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Adolescent Issues for Individuals with AS

by Tony Attwood, PhD
Autism Asperger’s Digest | July/August 2013

Adolescence is a difficult time of life for almost all teenagers but especially for those with Asperger’s Syndrome (AS), to be now known as Level 1 autism according to DSM-5, the primary text for the diagnosis of autism spectrum disorders (ASD).

The main issues can be the:

•    physical changes associated with puberty
•    unusual learning style associated with autism spectrum disorder
•    special interests
•    development of friendships and issues regarding sexuality and bullying
•    sensory sensitivities
•    management of emotions
•    moving to employment or college.

It is also a time for self-reflection on the transition to becoming an adult. Lack of social and perhaps also academic success and subsequent stress can lead to the development of secondary psychological disorders. Some adolescents, especially girls, who have the signs of AS may have previously been able to camouflage their social confusion and observe and imitate their peers in relatively simple social situations, but as social interactions between teenage peers become more complex, their ability to socialize successfully becomes more elusive and stressful. Then, for the first time, a diagnosed mood disorder or eating disorder can be confirmed to be AS through a detailed assessment of developmental history.

Puberty

People who have ASD have considerable difficulty coping with new experiences and change—and puberty heralds considerable physical changes. It is important that the teenager who has AS has clear and accurate education about those changes, especially in relation to personal hygiene and changes in body size, proportions, and function. Fortunately, there is now literature available for adolescents with AS and their parents to explain the changes associated with puberty (see Attwood 2008). It is vital that adolescents with ASD receive detailed, unambiguous information about sex and sexuality, as this is seldom included in teenage discussions where their typical peers acquire such information.

Learning Styles

There is a different learning style, or profile, associated with ASD, which can be conceptualized as a different way of perceiving, thinking, and learning. We recognize that adolescents with ASD will have problems with executive function, a term psychologists use to describe the ability to plan how to do an activity, organize what you need, know how long it will take to complete the activity, and not be distracted by other activities. Teenagers with AS often need a parent to act as an executive secretary for school projects and need teachers to be aware that organizational and planning difficulties are not a sign of intellectual disability or a lack of respect for the teacher and the subject. They may have a one-track mind—that is, a lack of flexibility in problem solving—not listening to advice or learning from the experience of others, and not realizing someone else may have a solution to the problem. Programs that encourage flexible thinking and seeking new information may be needed.
Another characteristic is a fear of making a mistake and the belief that as long as you do not try, you cannot make a mistake. An associated fear is appearing to be stupid and being ridiculed by peers for making a mistake. It is important to emphasize that we learn more from our failures than our successes, that attempting difficult problems leads to greater intellectual strength, and that an error provides valuable data that can lead to the correct solution to a problem.
Learning in a classroom requires considerable linguistic and social abilities, which can be very difficult for adolescents with AS. The AS learning profile can include being distracted by parts of things or odd details. If interrupted, the individual needs to learn to take time to reorganize thoughts. Learning can be facilitated by reading a textbook or completing a computer-based program.
There is always the issue of homework and whether the stress and strain on the adolescent and his family to complete homework on time are worth the extreme effort. Handwriting can also become an issue, with a preference for typing in class and for exams. For some adolescents, the degree of stress at high school can lead to discussion on whether homeschooling would be a positive option to prevent a clinical depression and whether the high school curriculum could be pruned to discard subjects of limited long-term value to the teenager with ASD who has difficulty maintaining motivation.

Special Interests

Adolescents with AS can spend considerable time engaged in their special interests. Why are the interests so important for these teenagers? The interest has many positive aspects: for example, it can be energizing (but perhaps not for the parents); provide a wide range of enjoyable experiences greater than those experienced with the interpersonal aspects of adolescent life; give rise to the euphoria of discovering new items or information to add to the collection; and increase the expertise or reputation of the adolescent. The interest can be a “thought blocker” to keep feelings of anxiety or depression at bay; a form of escapism in terms of enjoying an alternative world (as in science fiction), where the teenager with AS is valued and respected (the Mr. Spock syndrome); and a way of making friends who have similar interests.
Experience has shown that teenagers with AS can have talents in mechanical abilities and information technology, science and mathematics, the fine arts (especially visual arts, music, and writing fiction), and working with animals. Thus, adolescence can be a time to develop such abilities in preparation for a successful adult life.
Controlling Access to Special Interests. It is wise to consider controlled access to acceptable interests, to incorporate the interest in the school curriculum and in psychological therapies where it may be used as a metaphor or a means of encouraging motivation by earned access. The interest may also be used to develop specific talents in areas such as drawing, playing an instrument, animation, and computer programming to improve self-esteem and gain positive appreciation from peers. Sometimes the interest can be the basis of a successful career as an expert in a particular area.
Unacceptable Special Interests.There can be interests, such as weapons, fires, and pornography, that give cause for concern for parents, clinicians, and law enforcement agencies. It is important to logically explain why the interest is of concern from the perspective of others, perhaps using Comic Strip Conversations by Carol Gray (Future Horizons, 1994) to explain the thoughts and feelings of others and how continuing with the interest could have a detrimental effect on the quality of life of the adolescent with AS.

Relationships

Friendships. Adolescence is a time of change in the nature of friendships, with typical teenagers considering peer group acceptance as more important than the opinion of parents. There is a greater degree of self-disclosure between friends and a desire to be accepted and respected by peers. Unfortunately, most teenagers with AS feel that they are frequently rejected, humiliated, and ridiculed by their peers. They often experience an intense loneliness and great difficulty integrating with “toxic” teenagers, those perceived as social zealots, intolerant of anyone of their age who is different. Friendships may end at the school gate, with the adolescent’s home being a safe refuge from the vulnerability and exhaustion of spending a day at high school.
Teenagers with AS need social skills programs on friendship, often based on drama activities to learn how to act in everyday situations with peers at high school. Social success can be achieved, but should not be at the price of emotional and intellectual exhaustion, and not being true to the adolescent’s real personality.
Romantic Relationships. The nature of friendship changes during adolescence with the emergence of the new dimension of sexuality and romantic relationships. Teenagers with AS are often delayed by several years in their experiences of romantic relationships. In early adolescence there may be little interest in friendships beyond conversation, and with the new social conventions of dating, anxiety abounds with a fear of rejection. This is another reason to feel different from peers, as the adolescent senses his lack of abilities, experience, and confidence. There can be difficulties understanding the subtle signals of mutual attraction, a tendency to misinterpret acts of kindness as meaning more than was intended, and a vulnerability to developing a crush that is misperceived as stalking. Girls especially are vulnerable to sexual predators. We now have resources and programs to teach the dating and relationship game and to provide strategies to reduce vulnerability to unwanted sexual experiences (see Uhlenkamp 2009 and Brown 2013).
Bullying. Teenagers with ASD are also vulnerable to being bullied and teased by peers, and the consequences can lead to concerns with school refusal or being suspended for retaliation. The teenager may have a limited range of responses to being bullied or teased and lack the ability to explain why he retaliated with such ferocity or why he has a vendetta against certain individuals. There are several strategies that can be used to reduce the vulnerability to being bullied and teased and the consequences, such as more supervised areas at high school, help in finding a safe refuge, and encouragement of the “silent majority” to intervene on behalf of the teenager with AS.

Sensory Sensitivities

The revised diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association for ASD includes the characteristics of hyper- and hyposensitivity to sensory experiences. It is important that teachers in particular recognize that some sensory experiences can be perceived as aversive by an adolescent with AS. These include someone shouting, including a teacher shouting in class, other students accidentally or unexpectedly touching the adolescent with ASD, specific aromas, such as someone’s perfume, and bright sunlight in the classroom. Teenagers with ASD often need an assessment of the nature and degree of sensory sensitivity, which can help explain the aversion to some school activities or individuals.

Managing Emotions

Anxiety. There is one emotion that teenagers with AS are very good at—worrying. ASD is associated with high levels of anxiety, and the teenager may have discovered a range of strategies to cope with a general level of high anxiety, or anxiety associated with specific situations. There can be a diagnosis of Generalized Anxiety Disorder (GAD), Obsessive Compulsive Disorder (OCD), gelotophobia (fear of being laughed at), and other specific phobias, such as a fear of the sound of a dog barking.
The high levels of anxiety can lead to chronic insomnia, school refusal, and concern by parents and teachers regarding behaviors used by the adolescent to reduce anxiety levels. The individual may become very controlling to avoid anxiety-provoking situations, which may lead to a secondary diagnosis of Oppositional Defiant Disorder (ODD) or Pathological Demand Avoidance (PDA). Routines and rituals are imposed to alleviate anxiety, but they can become more prolonged and elaborate during adolescence.
The special interest can be used as a thought blocker, with consequent anger expressed when the adolescent is thwarted from access to one of the few means that he has of alleviating anxiety. Another strategy is to have an emotional explosion or destructive meltdown to cleanse the emotional system or clear the air, effective for the teenager with ASD but frightening (and possibly expensive) for everyone else. Psychologists have developed a range of Cognitive Behavior Therapy (CBT) programs to treat secondary anxiety disorders, and medication can be a valuable treatment for such adolescents.
Depression. Unfortunately, one in three teenagers with AS is prone to having a clinical depression (severe, persistent depression). This can be due to low self-esteem from being rejected and ridiculed by peers, a painful awareness of being different, loneliness, and mental exhaustion from having to learn both the academic and social curriculums of high school. Such individuals are also prone to depression attacks, intense overreactions to an event—a form of catastrophizing that can lead to intense emotions and sudden, impulsive suicide attempts. We now have strategies to help parents and teachers manage a brief but intense depression attack, and psychological therapies that include CBT as well as developing a positive concept of self and achieving a sense of optimism. Medication can also be a valuable means of reducing a prolonged clinical depression.
Anger. Two out of three teenagers with AS are of concern to others and themselves for inadequate anger management. A deeper analysis of the cause of the anger can reveal frustration at not being able to access strategies to alleviate anxiety. The adolescent may use threats and acts of violence to control experiences. He may show signs of externalized agitated depression (blaming others rather than self) as well as anger in response to being provoked and not being valued or respected by peers. Again, psychological therapies and medication can alleviate feelings of anger.
The Role of Exercise in Managing Emotions. Clinical experience has also indicated that regular physical exercise for teenagers in general, and for those with ASD in particular, can reduce feelings of anxiety, sadness, and anger. However, teenagers with ASD usually prefer to be engaged in solitary, sedentary activities. Aware of their problems with motor coordination and team sports, they are usually reluctant to participate in sports. A personal trainer may be able to design a physical activity program for the adolescent with AS that is based on the individual’s personality and body type. Regular physical activity can improve both mood and cognitive abilities.

Employment and College

Support for Vocational Choices. Teenagers with AS benefit from assessment and planning for further education beyond high school and employment at a younger age than their typical peers. The school can assess vocational abilities; teachers and parents can arrange vocational experiences and create a portfolio of work abilities and achievements. Counselors can suggest which career might suit the adolescent’s profile of abilities and personality and offer an opportunity to rehearse a job interview. Employment agencies are gradually becoming aware of the special needs of teenagers with AS who are seeking employment.
Support in Academia. When starting college or university, the adolescent or young adult with AS will need support with courses that require executive function skills and creating a study plan. Student services will need to know how to support a student with AS, not only for the academic requirements but also for making friends and the new social conventions of being a student as well as for concerns about independent living, such as budgeting. Staff can act as a liaison with tutors and lecturers should any problems emerge. The student may need to be monitored for his adjustment to the new environment and vulnerability to deep emotions.

Adolescence is a difficult time for all teenagers. However, I am amazed at how well adolescents with AS cope with the changes associated with puberty and the teen years. From my extensive clinical experience, I’ve learned that the young adult years can be a time of significant progress socially and academically and in terms of self-esteem and independence.

BIO
Tony Attwood, PhD, is a clinical psychologist in Brisbane, Australia. His books on Asperger’s Syndrome are appreciated by parents, professionals, and people who have AS. Each October he travels to the United States to speak at a series of Future Horizons conferences.

Resources
Attwood, S. 2008. Making Sense of Sex: A Forthright Guide to Puberty, Sex, and Relationships for People with Asperger’s Syndrome. London: Jessica Kingsley Publishers.

Brown, D. 2013. The Aspie Girl’s Guide to Being Safe with Men. London: Jessica Kingsley Publishers.

Scarpa, A., S. Williams, and T. Attwood, eds. Forthcoming. CBT for Children and Adolescents with High-Functioning Autism Spectrum Disorders. New York: Guilford Press.

Uhlenkamp, J. 2009. The Guide to Dating for Teenagers with Asperger Syndrome. Shawnee Mission, Kansas: AAPC.

Copyright © Autism Asperger’s Digest. 2013. All Rights Reserved. Distribution via print is prohibited without written permission of publisher.

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