Asperger FAQ
- What is Asperger’s Syndrome?
- What is Asperger’s Disorder?
- Who determined the diagnostic criteria for this syndrome and are other criteria available?
- How is Asperger’s Syndrome related to Autism?
- How is Asperger’s different from Autism?
- What is the difference between Asperger’s Disorder and High Functioning Autism?
- How is Asperger’s Syndrome treated? Is there a cure?
- What is the difference between a disorder and the normal range of abilities and personality?
- Do girls experience Asperger’s Disorder differently?
- What other problems may a person with Asperger’s Disorder experience?
- What are the advantages and disadvantages of having the label Asperger’s Disorder?
- What is meant by “impaired social interaction”?
- What is pedantic speech?
- What is “theory of mind” or “mind blindness”?
- What are “stereotyped behaviors”?
- What are “stim behaviors” and why does the person with Asperger’s Disorder do them?
- How can I find out if my child has Asperger’s Syndrome?
- When is it good to look for help for my child with Asperger’s Syndrome?
- What is Asperger’s Syndrome?
- Back to Top
Generally, Asperger’s Syndrome is understood to involve problems with social skills and relationships, nonverbal communication difficulties, restricted, repetitive behaviors, narrow areas of interest, and adequate development of language skills and intelligence.
Since 1944 when Hans Asperger first wrote of the symptoms he observed, professionals have included different groupings of the following symptoms in their definitions of the condition: social impairment, narrow interest, repetitive routines, nonverbal communication problems, motor clumsiness, preference for solitary activities, odd speech, stereotyped behaviors, lack of delay in speech or language comprehension skills, normal intellectual development, delayed motor skills, problematic peer relationships, restricted interests, compulsive adherence to nonfunctional routines, preoccupation with parts of objects or nonfunctional aspects of toys, tools, machines, etc.
- What is Asperger’s Disorder?
- Back to Top
The terms “Asperger’s Disorder” and “Asperger’s Syndrome” are used interchangeably to describe the same set of behaviors. Prior to the publication of the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV; 1994), the term Asperger’s Syndrome appeared to be more prevalent. In 1994, the DSM-IV made a group of symptoms a “diagnosable” condition named Asperger’s Disorder. The term Asperger Syndrome seems to be used more in other countries (i.e., outside of the United States; Attwood, 2003). American’s, in contrast, tend to use the label Asperger’s Disorder. This difference is likely due to the fact that it was the American Psychiatric Association which first officially “named” the disorder in its 1994 publication of the DSM-IV.
The following symptoms were required for a DSM-IV diagnosis of Asperger’s Disorder: (a) impaired social interaction; (b) limited, habitual, stereotyped patterns of behavior, activities or areas of interest; (c) lack of significant delay in language skills; (d) lack of delay in cognitive skills, age-appropriate adaptive or self-help skills; (e) presence of curiosity in the outside world or the environment; (f) the first two symptoms must lead to problems in social, occupational, or other types of functioning for the person; and (g) the symptoms are not related to a diagnosis schizophrenia or another pervasive developmental disorder.
These criteria attempt to describe people who:
a. Appear to experience a lack of reciprocity in social interactions (Meyer & Minshew, 2002). This means a person who does not understand nonverbal communication (e.g., gestures, facial expressions) and, for example, may continue a conversation even though the person s/he is talking to is looking at his watch trying to get away. The person with Asperger’s has difficulty recognizing and understanding others’ use of facial expression and gestures during conversation. Their lack of response to this type of communication creates great difficulty for them in social relationships. Similarly, a person with Asperger’s may not use nonverbal communication and may appear expressionless in most conversations or interactions with others.
b. Lack a theory of mind (the ability to understand what another person may be thinking in a given situation). They have difficulty imagining or understanding how someone else’s thoughts, experiences, knowledge, or desires could influence their behavior. This concept has also been called “mind blindness” (Attwood, 1998, p. 114).
c. Have unusual speech patterns. While people with Asperger’s may have begun talking at an appropriate age, they often “ . . . used a rather pedantic, long-winded and sometimes rather concrete or literal style of speaking” (Bowler, 1992, p. 877). Pedantic describes speech that is overly focused on the details of its topic. It is speech that appears to list details about a topic one after the other. In a person with Asperger’s, this type of speech does not appear to be impacted by the environment (such as by the nonverbal cues of others), and therefore seems less conversational and more like a monologue. People with Asperger’s often also understand and use words concretely and literally. An example could be when a teacher discussed possible consequences for misbehavior with a student who has Asperger’s. The student heard that if he did not complete his homework or class work at any one time, that he would receive a detention. He became very angry over this perceived injustice. He did not understand that the teacher had meant that when she saw a pattern of incomplete work, she would provide the consequence of a detention. With such a concrete way of understanding others, the person with Asperger’s can easily misinterpret others’ intent and respond in an unexpected and possibly inappropriate way.
d. Have an area of special, sometimes obsessive interest. Many times, people with Asperger’s develop this interest as a way to overcome fear - however this does not always have to be the case. Weather, especially tornadoes and hurricanes, can be fearful or even terrifying. A child with Asperger’s may develop a preoccupation with weather to cope with this fear. He might watch the Weather Channel continuously, read the weather report in the paper numerous times across the day, or read about different weather phenomena and be able to share details of past storms when the weather worsens. Trains are often a focus of interest for many children with autism. Video games and computers also appear to be strong interests as the younger children mature.
e. Tend to prefer routine, repetitive activities and to avoid and dislike transitions and change. They have been described as often having a “one track mind”. They can have a plan, and if it fails, will continue with it until it does work.
f. Have great ability to attend to detail and recall detailed information about their areas of interest. While people with Asperger’s can amaze others with the amount of detailed information they have stored on certain topics, they often have difficulty using and applying this information constructively. They can experience difficulty recognizing the “big picture”, or recognizing the forest from the trees. The relevancy of the information they know is often limited.
- Who determined the diagnostic criteria for this syndrome and are other criteria available?
- Back to Top
Although the DSM-IV provides the criteria for diagnosing Asperger’s Disorder, alternative criteria for identifying Asperger’s have been suggested by other professional organizations and individual researchers such as the World Health Organization (WHO, 1993), Gillberg (1991), and Szatmari, Bremner and Nagy (1989). Tony Attwood’s (1998) book, Asperger’s Syndrome: A guide for parents and professionals, provides a listing for each of the different sets of criteria, and readers are referred to that book for such a list. Notably, only the DSM-IV version contains the criterion that a child should not have experienced language delay. The criteria suggested by Gillberg and the WHO both included the presence of motor clumsiness (DSM-IV did not). Szatmari, et al’s criteria require the presence of solitariness (e.g., no close friends, a loner), while the DSM-IV merely discussed “impaired social interaction”. At a recent conference (2003), Tony Attwood suggested that the DSM-IV was incorrect in requiring no significant speech delay for a diagnosis of Asperger’s. In the case of Asperger’s Disorder and other diagnoses, criteria are constantly evolving as we learn more about disorders and the behaviors that characterize them.
Debate also continues regarding the validity of the Asperger’s diagnosis at all. Some who have reviewed the cases upon which Hans Asperger first developed his criteria suggest that the children Asperger worked with would more likely be diagnosed with Autistic Disorder today (Miller & Ozonoff, 1997). Additionally, a good deal of recent research has focused on trying to distinguish Asperger’s Disorder from High Functioning Autism (HFA). To date, support for significant differences between the disorders has been very weak (Ozonoff, 2003). It has been suggested that the differences between children with Asperger’s and children with autism: a) are based more on differences in abilities (McLaughlin-Cheng, 1998; Miller & Ozonoff, 2000; Prior, Eisenmajer, Leekham, Wing, Gould, Ong, & Dowe, 1998); and b) fewer symptoms during early development among children with Asperger’s than among children with autism (Klin, et al., 2000; Ozonoff, South, & Miller, 2000). Questions are still being debated within the literature regarding the existence of any difference between these two disorders and how to accurately diagnose the condition.
- How is Asperger’s Syndrome related to Autism?
- Back to Top
Asperger’s and some other disorders are believed to fall along a spectrum. This spectrum has been called the autism spectrum, and also the pervasive developmental disorder spectrum. Whatever it is called, Autistic Disorder (or autism) would fall at one end of the spectrum, while “average” or “neurotypical” functioning would be found at the other end. Asperger’s has been conceptualized as a mild, less problematic form of autism that falls between average functioning and autism on this continuum.
This means that children with autism experience many of the same symptoms as people with Asperger’s. However, the symptoms of children with autism are usually more severe and their functioning is much more impaired. For example, while a child with Asperger’s may have difficulty using language socially, a child with autism may be mute. Both Asperger’s and Autistic Disorders may involve social rejection, lack of understanding or interest in other people’s feelings, difficulties interacting with others, some rigidity (instead of flexibility) in play, difficulty using language socially, poor nonverbal communication skills, odd motor behaviors, and narrow interests or abilities.
- How is Asperger’s different from Autism?
- Back to Top
Autism is the more severe form of problems with social interaction, restricted behaviors and areas of interest, and impaired language skills. For example, while a child with Asperger’s Disorder may have difficulty interacting with others socially and forming friendships, a child with autism may often avoid direct eye contact with any individual, dislike physical touch including the experience of hugs or loving touches, and may not develop verbal skills (a more severe expression of impaired social skills). According to the present diagnostic criteria, people with autism usually experience significant delay in the acquisition of language skills (e.g., the child did not use single words before the age of 2; communicative phrases were not used until after age 3). Cognitive skills are also often impaired. In contrast, people with Asperger’s Disorder should not have experienced delay or impairment in cognitive or language skills.
Miller and Ozonoff (2000) summarized the differences between autism and Asperger’s Disorder as: a) differences in motor ability (original descriptions of children with autism did not suggest any motor difficulties, while early descriptions by Asperger did); b) language ability (as described in #4); c) cognitive skill (Asperger wrote about children with normal intelligence; research has demonstrated that the majority of children with autism are cognitively impaired); and d) “visuospatial development” (p.228) - which means skill at processing and understanding visual, nonverbal information (in some children with autism this could be a strength, whereas this was never addressed by Asperger). Others have suggested that while people with autism show little interest in peer interaction, people with Asperger’s often seek such companionship (Powers & Poland, 2002).
- What is the difference between Asperger’s Disorder and High Functioning Autism?
- Back to Top
Many people identified as having high functioning autism (HFA) had more pronounced symptoms of autism as children. As they aged, the development of basic social skills, age appropriate cognitive skills, and verbal ability occurred. Tony Attwood (1998), a psychologist who has much experience and expertise in Asperger’s, has written that HFA is a phrase that is most often used in the United States and often applies to people who qualified for a diagnosis of autism as children.
Controversy still exists within the literature about the differences between these diagnoses. Some people use the terms interchangeably. At this point, differences between the two labels (HFA and AS) have yet to be effectively clarified.
- How is Asperger’s Syndrome treated? Is there a cure?
- Back to Top
Currently, there is no “cure” for Asperger’s Syndrome. Different symptoms of Asperger’s can be treated with the goal of reducing the problems they create for the child or individual. Treatment can include medication management of problems such as anxiety and depression, conditions that often occur as a result of the difficulties experienced by the person with Asperger’s. Medication has also been used to manage the obsessive (recurring, bothersome thoughts) and compulsive traits (behaviors used to get rid of the bothersome thoughts) that can be exhibited. Historically, these people have been incorrectly diagnosed with other types of disorders including schizophrenia, personality disorders, Attention Deficit Hyperactivity Disorder (ADHD), and Obsessive Compulsive Disorder (OCD). Medications, such as anti-psychotics, have been prescribed. The problem with this approach is that although people with Asperger’s may experience obsessive thinking, repetitive thoughts or interests, or exhibit unusual social behavior, their symptoms are best reflected by the criteria for Asperger’s Disorder rather than these other diagnoses.
Behaviorally, interventions targeting skill development tend to be the most common and can be affective at any age. Early intervention with young children often relies on behavioral principles. Children are taught new behaviors and rewarded based on their ability to engage in that behavior with increasing frequency. Consequences may also be applied to decrease negative behaviors. Interventions for older children and adolescents focus more on educating them about their diagnosis, developing new skills, and providing opportunities to practice those skills. Parents, teachers, and / or therapists can all play a role in this process. Often however, there needs to be some intervention at school if a child is going to successfully learn new behaviors. Parents need to talk to school staff (teachers, administrators) to determine what resources are available for their child within the school (such as counselors, special programs, teacher assistance, etc.). Therapy also provides a means of learning new skills. Individual therapy helps address emotional difficulties that may arise as a result of the Asperger’s Disorder. Social skill training can be a part of this work. Group therapy offers a chance to learn new skills in a setting designed to offer the chance to practice and receive feedback on what is being learned.
- What is the difference between a disorder and the normal range of abilities and personality?
- Back to Top
It is important to remember that all behaviors fall along a continuum or spectrum. At one end of the spectrum is “normal” behavior, or abilities, traits, and individual characteristics that are considered appropriate (or typical) on the basis of a person’s culture, age, gender, etc. At the other end of the spectrum are groups of behaviors that, when exhibited regularly by an individual, create problems for that person in terms of his or her functioning socially, emotionally, or occupationally.
Many people have certain eccentricities, including unusual hobbies, anxiety or awkwardness in social situations, or clumsiness. This is considered well within the range of normal behavior. However, when these behaviors coincide, form a pattern across time, and negatively impact a person’s ability to function, then they are viewed as “clinically significant”, and as requiring diagnosis and treatment.
There is a lot of controversy about the diagnosis of Asperger’s (summarized in previous questions). Added to the mix is concern that people with poor social skills are being “pathologized”. Put another way, the “loners” are now qualifying for a diagnosis. Our society expects people to be social. When they are not do we view them as disabled? Simon Baron-Cohen (2002) explored this argument and looked at both sides. He suggested that many of the behaviors associated with Asperger’s Disorder represent a focus on things rather than on people. If placed in a different environment, he believed that Asperger’s would not be seen as a “disorder”. He also pointed out that children with Asperger's tend to meet the majority of developmental milestones on time, and emphasized the typical or “normal” aspect of their development. In contrast, he also discussed two reasons for continuing to consider Asperger’s a “disability” (p.189): a) so that people with this diagnosis could have access to support at school (possibly through special education services) and within the community (some insurance companies will pay for a person with Asperger’s to get treatment in outpatient therapy); and b) because lack of empathy (or theory of mind) can create significant problems emotionally for people with Asperger’s.
- Do girls experience Asperger’s Disorder differently?
- Back to Top
Yes, however far fewer girls are diagnosed with Asperger’s than boys. Earlier, the ratio was believed to be one girl to every ten boys was diagnosed with Asperger’s (10:1). Currently however that ratio is believed to be more in the range of one girl to every four boys (4:1; Attwood, 2003). As professionals become more familiar with the diagnostic criteria, more girls appear to be receiving the Asperger’s diagnosis.
Generally, it is believed that girls experience a much milder form of the difficulties associated with Asperger’s Disorder. American society emphasizes and pushes girls to develop strong social skills at an early age. This may benefit girls with Asperger’s by helping them learn compensatory skills or address any deficits earlier in life. Alternatively, it has been suggested that girls use different coping strategies when dealing with social situations (Attwood, 2003). Girls tend to hide in social situations, and remain on the periphery. This allows them to observe the behaviors of others, and once comfortable with the process, to mimic those behaviors (e.g., facial expressions, gestures, tone of voice). Doll play allows younger girls to re-experience social situations, replay them, alter them, and learn from them. Girls also often have invisible friends - a safe tool to use when practicing social skills. Among females, Asperger’s Disorder may express itself more through immaturity. Topics of special interest also may not be as intense as the interests exhibited by boys. Girls’ areas of special interest seem to be different from those of boys. Their preoccupations center more on animals and classical literature. The long-term prognosis for females with Asperger’s Disorder also seems better than for males (Attwood, 1998), largely because of the females’ ability to hide their difficulties from others over time.
- What other problems may a person with Asperger’s Disorder experience?
- Back to Top
A number of difficulties can accompany the behaviors that define Asperger’s. As people with limited social skills and awareness of others, who tend to have areas of unusual or intense interest, a strong need for routine, and unusual mannerisms, people with Asperger’s often experience emotional difficulties, including depression, anxiety, and anger. Social interaction and negative feedback from others creates stress. People react differently to such stress. Some people internalize distress through the experience of feelings of low self-esteem, hopelessness, helplessness and sadness. Some internalize the distress through feelings of anxiety. Others externalize the distress through angry, aggressive, destructive, or rule-breaking behaviors. These reactions can be triggered by teasing, perceptions of being treated unjustly, frustration and confusion in response to certain situations - many triggers can exist and depend solely on the individual. If any of these additional problems (depression, anxiety, or anger) affect the person’s ability to function and are pervasive, they may require diagnosis and treatment as well.
Other conditions can also occur with Asperger’s, but are not part of the criteria for the Asperger’s diagnosis. Problems with attention, concentration, and/or impulsive, distracted, or hyperactive behaviors might suggest a possible diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). The occurrence of motor and verbal tics could suggest problems associated with Tourette’s Disorder. For people who experience these problems as well as the difficulties associated with Asperger’s Disorder, a dual diagnosis may be necessary.
- What are the advantages and disadvantages of having the label Asperger’s Disorder?
- Back to Top
The advantages tend to be personal and emotional. For parents, the diagnosis and label provides them with a sense of relief. Many parents of children with Asperger’s say that they have known that something was “wrong”, but felt that they could not get “the problem” properly identified. When such difficulties are identified and labeled, parents and individuals are better able to understand the nature of the problems and how to remedy them. By labeling the disorder, it is easier to address any problems that are associated with it, and allows parents and individuals the opportunity to maximize the positive aspects of the disorder. People with Asperger’s often have a unique ability to focus, and to catalogue detailed information about their areas of interest. In many situations, these talents can be put to very positive, constructive uses. One only needs to look at the celebrities who some suggest may qualify or may have qualified for an Asperger’s diagnosis (e.g., Thomas Jefferson, Albert Einstein) to realize what talents can be associated with what is called a “disorder”. Other advantages to “labeling” include providing parents and teachers with a way to learn about a child’s behaviors. By learning about Asperger’s people can better understand its implications so that parental, teacher, and community expectations of the individual are realistic, reasonable, and do not require that person to meet standards that are outside his/her range of abilities. Additionally for children, the diagnosis qualifies the child for assistance in the schools as defined by IDEA. This means that the schools are required to provide special accommodations for the child’s education. The accommodations need to be tailored to the child’s condition so that they help create a learning environment that is best suited to the child’s abilities.
Disadvantages associated with the label of Asperger’s are similar to the disadvantages associated with any label, and generally refer to people’s tendency to think in stereotypes. Labeling an individual gives others the ability to “pigeonhole” or make assumptions about the person based on the diagnosis, or their understanding of the diagnosis. This can lead people to make decisions and judgements about the individual based on the diagnosis rather than on the needs and characteristics of that person.
It is always important to remember that no person is a diagnosis, and that no diagnosis is a person. Asperger’s Disorder is merely one quality of an individual. That person will have many other traits, characteristics, and aspects of his/her personality. Readers are encouraged to learn about the person first, then to explore the way the Asperger’s diagnosis affects his/her functioning.
- What is meant by “impaired social interaction”?
- Back to Top
Essentially, this means that the person with Asperger’s experiences difficulty developing relationships, responding appropriately, and interacting with others with ease. Certain qualities of human interaction are very difficult for people with Asperger’s. People communicate with each other through verbal (e.g., speech) as well as nonverbal (e.g., eye-to-eye gaze, gestures, body posture) communication. While verbal ability is often a strength for people with Asperger’s, nonverbal communication is usually an area of difficulty. People with Asperger’s have trouble understanding the nonverbal communication of others. They overlook or don’t recognize the meaning behind another person’s gestures or facial expressions. This means that they frequently miss the cues they are given that a person wants to leave, is getting bored, or wants to say something herself. The person with Asperger’s can also have difficulty using nonverbal communication, for example: hand gestures do not fit with what is being said, or there is an absence of gesturing or a complete lack of nonverbal communication.
Impaired social interaction also means that a person has difficulty making and keeping friends. As can be imagined, interacting with someone who does not understand or use nonverbal communication can be unsettling and uncomfortable. As a result, many people avoid the person with Asperger’s and relationships do not develop. When friendships do occur, they are usually built on a shared area of interest. That interest is typically the focus of the intense interest and preoccupation of the person with Asperger’s. Maintaining such friendships can be difficult because the person with Asperger’s can be rigid and inflexible regarding the area of interest. In other words, their conversation rarely addresses other topics, and they tend to be the center of any conversation about the topic (leaving the other child to listen rather than contribute to a discussion). Because the person with Asperger’s is so focused on this interest, s/he often knows a great deal of detailed information about it. This can often be intimidating to other children who do not feel as much an “expert”.
Lastly, impaired social interaction also encompasses the distressing social situations that many people with Asperger’s encounter. The term “playground predator” has often been used to describe children who appear to purposefully, intentionally, and vindictively single out a child with Asperger’s for teasing and taunting. Bullies often do pick on children who are “easy targets” or vulnerable. With their difficulties understanding nonverbal cues, and having limited social support, people with Asperger’s are often the targets of bullies.
- What is pedantic speech?
- Back to Top
Pedantic describes speech that is overly focused on the details of its topic. It is speech that appears to list details about a topic one after the other. In a person with Asperger’s, this type of speech does not appear to be impacted by the environment (such as by the nonverbal cues of others), and therefore seems less conversational and more like a monologue. This includes the person’s likely idiosyncratic, or unusual use of words, e.g., a “Hoover for the face” being used for razor (Attwood, 2003), or tendency to make up words to communicate their thoughts. The volume of the person’s speech may be off - either too loud or too quiet for the environment or situation. The person with Asperger’s may also vocalize his or her thoughts rather than keeping those thoughts to themselves.
- What is “theory of mind” or “mind blindness”?
- Back to Top
It has been suggested that children with Asperger’s Disorder (and autism) lack a theory of mind (the ability to understand what another person may be thinking in a given situation). They have difficulty imagining or understanding how someone else’s thoughts, experiences, knowledge, or wishes could influence their behavior. This concept has also been called “mind blindness” (Attwood, 1998, p. 114).
- What are “stereotyped behaviors”?
- Back to Top
Stereotyped behaviors are those that are repetitive and unvarying. They are behaviors that do not have to serve any apparently useful, constructive purpose, but instead have only personal meaning to the individual with Asperger’s. They reflect the person’s adherence to a routine way of behaving.
- What are “stim behaviors” and why does the person with Asperger’s Disorder do them?
- Back to Top
Stim behaviors refer to behaviors that tend to appear in response to an anxiety-provoking situation or experience, they are repetitive, and often times appear unusual or inappropriate socially. Children with Asperger’s often become obsessed with the need for sameness or routine. When changes occur in their environment that deviate from that sameness, anxiety is produced and repetitive, ritualistic behaviors restore some of the sense of “sameness” that was lost. These behaviors are the way the person with Asperger’s copes with change, unpredictability, and anxiety. Attempts by teachers, parents, or significant others to stop these behaviors may lead the person with Asperger’s to feel panic, anger, and/or extreme anxiety and can results in extreme behaviors (screaming, temper tantrums) that are often less desirable than the stim behavior. In these instances, it is often best to try to help the person with Asperger’s learn an alternative, more socially acceptable behavior to achieve this same goal.
- How can I find out if my child has Asperger’s Syndrome?
- Back to Top
Currently, awareness of Asperger’s appears to be increasing. While this is positive, some confusion continues to exist among professionals about diagnosing the condition. For this reason, it will be important to work with someone who either has some pre-existing knowledge of Asperger’s, or who is willing to learn more about it. Physicians, psychologists, therapists, and educators are usually among the first people to identify Asperger symptoms. Consulting with a trusted person in any of these fields would likely be a good first step. They can then either help you directly, or can refer you to someone else within the community who can.
Accurate diagnosis often involves testing by the use of questionnaires, check lists, clinical interview, psychological tests and possibly medical examination. Different professions emphasize different means of identification. If you believe you or your child may qualify for a diagnosis of Asperger’s, or another autism spectrum disorder, taking that first step of contacting a trusted professional will be very important. If you need help identifying providers within Mississippi, TEAAM can provide you with the names of professionals who may be able to help.
- When is it good to look for help for my child with Asperger’s Syndrome?
- Back to Top
The earlier the better. Interventions targeted at young children can help them learn social skills and ways of interacting with others that will help them avoid the social difficulties (such as teasing, bullying, social rejection and isolation, and social anxiety) that affects older children, adolescents, and adults with the disorder. Alternatively, older children and adults can benefit tremendously from learning about the disorder, and ways to address its negative aspects while maximizing its positive side. The key is to seek help. Without knowledge of the disorder and proper diagnosis, many people can continue to experience difficulties that can affect them for a lifetime.
