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The Adult Asperger Assessment (AAA): A Diagnostic Method

At the present time there are a large number of adults who have suspected Asperger syndrome (AS). In this paper we describe a new instrument, the Adult Asperger Assessment (AAA), developed in our clinic for adults with AS. The need for a new instrument relevant to the diagnosis of AS in adulthood arises because existing instruments are designed for use with children. Properties of the AAA include (1) being electronic, data-based, and computer-scorable; (2) linking with two screening instruments [the Autism Spectrum Quotient (AQ) and the Empathy Quotient (EQ)]; and (3) employing a more stringent set of diagnostic criteria than DSM-IV, in order to avoid false positives. The AAA is described, and its use with a series of n = 42 clinic-patients is reported. Thirty-seven of these (88%) met DSM-IV criteria, but only 34 of these (80%) met AAA criteria. The AAA is therefore more conservative than DSM-IV.

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Acknowledgements

We are grateful to the Three Guineas Trust for supporting the CLASS clinic (Cambridge Lifespan Asperger Syndrome Service) and to the Medical Research Council during the development of this work. We also acknowledge the support of Lifespan Healthcare NHS Trust, and its replacement, the Cambridgeshire and Peterborough Mental Health Partnership NHS Trust, for their support of the clinic.

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Correspondence to Simon Baron-Cohen.

Appendices

Appendix A: Adult Asperger Assessment (AAA)

 

PATIENT DETAILS
Name: Max Asperger
Sex: Male
Date of birth: 10/15/1970
Appointment: 6/1/2001
Age (in years): 30.6

 

SCREENING INSTRUMENT SCORES
Autism-Spectrum Quotient (AQ) score: 50
Max = 50, and 80% of AS patients score 32 or more  
Reference: Baron-Cohen, S., Wheelwright, S., et al. (2001) The Autism-Spectrum Quotient: a new instrument for screening AS and HFA in adults of normal intelligence. Journal of Autism and Developmental Disorders, 31, 5–17  
Empathy Quotient (EQ) score: 0
Max = 80, and 80% of AS patients score 30 or less  
Reference: Baron-Cohen, S. & Wheelwright, S. (2004) The Empathy Quotient (EQ). An investigation of adults with AS or HFA, and normal sex differences. Journal of Autism and Developmental Disorders, 34, 163–175  

 

AAA DIAGNOSTIC CRITERIA
In order to receive a diagnosis of AS, patients must have 3 or more symptoms in each of Sections A–C, at least 1 symptom from Section D and meet all 5 prerequisites in Sections E–I.
Section Domain No. of symptoms required No. of symptoms observed
A (max = 5) Social 3 5
B (max = 5) Obsessions 3 5
C (max = 5) Communication 3 5
D (max = 3) Imagination 1 3
Total (max = 18)   10 18
E–I (max = 5) Prerequisites 5 5

 

DIAGNOSIS
Asperger Syndrome

 

A. Qualitative impairment in social interaction YES NO
1. Marked impairment in the use of multiple nonverbal behaviours such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction. 1  
2. Failure to develop peer relationships appropriate to developmental level. YES NO
  1  
prefers to do things on own rather than with others (AQ1)   
finds self drawn more strongly to things than people (AQ15)   
finds it hard to make new friends (AQ22)   
does not enjoy social situations (AQ44)   
finds friendships and relationships difficult so tends not to bother with them (EQ12)   
3. No interest in pleasing others; no interest in communicating his/her experience to others, including: lack of spontaneous seeking to share enjoyment, interests or achievements with other people; lack of showing, bringing or pointing out objects of interest. YES NO
  1  
4. Lack of social or emotional reciprocity (e.g. not knowing how to comfort someone; and/or lack of empathy). YES NO
  1  
is not concerned if late when meeting a friend (EQ11)   
finds it hard to see why some things upset people so much (EQ21)   
does not spot when someone in a group is feeling awkward or uncomfortable (EQ26)   
is not upset by seeing people cry (EQ32)   
makes decisions without being influenced by people's feelings (EQ39)   
friends don't talk to them about problems as not considered understanding (EQ43)   
can't sense when intruding (EQ44)   
often described as insensitive, but can't see why (EQ48)   
if sees stranger in a group, thinks it's up to them to join in (EQ49)   
stays emotionally detached when watching films (EQ50)   
difficulty with tuning in to how others feel (EQ52)   
does not get emotionally involved with friends' problems (EQ59)   
5. Difficulties in understanding social situations and other people's thoughts and feelings. YES NO
  1  
can't keep track of conversations in social group (AQ10)   
finds social situations difficult (AQ11)   
finds it difficult to work out characters' intentions when reading a story (AQ20)   
finds it difficult to read between the lines when talking with others (AQ27)   
often the last to understand the point of a joke (AQ35)   
finds it difficult to work out what someone is thinking/feeling from facial expression (AQ36)   
finds it difficult to work out people's intentions (AQ45)   
finds it hard to know what to do in social situations (EQ8)   
can't pick up if someone says one thing but means another (EQ19)   
finds it difficult to put self in someone else's shoes (EQ22)   
not good at predicting how someone will feel (EQ25)   
finds social situations confusing (EQ35)   
difficulty with detecting whether someone is masking their true emotion (EQ55)   
consciously works out the rules of social situations (EQ57)   
not good at predicting what someone else will do (EQ58)   

 

B. Restricted repetitive and stereotyped patterns of behaviour, interests, and activities YES NO
1. Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus. 1  
gets so strongly absorbed in one thing that loses sight of other things (AQ4)   
tends to have very strong interests which gets upset about if can't pursue (AQ16)   
collects information about categories of things e.g. types of car (AQ41)   
2. Apparently inflexible adherence to specific, nonfunctional routines or rituals. YES NO
  1  
prefers to do things the same way over and over again (AQ2)   
gets upset if daily routine is disturbed (AQ25)   
3. Stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements). YES NO
  1  
4. Persistent preoccupation with parts of objects/systems. YES NO
  1  
often notices small sounds that others do not (AQ5)   
usually notices car number plates or similar strings of information (AQ6)   
fascinated by dates (AQ9)   
tends to notice details that others do not (AQ12)   
fascinated by numbers (AQ19)   
notices patterns in things all the time (AQ23)   
usually concentrates on the small details rather than the whole picture (AQ28)   
usually notices small changes in a situation or a person's appearance (AQ30)   
5. Tendency to think of issues as being black and white (e.g. in politics or morality), rather than considering multiple perspectives in a flexible way YES NO
  1  
often told gone too far in driving point home in discussion (EQ10)   
can't appreciate another's viewpoint if disagrees with it (EQ60)   

 

C. Qualitative impairments in verbal or non-verbal communication YES NO
1. Tendency to turn any conversation back on to self or own topic of interest. 1  
often told keeps going on and on about the same thing (AQ39)   
in conversation, focuses more on own thoughts rather than listener's (EQ15)   
tends to concentrate on talking about own experiences (EQ37)   
2. Marked impairment in the ability to initiate or sustain a conversation with others. Cannot see the point of superficial social contact, niceties, or passing time with others, unless there is a clear discussion point/debate or activity. YES NO
  1  
does not enjoy social chit-chat (AQ17)   
frequently finds doesn't know how to keep a conversation going (AQ26)   
when talking on the phone, is not sure when it is their turn to speak (AQ33)   
is not good at social chit-chat (AQ38)   
can't tell if someone else wants to enter a conversation (EQ1)   
can't work out what other person might want to talk about (EQ54)   
3. Pedantic style of speaking, or inclusion of too much detail. YES NO
  1  
4. Inability to recognise when the listener is interested or bored. Even if the person has been told not to talk about their particular obsessive topic for too long, this difficulty may be evident if other topics arise. YES NO
  1  
doesn't know if listener is getting bored (AQ31)   
can't easily tell if someone is interested or bored with what they are saying (EQ41)   
5. Frequent tendancy to say things without considering the emotional impact on the listener (faux pas). YES NO
  1  
often told has been impolite even though they think they have been polite (AQ7)   
not a good diplomat (AQ48)   
often finds it difficult to judge if something is rude or polite (EQ14)   
doesn't think it's their problem if they offend someone (EQ27)   
if asked opinion about new haircut, would answer truthfully even if didn't like it (EQ28)   
can't always see why someone should have felt offended by a remark (EQ29)   
is very blunt without being intentionally rude (EQ34)   
sometimes told has gone too far with teasing (EQ46)   

 

D. Impairments in imagination   
1. Lack of varied, spontaneous make believe play appropriate to developmental level. YES NO
   1  
as a child, did not enjoy playing games which involved pretending with other children (AQ40)   
finds it difficult to imagine what it would be like to be someone else (AQ42)   
finds it difficult now to play games with children that involve pretending (AQ50)   
*2. Inability to tell, write or generate spontaneous, unscripted or unplagiarised fiction YES NO
  1  
finds making up stories difficult (AQ14)   
*3. Either lack of interest in fiction (written, or drama) appropriate to developmental level or interest in fiction is restricted to its possible basis in fact (e.g. science fiction, history, technical aspects of film). YES NO
  1  
doesn't particularly enjoy reading fiction (AQ21)   
would rather go to a museum than the theatre (AQ24)   

 

E. Prerequisites YES NO
1. Delays or abnormal functioning in each of A–D occur across development. 1  
2. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning. YES NO
  1  
3. There is no clinically significant general delay in language (e.g. single words used by age 2 years, communicative phrases used by age 3 years). YES NO
  1  
4. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behaviour (other than in social interaction or skills linked to social awareness e.g. personal hygiene). YES NO
  1  
5. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia. YES NO
  1  

Appendix B: The AQ

 

1. I prefer to do things with others rather than on my own. definitely agree slightly agree slightly disagree definitely disagree
2. I prefer to do things the same way over and over again. definitely agree slightly agree slightly disagree definitely disagree
3. If I try to imagine something, I find it very easy to create a picture in my mind. definitely agree slightly agree slightly disagree definitely disagree
4. I frequently get so strongly absorbed in one thing that I lose sight of other things. definitely agree slightly agree slightly disagree definitely disagree
5. I often notice small sounds when others do not. definitely agree slightly agree slightly disagree definitely disagree
6. I usually notice car number plates or similar strings of information. definitely agree slightly agree slightly disagree definitely disagree
7. Other people frequently tell me that what I’ve said is impolite, even though I think it is polite. definitely agree slightly agree slightly disagree definitely disagree
8. When I’m reading a story, I can easily imagine what the characters might look like. definitely agree slightly agree slightly disagree definitely disagree
9. I am fascinated by dates. definitely agree slightly agree slightly disagree definitely disagree
10. In a social group, I can easily keep track of several different people’s conversations. definitely agree slightly agree slightly disagree definitely disagree
11. I find social situations easy. definitely agree slightly agree slightly disagree definitely disagree
12. I tend to notice details that others do not. definitely agree slightly agree slightly disagree definitely disagree
13. I would rather go to a library than a party. definitely agree slightly agree slightly disagree definitely disagree
14. I find making up stories easy. definitely agree slightly agree slightly disagree definitely disagree
15. I find myself drawn more strongly to people than to things. definitely agree slightly agree slightly disagree definitely disagree
16. I tend to have very strong interests which I get upset about if I can’t pursue. definitely agree slightly agree slightly disagree definitely disagree
17. I enjoy social chit-chat. definitely agree slightly agree slightly disagree definitely disagree
18. When I talk, it isn’t always easy for others to get a word in edgeways. definitely agree slightly agree slightly disagree definitely disagree
19. I am fascinated by numbers. definitely agree slightly agree slightly disagree definitely disagree
20. When I’m reading a story, I find it difficult to work out the characters’ intentions. definitely agree slightly agree slightly disagree definitely disagree
21. I don’t particularly enjoy reading fiction. definitely agree slightly agree slightly disagree definitely disagree
22. I find it hard to make new friends. definitely agree slightly agree slightly disagree definitely disagree
23. I notice patterns in things all the time. definitely agree slightly agree slightly disagree definitely disagree
24. I would rather go to the theatre than a museum. definitely agree slightly agree slightly disagree definitely disagree
25. It does not upset me if my daily routine is disturbed. definitely agree slightly agree slightly disagree definitely disagree
26. I frequently find that I don’t know how to keep a conversation going. definitely agree slightly agree slightly disagree definitely disagree
27. I find it easy to “read between the lines” when someone is talking to me. definitely agree slightly agree slightly disagree definitely disagree
28. I usually concentrate more on the whole picture, rather than the small details. definitely agree slightly agree slightly disagree definitely disagree
29. I am not very good at remembering phone numbers. definitely agree slightly agree slightly disagree definitely disagree
30. I don’t usually notice small changes in a situation, or a person’s appearance. definitely agree slightly agree slightly disagree definitely disagree
31. I know how to tell if someone listening to me is getting bored. definitely agree slightly agree slightly disagree definitely disagree
32. I find it easy to do more than one thing at once. definitely agree slightly agree slightly disagree definitely disagree
33. When I talk on the phone, I’m not sure when its my turn to speak. definitely agree slightly agree slightly disagree definitely disagree
34. I enjoy doing things spontaneously definitely agree slightly agree slightly disagree definitely disagree
35. I am often the last to understand the point of a joke. definitely agree slightly agree slightly disagree definitely disagree
36. I find it easy to work out what someone is thinking or feeling just by looking at their face. definitely agree slightly agree slightly disagree definitely disagree
37. If there is an interruption, I can switch back to what I was doing very quickly definitely agree slightly agree slightly disagree definitely disagree
38. I am good at social chit-chat. definitely agree slightly agree slightly disagree definitely disagree
39. People often tell me that I keep going on and on about the same thing. definitely agree slightly agree slightly disagree definitely disagree
40. When I was young, I used to enjoy playing games involving pretending with other children. definitely agree slightly agree slightly disagree definitely disagree
41. I like to collect information about categories of things (e.g. types of car, types of bird, types of train, types of plant, etc.). definitely agree slightly agree slightly disagree definitely disagree
42. I find it difficult to imagine what it would be like to be someone else. definitely agree slightly agree slightly disagree definitely disagree
43. I like to plan any activities I participate in carefully. definitely agree slightly agree slightly disagree definitely disagree
44. I enjoy social occasions. definitely agree slightly agree slightly disagree definitely disagree
45. I find it difficult to work out people’s intentions. definitely agree slightly agree slightly disagree definitely disagree
46. New situations make me anxious. definitely agree slightly agree slightly disagree definitely disagree
47. I enjoy meeting new people. definitely agree slightly agree slightly disagree definitely disagree
48. I am a good diplomat. definitely agree slightly agree slightly disagree definitely disagree
49. I am not very good at remembering people’s date of birth. definitely agree slightly agree slightly disagree definitely disagree
50. I find it very easy to play games with children that involve pretending. definitely agree slightly agree slightly disagree definitely disagree
  1. © MRC-SBC/SJW Feb 1998.

Appendix C: The EQ

 

1. I can easily tell if someone else wants to enter a conversation. strongly agree slightly agree slightly disagree strongly disagree
2. I prefer animals to humans. strongly agree slightly agree slightly disagree strongly disagree
3. I try to keep up with the current trends and fashions. strongly agree slightly agree slightly disagree strongly disagree
4. I find it difficult to explain to others things that I understand easily, when they don’t understand it first time. strongly agree slightly agree slightly disagree strongly disagree
5. I dream most nights. strongly agree slightly agree slightly disagree strongly disagree
6. I really enjoy caring for other people. strongly agree slightly agree slightly disagree strongly disagree
7. I try to solve my own problems rather than discussing them with others. strongly agree slightly agree slightly disagree strongly disagree
8. I find it hard to know what to do in a social situation. strongly agree slightly agree slightly disagree strongly disagree
9. I am at my best first thing in the morning. strongly agree slightly agree slightly disagree strongly disagree
10. People often tell me that I went too far in driving my point home in a discussion. strongly agree slightly agree slightly disagree strongly disagree
11. It doesn’t bother me too much if I am late meeting a friend. strongly agree slightly agree slightly disagree strongly disagree
12. Friendships and relationships are just too difficult, so I tend not to bother with them. strongly agree slightly agree slightly disagree strongly disagree
13. I would never break a law, no matter how minor. strongly agree slightly agree slightly disagree strongly disagree
14. I often find it difficult to judge if something is rude or polite. strongly agree slightly agree slightly disagree strongly disagree
15. In a conversation, I tend to focus on my own thoughts rather than on what my listener might be thinking. strongly agree slightly agree slightly disagree strongly disagree
16. I prefer practical jokes to verbal humour. strongly agree slightly agree slightly disagree strongly disagree
17. I live life for today rather than the future. strongly agree slightly agree slightly disagree strongly disagree
18. When I was a child, I enjoyed cutting up worms to see what would happen. strongly agree slightly agree slightly disagree strongly disagree
19. I can pick up quickly if someone says one thing but means another. strongly agree slightly agree slightly disagree strongly disagree
20. I tend to have very strong opinions about morality. strongly agree slightly agree slightly disagree strongly disagree
21. It is hard for me to see why some things upset people so much. strongly agree slightly agree slightly disagree strongly disagree
22. I find it easy to put myself in somebody else’s shoes. strongly agree slightly agree slightly disagree strongly disagree
23. I think that good manners are the most important thing a parent can teach their child. strongly agree slightly agree slightly disagree strongly disagree
24. I like to do things on the spur of the moment. strongly agree slightly agree slightly disagree strongly disagree
25. I am good at predicting how someone will feel. strongly agree slightly agree slightly disagree strongly disagree
26. I am quick to spot when someone in a group is feeling awkward or uncomfortable. strongly agree slightly agree slightly disagree strongly disagree
27. If I say something that someone else is offended by, I think that that’s their problem, not mine. strongly agree slightly agree slightly disagree strongly disagree
28. If anyone asked me if I liked their haircut, I would reply truthfully, even if I didn’t like it. strongly agree slightly agree slightly disagree strongly disagree
29. I can’t always see why someone should have felt offended by a remark. strongly agree slightly agree slightly disagree strongly disagree
30. People often tell me that I am very unpredictable. strongly agree slightly agree slightly disagree strongly disagree
31. I enjoy being the centre of attention at any social gathering. strongly agree slightly agree slightly disagree strongly disagree
32. Seeing people cry doesn’t really upset me. strongly agree slightly agree slightly disagree strongly disagree
33. I enjoy having discussions about politics. strongly agree slightly agree slightly disagree strongly disagree
34. I am very blunt, which some people take to be rudeness, even though this is unintentional. strongly agree slightly agree slightly disagree strongly disagree
35. I don’t tend to find social situations confusing. strongly agree slightly agree slightly disagree strongly disagree
36. Other people tell me I am good at understanding how they are feeling and what they are thinking. strongly agree slightly agree slightly disagree strongly disagree
37. When I talk to people, I tend to talk about their experiences rather than my own. strongly agree slightly agree slightly disagree strongly disagree
38. It upsets me to see an animal in pain. strongly agree slightly agree slightly disagree strongly disagree
39. I am able to make decisions without being influenced by people’s feelings. strongly agree slightly agree slightly disagree strongly disagree
40. I can’t relax until I have done everything I had planned to do that day. strongly agree slightly agree slightly disagree strongly disagree
41. I can easily tell if someone else is interested or bored with what I am saying. strongly agree slightly agree slightly disagree strongly disagree
42. I get upset if I see people suffering on news programmes. strongly agree slightly agree slightly disagree strongly disagree
43. Friends usually talk to me about their problems as they say that I am very understanding. strongly agree slightly agree slightly disagree strongly disagree
44. I can sense if I am intruding, even if the other person doesn’t tell me. strongly agree slightly agree slightly disagree strongly disagree
45. I often start new hobbies but quickly become bored with them and move on to something else. strongly agree slightly agree slightly disagree strongly disagree
46. People sometimes tell me that I have gone too far with teasing. strongly agree slightly agree slightly disagree strongly disagree
47. I would be too nervous to go on a big rollercoaster. strongly agree slightly agree slightly disagree strongly disagree
48. Other people often say that I am insensitive, though I don’t always see why. strongly agree slightly agree slightly disagree strongly disagree
49. If I see a stranger in a group, I think that it is up to them to make an effort to join in. strongly agree slightly agree slightly disagree strongly disagree
50. I usually stay emotionally detached when watching a film. strongly agree slightly agree slightly disagree strongly disagree
51. I like to be very organised in day to day life and often make lists of the chores I have to do. strongly agree slightly agree slightly disagree strongly disagree
52. I can tune into how someone else feels rapidly and intuitively. strongly agree slightly agree slightly disagree strongly disagree
53. I don’t like to take risks. strongly agree slightly agree slightly disagree strongly disagree
54. I can easily work out what another person might want to talk about. strongly agree slightly agree slightly disagree strongly disagree
55. I can tell if someone is masking their true emotion. strongly agree slightly agree slightly disagree strongly disagree
56. Before making a decision I always weigh up the pros and cons. strongly agree slightly agree slightly disagree strongly disagree
57. I don’t consciously work out the rules of social situations. strongly agree slightly agree slightly disagree strongly disagree
58. I am good at predicting what someone will do. strongly agree slightly agree slightly disagree strongly disagree
59. I tend to get emotionally involved with a friend’s problems. strongly agree slightly agree slightly disagree strongly disagree
60. I can usually appreciate the other person’s viewpoint, even if I don’t agree with it. strongly agree slightly agree slightly disagree strongly disagree
  1. © MRC-SBC/SJW Feb 1998.

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Baron-Cohen, S., Wheelwright, S., Robinson, J. et al. The Adult Asperger Assessment (AAA): A Diagnostic Method. J Autism Dev Disord 35, 807 (2005). https://doi.org/10.1007/s10803-005-0026-5

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Key Words

  • Asperger Syndrome (AS)
  • Adult Asperger Assessment (AAA)
  • Autism Spectrum Quotient (AQ)
  • Empathy Quotient (EQ)