provided by the
interlocutor), and content, coherence, and contingency of conversation.
Particular attention should be given to perseveration on circumscribed
topics, metalinguistic skills (e.g., understanding of the language of mental
states including intentions, emotions, and beliefs), reciprocity, and rules
The diagnostic assessment should integrate
information obtained in all.orgponents of the.orgprehensive evaluation, with
a special emphasis on developmental history and current symptomatology. It
should include observations of the child during more and less structured
periods. This effort should take advantage of observations in all settings,
including the clinic's reception area (e.g., contacts with other children or
with family members), the halls (e.g., how the child interacts initially
with the examiners), as well as in the testing room during breaks, periods
of silence, or otherwise unstructured situations. Quite often, the child's
disability is much more apparent during such periods in which the child is
not given any instruction and has no adult-imposed expectation as to how to
behave. Specific areas for observation and inquiry include the patient's
patterns of special interest and leisure time, social and affective
presentation, quality of attachment to family members, development of peer
relationships and friendships, capacities for self-awareness,
perspective-taking and level of insight into social and behavioral problems,
typical reactions in novel situations, and ability to intuit other person's
feelings and infer other person's intentions and beliefs. Problem behaviors
that are likely to interfere with remedial programming should be noted
(e.g., anxiety, temper tantrums). The children's ability to understand
ambiguous nonliteral.orgmunications (particularly teasing and sarcasm)
should be further examined, particularly in regards to the child's patterns
of response (e.g., misunderstandings of such.orgmunications may elicit
aggressive behaviors). Other areas of observation involve the presence of
obsessions or.orgpulsions, ritualized behaviors, depression and panic
attacks, integrity of thought, and reality testing.
As in autism, treatment of AS is
essentially supportive and symptomatic, and to a great extent, overlap with
the treatment guidelines applicable to individuals with autism una.orgpanied
by mental retardation.18 One initial difficulty encountered by
families is proving eligibility for special services. As individuals with AS
are often very verbal and many of them do well academically (at least in
some areas), educational authorities might judge that the deficits –
primarily social and.orgmunicative – are not within the scope of educational
intervention. In fact, these two aspects should be the core of any
educational interention and curriculum for individuals with this condition.
In regards to learning strategies, skills, concepts, appropriate procedures,
cognitive strategies, and behavioral norms may be more effectively taught in
an explicit and rote fashion using a parts-to-whole verbal instruction
approach, where the verbal steps are in the correct sequence for the
behavior to be effective. Additional guidelines should be derived from the
individual's neuropsychological profile of assets and deficits. The
acquisition of self-sufficiency skills in all areas of functioning should be
a priority. The tendency of individuals with AS to rely on rigid rules and
routines can be used to foster positive habits and enhance the person's
quality of life and that of family members. Specific problem-solving
strategies, usually following a verbal algorithm, may be taught for handling
the requirements of frequently occurring, troublesome situations (e.g.,
involving novelty, intense social demands, or frustration). Training is
usually necessary for recognizing situations as troublesome and for
selecting the best available learned strategy to use in such situations.
Social and.orgmunication are best taught by a.orgmunication specialist with
an interest in pragmatics in speech in the context of both individual and
small group therapy. Communication therapy should include appropriate
nonverbal behaviors (e.g., the use of gaze for social interaction,
monitoring and patterning of inflection of voice), verbal decoding of
nonverbal behaviors of others, social awareness, perspective-taking skills,
and correct interpretation of ambiguous.orgmunications (e.g., nonliteral
language). Often, adults with AS fail to meet entry requirements for jobs in
their area of training (e.g., college degree) or fail to maintain a job
because of their poor interview skills, social disabilities, eccentricities,
or anxiety attacks. It is important, therefore, that they are trained for
and placed in jobs for which they are not neuropsychologically impaired, and
in which they will enjoy a certain degree of support and shelter. It is also
preferable that the job does not involve intensive social demands, time
pressure, or the need to quickly improvise or generate solutions to novel
situations. The little experience available with self-support groups
suggests that individuals with AS syndrome enjoy the opportunity to meet
others with similar problems and may develop relationships around an
activity or subject of shared interest. Special interests may be utilized as
a way of creating social opportunities through hobby groups. Supportive
psychotherapy as well as pharmacological interventions may be helpful in
dealing with feelings of despondency, frustration, and anxiety, although a
more direct, problem-solving focus is taught to be more beneficial than an
Although AS was first described over 50
years ago,10 it was not until 1994 that is was included in DSM-IV1
as one of the PDDs. Inclusion in the DSM-IV followed limited evidence that
it could be differentiated from autism una.orgpanied by mental retardation,
or higher functioning autism (HFA).19 As noted, however, its
nosological status remains unclear, in part due to the adoption of varying
diagnostic schemes in the research literature.12 Although the
advent of the DSM-IV definition was intended to create a consensual
diagnostic starting point for research, it has been consistently criticized
as overly narrow,20,21 rendering the diagnostic assignment of AS
improbable or even "virtually impossible".22,23
The introduction of AS in DSM-IV and ICD-1013
was prompted by the recognition that autism is a clinically heterogeneous
disorder and that the characterization of subtypes of PDD might help
behavioral and biological research by allowing the identification of
clinically more homogeneous groups.24-26 While this effort has
been successful for some PDD conditions (e.g., Rett syndrome),27
it has not been the case in AS. Published reports have modified DSM-IV or
ICD-10 criteria,15,28 treated AS and HFA interchangeably,
16,17, 29,30 or used unique investigator-defined criteria,31
making it difficult to.orgpare studies. Only two studies32,33
have systematically.orgpared different diagnostic schemes. These two studies
generally revealed that different nosologic schemes result in the assignment
of different diagnoses to the same patients, raising the important issue of
how to.orgpare studies utilizing different definitions of AS. However, these
studies did not consider the question of the utility of a given diagnostic
concept relative to important predictions that may have practical value to
research (e.g., differences in neuropsychological or neurobiological
findings between AS and HFA), or clinical practice (e.g., differences in
treatment efficacy,.orgorbid symptomatology, or ou.orge as a function of the
given diagnostic assignment).34 To summarize, the state of
discussions on the nosologic status of AS is, therefore, extremely
problematic, given that studies cannot be necessarily.orgpared because of
the adoption of different diagnostic definitions, and there has been no.orgparison across different diagnostic schemes in regards to the relative
utility of each of the schemes. And yet, the absence of a consensual or
validated definition has not deterred the upsurge of research publications
on the syndrome nor the apparently marked increased in the use of the
diagnosis in clinical and educational settings.35
It is apparent from this brief discussion
of the external validity of AS that studies.orgparing the utility of
different diagnostic schemes is badly needed. This agenda for research is
needed for several reasons: First, there is a need to gauge the extent to
which available research data obtained using different diagnostic systems
are.orgparable. Second, despite the upsurge in research and clinical
interest in AS, the absence of a validated definition prevents the
development of standardized instrumentation that could enhance reliability
of diagnostic assignment and make possible cross-site collaborations that
are essential to both behavioral and biological research. Third, there are
indications that the DSM-IV definition is being ignored in clinical
practice,23 with the term being used as synonymous to HFA or,
maybe even more.orgmonly, to PDD-NOS,12 creating a rift between
DSM-IV and research and clinical practice, thus confusing and alienating
investigators, clinicians, and parents alike. And fourth, the scientifically
interesting question as to whether or not there are qualitative
discontinuities among the PDDs, or alternatively, whether the PDDs should be
considered along a dimensional continuum (and what this dimension should be)
is left unresolved without some resolution of the validity of the AS
Several lines of research could serve the
purpose of assessing the utility of different diagnostic schemes. First,
learning profiles of assets and deficits are of great importance in
educational treatment planning for individuals with PDDs,6
particularly in individuals with normative IQs.17
Neuropsychological research of AS is extremely equivocal to date. In 1995,
our group15 documented considerable differences between
individuals with HFA and AS. Specifically, individuals with AS showed a
profile of assets and deficits consistent with a nonverbal learning
disability (NLD).36 NLD is characterized by strengths in
verbally-mediated skills (e.g., vocabulary, rote knowledge, verbal memory,
verbal output) and deficits in nonverbal skills (e.g., visual-spatial
problem solving, visual-motor coordination). Individuals with HFA exhibited
the opposite profile. Such "double dissociation" has been shown to be one of
the most powerful external validators of specific subtypes of syndromes.37
These findings have been supported by a number of studies focused on IQ
profiles,38-40 although several other studies have failed to
replicate them.21,41 However, as noted, direct.orgparison across
studies is not possible since different diagnostic schemes were used in
A second potential area of validation
research in AS could utilize patterns of.orgorbidity. Research on the
psychiatric difficulties associated with the PDDs is of great importance for
treatment planning given that these symptoms may have the potential of being
extremely debilitating, e.g., limiting the effectiveness of educational
interventions, posing further limitations on the individual's ability to
utilize his or her internal coping resources. Documentation of these
difficulties can lead to psychopharmacological approaches that can greatly
allevi ate such symptoms, thus making the student more available to other
forms of intervention, e.g., educational. AS has been associated with a host
of.orgorbid conditions, including schizophrenia,42,43 Tourette's
syndrome,44 attentional, affective, and obsessional disorders.45,46
More recent research has emphasized anxiety, mood and obsessional disorders
to be particularly prevalent in this population.47,48 As
previously, however, there has been no attempt to study patterns of.orgorbidity that may be specific to HFA and AS, with most studies using the
two diagnoses interchangeably.
A third potential line of research for
external validation studies of AS relates to the aggregation of social and
other psychiatric disorders in family relatives. Research into patterns of
genetic liability associated with the PDDs has been one of the most active
areas of investigation in autism and related conditions.4 Studies
have consistently shown higher rates of social disabilities or difficulties
in family members of individuals with autism,49,50 as well as of
other psychiatric symptoms including anxiety, mood, and obsessional
disorders.51,53 None of these studies, however, has made the
attempt to assess the utility of separating families of probands with HFA
from those of probands with AS. The available data on the familiality of AS
are essentially limited to a handful of case reports and some preliminary
studies.53,54 Many case reports have been consistent with
Asperger's original observation10 of similar traits in family
members, particularly fathers or male relatives.55-57 Whether or
not variants of autism such as AS might reflect greater or lower genetic
liability could be of great significance in elucidating mechanisms involved
in producing the marked heterogeneity among PDDs. Such studies, however,
cannot be conducted without standardized diagnostic procedures, which, in
turn, depend upon some initial consensus as to criteria for the definition
In order to avoid insularity among research
groups (i.e., each one adopting its own diagnostic scheme) and to advance
the field from its current stalemate, on approach might be to simultaneously.orgpare different diagnostic schemes and assess each one on the basis of
independent factors of clinical or research significance. Such research is
not yet available.
Future directions for research and
The current state of affairs in nosologic
research of AS, with little available evidence to point to a distinction
between this concept and HFA and PDD-NOS, as well as other similar
diagnostic entities,12 has prompted many investigators to derive
premature conclusions. For example, some have treated AS as different than
other conditions, whereas others have treated as the same as other
conditions. The more typical approach is to see AS within the spectrum of
PDDs, maybe indicating some half point between autism and normalcy. Our
discussion suggests that either position is unwarranted at present. Those
who view AS as different from other disorders have the onus to document in
what ways is AS unique among the social disabilities. This task requires.orgparison of extant diagnostic schemes. Those who view AS a within the
spectrum of social disabilities have the onus to define what this spectrum
consists of. This task requires isolation of specific psychological (e.g.,
IQ, language functions, metacognitive skills) or neurobiological (e.g.,
genetic liabilities, neurostructure or neurofunction findings) that can
quantify the social disability spectrum and predict social ou.orge. Both of
these programmatic research areas are still in their incipience.
It is nevertheless crucial to separate this
research discussion from the areas of clinical practice and provision of
services dedicated to individuals with AS and their families. The
unavoidable confusion conveyed to parents and advocates inherent in the
fragility of the validity status of AS is sufficiently harmful to justify a
concerted effort on the part of clinicians and advocates to adhere to some
unequivocal principles so that the needs of their clients are properly
addressed. First, whether or not there is controversy over the fine-grained
distinctions between AS and other conditions, and despite some literature
and great media coverage over some famous individuals exhibiting or not this
condition, the vast majority of children, adolescents, and adults with AS
require a.orgprehensive package of treatments. Equivocating about these
individuals' needs on the basis of the poor scientific status of the
diagnostic concept is unjustified. Second, adequate educational programs
should not be based on a diagnostic label and generalizations associated
with it, but on individualized profiles of assets and deficits, which can
only be a.orgplished through thorough evaluations involving psychological,.orgmunication, and psychiatric assessments. And third, the notion that AS is
simply a 'milder' form of autism, regardless of whether or not this
statement is scientifically justified, should be well-contextualized in that
whereas 'mild' is a term.orgparing individuals with this condition with
those with prototypical autism and a degree of mental retardation, and it is
certainly not 'mild' when.orgparing these individuals great difficulties in
meeting the demands of everyday life. In other words, eligibility for
services should be fiercely advocated. Treatment should focus on those areas
of greatest challenges, and which are known to deleteriously impact on these
individuals capacity for independent living, vocational satisfaction, and
better social adjustment. These include socialization skills in general
(e.g., social reciprocity and social.orgmunication), adaptive skills (e.g.,
"street smarts", how to function in the.orgmunity, how to fend for oneself
in potentially inhospitable environments), organizational skills (e.g., how
to perform.orgplex tasks and anticipate problems), a cognitive-behavioral,
and sometimes psychopharmacological plan to alleviate anxiety and depression
when these emerge, and sympathetic mental health and educational
professionals who strive to building upon these individuals' unique assets
to.orgpensate for their deficits and to create more positive social
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Recieved on 7/8/2002, Approved on 2/4/2002.
This work was partly supported by grants
P01 HD 03008 and P01 HD/DC35482 from the National Institute of Child Health
and Human Development, Bethesda, MD.