THE CHILD PLAYING ALONE—CAUSE FOR CONCERN?

Q More and more parents ask me about Asperger syndrome. I see many children labeled "Asperger" by their teachers who seem normal to me. Can you help me understand this condition better?

To be specific, I am interested in knowing when a child who enjoys being alone has a marked deficiency or a "qualitative impairment in social interaction"* If a child has a special interest and spends a good deal of time pursuing it on his own, should we encourage it or be concerned that the child may develop a "restricted repetitive and stereotyped pattern of behavior, interest, and activity"*?

If a child doesn't have many friends and feels comfortable about it, is that normal or should we be concerned about a failure "to develop peer relationships appropriate to developmental level"*? How do we gauge what is normal and what isn't? I'm all for trying to help parents and patients when they need it, but I think that many times we may stigmatize a child unfairly for nothing more than being an individual.

Douglas G. Olk, MD
Dubuque, Iowa

*American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4. Washington, D.C., American Psychiatric Association, 1994

A One of the frustrating and worrisome things about psychiatric diagnosis is its subjective nature and large overlap with normal behavior. Asperger syndrome is an excellent example because we all know productive adults who probably meet the criteria for this condition.

In the case of children, it helps to think of the typical, or normal, child as being inherently more interested in social interaction than solitary activities. If a child almost always prefers solitary play when social play is readily available, the child's behavior is atypical. A preschool child can generally play alone for 30 minutes or less; a child raised without siblings may become skilled at solo play but—when given the opportunity—shows an interest in other children, even if he is too shy to interact.

The type of play the child chooses and the interests of the child with Asperger syndrome also differ qualitatively from those of the typical child. The child with Asperger syndrome is often obsessed with unusual topics for a child—for example, fire extinguishers, engine parts, or all the different kinds of a specific object such as wheel covers. The very bright normal child is more likely to have a deep interest in all the different aspects of a specific topic such as rockets, their fuels, the astronauts who ride in them, and the history of space travel.

The child with Asperger syndrome also finds it difficult to stop what he is doing to change topics, even when it is socially necessary to do so. This problem with social skills or reciprocity may make him a less desirable playmate to his peers. The difference in the quality of friendships between children with Asperger syndrome and normal children can be so extreme that a child with Asperger syndrome may not even be able to name or describe anyone in his class.

Other features that help distinguish a child with Asperger syndrome from the typical child are: a greater likelihood of motor incoordination, peculiar sensory likes and dislikes, and use of awkward speech patterns that sound like an adult's speech or are hard to follow.

I agree that we should celebrate rather than label uniqueness. Interestingly, many children with Asperger syndrome fit in much better as college students or adults because differences are more highly valued in these age groups.

Barbara J. Howard, MD
Baltimore, Md.

DR. HOWARD is assistant professor of pediatrics, Johns Hopkins University School of Medicine, and Co-Director, Center for Promotion of Child Development Through Primary Care, Annapolis, Md.

Some additional insights from Morris Green, MD:

Asperger syndrome is a complex disorder to which Dr. Howard's comments offer an instructive opening. When we talk to parents of children who have been given a diagnosis of Asperger syndrome, my psychology colleague and I suggest a paperback book we have found helpful and detailed: A Parent's Guide to Asperger Syndrome and High-functioning Autism: Meet the Challenges and Help Your Child Thrive, by Sally Ozonoff, PhD, Geraldine Dawson, PhD, and James McPartland, The Guilford Press, 2002.

Morris Green, MD

DR. GREEN is Perry W. Lesh Professor of Pediatrics, Indiana University School of Medicine, Indianapolis, and a member of the Contemporary Pediatrics Editorial Board.