Bitterness, Compulsive Shopping, Internet Addiction & The Tyranny of Diagnosis
For those who have asked me about the usefulness or otherwise of diagnosis and the process of developing diagnostic criteria, here is a thought provoking article from slate.com’s Christopher Lane posted last week.
There’s an awful lot of money to be made from compulsive shopping, judging by the career of Madeleine Wickham. Her Shopaholic series, written under the pen name Sophie Kinsella, is required reading for chick-lit enthusiasts, and the romantic comedy Confessions of a Shopaholic, the first of several planned big-screen adaptations, grossed more than $100 million worldwide. While the film, starring Isla Fisher, isn’t terribly funny, it does make the valid point that to enjoy shopping for elegant clothes isn’t a pathology. It’s a style.
The American Psychiatric Association risks losing sight of that distinction by grimly—and rather inexpertly—debating whether avid shopping should be considered a sign of mental illness. The fifth edition of the association’s Diagnostic and Statistical Manual of Mental Disorders is expected in 2012. The APA isn’t just deciding the fate of shopaholics; it’s also debating whether overuse of the Internet, “excessive” sexual activity, apathy, and even prolonged bitterness should be viewed, quite seriously, as brain “disorders.” If you spend hours online, have sex more frequently than aging psychiatrists, and moan incessantly that the federal government can’t account for all its TARP funds, take heed: You may soon be classed among the 48 million Americans the APA already considers mentally ill.
Emily Yoffe explored the connection between Narcissistic Personality Disorder and economic collapse. David Greenberg discussed the history of presidential character assessment after John McCain released his entire mental-health profile. Daniel Engber wondered whether sex addiction is still a laughable affliction, and Larissa MacFarquhar defended the last DSM against its overdiagnosis-fearing critics.
Quite how the association will decide when normal kvetching becomes a sickness—or reasonable amounts of sex become excessive—is still anyone’s guess. Behind the APA’s doors in Arlington, Va., the fine points of the debate are creating quite a few headaches. And they’re also causing a rather public dust-up.
To linger anxiously, even bitterly, over job loss is all too human. To sigh with despair over precipitous declines in one’s retirement account is also perfectly understandable. But if the APA includes post-traumatic embitterment disorder in the next edition of its diagnostic bible, it will be because a small group of mental-health professionals believes the public shouldn’t dwell on such matters for too long.
That’s a sobering thought—enough, perhaps, to make you doubt the wisdom of those updating the new manual. The association has no clear definition of the cutoff between normal and pathological responses to life’s letdowns. To those of us following the debates as closely as the association will allow, it’s apparent that the DSM revisions have become a train wreck. The problem is, everyone involved has signed a contract promising not to share publicly what’s going on.
Back in 1952, when the APA’s diagnostic manual first appeared, it was a thin, spiral-bound edition that offered sketches of such ’50s-sounding traits as passive-aggressive personality disorder, emotionally unstable personality disorder, and inadequate personality disorder. It was seen more as a guide to psychiatry than as a chapter-and-verse authority on everything pertaining to mental health. Somehow it acquired those pretensions in 1980, with publication of the third edition, which included more than 100 new mental disorders, quite a few of them still being contested.
Inadequate personality wasn’t quite dropped from DSM-III; it was allowed to merge with “atypical, mixed, or other personality disorder,” which is, if anything, even more nebulous. Among the more hair-raising mental illnesses also added to the manual were avoidant personality disorder, oppositional defiant disorder, and social phobia. The latter’s symptoms to this day include fear of eating alone in public and concern that “one will act in a way … that will be humiliating and embarrassing.” The DSM also included such gems as caffeine intoxication disorder, mathematics disorder, sibling relational problem, and frotteurism, the “intentional rubbing up against or touching of another, usually unsuspecting, person for the purpose of sexual arousal.”
The DSM now contains three times as many disorders as it did in 1952 and is more than seven times longer than that first edition. The jury is still out on whether the dozens of new additions hold up to scientific scrutiny. Robert Spitzer, editor of two previous editions, including the one that formally approved post-traumatic stress disorder, recently conceded that his colleagues must now “save PTSD from itself.”
To its members and to the public, the APA boasts that the manual is rigorous and evidence-based, drawing meticulously on data and field trials. But the very fact that the APA has produced a task force to decide whether bitterness, apathy, extreme shopping, and overuse of the Internet belong in the manual indicates, as Allen Frances, who chaired the DSM-IV task force, told Psychiatric News last month, that DSM-V is “headed in a very wrong direction.” “I don’t think they realize the problems they are about to create,” he declared, “nor are they flexible enough to change course.”
Serious questions have also surfaced about the competence, procedure, and secrecy of the DSM-V task force. And the two most vocal skeptics are Frances and Spitzer, former editors of the manual. In one open letter, they chide the APA’s leaders for creating a “rigid fortress mentality,” insisting that “continuing problems … have forced us to intervene in so public a way.”
High on their list of concerns is the absence of transparency. Last July, Spitzer warned readers of Psychiatric News that the amount of secrecy cloaking the revisions was unprecedented and alarming. He quoted the contract that participants are required to sign, which reads, in part:
I will not, during the term of this appointment or after, divulge, furnish, or make accessible to anyone or use in any way … any Confidential Information. I understand that “Confidential Information” includes all Work Product, unpublished manuscripts and drafts and other pre-publication materials, group discussions, internal correspondence, information about the development process and any other written or unwritten information, in any form, that emanates from or relates to my work with the APA task force or work group.
The APA alleges that the paragraph was not meant to block input from interested colleagues or output to the media (for which we are still waiting, by the way!). The president of the APA and the vice chair of the DSM-V task force bluntly dismissed other complaints about secrecy, insisting, against all contrary evidence, that its procedure is “a model of transparency and inclusion.” The agreement was allegedly crafted to protect intellectual property. (The DSM is already copyrighted.) But the agreement also remains binding even after DSM-V is published; to avoid breaking it, participants must keep their drafts, memos, and working papers to themselves. Apparently we’re never to know exactly how or why bitterness, anger, and Internet addiction become mental disorders. Indeed, the contract appears to have been designed to make that omission a foregone conclusion—otherwise, why did the APA enforce it so rigidly at the start? When Spitzer requested the minutes of earlier discussions, he was told that if the APA made them available to him, it would need to share them with others.
After Frances made his objections public last month, he and Spitzer followed up by sending the APA an open letter: “Unless you quickly improve the internal APA DSM-V review process, there will inevitably be increasing criticism from the outside. Such public controversy will raise questions regarding the legitimacy of the APA’s continued role in producing subsequent DSMs—a result we would all like to avoid.”
Spitzer and Frances also strongly disagree with a proposal to include “subthreshold” and “premorbid” diagnoses in the new manual. Both terms give cover to the so-called “kindling” theory of mental illness in children and infants—some psychiatrists believe that it’s possible to stamp out ailments before they burgeon into full-blown disorders. In practice, as the St. Petersburg Times reported in March, psychiatrists in Florida alone gave antipsychotic drugs off-label (without formal FDA approval) in 2007 to 23 infants who were less than 1 year old at the time. They extended the practice to 39 toddlers aged 1; 103 aged 2; 315 aged 3; 886 aged 4; and 1,801 aged 5. One shudders to think what is going on in other states.
The kindling theory of infant mental disorders reminds us—as Darrel Regier (then the APA’s deputy medical director) told the FDA’s Psychopharmacologic Drugs Advisory Committee in October 2005—that the APA already considers 48 million Americans mentally ill. “Subthreshold” and “premorbid” diagnoses, warn Spitzer and Frances, “could add tens of millions of newly diagnosed ‘patients’ “—their quotation marks—to that roster, “the majority of whom would likely be false positives subjected to the needless side effects and expense of treatment.” Conceivably, we might by 2012 reach a point where the APA is defining more than half the country as mentally ill.
“In its effort to increase diagnostic sensitivity,” Spitzer and Frances conclude, the DSM-V task force “has been insensitive to the great risks of false positives, of medicalizing normality, and of trivializing the whole concept of psychiatric diagnosis.” These are remarkable accusations from two men who, between them, oversaw the formal approval of more than 150 mental disorders in two-dozen years.
In three years’ time, will bitterness be seen as one of these disorders? Count me among the afflicted, if you must; some days that does seem possible, even likely. Given its track record and the grave doubts of two former editors of the DSM, should the APA really be given sole rights to decide something so consequential?
Aspergers and Ipods: Reaching into the Hearts & Minds of ASD Youth
I love using technology to engage and reach people in therapy. For me, it started with the relaxation cassette tape! I frequently use the internet,email, PowerPoint narratives and mp3’s and even Twitter and this Blog with clients. A Minneapolis center is experimenting with Ipods as an intervention tool with ASD youth. The wonderful book “Getting IT” is a must for anyone interested in using technology with children and youth in the areas of mental heath and disability. I thoroughly recommend it.
This story from Reuters
Sue Pederson knows that the teenage boys in her treatment program have trouble making conversation. They may not know what to talk about; or once they get started, when to shut up.
That’s one of the striking features of people with Asperger’s syndrome: they struggle with the social skills that come so naturally to others.
But about a year ago, Pederson, a psychologist, and her colleagues at the Fraser Child & Family Center in Minneapolis found a new way to reach these students — right through their headphones.
They’re using iPods, which play music and videos, to teach them how to fit in.
It may have started out as a form of entertainment, but Pederson says this kind of technology is turning into an unexpected boon for children and teenagers with special needs. The devices, it turns out, can be crammed with the kind of information they need to get through the day. While it’s still experimental, she said, “I think it’s going to spread like wildfire.”
With Asperger’s, a form of autism, people lack the inner voice that tells them what is, or is not, appropriate behavior. At Fraser, Pederson’s staff came up with the idea of programming iPods to act as an electronic substitute for that missing voice.
In this case, the staff helped students create a series of short videos and slide shows on how to behave in different social settings. Some are barely 30 seconds long: How to carry on a conversation (“Let the other person talk AND change the topic…”); how to respect other people’s boundaries, and think before they speak (“Use your filter!”)
In the world of special education, these scripts are known as “social stories,” used to teach basic social skills. “It’s a mental checklist for things to think about when you’re interacting with other people,” explained Mandy Henderson, who works with Fraser’s Asperger’s program.
As part of the Fraser project, the students can transfer the videos onto their iPods, and replay them over and over, to drive the lessons home.
Jack O’Riley, of Eagan, said it’s just what his 15-year-old son P.J. needed. “This really hit the mark,” he said. Like many kids with Asperger’s, P.J. is baffled by the normal rhythms of social interaction: in conversation, he may blurt out too much information, or say nothing at all, his father says.
At the same time, P.J. is easily distracted and has a hard time staying on task, another common trait of Asperger’s. For years, O’Riley posted laminated signs around the house to remind his son how to get through the day — take a shower, brush his teeth, get ready for school.
Now, with the videos developed at Fraser, “we can plug this stuff into his little ‘extended memory,'” O’Riley said. P.J. is building a library of videos on his iPhone, so they’ll be at his fingertips. “He can pull up a topic on his ‘to do list’ and find everything he needs to know,” his father said.
Sixteen-year-old Myles Lund of Lakeville, another student in the Fraser program, said he’s learned to use the iPod to help control his emotions by playing his favorite music. “It helps take my mind off of it,” he said. At the same time, Myles, who says he rarely initiates a conversation, agrees the videos can help in social situations. “I just pull out my iPod and go through a list of things to talk about.”
The staffers at Fraser came up with the idea after they noticed how students with Asperger’s would use iPods as a calming device, to block out noise or other distractions. “We just started thinking how else can we use this technology,” said Pederson. They got a $7,500 private grant to buy the iPods and other equipment, and started experimenting.
Jim Ball, an adviser to the Autism Society of America, said similar projects are popping up around the country. Some people are designing adaptations for smart phones, Palm Pilots and other devices to fill the same need, he said.
“This is just another way of prompting kids when they’re in situations when they don’t know what to do,” said Ball, who works with autistic children in New Jersey. “The technology gives them the ability to be independent.”
Ball noted the devices could work especially well with Asperger’s kids, because they’re often far more comfortable with electronic gadgets than they are with people. “It’s a machine; they don’t have to react to it, they don’t have to understand it,” Ball said. “They just need to know how to work it. And they do.”
Another advantage, especially for teenagers, is that they won’t stand out using this kind of device, noted Pederson. “If you walk into a family reunion and you’ve got a teenager with an iPod, nobody bats an eye,” she said.
Barbara Luskin, a psychologist with the Autism Society of Minnesota, agrees. “Adolescents with Asperger’s, like all adolescents, don’t want to look different,” she said. If the device just blends in with everyone else’s, she said, “you’re much more likely to use it.”
So far, there appear to be few commercial products aimed at this market, but that may be changing. The Conover Co., a special-education software company in Appleton, Wis., recently adapted its “Functional Skills System” for the iPod Touch. But the package, which sells for $3,500, is mainly marketed to schools and other organizations.
Fraser, meanwhile, is hoping to get another grant to expand its iPod program.
Ball, of the Autism Society, predicts this is just the beginning. “I think that technology is limitless in its potential for working with kids,” he said.
Just Do It: Asking For Help & Why People Are Twice as Likely to Assist as You Think!
In everyday life asking others for help can be embarrassing, perhaps even a painful experience. Requesting help potentially shows our own weakness and also opens us up to rejection. It’s a relief when people say yes.
Perhaps this explains the conclusion of new research published in the Journal of Personality and Social Psychology that finds we grossly underestimate just how willing others are to help us out.
In a series of studies Francis Flynn and Vanessa Lake of Columbia University tested people’s estimation of how likely others were to help them out. They got people to ask others to fill in questionnaires, to borrow cell phones and to escort them to the gym.
Across these studies they found that people underestimated how likely others were to help them by as much as 100%.
This is such a high figure that it demands an explanation – what’s going on here?
Part of the answer is our egocentric bias – we find it difficult to understand what others are thinking and feeling because we are stuck inside our own heads.
But it’s more than just that, argue Flynn and Lake, it’s also the fact that we underestimate just how much social pressure there is on other people to say yes. In effect, when you ask someone to help you, it’s much more awkward and embarrassing for them to say ‘no’ than you might think.
In two further studies Flynn and Lake supported this intuition by asking participants to put themselves in either the role of someone asking for help, or someone being asked for help.
They found that when people were help-seekers they reliably played down the social costs of saying no. But when they were the potential helper they realised how difficult it was to say no.
There’s two very practical messages coming out of this research:
- If you want help, just ask. People are much more likely to help than you think, especially if the request is relatively small. Most people take pleasure in helping others out from time-to-time.
- Make it easy for others to say no. The other side of the coin is that most of us don’t realise just how hard it is to say no to a request for help. Other people feel much more pressure to say yes to our requests than we realise. If the help you need is likely to be burdensome then think about ways of making it easier to say no.
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“I Just Want to be Happy!” The Struggle for Happiness PART 1: The Complete First Chapter of “The Happiness Trap”
If you’ve read some previous posts, you’ll be aware that I’m a huge fan of Australian MD Dr Russell Harris’ book “The Happiness Trap”. “The Happiness Trap” is a book which outlines the key principles of Acceptance and Commitment Therapy (ACT). I have said previously that I would come back to this topic so here goes!
ACT is a relatively new (mid to late 1990’s) approach to cognitive therapy, based around the principles of “mindfulness” and acceptance of the difference between the realities of what is going on around you as opposed to your evaluation or judgment of what is going on around you. These evaluations and judgments are often dependent on how your thoughts and assumptions are attached to or “fused” to your emotions and perceptions of yourself and others. It is a well researched model which is widely becoming more and more accepted as an effective intervention for anxiety,depression and other mental health and wellness issues.
Sound complicated and confusing? Well actually it’s not. And to prove it I am providing a link here to The full first Chapter of Dr Harris’ book in PDF format. You will need acrobat reader (free) or another free PDF reader to access this chapter which you can find by clicking on the link below.
I will be coming back to the principle of ACT and mindulness hopefully once or twice a week, and my aim is to walk you through the rationale of this approach and show you some tools,worksheets and strategies to help you to explore and implement some of basics of ACT, so subscribe to my RSS or come back regularly to keep up!
Here’s the link!
Chapter 1 of “The Happiness Trap” – Dr Russell Harris (No catches or tricks..it’s free!)
You will probably find a copy of The Happiness Trap and other ACT Books in your local library. You can also purchase a copy Here, and if you are in Australasia, Here. You can read more about it at Dr Harris’ website and there are customer reviews in My Highly Recommended Books.
Enjoy
Part Two coming soon!
Do Professional Movie Critics Evaluate Films the Same Way as the Rest of Us?
If you want to know whether you’re going to enjoy a movie, the opinion of professional film critics might not be the best place to find out. Jonathan Plucker and colleagues compared the ratings given to films by professional critics, “amateur critics”, and undergrad students, and discovered a continuum of overlapping opinion with the experts being the harshest judges, followed by the amateur critics, while the students were the most generous.
A further finding to emerge was that undergrads who’d watched more films tended to provide harsher ratings, but these were still more generous on average than the amateur and professional critics.
Plucker’s team said this is one of the first studies to compare expert and lay opinion on films in a systematic way. Their results involved the assessment of 680 films dating from 2001 and 2005, with professional ratings garnered from metacritic.com and amateur critics’ ratings taken from www.imdb.com and www.boxofficemojo.com. One hundred and sixty-nine undergrads provided their ratings for comparison.
The researchers said their findings support the idea of “creative gatekeepers” who help society decide what products in a given realm are truly creative. A continuum of film opinion suggests different people might best be served by different gatekeepers. They explained: “a gatekeeper for one person may be a well-known critic, for another, novice critics on the most popular film sites; and for yet another, their next-door neighbour or best friend.”
Plucker, J., Kaufman, J., Temple, J., & Qian, M. (2009). Do experts and novices evaluate movies the same way? Psychology and Marketing, 26 (5), 470-478 DOI: 10.1002/mar.20283
Do We Need A Simpler Definition For Major Depressive Disorder?
I’ve just come across this press release. Thought provoking..will have to chew it over.
Researchers from Rhode Island Hospital’s department of psychiatry propose that the definition for major depressive disorder (MDD) should be shortened to include only the mood and cognitive symptoms that have been part of the definition in the Diagnostic and Statistical Manual of Mental Disorders (DSM) for the past 35 years. Their recommendation would exclude those symptoms that are currently part of the definition that may be associated with medical illness rather than depression. The proposal is based on a study that appears in the July 23 online first edition of the journal Psychological Medicine.
The current definition of major depressive disorder in the fourth edition of the DSM (DSM-IV) includes nine symptoms — a definition that has remained essentially unchanged since the 1970s. With preparations for the fifth edition of the DSM underway, the researchers propose that there are two practical problems with the symptom criteria: the length of the definition and the difficulty in applying some of the criteria to patients with co-morbid medical illnesses. The researchers’ proposal recommends a shortened list of symptom criteria that includes only low mood, loss of interest or pleasure, guilt/worthlessness, impaired concentration/indecision and suicidal thoughts. It would exclude the somatic criteria of fatigue, appetite disturbance and sleep disturbance (increased sleep or insomnia) as these may be associated with medical illnesses other than depression. Their proposal is called the “simpler definition of MDD.”
Lead author Mark Zimmerman, MD, director of outpatient psychiatry at Rhode Island Hospital, says, “While the principles guiding criteria revision have not been clearly explained, we believe that existing diagnostic criteria should be revised when a conceptual problem is identified, or a more valid or simpler method of defining a disorder is developed. The reason for even considering a change to the symptom criteria for major depressive disorder after all these years is two-fold.”
Zimmerman, who is also an associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, continues, “First, studies have indicated that there are significant gaps in the knowledge or application of the MDD criteria among practitioners. Second, somatic criteria that are currently part of the DSM-IV definition such as fatigue or sleep or appetite disturbances are also symptoms of other medical illnesses and may not be indicative of a major depressive episode.”
Under Zimmerman’s direction, researchers from Rhode Island Hospital and The Warren Alpert Medical School of Brown University previously developed the simpler definition of MDD for a project known as the Rhode Island Methods to Improve Diagnostic Assessment and Services (RI MIDAS) project, an integration of research quality diagnostic methods into a community-based outpatient practice affiliated with an academic medical center.
Zimmerman says, “In our previous report from the RI MIDAS project, we developed a briefer list of the symptom criteria of MDD that was composed entirely of the DSM-IV mood and cognitive symptoms. That simplified definition did not include the somatic symptoms.” He continues, “Our initial research found high levels of agreement in diagnosing MDD between the simplified and DSM-IV definitions of MDD. Our goal in this study was to replicate these findings in a large sample of psychiatric outpatients, and to extend the findings to other patient populations, including those presenting for treatment of pathological gambling and candidates for bariatric surgery.”
Zimmerman says, “After eliminating the four somatic criteria from the DSM-IV definition of MDD, leaving the five mood and cognitive features, a high level of concordance was found between this simpler definition of MDD with the original classification in all three patient samples studied.” He adds, “This new definition offers two advantages over the DSM-IV definition – it is briefer and therefore more likely to be recalled and correctly applied in clinical practice, and it is free of somatic symptoms, thereby making it easier to apply with medically ill patients.”
Using the Structured Clinical Interview for DSM-IV (SCID), the researchers conducted a study of more than 2,500 patients. The patient population consisted of 1,100 psychiatric outpatients, 210 pathological gamblers who presented for treatment and 1,200 candidates for bariatric surgery. Across all patients, the level of agreement between the simplified definition and the DSM-IV definition was more than 95 percent.
The researchers note that there are implications to changing the criteria for MDD. Because their findings indicate that the simpler definition is highly concordant with the current version, there would be no meaningful impact on prevalence rates. Reducing the number of criteria, however, would reduce the time needed to fully assess criteria in patients and diagnostic interviews could be shortened.
Zimmerman and the researchers conclude, “In deciding how to proceed in the next version of the DSM, the conceptual and practical advantages of a briefer set of criteria that is easy to apply to all patients, particularly medically ill patients, needs to be weighted against the disadvantages of deviation from tradition.”
Along with Zimmerman, other researchers involved in the study include Janine Galione, PhD; Iwona Chelminski, PhD; Joseph McGlinchey, PhD; Diane Young, PhD; Kristy Dalrymple, PhD; Camile Ruggero, PhD; and Caren Francione Witt, PhD; all of Rhode Island Hospital and Brown University.
Source: Nancy Jean Lifespan
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What do you think? Leave a comment and we’ll see if we can get some discussion happening!
Using Music to Help Children with Autism Understand Emotions (Plus Some Favorite ASD Resources)
This post got so many Retweets on my Twitter Timeline that I decided to repost it here. The original source is examiner.com, and the author is Sharon GillsonMusic affects all of us, and we can attest to it’s appeal to our emotions. Now researchers have developed a program designed to help children with ASD better understand emotions, and learn to recognize emotions in other people.
The children use a method of music education known as the Orff-Schulwerk (schulwerk is German for schooling) approach, which was developed by 20th-century German composer Carl Orff. This approach to music learning uses movement and is based on things that kids intuitively like to do, such as sing, chant rhymes, clap, dance and keep a beat or play a rhythm on anything near at hand.
The 12-week program uses elements from the Orff method — including games, instruments and teamwork — and combines them with musical games. The idea is to pair emotional musical excerpts with matching displays of social emotion (happy with happy, sad with sad, etc.) in a social, interactive setting.
Istvan Molnar-Szakacs, a researcher at the UCLA Tennenbaum Center for the Biology of Creativity and member of the of the Help Group–UCLA Autism Research Alliance, stated, “The purpose of this work is to provide a means for awakening the potential in every child for being ‘musical’ — that is, to be able to understand and use music and movement as forms of expression and, through that, to develop a recognition and understanding of emotions.”
Molnar-Szakacs also said that participating in musical activities has the potential to scaffold and enhance all other learning and development, from timing and language to social skills. “Beyond these more concrete intellectual benefits, the extraordinary power of music to trigger memories and emotions and join us together as an emotional, empathic and compassionate humanity are invaluable”
The goal of the research is to evaluate the effect of the music education program on outcomes in social communication and emotional functioning, as well as the children’s musical development.
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I am constantly delighted and enthralled by the children, young people and adults with ASD with whom I have the opportunity to work. There is a frankness and depth in these conversations that blows my socks off just about every time we get together.
Here are some of the ASD resources that I use and recommend to my clients and patients as well as my colleagues.
This is not an exhaustive list by any means, but rather some of those I have found most useful or been described as most helpful. Please have a look and see if you think they may be of use to you or someone you know. There are others listed in my “Highly Recommended Books and Resources” Link to the right of this page.
Tony Atwood‘s Brilliant The Complete Guide to Asperger’s Syndrome
Freaks, Geeks & Asperger Syndrome: A User Guide to Adolescence
and there are so many others! I’m just realising that this is an entire post topic in itself. Stay tuned. Any others you like” Any questions? Leave a comment!