Reviews of Current Research

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Stein, M.T., Klin, A., and Miller, K. (2004). Challenging case: When Asperger’s syndrome and a nonverbal learning disorder look alike. Developmental and Behavioral Pediatrics. 25 (3): 190-95.

In this case study, an overview of the basic medical, psychological, and educational history of Joey, age seven is given. Then several pediatricians and psychologists weigh in on what the symptoms described may indicate, and about what further tests may help clarify a diagnosis. Joey has already shown signs of attention-deficit hyperactivity disorder – he has had a hard time staying on task in the classroom, and his pediatrician found him to be hyperactive with a short attention span. However, Joey also has trouble with fine motor skills and coordination, eye contact, and initiating social contact with peers. He has a substantially higher verbal IQ than performance IQ, based on the Wechsler Intelligence Scale for Children-Revised. The pediatrician suspects Joey might have Asperger syndrome in addition to ADHD.

The authors outline the next steps in diagnosis of developmental disorders in such a child, including obtaining a more detailed childhood history; observing the child in his typical environments like at home and school; and administering possible interview schedules and pencil-and-paper tests such as the Vineland Adaptive Behavior Scales, the Autism Diagnostic Observation Schedule, and the Autism Diagnostic Interview. Indications that Joey might have Nonverbal Learning Disorder as opposed to Asperger syndrome, such as the lack of mention of any stereotyped behaviors or interests and the fact that his one-on-one interactions are fairly appropriate in spite of his difficulties in peer groups, are pointed out. Several less formal responses to the case submitted online by physicians present a wide spectrum of medical opinion on the distinctions between AS, NLD, and similar conditions: One doctor calls for broadening the Asperger diagnosis so that it is an umbrella for anyone who needs access to the interventions to which such a diagnosis would lead, so no child is denied necessary services due to semantics. Another calls for rejecting the Asperger label in less extreme cases where the phenotype (the presence of some but not all of the symptoms of the condition are present) as opposed to the official diagnosis is at all possible, lest the diagnosis become a self-fulfilling prophecy, and suggests that Joey learn karate to build confidence.

This article would be most useful for pediatricians, child psychologists, and other professionals who might be diagnosing – or referring for diagnosis – children with apparent high-functioning developmental disabilities. It might also be of interest to parents whose children are in the diagnostic stages for some sort of issue on or near the Autistic spectrum – it is certainly readable for people without medical training. Some of the information might also be applicable to figuring out the best diagnoses for adults as well. The article presents an interesting and seemingly plausible example of the ambiguity that can exist among similar developmental disorders in comparatively high functioning individuals, and the added confusion when another, unrelated condition (such as ADHD) appears to be present as well. Clearly, even the medical community has yet to reach a complete consensus on the boundaries between AS and NLD. As in any case study, this child is not representative of the “typical” child with any of the conditions discussed – the point being that there is no typical patient and everyone, even with the same clinical diagnoses, will have different strengths and deficits in their profiles. One limitation of this article is that none of the commentators address the fact that many are diagnosed with both AS and NLD – the two are not mutually exclusive, and NLD is certainly not just a milder version of the same symptoms present in AS (or vice versa).

- John Cavanagh

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