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Running Head: COUNSELING ADULTS WITH ASPERGER‟S

Counseling Asperger‟s 1

Rehabilitation and Vocational Counseling for Adults with Asperger’s Syndrome

Jamie Schutte

University of Pittsburgh

Scholarly Paper: HRS 2926

Dr. Donald Angelone, Dr. Michael McCue, and Dr. John McGonigle

April 18, 2008


ABSTRACT

Counseling Asperger‟s 2

Adults with Asperger‟s Disorder, despite being of typical intellectual ability, struggle without

supports in higher education and the workplace. The following literature review begins by

defining the population, specifically the social deficits, restricted and repetitive interests, sensory

issues, executive function deficits, and common co-morbid diagnoses of adults with Asperger‟s.

Social rehabilitation should revolve around cognitive behavior therapy, social skills groups,

education, and visual assistive technologies that promote generalization of skills. Cognitive

rehabilitation should include modifying the client‟s sensory environment to improve attention

and visual cues to promote memory and organization. Finally, implications for rehabilitation and

vocational counselors are discussed, including challenges and techniques for promoting success

in higher education and in the workplace. Specifically, the importance of forming a therapeutic

relationship, providing communication and social supports, and matching the job to the client are

highlighted. While this paper reviews interventions and strategies that are generally effective for

adults with Asperger‟s, each client should be considered on an individual basis and receive

distinctive services and supports.


TABLE OF CONTENTS

Counseling Asperger‟s 3

List of Figures .............................................................................................................................5

Introduction and Statement of the Problem ..................................................................................6

Methodology ...............................................................................................................................7

Electronic Search .....................................................................................................................7

Analysis of Resources..............................................................................................................7

Literature Review ........................................................................................................................9

Psychological and Medical Aspects .........................................................................................9

Impairment in Social Interaction ..........................................................................................9

Restricted and Repetitive Interests...................................................................................... 11

Sensory Integration ............................................................................................................ 11

Academic/Vocational Characteristics ................................................................................. 13

Co-Morbid Diagnoses ........................................................................................................ 15

Psychosocial Rehabilitation ................................................................................................... 18

Cognitive Behavioral Therapy ............................................................................................ 19

Social Skills Groups ........................................................................................................... 24

Psycho-Education .............................................................................................................. 28

Assistive Technology ......................................................................................................... 29

Cognitive Rehabilitation ........................................................................................................ 33

Attention ............................................................................................................................ 34

Memory ............................................................................................................................. 35

Organization ...................................................................................................................... 37

Problem Solving ................................................................................................................ 38


Counseling Asperger‟s 4

Flexibility .......................................................................................................................... 39

Central Coherence .............................................................................................................. 40

Implications for Rehabilitation Counselors ............................................................................ 42

Rehabilitation Counseling Techniques ............................................................................... 42

Meeting Educational Support Needs................................................................................... 46

Meeting Vocational Support Needs .................................................................................... 49

Summary and Conclusions ........................................................................................................ 57

References ................................................................................................................................ 59

Appendix .................................................................................................................................. 68


LIST OF FIGURES

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Figure 1. Characteristics of specific sensory processing patterns according to Dunn‟s conceptual

model of sensory processing (Dunn et al., 2002, p. 175) ............................................................ 12

Figure 2. Social skills group program (Howlin & Yates, 1999, p. 301) ...................................... 25

Figure 3. Topics and guiding questions covered in Aspirations sessions (Hillier et al., 2007, p.

111) .......................................................................................................................................... 27

Figure 4. Types of jobs found by supported clients with Asperger‟s (Howlin et al., 2005, p. 538)

................................................................................................................................................. 52


Counseling Asperger‟s 6

INTRODUCTION AND STATEMENT OF THE PROBLEM

Adults with Asperger‟s Disorder are becoming more common in society, due to either an

increase in prevalence of the disorder or more accurate diagnosis. However, most research on

Asperger‟s is conducted with children; which is to be expected given Asperger‟s is a

developmental disorder most often diagnosed in early childhood. Regrettably, many programs

are only funded for children and services for individuals with Asperger‟s taper off dramatically

after the child turns 18 or graduates from high school. While there are a plethora of books,

resources, and training available for primary education teachers on how to work with children on

the autism spectrum, once these young adults enter the real world, they find that their professors

and bosses are either unaware of or unsympathetic towards their disability. Rehabilitation and

vocational counselors struggle to apply strategies that have been successful with other

populations—traumatic brain injury, ADHD, and learning disabilities—to Asperger‟s. While

some of these interventions may be effective, they do not fully address the social and cognitive

deficits that are unique to individuals with Asperger‟s. To date, there is not a comprehensive

account of what Asperger‟s looks like, and what interventions and therapeutic techniques would

be effective for helping adults achieve success in higher education and careers.

The following discussion will begin by defining the population, examining both the

diagnostic criteria and common characteristics and co-morbid diagnoses of Asperger‟s. Social

and cognitive interventions, counseling and technology-based, will be examined. Finally,

specific techniques rehabilitation and vocational counselors can use to form a solid working

relationship with clients and help them to be successful at school or on the job will be reviewed.

With the right therapies, interventions, and supports, individuals with Asperger‟s can lead

fulfilling lives as productive members of society.


METHODOLOGY

Electronic Search

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The OVID databases PsycINFO, MEDLINE, and CINAHL, as well as the PubMed

database were searched using terms that included but were not limited to: Asperger‟s Disorder,

psychological, medical, impairment, social interaction, restricted and repetitive interests, sensory

integration, co-morbid diagnosis, rehabilitation, cognitive behavioral therapy, social skills

groups, assistive technology, attention, memory, organization, problem solving, flexibility,

counseling, vocational, academic, higher education, and support. Articles led to the discovery of

several pertinent journals, including Focus on Autism and other Developmental Disabilities,

Journal of Autism and Developmental Disabilities, Autism, and Journal of Vocational

Rehabilitation, which were then browsed for relevant articles. The reference sections of all

important articles were searched for further resources and also for prominent authors and

researchers in the field. The author also interviewed several individuals who are currently active

in the field of Asperger‟s rehabilitation.

Analysis of Resources

Ideal resources are recent (within the last 10-15 years) adult-focused, and Asperger‟s

specific. Most information reviewed is relatively recent, but all important research, whenever

conducted, is included.

Most autism spectrum research is child-focused. Given the motivation of this paper,

research focusing on high school graduates and adults was the primary focus. However, due to a

lack of publications that focus on adults with Asperger‟s, occasionally younger population-

focused articles were included if the results could theoretically be applied to adults. It is clearly

stated when the results described are based on research that used children or adolescent subjects.


Counseling Asperger‟s 8

An attempt was made to focus on articles that were concerned solely with Asperger‟s

Disorder, not the entire autism spectrum. However, in research, often individuals with

Asperger‟s and high functioning autism were grouped together. Also, because there are

similarities between Asperger‟s and autism, (e.g. restricted and repetitive interests), if research

was concerned with an aspect of autism that is shared by individuals with Asperger‟s, it was

included. In these ways the meager recent research on adults with Asperger‟s was supplemented.


LITERATURE REVIEW

Psychological and Medical Aspects

Counseling Asperger‟s 9

Asperger‟s Disorder is a Pervasive Developmental Disorder (PDD). The American

Psychiatric Association‟s (ADA) Diagnostic and Statistical Manual of Mental Disorders, Fourth

Edition, gives the following criteria for Asperger‟s Disorder:

A. Qualitative impairment in social interaction

B. Repetitive and restricted stereotyped patterns of behavior, activities, and

interests

C. Clinically significant social, occupational, or other functioning impairment

D. Absence of a clinically significant general language delay

E. Absence of a clinically significant delay in cognitive development or in

development of age-appropriate adaptive behavior (other than social

interaction), self-help skills, and childhood curiosity about the environment

F. Failure to meet diagnostic criteria for schizophrenia, or for other types of

pervasive developmental disorders (p. 84).

In an effort to define the population, what follows is a more detailed description of criteria A and

B, as well as an explication of other common characteristics and co-morbid diagnoses of

Asperger‟s, as they apply to the adult population.

Impairment in Social Interaction

Asperger‟s is primarily a social disorder. However, unlike individuals with profound

autism, those with Asperger‟s desire social interaction, but they do not know how to

appropriately achieve it (Myles & Simpson, 2002).


Counseling Asperger‟s 10

Individuals with Asperger‟s struggle with spontaneously inferring the meaning of facial

expressions, matching events with facial expressions, interpreting subtle social prompts, and

performing within social norms regarding eye contact, proximity to others, gestures, and posture

(Myles & Simpson, 2002; Koning & McGill-Evans, 2001; Myles & Southwick, 1999). It is

unsurprising that the combination of the desire to be social and the inability to comprehend the

complex and subtle social rules leads to a great deal of stress and anxiety for this population.

However, because these individuals are unskilled at expressing their emotions through the

typical means (e.g. voice inflection, posture), situations can escalate to an explosion before

others realize the individual was feeling anger or excitement (Myles & Simpson, 2002; Myles &

Southwick, 1999).

Individuals with Asperger‟s especially struggle with “theory of mind” issues, (i.e.,

understanding that others have feelings and thoughts different from their own). Myles &

Simpson (2002) identified three areas where theory of mind is especially difficult for those with

Asperger‟s: ability to understand the intentions of others, ability to understand how their

behavior affects others, and ability to participate in reciprocal skills, such as turn-taking.

In an interesting study, Klin (2000) showed a silent cartoon with geometric shapes

enacting a social plot to three groups of adolescents and adults: (1) high-functioning autism, (2)

Asperger‟s, and (3) a neurologically typical group. In both clinical groups, one third of their

attributions were irrelevant to the cartoon, they missed three-fourths of the social elements in the

cartoon, and they used significantly fewer theory of mind cognitive and affective terms. Even

when provided with explicit verbal information regarding the nature of the cartoon, the

Asperger‟s group was still unable to significantly improve their performance. According to Klin,

these results suggest that:


Counseling Asperger‟s 11

When coming face to face with a complex social situation—say, a high school

cafeteria—they might be able to identify only a small number of important clues

required for creating the social context of that setting. Failing to do so might

place them at great disadvantage when having to predict other people‟s intentions

and the select responses that will be appropriate to the social demands of that

situation (p. 840-841).

Restricted and Repetitive Interests

Individuals with Asperger‟s often have restricted and repetitive interests. There does not

seem to be a theme or pattern to the interests; they may be engrossed in geology, astronomy,

mechanics, numbers, fabrics, (Myles & Simpson, 2002) computers, chairs, wrestling, trains,

weapons, or forensic science. However, these interests are not completely random. Individuals

with Asperger‟s are significantly more interested in areas of folk physics (an interest in how

things work) than in folk psychology (an interest in how people work) (Baron-Cohen &

Wheelwright, 1999). This is not surprising given the previously discussed inability of those with

Asperger‟s to comprehend social phenomena. There are several hypothesized reasons for these

obsessive interests: something to talk about, to either facilitate or avoid social interactions, to

demonstrate intelligence, a fun, intensely enjoyable activity, a way to relax, or a way to create

order and consistency, security, and comfort (Barnhill, 2001, p. 262; Bashe & Kirby, 2001).

Because individuals with Asperger‟s don‟t gain much enjoyment from the social aspects of life,

they find pleasure in their special interests (Bashe & Kirby, 2001).

Sensory Integration

Though it is not a criterion listed in the DSM-IV, Hans Asperger, who first identified and

described Asperger‟s Disorder in 1944, observed that in addition to social deficits and restricted


Counseling Asperger‟s 12

and repetitive interests, his clients had abnormal reactions to sensory input (Dunn, Myles, & Orr,

2002). Individuals with Asperger‟s have a sensory profile that is different from that of neuro-

typical individuals. Specifically, they may differ when interpreting information from the seven

different sensory systems: tactile (touch), vestibular (balance), proprioception (body awareness),

visual (sight), auditory (hearing), gustatory (taste), and olfactory (smell) (Dunn, Saiter, & Rinner,

2002).

Asperger‟s:

The following table concisely describes the potential sensory profiles of individuals with

Neurological

thresholds (The

amount of stimuli

we need to notice or

react)

Behavioral

response/self-

regulation strategy

Functional

characteristics of

this pattern of

sensory processing

Potentially

interfering

characteristics of

this pattern of

sensory processing

Low Registration Sensation Seeking Sensory Sensitivity Sensation Avoiding

High

Passive

High ability to focus

on something

Unaffected by

varying emotions

Appears to be

uninterested or

withdrawn

May have a dull

affect or seem selfabsorbed

May seem “overly

tired” or apathetic

High

Active

High ability to

generate ideas and

responses

Notices and enjoys

all the activity in the

environment

Always active,

continuously

engaging

Fidgety and

excitable

Low

Passive

High ability to

notice what is going

on in the

environment

Particular about task

completion

parameters

Distractible in busy,

complex settings

May seem like a

“complainer”

Low

Active

High ability to

design & implement

structure

Enjoys routines

Resistant to change

Reliant on rituals to

participate

Figure 1. Characteristics of specific sensory processing patterns according to Dunn’s conceptual model of

sensory processing (Dunn et al., 2002, p. 175)

It is important to understand that individuals may not necessarily have only one consistent

sensory processing pattern. They may have different patterns for different locations, times of

day, or sensory systems. For instance, someone might avoid all tactile stimulation but seek out

or have moderate responses to visual or auditory input (Dunn, Saiter, & Rinner, 2002).


Counseling Asperger‟s 13

Of particular interest in Figure 1 is the bottom row, “Potentially interfering characteristics

of this pattern of sensory processing.” These are the symptoms of Asperger‟s that are often

misattributed to behavioral or attitudinal problems. However, when the sensory needs of

individuals with Asperger‟s are not met, it is very difficult to behave appropriately (Dunn,

Myles, & Orr, 2002).

Academic/Vocational Characteristics

Because Asperger‟s does not include intellectual or language impairments, one might

assume that these individuals would do well in a school or work environment, especially if they

are not pressured to socialize and have their sensory needs met. In fact, individuals with

Asperger‟s do excel in understanding and retention of factual information (Church, Alisanki, &

Amanullah, 2000). However, it is difficult to predict how someone with Asperger‟s will perform

on a variety of educational tasks. In a 2002 study, Griswold, Barnhill, Myles, Hagiwara, and

Simpson found that participants with Asperger‟s scores on tests including Wechsler IQ, WIAT,

and TOPS-R/TOPS-A were notable for their variety and unpredictability. Participants scored

from far below what might be expected given their grade level to far above average. This

seeming disconnect might be due to the belief that individuals with Asperger‟s struggle with

concrete and literal thinking styles, inflexibility, difficulty comprehending abstract materials,

difficulty understanding inferentially based materials, difficulty with generalizing information,

poor organizational skills, difficulty in discerning relevant from irrelevant stimuli, and difficulty

applying skills and knowledge to solve problems (Frith, 1991; Siegel, Minshew, & Goldstein,

1996; Myles & Simpson, 2002). In other words, individuals with Asperger‟s may struggle with

executive functions.


Counseling Asperger‟s 14

Executive function is an umbrella term for abilities such as problem and goal

identification, organization and planning, insight and awareness, initiation and modulation, and

dexterity, flexibility, and speed. While there is mixed evidence as to the presence of executive

dysfunction in individuals with Asperger‟s, Hill and Bird (2006) conducted an interesting study

in which they compared a group of 22 adults with Asperger‟s to a well-matched control group of

22 neuro-typical adults on a range of tests of executive functions. The executive function tests

were: Behavioural Assessment of the Dysexcecutive Syndrom (BADS), Hayling test, Modified

Cared Sorting test (MCST), Stroop test, and Trail-making test. Overall, once difficulties in

psychomotor processing and visual search were accounted for, there were no significant

differences between those with and without Asperger‟s. However, there were significant

differences on two tests, the Six Elements task of the BADS and the Hayling test. The Six

Elements task consists of giving participants six tasks to work on in ten minutes: two dictation,

two arithmetic, and two picture-naming tasks. Participants are told they are not expected to

complete each task, but they must work on each task, and they cannot work on two tasks in the

same category in a row. This is a test of planning, organization, and monitoring of behavior.

The Hayling test is comprised of two parts. In the first part, participants must complete a

sentence with a word that makes sense, which fits into the context. In the second part,

participants must complete sentence with a word that does not make sense. This is a test of

response initiation and suppression. From these results, the researchers concluded that

individuals with Asperger‟s may have especial deficits in areas of planning, organization, action

monitoring, initiation, intentionality, and goal/sub-goal coordination (Hill & Bird, 2006), all of

which could clearly have dramatic impacts on an individual in a higher education or work

setting.


Co-Morbid Diagnoses

Counseling Asperger‟s 15

Individuals with Asperger‟s exhibit a high rate of co-morbid diagnoses (Sverd, 2003).

Co-morbid, or overlapping/associated conditions, are defined as either (a) coincidental, (b)

causally directly related (i.e., one condition leads to the other), or (c) causally indirectly related

(i.e., another underlying condition led to both the Asperger‟s and the overlapping condition)

(Gillberg & Billstedt, 2000).

Mood Disorders

Both major depressive disorder and bipolar disorder have been associated with

Asperger‟s (Ghaziuddin, 2002). Most individuals with Asperger‟s present with depression once

they reach puberty (Ghaziuddin, Weidmer-Mikhail, & Ghaziuddin, 1998). For individuals who

want to be social but lack the necessary tools, and are becoming more aware of their isolation,

the development of depression is unsurprising.

Obsessive-Compulsive Disorder

Because restricted and repetitive interests are diagnostic criteria for Asperger‟s, it is often

difficult to determine where to draw the line between Asperger‟s and OCD. However, with

Asperger‟s, the obsessions are pleasurable and desirable, whereas with OCD, the thoughts and

compulsions are unwanted. Occasionally, Asperger‟s and OCD do occur together. It is

important to recognize the addition of OCD because of its implications for treatment

(Ghaziuddin, 2002).

Anxiety Disorder

All PDD disorders experience a higher level of anxiety than the neuro-typical population

(Matson & Love, 1990). In a 2006 study, Farrugia and Hudson found that adolescents with

Asperger‟s experienced comparable amounts of anxiety with a group of adolescents diagnosed


Counseling Asperger‟s 16

with anxiety disorder, and both groups experienced significantly more anxiety than a non-clinical

adolescent group. The high levels of anxiety were reported by both the individuals with

Asperger‟s and their parents. Possible explanations for this high level of anxiety include

reactions to having to deal with the core symptoms of Asperger‟s, peer relationship problems,

and negative peer interactions (Farrugia & Hudson, 2006), and an inability to be flexible

combined with an inability to predict common life events.

Non-Verbal Learning Disorder

There may be an overlap between people with Asperger‟s and people with non-verbal

learning disabilities (NLD). Individuals with NLD display a tendency towards social

withdrawal, which is similar to the social impairment found in Asperger‟s (Klin, Volkmar,

Sparrow, Dichetti, & Rourke, 1995).

ADHD

According to the DSM-IV, Attention Deficit Hyperactivity Disorder (ADHD) cannot be

diagnosed if the disturbance occurs exclusively during the course of a PDD (AMA, 1994, p. 93).

As Asperger‟s is characterized as a PDD, it is clinically impossible to have a duel diagnosis of

ADHD and Asperger‟s. However, most individuals with Asperger‟s do present with ADHD-like

symptoms in their childhood and middle school years (Ghaziuddin et al., 1998; Ghaziuddin,

2002), and it can be difficult to differentiate between Asperger‟s symptoms and ADHD

symptoms. For instance, social oddities and intrusiveness can be misinterpreted as inattention

and hyperactivity (Ghaziuddin, 2002). However, some studies have shown that attention deficits

are prominent, if not universal in disorders on the autism spectrum. In fact, there may be a

subgroup of individuals with Asperger‟s that is better defined as having a duel diagnosis of

Asperger‟s and ADHD than simply being on the autism spectrum (Gillberg & Billstedt, 2000).


DAMP

Counseling Asperger‟s 17

DAMP is a Scandinavian concept that is conceptualized as the combination of ADHD

and motor-perceptual dysfunctions (Gillberg & Billstedt, 2000). It is not uncommon for

hyperactivity to be found in conjunction with poor coordination. Individuals with Asperger‟s

disorder tend to have poor motor skills, including coordination and balance difficulties (Wing,

1981; Smith, 2000). Clumsiness is often present (Ghaziiuddin & Butler, 1997). Children and

youth with Asperger‟s also report difficulty with handwriting (Myles, Huggins, Rome,

Hagiwara, & Barnhill, 2003).

Tics and Tourette Syndrome

There appears to be a close relationship between Asperger‟s and tic disorders or Tourette

Syndrome. Ghaziuddin (2002) describes two studies in which 40-50% of participants with

Asperger‟s experienced tics. In another study, 20% of all school-age children with Asperger‟s

met the criteria for Tourette‟s, while 80% demonstrated some sort of tics (Ehlers & Gillberg,

1993). Kadesjo and Gillberg (2000) found that approximately one third of their participants with

Tourette‟s also displayed symptoms of autism or Asperger‟s.

Violence and Aggression

Individuals with Asperger‟s‟ behavioral problems may be connected to the fact that it is

extremely stressful to function in a world perceived as utterly unpredictable (Myles & Simpson,

2002). However, there is currently not enough information to make a general statement about

whether or not having a diagnosis of Asperger‟s increases one‟s propensity for crime and

violence. When individuals with Asperger‟s do commit crimes, they usually have some similar

characteristics: (a) the criminal or violent acts are an extension of their restricted and repetitive

interests, (e.g., a fixation on weapons leads one to experiment with guns), (b) unlike most


Counseling Asperger‟s 18

individuals or individuals with conduct disorder, when someone with Asperger‟s commits a

crime, he or she is unlikely to attempt to hide or cover-up his or her actions or motivations, and

(c), violence and crime might not have anything to do with Asperger‟s but with an unrelated

undiagnosed psychiatric disorder, (e.g., a major depressive disorder could be the cause of an

attempt to hurt oneself or others) (Ghaziuddin, 2002).

Seizure Disorder

There is a relationship between autism and epilepsy; at least 30% of individuals with

autism experience seizures. However, the link between Asperger‟s and epilepsy, while likely, is

less clear (Ghaziuddin, 2002).

Sleep Disorders

Godbout, Bergeron, Limoges, Stip, and Mottron (2000) found that individuals with

Asperger‟s demonstrated a variety of sleep abnormalities, including decreased sleep time in the

first two thirds of the night, increased number of shifts into REM sleep, and evidence of REM-

sleep disruption. The authors suggested that there is a link between Asperger‟s and defective

sleep mechanisms.

Disordered Eating

Some studies suggest that individuals with Asperger‟s are often underweight and

experience disordered eating (Sobanski, Marcus, Hennighausen, Hebebrand, & Schmidt, 1999).

Psychosocial Rehabilitation

Psychosocial rehabilitation addresses the first and perhaps most debilitating symptom of

Asperger‟s: impairments in social interactions. At college, socializing is arguably as important

as education; at work, while employers do value an employee who can successfully perform the

functional aspects of the job, “failing coffee break” can lead to termination. Even individuals


Counseling Asperger‟s 19

with Asperger‟s of normal intelligence will likely have difficulty in school and on a job due to

their previously detailed social impairments (Barnard, Prior, & Potter, 2000; Morgan, 1996).

Unfortunately, scientific evaluations of the current social skills training programs for adults are

lacking. This section will focus on specific therapies, counseling-based and technology-based,

that have demonstrated success in improving the social functioning of individuals with

Asperger‟s. Specifically, cognitive-behavioral therapy, group therapy, education, and hardware

and software interventions will be described and evaluated.

Theory

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is based on the cognitive model of psychotherapy

that believes psychiatric problems are caused by faulty cognitions and beliefs about the world

(Beck, 1976). While Asperger‟s is certainly not caused by faulty beliefs, growing up with a

dramatic lack of social skills can lead to negative thoughts that are over-generalized, self-

defeating behaviors, and rigidity, all of which are potentially treatable by CBT (Ramsay et al.,

2005; Anderson & Morris, 2006) . While there is little available literature detailing treatments

for adults with Asperger‟s, behavior modification programs have been effective with children on

the autism spectrum, and CBT is effective in treating the mood and anxiety symptoms that are

often co-morbid with Asperger‟s. Another benefit of CBT is that it has an experiential

component. Individuals with Asperger‟s learn more by doing than by talking. Role-playing and

behavioral experiments will help the individual to fully understand and generalize behaviors that

are learned (Ramsay et al., 2005).

Therapy for individuals with Asperger‟s is going to look different than typical therapy. It

must be sensitive to the social and cognitive limitations of the population. According to Ramsay


Counseling Asperger‟s 20

et al. (2005, p. 484) there are two features of the therapeutic relationship that must be

emphasized when working with someone with Asperger‟s: 1) therapists are in a position to

provide information and explicit guidance regarding various aspects of social relationships, and

2) the therapeutic relationship provides a useful laboratory for helping individuals with

Asperger‟s learn and practice how to better handle social situations.

Attwood (2003) identified several cognitive distortions that are common in individuals

with Asperger‟s. These include errors of commission (faulty thinking) such as interpreting

situations in all or nothing terms, engaging in magical thinking, tending to overestimate the

likelihood of desired outcomes, resisting taking actions to influence an outcome, and blaming

others for events that are beyond their own control. Ramsay et al. (2005) identified errors of

omission (overlooked information) common in the Asperger‟s population. These include errors

such as not noticing when others are making friendly social overtures.

Therapeutic Interventions

For errors of commission, Ramsay et al. (2005) suggest using Socratic questions. These

questions can assume the other person had a different point of view, such as, “If that is what you

were thinking, what do you think he/she was thinking?” Questions can also point out objective

or subjective cues, “Did they say they were angry? Was his/her voice raised?” (Ramsay et al,

2005). Instruct the client to practice flexible thinking and seek clarification by using questions

and comments during ambiguous conversations, such as, “Are you serious?” or “I don‟t

understand what you just said” (Attwood, 2004). The therapist can explore automatic cognitions

by asking the client what they thought about something the therapist did or said, then providing

information about actual thoughts and feelings. The therapist can also point out where possible

miscommunications might erupt due to the client‟s communication style, such as not smiling


Counseling Asperger‟s 21

when pleased. Visual cues are also encouraged. Illustrations can be effective in demonstrating

different thoughts from different points of view (Ramsay et al., 2005).

Sometimes a client simply needs more explicit social directions and behavioral

suggestions. Making scripts or creating lists of acceptable and unacceptable small talk topics of

conversation may help an individual feel less anxious in social situations. Role playing with the

therapist, then walking down the street to practice with store employees, can be a valuable

therapeutic activity. The therapist can help an individual develop ways to recognize when it is

time to stop talking, how to make eye contact, when to ask questions, and when to say goodbye.

“Mirroring” the physical behavior of others and summarizing the ideas expressed by others can

be practiced in the counseling setting (Ramsay et al., 2005). However, if even more structure is

needed, the therapist and client together can work to develop concrete guidelines such as: during

conversations, make eye contact and periodically look away, pause and give the other person an

opportunity to talk after you have spoken two sentences, or conversations during work hours

should not last more than five minutes (Ramsay et al., 2005, p. 92).

For errors of omission, affective education should play an important role in the

therapeutic interaction. Naming emotions, discussing why we have emotions, and identifying

different levels of emotions are all important therapeutic activities (Anderson & Morris, 2006;

Attwood, 2004). During the counseling session, social cues during the conversation should be

commented on. The therapist can tell the clients what feelings he/she perceives from the client‟s

facial expression and posture, and the client can practice reading emotions on the face of the

therapist (Ramsay et al., 2005)

One means of learning about emotions of others is comic strip conversations. In this

activity, stick figures are drawn in a social situation, with thought and speech bubbles identifying


Counseling Asperger‟s 22

what the characters are doing, saying, and thinking. Colors can be used to identify the characters

emotions and intensity (Gray, 1998).

When discussing the client‟s own emotions, especially negative emotions, a visual

activity designed to help learn about and moderate emotions is the “emotional thermometer.”

This is a diagram that demonstrates different levels of emotions. Physiological, behavioral, and

cognitive cues to the level of emotion can be marked on the thermometer, and when the

“temperature gets too high,” action steps, such as relaxation techniques, can be taken (Sofronoff

& Attwood, 2003).

Attwood (2004) developed a strategy he has found useful for treating anxiety and anger

in children with Asperger‟s, but which he postulates will also be useful for adults. This strategy

involves creating a personal toolbox full of actions or thoughts that can be used to fix problems

associated with negative emotions. (Perhaps when someone‟s emotional thermometer gets too

hot, they are prompted to choose a strategy from their emotional toolbox.) There are five main

types of tools that go into the toolbox: (1) physical tools, (2) relaxation tools, (3) social tools, (4)

thinking tools, and (5) special interest tools.

Physical tools, represented by a hammer, are tools or actions that physically release

energy. These may include walking, running, riding a bike, shooting hoops, playing a sport, or

dancing. Relaxation tools, represented by a paintbrush, are tools that help calm a person down

and lower the heart rate. Examples of these types of tools are drawing, reading, listening to

music, taking a nap, or routine household chores. Social tools, represented by a two-handle saw,

are tools that use other people as a way of managing emotions. These social situations must be

enjoyable without the stress that can accompany social interaction. The interaction should be

limited to with one other person, a family member or friend who truly appreciates and enjoys the


Counseling Asperger‟s 23

person. Social tools can also involve on-line communication, perhaps in an Asperger‟s support

chat room. Spending time with a favorite pet can also be considered a social tool. Thinking

tools, represented by a screwdriver or wrench, are tools that are used to change thinking or

knowledge. These are the most cognitively based tools. Examples of thinking tools include self-

talk such as “I can do it,” “I can control my emotions,” or “The smart thing to do is ask for help.”

Other thinking tools include putting the event into perspective or making an intellectual project

out of the source of stress (e.g. researching why sounds are so loud in a gymnasium). A therapist

might recommend keeping a picture on hand that reminds the person with Asperger‟s of solitude

and tranquility, that they can look at in times to stress to promote relaxation. The last category of

tools in the emotional toolbox is special interest tools. These tools focus on the restricted and

repetitive interests that individuals with Asperger‟s derive pleasure from. Some other,

miscellaneous tools that may be helpful to individuals with Asperger‟s are medication (if the

individual has a co-morbid diagnosis of depressive or anxiety disorder), enjoyable activities

(such as watching a favorite movie), reading the autobiographies of individuals with Asperger‟s,

and managing the sensory environment. The emotional toolbox is something that can be

incorporated into group therapy or a social skills group. Individuals can share their own

strategies and “borrow” tools from others‟ toolboxes (Attwood, 1994).

It is also important to recognize and discuss inappropriate tools. These are tools such as

violence, engaging in retaliation, taking out stress on an innocent bystander, destruction of their

own or other‟s belongings, thoughts of suicide, self-injury, retreating into a fantasy world, and

drugs and alcohol. Family, friends, professors, coworkers, and bosses might also use

inappropriate tools. Gestures that are designed to be comforting (e.g. a hug or pat on the back)

may serve only to increase the anxiety of an individual with Asperger‟s. Once these


Counseling Asperger‟s 24

inappropriate tools are discovered, the individual should work towards informing the person of

better ways to help them in times of anxiety and stress (Attwood, 2004).

Social Skills Groups

Social skills groups for young adults are far rarer than social skills groups for children,

but the few that have been formed have shown some success (Hillier, Fish, Cloppert, &

Beversdorf, 2007). For example, Mesibov (1984) conducted a 12-week group for adolescents

and young adults with autism and found improvements in areas such as initiating and

maintaining conversations and understanding and expressing emotions. Ozonoff and Miller

(1995) demonstrated that individuals with autism spectrum disorder in a social skills group

showed significant improvement in social-cognitive skills compared to a control group that was

not in a therapy group. There are several benefits to group counseling. It provides an

opportunity for individuals to learn they are not alone, to meet others who think like them; it is

ideal for replicating problematic social situation, receiving behavioral feedback, and practicing

new skills in a safe and structured environment (Ramsay et al., 2005). The following discussion

will look more closely into two successful social skills group and attempt to discern the specific

keys to their success.

Howlin and Yates (1999) conducted a year-long social skills group for adults with

Asperger‟s and high-functioning autism. Their aims were to develop appropriate ways to deal

with social difficulties, with a focus on conversation skills and fostering independence. The

group met once a month for approximately two and a half hours. Each meeting had a specific

agenda (see figure 2), but the first part of each session was reserved for participants to discuss

important life events that had transpired in the last month. The teaching strategies relied heavily

on role-play, team activities, and structured games. Importance was placed on conversation


Counseling Asperger‟s 25

ability, so the group leaders stressed appropriate ways of responding to conversation, the need to

avoid repetitive or stereotyped responses, the need to reply directly and relevantly to questions,

and the ability to avoid inappropriate comments or verbalizations (p. 301). At the end of the

year, all families of the group members reported improvements in the participants‟

communication skills, social skills, appearance, self-confidence, and general independence.

Session Main activities and problem areas covered

1 Initial assessments and planning session

2 Identifying with others; talk and discussion related to „understanding autism‟

3 Identifying and expressing different emotions using role-play

4 Conversational skills: use of video and role play to practice and provide feedback on verbal and nonverbal

behaviors, e.g. body language; proximity; eye contact; turn-taking, etc.

5 Communication with friends and strangers: role-play of scenes in the street or a pub; practice in what to

say; how to initiate and maintain contact; how close to approach; how to take leave, etc.

6 Assertiveness: discussion, role-play and video of how to deal with shopkeepers/others, when there are

problems such as needing help, or being short-changed, etc.

7 Problem solving: how to cope in stressful situations, such as dealing with an emergency gas or water

leak; more work on assertiveness, making needs clearly known

8 Job interviews; how to dress; how to listen to and answer questions; asking question; responding to

verbal and non-verbal cues; general preparation; telephone conversations to apply for work ;practice

with non-autistic volunteers

9 Revision of work on body language; conversational skills and assertiveness; practice in using various

aspects of verbal/non-verbal expression to indicate different emotions

10 Coping with stressful situations: discussion and role-play of how to deal with problems faced by

individuals in the group

11 „Putting it all together‟: attending a lunch party organized by hosts unknown to the group members

12 Final assessment and feedback session

Figure 2. Social skills group program (Howlin & Yates, 1999, p. 301)

Howling & Yates (1999) noted one important limitation of the social skills group.

Individuals with Asperger‟s have difficulty generalizing, so although they were successful in the

group, their ability to use their new skills in the world at large remained limited. There are ways

to combat this limitation. There must be an experiential component of the therapy, e.g. initiating

conversations with strangers in a public pace or calling an acquaintance and asking them to go to

the movies. Because these are high-anxiety situations, therapists should be ready to provide

support to clients during these experiences, as well as provide valuable immediate feedback.

Another strategy is to work social events into the social skills group (Ramsay et al, 2006), which

Howling and Yates have done in session 11.


Counseling Asperger‟s 26

The Aspirations program is another successful social skills group that focused on adults

on the autism spectrum (Hillier et al., 2007). Aspirations is an 8-week program with weekly

one-hour meetings. The aims of the program are to “foster understanding of a range of social

and vocational issues, to enhance insight and awareness, and to provide social opportunities for

group members” (p. 109). The sessions are participant-led with two leaders acting or facilitators

that ensure the participants stay on task. Skills are not explicitly taught; instead, participants

discuss, learn from each other, and problem solve together to arrive at solutions. After

completing the program, participants attend monthly reunions. The objective of the reunions is

to facilitate the transference of skills to the real-world environment, and to continue to encourage

previously established friendships between participants. A description of the topics and guided

questions can be found in Figure 3.

Hillier et al. (2007) evaluated the success of Inspirations by self-report measures,

observational data, and notes. The largest improvement was found on the participants‟ responses

on the Empathy Quotient, a measure of participants‟ perceptions of other people‟s feelings and

their own behavior in social situations. However, the authors are also quick to point out that

many of the benefits they observed and reported by the participants are subtle and difficult to

measure, and were not reflected in any of their measures.

Session Topics Covered Guiding Questions

1: Introductions Member introductions

Group rules and expectations

Review of members‟ friendships &

vocational experience

2: Employment Importance of employment

Achieving member‟ employment goals

3: Friendship Characteristics of a good friend

How to find, make, and keep friends

What do you hope to get out of Inspirations?

Tell us about yourself.

Talk about your current friendships/work

experience.

Why is work important?

What job would you like/would suit you?

What do you need to do to get that job?

How does work make you feel about yourself?

What is an employer looking for in an employee?

Why are friends important?

How do you know whether someone is a good

friend or not?

Are you a good friend? In what way(s)?

How can you meet and make friends?


4: Interpersonal

problem-solving

Difficulties that arise during interpersonal

relationships (friends, coworkers, family)

Strategies to overcome difficulties with

others

Counseling Asperger‟s 27

What problems have you experienced in

relationships with others?

Who has experienced bullying before?

Who has had problems with opposite-sex

relationships?

How can (specific) issues/problems be avoided?

5: Social event Social even (pizza outing) to provide opportunity to interact socially, practice social skills, and

foster friendships among group members

6: General Important life problems experienced by What are you struggling with in your lives

problem-solving members

currently?

Effective problem-solving strategies What do you worry about?

What things do you find particularly difficult?

What strategies have you tried in order to deal

with these problems?

What might be good strategies to try in the

future?

7: Social

Evaluating interactions with others How do you know whether you are getting on

communication Discussing how members‟ behavior well with someone?

and theory of influences the opinions of others What do people think of you (positive and

mind

negative)?

Are other people‟s opinions of you important?

How do you make judgments about people?

Why is nonverbal behavior important?

8: Review Review skills learned during program and What have you learned in Aspirations?

how these skills will be utilized

How will what you have learned be useful in the

Feedback regarding program

future?

What have you learned about yourself and other

group members?

Will you keep in touch with other group

members?

Have you seen any changes in yourself?

How could the program have been better?

What did you like/dislike about the program?

Figure 3. Topics and guiding questions covered in Aspirations sessions (Hillier et al., 2007, p. 111)

There are some notable similarities between Howlin and Yates‟ group and the

Aspirations group. For instance, the groups were of a similar size, 10 and 13 participants

respectively. Both groups had aims involving improving self-awareness. The outlines of the

programs also have some striking similarities. Both involve introductions and identifying others

at the beginning, and conclude with review and final assessments. Both include a social event,

attending a lunch party or a pizza outing. Both include employment related focuses, though

Howlin and Yates focus more on the interviewing aspect of employment. Both also focus on

problem solving and theory of mind awareness. Finally, both programs are fairly long-term.

Howlin and Yates‟ program lasts a year; Aspirations condenses the sessions into two months, but


Counseling Asperger‟s 28

then holds monthly maintenance meetings. By acknowledging the similarities, it is easy to

identify what are widely considered the most important therapeutic conventions for social skills

groups.

The main difference of between the programs is that Howlin and Yates took an active

role in leading the group by using teaching strategies such as role-playing, team games, and

structured games. The Aspirations group used a counseling support group model where the

group leaders‟ main role was to pose guiding questions and facilitate. This may be due to the

fact that Aspirations had a higher functioning group, as they only accepted Asperger‟s diagnoses,

while Howlin and Yates‟ group included all ASD diagnoses. It would be interesting to evaluate

the effectiveness of a group where both teaching strategies and support group strategies were

incorporated.

All authors agreed that an important benefit of group therapy is that it has the potential to

decrease the individual‟s sense of isolation. A therapeutic tool used several times by Stoddart

(1999) was to introduce a client to another individual with Asperger‟s. This served both a

learning experience and an opportunity to be accepted and to alleviate the sense of loneliness felt

by many individuals with Asperger‟s. There are other, less formal, ways this can be

accomplished: by providing access to both counseling (e.g. special friends, peer support groups)

and community (e.g. religious groups, hobby teams) supports. Regardless of where or when it

happens, participants in social skills groups often report valuing the friendships they form more

than the skills they learned (Hillier et al., 2007).

Psycho-Education

A final important CBT intervention is simple information about the diagnosis. Many

individuals have no idea what Asperger‟s is or why they experience the difficulties they do.


Counseling Asperger‟s 29

Information should be presented in an accurate and positive light that is sensitive to the literal

way it is likely to be interpreted. Counselors should be prepared to recommend autobiographies

of individuals with Asperger‟s to clients (Anderson & Morris, 2006). According to Stoddart

(1999) a large part of his therapy included education about Asperger‟s. He found it important

that his clients were able to identify those behaviors that were a symptom of Asperger‟s and

those that were typical of any adolescent or young adult. Howlin and Yate‟s (1999) social skills

group also focused on providing the clients with a better understanding of their social

difficulties.

It is also important to educate those who will be teaching or working with individuals

with Asperger‟s. For instance, what might be interpreted as selfish or even sociopathic

tendencies can be refrained as lacking theory of mind skills (Stoddart, 1999).

Hardware

Assistive Technology

Video camera. It is generally believed that the Asperger‟s population has an easier time

understanding information that is presented visually as opposed to verbally (Bernad-Ripoll,

2007). It is also known that individuals with Asperger‟s have difficulty generalizing

information, so just because they can interpret the emotions of others, it does not mean they are

capable of effectively coping with their own emotions. For these reasons, using video tape of the

client him or herself can be an effective tool in learning to recognize and respond to emotions.

Bernad-Ripoll, (2007) conducted a study that aimed to provide direct instruction via

video modeling and social stories. The subject of this study was a 9-year-old boy, but one can

easily see how the same methods could be applied to adults. The researcher videotaped the

participant in his home environment, experiencing a variety of emotions. Social stories—brief,


Counseling Asperger‟s 30

straightforward, and personalized explanations of emotions and coping strategies that include

pictures—were written about five emotions: happiness, anger, anxiety, calmness, and frustration.

During baseline, the participant was shown videos and asked, “How are you feeling?” “Why did

you feel like this?” and “What should you do the next time?” During intervention, social stories

were introduced. The participant read the social stores related to the emotions he was about to

watch in the video. Then, the participant watched the videotaped segment. Then, same

questions as were asked in baseline were presented. In generalization, the participant reviewed a

social story over a four day period. After that period, anytime the participant experienced that

emotion, his parents were instructed to read the Social Sotry and prompt the participant to

engage in the coping techniques recommended in the story (e.g., if the participant recognizes he

is angry, he should sit in a favorite chair and squeeze a ball for a few minutes). Overall, this

intervention was successful. The participant went from a mean accuracy of recognizing

emotions of 55% during baseline to a mean accuracy of 95%; and from a mean accuracy of

correct explanations and action responses of 10% to a mean accuracy of 100% (Bernad-Ripoll,

2007). With a video camera and a digital camera, this intervention could be easily reproduced

and used in a variety of therapy environments.

In a slightly different use of a video camera, Howlin and Yates‟s (1999) recorded their

social skills group participants completing two social tasks (making small talk with a stranger

and requesting information about a job) at the beginning and the end of the sessions. These tapes

allowed participants to objectively evaluate their performance and also appreciate the amount of

progress they made over the year-long group.

Television/movies. In a case study, Breen (2007) used soap operas to promote theory of

mind and recognition of emotions. Soap operas are a visual media, and have a focus on inter-


Counseling Asperger‟s 31

character relationships. The researcher discovered the client‟s love of soap operas before

deciding to use them as a therapeutic intervention (Breen, 2007), suggesting that is a good idea to

use the interests of the client as a starting point for social therapy. If the client is not interested in

soap operas, perhaps another fictional, ongoing media captures their interest (e.g. Harry Potter

movies, sitcoms, dramas, cartoons, etc.). Breen‟s therapeutic plan was to explore a character‟s

situation and emotions through recently broadcast episodes and promotional pictures in

magazines. Pictures were selected that depicted a variety of emotions. The client was asked to

describe the emotions and sometimes speculate about the character‟s thought process. The

accuracy of the client‟s predictions was evaluated though monitoring the storylines. No data

collection occurred, and it was unclear what extent these skills translated to real life. However,

the client‟s teachers did report an improvement in class participation and reduction in imitative

behaviors. Breen (2007) does caution that when using this or a similar therapeutic intervention,

it is important to keep in mind that individuals with Asperger‟s may have difficulty

distinguishing fantasy from reality.

Software

Emotion recognition. One promising method of teaching emotion recognition (ER) is

through an interactive software program called Mind Reading: The Interactive Guide to

Emotions TM (Baron & Cohen, 2006). This software has three components: (a) emotions library,

(b) learning center, and (c) game zone. The emotions library uses photographs, short movie

clips, audio clips, and contextual examples to demonstrate 412 emotions and mental states.

Users can navigate freely, make their own notes, and add faces to a scrapbook for comparison.

In the learning center, emotions can be accessed in groups, lessons, and quizzes that require

matching emotions in faces, voices, and labels. You can also access quizzes about the 20 and


Counseling Asperger‟s 32

100 most common emotions. Rewards (birds, trains, etc., chosen for their potential appeal to

users with Asperger‟s) are given when questions are answered correctly. The game zone

consists of five different games that involve skills such as determining emotions on partially

concealed faces, matching emotions, and evaluating real-world faces. Mind Reading has six

levels of difficulty (Baron & Cohen, 2006).

After using the software for 10-20 hours over a period of 10-15 weeks, adult participants

significantly improved their ability to recognize emotions, compared to both their pre-

intervention scores and to a control group. However, the participants were still limited in how

much they could generalize this new knowledge. (Golan & Baron-Cohen, 2006). An enjoyment

of activities that involve using clear, rule-based systems is consistent with an Asperger‟s

diagnosis. Many individuals with Asperger‟s enjoy using technology and computer programs.

Using software like Mind Reading—predictable, routine, systems-oriented visual technologies—

is an ideal way to support the learning of emotion recognition and other functional deficits

possessed by individuals with Asperger‟s (Lacava, Golan, Baron-Cohen, & Myles, 2007).

Simulation games. While emotion recognition software may help a user to identify

solitary emotional states, software programs that simulate complex social situations are another

potential intervention. Early work indicates that The Sims 2, a simulation game in which players

create characters who navigate a slew of real life activities such as finding a job, maintaining a

home, and forming romantic relationships, has strong therapeutic potential to assist with self-

awareness and exploration of social issues (LoPresti, McCue, and Endres, 2007). If a client

creates a character who has goals and personality characteristics similar to his or her own, issues

such as poor hygiene or lack of motivation will be reflected in the life of the client‟s character,

who will also experience the negative consequences that go along with those behaviors. In The


Counseling Asperger‟s 33

Sims, individuals can navigate stressful social situations in a safe and familiar environment,

which is ideal for individuals with Asperger‟s. According to LoPresti et al. (2007), one client

played multiple characters and observed the different reactions characters had to the same event.

Character‟s reactions to social situations (sadness in response a death) can be starting points for

discussions on social behavior and etiquette. A benefit of the game is that individuals with

Asperger‟s cannot simply focus on their job and home, as every character has a socialization

need that must be met to avoid negative consequences (e.g., character becomes too depressed to

leave the house).

Another simulation game with therapeutic potential is Second Life

(www.secondlife.com), an online 3-D virtual world created entirely by its residents. To

participate in Second Life, a user must first create an avatar. Then, the user can explore the

world, meet other people, buy land, create anything from clothing to buildings, and participate in

the marketplace where items are bought and sold for real US dollars. Because Second Life has

the capacity for real-time interaction between peers, several support groups have already sprung

up, including one for individuals with autism spectrum disorder (Lester, 2005). Real time

communication between a therapist and client is also possible when using second life, which

lends itself well to social role-playing. Role-playing provides an opportunity to flush out social

anxieties such as intimacy, scrutiny, and assertiveness (Gagglio & Riva, 2007).

Cognitive Rehabilitation

While there is some research available regarding executive function deficits in the

Asperger‟s population, there is a definite need for research of successful interventions.

Interventions for executive functions deficits for other disorders, such as TBI, ADHD, and

Learning Disorders, should be evaluated for effectiveness with the Asperger‟s population. What


Counseling Asperger‟s 34

follows is a review of the specific areas of difficulty typically associated with Asperger‟s—

attention, memory, organization, problem solving, flexibility, and central coherence—and

suggestions for rehabilitation. The interventions fall into one of two categories: developing the

individual‟s skills in a specific area of weakness, or using the individual‟s strengths to work

around the area of weakness.

Attention

Individuals with Asperger‟s struggle with attention. However, as previously discussed,

appearing bored or hyperactive can be misinterpreted as an attention deficit when the actual

problem is sensory. It is an important task of the counselor or therapist to gain an understanding

of the client and his or her sensory profile by observation, ecological assessment (including

checklists, histories, and questionnaires) to determine what the first step is to making meaningful

changes (Dunn, Saiter, & Rinner, 2002).

Changing an individual‟s sensory profile (e.g., making them more tolerant of loud noise)

is not viable. Therefore, the counselor must work with the client to develop ways to compensate

for or work around these sensory distracters, in order to improve attention. Dunn, Saiter, &

Rinner (2002) identified four cognitive and behavioral paradigms that would likely positively

affect a client‟s ability to pay attention. 1

1. Priming: A preview activity that is meant to decrease anxiety and allow exploration. For

example, allow a student to explore a new computer program before a class lesson is

devoted to using it.

1 See Appendix for an adaptation of Dunn, Saiter, and Rinner‟s (2002) table specifying examples of interventions

using learning strategies adjusted for various sensory processing patterns.


Counseling Asperger‟s 35

2. Working Independently: After initial introduction and practice, allow the individual to

compete work in a quiet, solitary environment where they are not reliant on another

individual to assist, initiate, or terminate an activity.

3. Visual Supports: Provide visual cues that help individuals anticipate upcoming activities,

anticipate upcoming transitions, and understand expectations. Auditory cues are transient

and cannot be referred to. This strategy is helpful especially with clients who request

constant confirmation, or spend so much time worrying about what is going to happen

next that they cannot focus on the present.

4. Home Base: Provide access to a location apart from the routine environment where the

client can go to plan, regroup, or recover.

Memory

Research is minimal and somewhat conflicting concerning memory deficits in individuals

with Asperger‟s. The overarching theme seems to be that while individuals with Asperger‟s may

have strengths in rote memory skills, they struggle with free recall and use of semantic

information in free recall (Bowler, Gardiner, & Grice, 2000). It has also been suggested that

individuals with Asperger‟s might not have deficits in memory, but deficits in handling the

information to be remembered (Minshew, Goldstein, Taylor, & Siegel, 1994).

In an interesting study, Bowler, Gardiner, & Grice (2000) examined differences in

remembering (“bringing back to mind contextual details of previous events and experiences that

include an awareness of one‟s self,” p. 295) and knowing (“a more abstract awareness of

knowledge,” p. 295) in individuals with Asperger‟s compared to IQ-matched controls.

Researchers found that even though both groups had a similar capacity for memory, the


Counseling Asperger‟s 36

Asperger‟s group relied more on knowing and less on remembering than the matched control

group.

Building on this research, Bowler, Gardiner, and Berthollier (2004) conducted a study in

which they examined whether or not individuals with Asperger‟s would perform better on a test

of source memory when there was support for the correct recall versus when such support is

absent. Participants were shown a list of words and instructed to carry out a simple action with

that word, (“Think of a word close in meaning to…”). Then participants were shown another list

of words, some of which they had seen before and some of which were novel. When they saw a

word they had seen before, they were instructed to say yes. In the unsupported trials, they were

asked to explain what action they did with the word. In the supported trials, they were given a

list and asked to pick which action they did with that word. In a similar experiment, words were

presented either at the top of the screen, bottom of the screen, or read by a male or female voice.

When participants saw or heard a work they had been exposed to earlier, they were to explain

how the word was presented. There were supported and unsupported trials in this experiment, as

well. According to the results, showing supports enhances the source memory to a level

comparable to that of the controls. Without the supports, individuals with Asperger‟s performed

significantly worse than the controls (Bowler, Gardiner, & Berthollier, 2004).

According to the 2000 experiment, individuals with Asperger‟s have trouble with

forming episodic memories. Their memory is based on knowing, not remembering. However, it

is unclear whether or not these individuals are not creating contextual memories, or are not

retrieving them. The 2004 experiment demonstrates that individuals with Asperger‟s benefit

from contextual cues or supports, indicating that episodic memories are made but not retrieved.

Awareness of these memory strengths and weaknesses is invaluable to rehabilitation counselors


Counseling Asperger‟s 37

working with individuals with Asperger‟s. Memory strategies that are likely to make a

significant improvement are those that provide the episodic or contextual cues that individuals

with Asperger‟s are unable to retrieve. Visual cues are better, and verbal information should be

presented concisely to prevent confusion (Kamio & Toichi, 2007).

Organization

Individuals with Asperger‟s often have difficulty with organization. When they do not

complete assignments, it is not necessarily because they do not know how to do the work. They

may have forgotten to obtain the necessary materials, or have written down the wrong due date.

Individuals with Asperger‟s thrive on structure and cuing systems (Marks, Shaw-Hegwer &

Schrader, 2003). Because of its unobtrusiveness and ability to present information in a format

that is tailored to the sensory needs of the individual, a Personal Digital Assistant (PDA) is an

ideal support in an educational or vocational setting.

Myles, Ferguson, and Hagiwara (2007) conducted a study in which they evaluated how

effective a PDA was in prompting a 17-year-old boy with Asperger‟s to record his homework

assignments. The target behavior was that the participant would record the subject the

homework was assigned in, the date the assignment was due, and the important details of the

assignment (page numbers, sections to complete, etc.). During baseline, the participant entered

his homework assignments in his planner with a mean accuracy of 33% for history, 29% for

English, and 34% for science. After the intervention, he entered assignments into his PDA with

a mean accuracy of 75% for history, 75% for English, and 33% for science. The authors note

that though this demonstrates improvement, a longer time span would have allowed more

detailed information on the PDA‟s effectiveness (Myles, Ferguson, & Hagiwara, 2007). For

instance, by the time the PDA was introduced into science class, there were only a few days left


Counseling Asperger‟s 38

in the study. It is likely his mean accuracy for entering assignments in science would have

shown improvements similar to history and English, given more time.

In another study, Ferguson, Myles, and Hagiwara (2005) demonstrated that use of a PDA

effectively decreased a participant‟s reliance on adults to complete tasks at home and school.

Why does a PDA prove to be so effective in this population? There are three hypotheses. First,

using a PDA eliminates handwriting demands. As previously mentioned, individuals with

Asperger‟s often report difficulty with handwriting skills (Myles et al., 2003). Second, the PDA

is easy to use. Technology is often appealing to individuals with Asperger‟s, and they pick it up

easily. It is important to note, however, that an individual‟s success with technology is

somewhat limited by the expertise of the person who is supporting them. Finally, using a PDA

can be highly motivating. It is unobtrusive and does not cause the user to stand out from his or

her peers (Myles, Ferguson, & Hagiwara, 2007).

Problem Solving

Overlapping with their organizational difficulties, individuals with Asperger‟s also have

difficulty problem solving. Channon, Charman, Heap, Crawford, and Rios (2001) conducted a

study in which they compared a group of adolescents with Asperger‟s to a control group on a

measure of real-life-type problem solving. Several “predicaments,” videotaped awkward

everyday situations, were presented to the participants. Participants were given an opportunity to

ensure they understood the facts, instructed to generate solutions, to select the best solution for

the main character in the predicament (optimal) and the solution they would most likely use if

they were in the predicament (personal), and finally rated their degree of satisfaction with their

optimal and personal solutions.


Counseling Asperger‟s 39

Results showed that the Asperger‟s group required significantly more prompts to

correctly recall the relevant information in the predicament. They generated the same number of

solutions as the non-clinical group, but their solutions were of a lower quality concerning

problem awareness, social appropriateness, and practical effectiveness. Their final solution

quality was also poor, especially concerning social appropriateness. There was no significant

difference in the degree of satisfaction with solutions in the Asperger‟s and non-clinical group

(Channon et al., 2001).

The results of this study show that the participants with Asperger‟s had difficulty with

memory and social awareness, especially. It would be interesting to see if social skills training

as described in the previous section would have a positive impact on problem solving ability, or

help individuals to more accurately evaluate the appropriateness of their solutions. Specifically,

the previously described simulation game The Sims provides opportunities to practice planning

and problem solving skills. For instance, characters have a budget and they must decide which

items are most important to buy, and live with the consequences of their decisions. LoPresti et

al. (2007) report one client spent all his money on a large house, could not afford to eat, and

died. Another client frugally avoided buying a bed, slept on an uncomfortable sofa, and was

very unhappy as a result. Clients must learn to prioritize how they spend their money. For

instance, wants must be addressed before needs, and safety issues must take precedence. Clients

must evaluate which of their character‟s needs can be met quickly, and which are going to take

some time. Characters also encounter problems which much be solved, such as a cooking fire.

This problem might be solved by learning to cook better or buying a microwave, however each

solution will come with its own consequences (LoPresti et al., 2007).

Flexibility


Counseling Asperger‟s 40

The second criterion for Asperger‟s is restricted and repetitive interests. Individuals with

Asperger‟s appreciate routine and predictable activities. Situations in which individuals on the

autism spectrum were said to show an insistence on sameness and/or resistance to change are

(Green et al., 2006, p. 231):

1. A preferred item is unavailable or may have been broken, moved, or misplaced

2. A desirable event or activity is interrupted, cancelled, or delayed

3. The person is subjected to unexpected sensory stimulation

4. The person fails a task

5. A task is left unfinished

It is clear how this kind of inflexibility could cause friction at school or on the job,

however, there is a dearth of information on interventions to help facilitate flexibility. The

clearest way to support someone who is in flexible in any of the above areas is to do as much as

possible to modify the environment to reduce the likelihood of items being misplaced or sudden

sensory input. Other strategies include providing external structure, organization, and stability,

provide predictable and safe environments, educate peers, professors, and supervisors, use

positive reinforcements to widen the range of interests, and teach stress coping skills (Williams

1995). It is also important for counselors to know that flexibility is a weakness of individuals

with Asperger‟s, and placement in a job that requires novel problem solving skills, unpredictable

day formats, or generation of innovative ideas, is going to be difficult to impossible.

Central Coherence

Individuals with Asperger‟s have been described as having weak central coherence—

difficulty drawing together diverse information in context (Frith & Happe, 1994). Unlike neuro-

typical individuals who tend to pull information together in an effort to gather a higher meaning,


Counseling Asperger‟s 41

often at the expense of remembering specifics, those with Asperger‟s focus on details rather than

the global picture. This may be due to a lack of schema. According to schema theory,

individuals interpret incoming information based on our own personal schema, our personal store

of knowledge and past experiences. When we learn new information, it is added, ignored, or

transformed to fit into our schema (Bartlett, 1932). Kamio and Toichi (2007) hypothesis that

individual with high functioning autism, similar to Asperger‟s, have difficulty forming schema.

“If schemata are not formed appropriately, new information remains fragmented: it cannot be

integrated into a coherent whole, leading to difficulties in understanding the outer world” (p.

873).

Concept mapping has potential to be a therapeutic tool in helping individuals with

Asperger‟s to focus on the overarching connections between concepts and form schema. The

process of concept mapping involves externalizing a typically internal process. A visual map is

created to document knowledge on a topic, and as new knowledge is gained, links are drawn to

show connections between concepts and ideas. This method, being visual and concrete, draws

on the strengths of individuals with Asperger‟s (Roberts & Joiner, 2007). Concept maps can be

drawn by hand, or with the help of computer programs such as Inspiration Software. Inspiration

has integrated outline and diagram views, and has the ability to create graphic organizers and

expand topics into writing (Inspiration Software, Inc., n.d.). Diagram view has the most

potential to help individuals with Asperger‟s to visualize ideas, concepts, and relationships.

Researchers have found that students with autism spectrum disorder improved their ability to

retain and recall information after a concept mapping session. The participants learned four

times more after concept mapping than they did after traditional teaching methods (e.g. verbal

instruction). Promisingly, participants were able to generalize information learned in concept


Counseling Asperger‟s 42

mapping to other methods of recall. The researchers did point out that some students will need

more structure than others when completing a concept map, and providing a starting point

(usually a title) is often necessary to provide a structural foundation and reduce anxiety about

where to begin (Roberts & Joiner, 2007).

Implications for Rehabilitation Counselors

The following section will review counseling techniques to use when working with

clients with Asperger‟s, as well as specifics on how to meet educational and vocational support

needs.

Rehabilitation Counseling Techniques

Clients with Asperger‟s are likely to derive more benefit from counselors who provide

structure, directions, information, and suggestions than counselors who rely on reflection,

emotional encouragement, and support while clients develop their own solutions to problems. It

follows that cognitive-behavioral therapy (CBT), which, as previously described, has been

adapted for Asperger‟s and combined with psycho-education to enhance social and empathy

skills, has potential to be effective with this population. CBT is theorized to be a more effective

therapy than psychoanalysis and other psychotherapies that stress symbolic constructs,

introspection, and interpretation (Attwood, 2003; Cardaciotto & Herbert, 2004).

Challenges

Individuals with Asperger‟s are likely seeking therapy as a result of pressure or

encouragement from others in their lives. If things are not going well at home or at work, family

members may suggest the individual seek counseling. Reaching out for help is not a common

reaction to difficulties of people with Asperger‟s (Ramsay, 2005).


Counseling Asperger‟s 43

An effective therapeutic relationship is vital to effective counseling. However, it is

difficult to form this relationship with someone whose primary deficits are in understanding and

engaging in social relationships (Ramsay et al., 2005; Hare & Flood, 2000). As previously

discussed, individuals with Asperger‟s have poor communication skills, making interpretation of

their verbal and non-verbal cues difficult. Clients may have poor eye contact, poor voice

modulation, inappropriate affect, or other idiosyncratic communication tendencies.

Perseverating on one topic or making odd metaphors is not uncommon. On the other hand, the

therapist must be aware that some comments made by clients should be taken entirely literally

(Ramsay et al., 2005).

Techniques for Successful Therapeutic Intervention

Forming a relationship with clients, understanding them, and gaining their trust is often

the most difficult part of therapy. When working with someone with Asperger‟s, Ramsay et al.

(2005) suggest make a concerted effort to enter the world of the client. Learn about their inner

experiences. Ask about their interests and hobbies; have them explain their metaphors or media

references (Ramsay et al., 2005). Find out what idiosyncratic ways of expressing thoughts and

emotions the client uses, so that you, the therapist, can also use these specific names of

symptoms and experiences (Anderson & Morris, 2006). Speaking to a stranger is a daunting task

for those with Asperger‟s, if you ask them to talk about something familiar, it will likely

significantly lower their anxiety levels.

Another good starting point is to invite someone close to the client to one of the initial

therapy sessions. This will help the counselor to obtain more objective information about the

client‟s functioning. (Ramsay et al., 2005). Perhaps even recruit this person as a “co-therapist.”

This is someone who the client will communicate his or her goals to, and will help him or her to


Counseling Asperger‟s 44

practice strategies in the real world. Generalization is a difficult skill for individuals with

Asperger‟s and having someone to prompt them to use their techniques in everyday life could be

an invaluable tool.

One way to engage the client in therapy is to provide structure. Individuals with

Asperger‟s struggle with planning, organizing, and prioritizing; external structure can

compensate for these weaknesses (Anderson & Morris, 2006). Be clear about details concerning

where to wait, where to sit, the beginning and ending time of the session, etc. Set an agenda for

each session, including appropriate topics of discussion (Ramsay et al., 2005). Be aware that the

typical therapy hour may not be appropriate for this population. Clients may need shorter

sessions because they are mentally exhausted due to the combined stressors of social interaction

and CBT therapy. Conversely, clients may need longer sessions if they need extra time to

process information or are particularly difficult to redirect from their restricted and repetitive

interests (Anderson & Morris, 2006).

In order to develop workable treatment goals that are relevant to the client, motivational

interviewing techniques that delve into the client‟s desire to change and specific areas of social

interaction that are difficult may be helpful. However, open-ended questions can be difficult for

individuals with Asperger‟s. Use close-ended questions when possible, or give the client several

possible answers they may choose from or use as a starting point when formulating their own

answers (Ramsay et al., 2005). This strategy is especially helpful when clients generate

solutions that are not socially appropriate and the therapist needs to take a more directive

approach with concrete alternatives backed by logical evidence (Anderson & Morris, 2006). In

some cases, it may be helpful to write down questions so that the client can visualize the question

(Ramsay et al., 2005).


Counseling Asperger‟s 45

The use of visual strategies such as writing down questions, using diaries and diagrams,

simple drawings, tape recording, and working together on a computer program are not only ways

to communicate effectively, but also ways for the individual to distance him or herself from the

uncomfortable personal interaction. According to Anderson and Morris (2006), a promising

alternative to traditional therapy is computerized CBT. It works in terms of efficacy, (obtaining

the information regarding situations, thoughts, and emotions to be worked on in CBT) and cost-

effectiveness. One individual wrote on an internet forum requesting feedback from those with

autism who had experienced CBT:

One on one is really hard. I can talk to you like this because I am on a computer

but if I met you face to face it would be hopeless. I would be unable to

communicate very well at all. Most of the AS people I know can communicate

best in writing like this. CBT by computer would be helpful (Anderson & Morris,

2006, p. 295).

Another communication pitfall to be aware of is that of an expectation of reciprocity.

Individuals with Asperger‟s may begin speaking about a topic of interest to them that is either

inappropriate or boring, without noticing social cues indicating they are off topic or annoying. It

is a good idea for the therapist to warn the client early in treatment that he or she may sometimes

have to interrupt the client‟s monologue to ask for more information or provide feedback. It

might be useful to together develop a symbol (raised hand) that means the therapist needs to

interrupt (Ramsay et al, 2005).

It is important to determine the appropriate time to begin giving feedback. Individuals

with Asperger‟s are understandably sensitive to criticism and ridicule, especially by a

professional and a stranger. Feedback about the content of conversations, in the spirit of mutual


Counseling Asperger‟s 46

understanding, can occur in the first sessions. However, feedback about non-verbal behaviors

should generally wait until a therapeutic relationship has been developed. When offering

feedback, provide the rational behind it and do it in an educational way, in the service of

achieving goals stated by the client (Ramsay et al., 2005).

Finally, be attentive. Even though individuals with Asperger‟s might not be as cued in to

social niceties as other clients, they have a history of negative social experiences and interacting

with a counselor should not be one of them. People with Asperger‟s appreciate those who are

reliably present, who make an honest attempt to understand them, and who offer specific and

useful guidance. Ask clients what they think about your, the counselor‟s, statements and

behaviors. This is a useful activity to explore inaccurate interpretations and also for the therapist

to gain credibility as a useful source of information (Ramsay et al., 2005).

In conclusion, the following are five modifications of conventional CBT that will make it

more appropriate and useful for clients with Asperger‟s:

1. Place emphasis on social and affective education

2. Avoid use of metaphors or abstract concepts in favor or straightforward, literal meaning

3. Be directive

4. Use written and visual material whenever possible

5. Involve someone close to the client as co-therapist in order to learn about the client and to

help the client generalize skills outside of therapy

Meeting Educational Support Needs

Given that most individuals with Asperger‟s have average to above average intelligence

levels, it makes sense that many choose to seek post-secondary education. In fact, increasing

numbers of students with Asperger‟s are attending colleges and universities. According to the


Counseling Asperger‟s 47

Americans with Disabilities Act (ADA) of 1990, students with Asperger‟s cannot be

discriminated against based on their disability and reasonable accommodations must be

provided. However, many institutions are providing students with Asperger‟s with the same

accommodations used for students with very different disabilities, even though the needs of a

student with Asperger‟s are unique (Smith, 2007). The following discussion will detail both

obstacles faced by students seeking higher education and supports a counselor can either provide

or help the student to access.

Obstacles

Verbal, socially-based learning is the foundation for current educational practice (Jordan,

2005). Students are expected to discern the important information from a lecture to put in their

notes. Group projects are often a significant portion of a student‟s grade. This modality of

learning is not ideal for individuals with Asperger‟s. Communication barriers cause breakdowns

in other ways as well. Professors do not always provide the direct and specific instructions

individuals with Asperger‟s need to avoid confusion. Students often are unaware they are

allowed to approach professors with questions. The lack of structure in many college courses

can be debilitating to a student with Asperger‟s.

Socially, attending college is also a challenge. Dating and romantic relationships can be

especially confusing. Students with Asperger‟s have trouble interpreting signs from the opposite

sex meaning it is easy for them to either be taken advantage of or labeled a stalker. Failure at

school, socially and educationally, can lead to depression and anxiety (Jordan, 2005).

In an exploratory study, Smith (2007) found that most accommodations currently used

for individuals with Asperger‟s were developed for other disabilities, including extra time on

tests, moderately reduced course loads, registration assistance, limited leaves of absence,


Counseling Asperger‟s 48

assistance for applying for financial aid, preferential seating in the classroom, note-taking

assistance, and specialized housing accommodations. Some of these may be appropriate for

students with Asperger‟s, some may not. However, the types of services that are provided

should depend not on the institution or the labeled disability, but on the unique needs of the

individual student.

Supports

Luckily, there have been some recent developments aimed at providing individualized

and appropriate supports for students with Asperger‟s. A handful of colleges and universities

have taken it upon themselves to provide at least a few appropriate supports for students with

Asperger‟s (e.g. a safe room to relax, peers assigned to be a social translator). One example is

The College Program for Student‟s with Asperger‟s Syndrome at created by The West Virginia

Autism Training Center at Marshall University. Its goal is to provide individualized and

appropriate academic and social supports; faculty, staff, and peer tutor training; and a positive

behavior support approach (West Virginia Autism Training Center, n.d.). The College Living

Experience program serves students in six locations across the country. This program provides

intensive assistance to students with Asperger‟s and other disabilities in three areas: academics,

independent living skills, and social skills. The social skills supports include a peer mentor,

social skills group, and social events (College Living Experience, 2008).

One exemplary program, Achieving in Higher Education with Autism/Developmental

Disabilities (AHEADD), was developed to provide on-site support to students with high-

functioning autism and Asperger‟s. Specifically, AHEADD addresses communication, social,

and organizational skills. Students working with AHEADD receive assistance from professional

staff and peer mentors who work as liaisons, personal advocates, and coaches. Regular meetings


Counseling Asperger‟s 49

are held both with the student and the faculty to help the student manage all aspects of his or her

college career, including: “self-advocacy; faculty/classroom communication, organizational

skills/time management, social skills development, utilization of campus resources, independent

living skills/workforce development” (AHEADD, 2007, n.p.). AHEADD is also committed to

educating the community about autism spectrum disorders.

Unfortunately, this program is neither universally available nor free. AHEADD began in

the Pittsburgh area but will be expanding to support students in Albany, New York, northern

Virginia, and Dallas, Texas, beginning in fall 2008. The cost depends on the school the student

is enrolled in. Some scholarships are available, and AHEADD is currently in the process of

campaigning for funding so that the student and his or her family do not have to pay out of

pocket.

Meeting Vocational Support Needs

Individuals with Asperger‟s are chronically under- or un-employed. Vocational support

services specifically geared towards individuals with Asperger‟s are rare, but those that are in

effect have reported a high level of success (Nesbitt, 2000; Howlin, Alcock, & Burkin, 2005).

Supported employment results in not only higher rates of employment, but in higher quality jobs

that are more appropriate to the population‟s intellectual and educational levels (Howlin, Alcock,

& Burkin, 2005). The following section will detail both the obstacles people with Asperger‟s

face on the job, and the specific supports vocational rehabilitation counselors can provide to

promote success.

Obstacles

Individuals with Asperger‟s have been demonstrated to have difficulty with job finding,

problems arising from lack of social understanding, failure to respect coworkers‟ personal space,


Counseling Asperger‟s 50

talking too much, talking too little, over-reliance on supervisors, poor time keeping, anxiety,

slowness, rigidity, and inappropriate dress or personal habits (Mawhood & Howlin, 2005, p.

250). In line with this, Müller, Schuler, Burton, and Yates (2003) conducted a study in which

they interviewed 18 adults with Asperger‟s about their vocational experience. Analysis of the

interview transcripts revealed four major themes identified by people with Asperger‟s

concerning why they have difficulty becoming successfully employed. The four themes are: 1)

mastering the job application process, 2) adapting to new job routines, 3) communication, and 4)

navigating social interactions with employers and coworkers.

There are several aspects of mastering the job application process that individuals with

Asperger‟s had difficulty with: creating a resume, filling out job applications, contacting

potential employers by phone, interviewing, and coordinating the job search process. Because of

their tendency to focus on the details as opposed to the big picture, several participants expressed

not knowing how much information to provide or which experiences to highlight when asked a

question on an application or in an interview. (Müller et. al., 2003).

Individuals with Asperger‟s reported tremendous effort required to learn new tasks,

criticism from supervisors for taking too long to learn new tasks, and being fired for taking to

long to learn new tasks, all of which fall under the heading of adapting to new job routines. New

experiences are both emotionally and cognitively taxing for individuals with Asperger‟s. While

they are fully capable of learning new tasks, mastering new tasks will likely take them longer

than the typical employee (Müller et al., 2003).

Specific communication difficulties experienced by individuals with Asperger‟s on the

job include difficulty processing incoming information, failure to understand instructions,

difficulty “reading between the lines,” being fired because of work place miscommunication, and


Counseling Asperger‟s 51

being reprimanded for asking too many questions. Supervisors may attribute uncompleted tasks

to a poor work ethic, when the real reason is failure to understand the directions. Individuals

with Asperger‟s are often caught in a “catch-22”: if they don‟t understand the directions, their

choices are to incorrectly or partially complete work, or annoy supervisors by asking them

questions about what they just explained (Müller et al., 2003).

Not surprisingly, individuals with Asperger‟s also expressed difficulty navigating social

interactions. Specifically, they had difficulty with small talk, reading facial expressions and tone

of voice, feeling “odd” or “different” from coworkers, feeling isolated or alienated, and being

fired for failing to understand the social requirements of the job. Participants in Müller et al.‟s

(2003) study fully recognized that even though they were capable of completing the work, their

lack of social skills kept them from being successful.

Supports

In the same study that asked individuals with Asperger‟s about major obstacles to

successful employment, individuals were asked what supports could help them achieve success

(Müller et al., 2003). Following is an explication of the significant responses—job matching,

individualized Asperger‟s support, Asperger‟s awareness training, communication, and

attitudinal supports—along with other proven successful interventions vocational rehabilitation

counselors can apply to help their clients with Asperger‟s achieve gainful employment.

Job matching. Vocational counselors must learn to develop jobs that are appropriate

matches for individuals with Asperger‟s. Good match jobs are those which:

1. Built on technical skills—particularly savant skills or special interests/obsessions

relating to ASDs

2. Required minimal social skill


3. Followed clearly defined routines

4. Allotted adequate time for learning new tasks

5. Did not result in excessive sensory stimulation

6. Allowed for flexible work schedules (Müller et al., 2003, p. 169)

Counseling Asperger‟s 52

Every individual with Asperger‟s is different, and the perfect job for someone might not have to

fit all of the above criteria. One person might be more sensitive to sensory stimulation but learns

new tasks quickly, another may have a valuable technical skill and not need a flexible work

schedule. Importantly, the perfect job match is not one that only accommodates for the

individual with Asperger‟s weakness. The perfect job will also exploit the client‟s strengths.

Some individuals with Asperger‟s report feeling a kind of pride in their ASD, and frustration that

their strengths are not fully taken advantage of (Müller, et al. 2003).

To further underscore the point that individuals with Asperger‟s are capable of a wide

variety of employment outcomes, following is a table listing the types of jobs found by 89

individuals with Asperger‟s who were supported in employment:

Type of work % of jobs Examples of Jobs

Administration/technical 8% Statistician, chemist, research officer,

photography

Administration/accounts assistant 22% Archiving, accounts, etc.

Technical assistant 13% Library, finance, technical, BT operator

Data entry 6% Keyboard operator, data input

Data management 3.5% IT analyst, web design

Office work/clerical assistant 19% Offices, banks, etc.

Secretarial 1.5% Hospital and university posts

Shopwork 8% Customer service, travel agents, transport,

check-out till etc.

Stockroom 6% Shelf stocking etc.

Postal work 4% Mail delivery/sorting

Other 7% Support worker, nursery, messenger, joiner,

gardening, seamstress

Catering 1.5% Chef, kitchen hand

Cleaning 0.5%

Figure 4. Types of jobs found by supported clients with Asperger’s (Howlin et al., 2005, p. 538)


Counseling Asperger‟s 53

Before receiving vocational support these clients were either unemployed or working in low-

paying, temporary jobs. Eighty-five percent of the clients were satisfied with their job and 76%

felt their job lived up to their expectations. Ninety-eight percent believed being supported in

employment was helpful and 75% said they could not have managed without this support

(Howlin et al., 2005).

Individualized Asperger’s supports. Vocational rehabilitation counselors should be

willing and able to provide Asperger‟s-specific supports, including: assist with the job search

process, provide on-site job-coaching, facilitate social interactions, and provide mentoring

services (Müller et al., 2003). Supported employment schemes—defined as the process of

enabling a person with a disability to be successful in the work environment by providing, on-

site, all appropriate supports—specifically designed for individuals with Asperger‟s, are

relatively new (Mawhood & Howlin, 1999).

To help negate the previously mentioned difficulties individuals with Asperger‟s express

concerning the job search, the counselor must be prepared to help contact and follow up with

employers and ensure that the work site is a good match (Müller et al., 2003). Howlin, Alcock,

and Burkin (2005) reported that their vocational counselors spent 26% of their time with a client

in work finding activities 2 .

Once the individual gets a job, a job coach would have two primary functions. The first

is to make sure the individual with Asperger‟s is learning the new tasks. The job coach should

be able to help the client break down larger tasks into smaller, more manageable parts, and to

help the client develop strategies to prioritize which tasks should be completed first. The second

2 Of the remaining time, 34% was spent in work support and preparation programs and 40% was spent in

administrative duties (paperwork, meeting with job managers, dealing with enquiries, travel, etc.)


Counseling Asperger‟s 54

function of a job coach is to act as a social “translator” between the client and his or her

coworkers and supervisor. Some social skills training may be necessary. This training should be

specific to both the individual and the workplace environment he or she is going to be entering.

The job coach must be able to explicitly decode coworkers and supervisors‟ body language,

voice tone, and facial expressions for the individual with Asperger‟s (Müller et al., 2003).

In line with these self reports, the typical difficulties encountered in the workplace by

vocational counselors are organizational problems, low productivity, communication difficulties,

socially inappropriate behaviors, general anxiety, and difficulties coping with change. Strategies

used to overcome these problems include role playing, clear written guidelines/timetables, and

disability awareness training (Howlin, Alcock, & Burkin, 2005).

The final suggestion, mentoring services, has a lot of potential. The participants

suggested a mentoring program that is run by and for individuals with Asperger‟s. A job club

provides support and increases networking opportunities. More experienced individuals who

have successfully held jobs could be an invaluable source of information and support for younger

and less experienced individuals (Müller et al., 2003).

Individualized Asperger‟s supports may also include simple environmental

modifications. Requesting a cubicle in a corner and providing a client with a pair of noise

eliminating headphones may be the most effective way to decrease stress and increase

productivity. Vocational counselors should be prepared to conduct vocational community based

assessments and “think outside the box” to provide appropriate modifications to the job or the

environment.

Asperger’s awareness training. In general, the public is not as educated about

Asperger‟s as those who experience it would like. Participants in Müller et al.‟s (2003) study


Counseling Asperger‟s 55

expressed the belief that miscommunications and firings could be avoided if coworkers and

supervisors understood about what Asperger‟s is and how it affects an individual‟s performance.

In addition, employers should be aware of the strengths of employees with Asperger‟s.

Specifically, that these individuals typically excel areas such as mathematics and computing,

visuo-motor skills, memory for facts and dates, being punctual, attention to detail, honesty, and

reliability (Howlin, 1997).

The potential of these three vocational supports—job matching, individualized

Asperger‟s support, and Asperger‟s awareness training—was demonstrated in a study conducted

by Mawhood and Howlin (1999). Over two years, the researchers compared the vocational

outcomes of a supported group of 27 individuals with Asperger‟s and a control group of 20

individuals with Asperger‟s. The support program included identifying and obtaining a suitable

job, guidance from the support worker on a full-time basis for the first two to four weeks of

employment, gradual decrease of support while still being available in case of emergency (the

levels of support necessary depend greatly on the individual), and educating potential and

existing employers on how to deal with or avoid problems. The results of the study showed that

significantly more supported individuals found work (63.3%) than individuals in the control

group (25%). In the supported group, job levels were higher, they were in work for a greater

percentage of the time, and they received significantly higher wages 3 . None of the supported

clients who found work were fired due to behavioral or other work-related difficulties.

Significantly, employers and employees agreed that without the support, the extra demands

placed on coworkers and managers likely would have been so great as to result in terminating the

employee. Another reason the job placements worked was the great deal of time that was spent

3 One supported employee was earning more than his support worker.


Counseling Asperger‟s 56

collecting information on both clients and jobs so that successful matches were made. Several

employers had such a positive experience that they were willing to hire more employees with

Asperger‟s. One of the most important roles of the rehabilitation counselor was to form

relationships with employers in order to explore appropriate job opportunities and match those

jobs with individuals.

Communication supports. Communication supports should be offered even in the

interview phase. If possible, educate the interviewer on Asperger‟s and encourage him or her to

make questions as clear and direct as possible and to avoid abstract or misleading questions

(Mawhood & Howlin, 1999). On the job, individuals with Asperger‟s need coworkers and

supervisors to be as unambiguous and succinct as possible when giving instructions. No

instructions should be implied, vague, or incomplete. Ideally, instructions should be given not

only verbally, but also visually (a demonstration or checklist). Regular evaluations of

performance may help to keep individuals with Asperger‟s on track (Müller et al., 2003).

Attitudinal supports. While it may be unfair to expect a vocational rehabilitation

counselor to effect attitudinal changes, individuals with Asperger‟s note that their most

successful job experiences are those in which there is tolerance of differences within the

workplace and coworkers and supervisors are patient and caring (Müller et al., 2003). With the

right type of support, successful employment for individuals with Asperger‟s is possible.


SUMMARY AND CONCLUSIONS

Counseling Asperger‟s 57

Adults with Asperger‟s experience impairment in social interaction and repetitive and

restrictive interests and behaviors that prevent them from independently achieving success in

higher education or on the job. However, they also have typical intelligence levels and a unique

set of strengths. With the right supports, individuals with Asperger‟s have the potential to be

successful in higher education and employment.

Social rehabilitation must be structured with an aim of providing information which can

be practiced and generalized. CBT, social skills groups, psycho-education, and various assistive

technologies can help individuals with Asperger‟s learn about social relationships and to practice

behaving in a socially acceptable manner.

Cognitive rehabilitation should reflect the areas of executive function of particular

difficulty to individuals with Asperger‟s. These areas include attention, memory, organization,

problem solving, flexibility, and central coherence. It is important to recognize the impact

sensitivity to sensory input and being a primarily visual thinker has on these functions.

Finally, rehabilitation counselors face particular challenges when working with adults

with Asperger‟s, the first of which is forming an effective therapeutic relationship. By using

clear, literal language, being directive, using written and visual material as often as possible, and

placing emphasis on social education, the counselor is most likely to effectively use CBT with

individuals with Asperger‟s. Preparing an adult with Asperger‟s for college or a job both have

unique challenges and opportunities to provide supports. While most schools provide a standard

set of ineffective accommodations, some colleges and universities are developing programs

aimed at the specific social and organizational needs of individuals with Asperger‟s. When

working as a vocational counselor, the most important step is to find the right job for the client.


Counseling Asperger‟s 58

Finally, in addition to providing individualized Asperger‟s supports, it is time to educate the

public about Asperger‟s Disorder and begin to facilitate attitude changes.


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Intervention/Learning

strategy

Overall approach to

intervention

APPENDIX

Examples of Interventions Using Learning Strategies

Adjusted for Various Sensory Processing Patterns

Counseling Asperger‟s 68

Sensory processing pattern

Low registration Sensation seeking Sensory sensitivity Sensation

Embed sensation to

meet high

thresholds so

activity gains

individual‟s

attention

Learning strategy

Priming Prepare for

upcoming task by

meeting

individual‟s high

threshold with

media-related

activity

Working independently Embed sensations

that meet high

thresholds w/in

work activity

Visual support Place supports in

position that

includes access to

sensation

Home base Arrange home base

to offer items that

meet individual‟s

need for calming

sensation

Adapted from Dunn, Saiter, & Rinner, 2002, p. 179.

Embed sensation to

meet high

thresholds so

individual dose not

seek out distracting

sensation

Engage in

pleasurable task

with sensations that

meet thresholds of

next activity

Offer access to

preferred

sensations in a

manner that assists

performance

Add sensation to

maintain attention

Include sensations

in home base that

meet individual‟s

high thresholds

Offer

discriminating

sensory

information to

honor low

thresholds so

individual is

available to learn

Provide

discriminating

sensation prior to

task

Offer consistent

discriminating

input during work

tasks

Place visual so it is

accessible with low

sensory demands

Offer calming

sensations w/in

home base

environment

avoiding

Offer

discriminating

sensory

information

Offer expected or

familiar sensations

when introducing a

new task

Request/instruct

during tasks with

sensation below

individual‟s

thresholds

Use visuals with

sensations familiar

to the user

Set up safe room

with preferred

sensations

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