I challenge you @toth77

GarixTheChad

GarixTheChad

6'1 110kg roided mogger
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Hungarian warrior vs Polish husaria we will see who will rule the looksmax.me @stuckneworleans
 
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@stuckneworleans @toth77
 
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i accept it, what is the challenge
 
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I'm mirin this vicious combat declaration of a soon to be key player on this forum

giphy.gif
 
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No!

Poles and hungarians are brothers.
 
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High t thread
:what:
 
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GarixTheChad said:
but he is gay hungarian
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We cant fight with all hungarians because of one. I knew few hungarian people and they are probably most friendly people when it comes to poles.
 
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toth77 said:
i have to download league with my dog tier internet it will take a day
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when what
needsolution said:
We cant fight with all hungarians because of one. I knew few hungarian people and they are probably most friendly people when it comes to poles.
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but hes like my litte brother
 
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messed up
 
needsolution said:
We cant fight with all hungarians because of one. I knew few hungarian people and they are probably most friendly people when it comes to poles.
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Youre right give me some german
 
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Chad1212 said:

Autism - Wikipedia

en.m.wikipedia.org en.m.wikipedia.org
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Wikipedia



Autism


This article is about the classic autistic disorder. For other conditions sometimes called "autism", see Autism spectrum. For the journal, see Autism (journal).
Autism is a developmental disorder characterized by difficulties with social interaction and communication, and by restricted and repetitive behavior.[4] Parents often notice signs during the first three years of their child's life.[1][4] These signs often develop gradually, though some children with autism experience worsening in their communication and social skills after reaching developmental milestones at a normal pace.[15]
Autism is associated with a combination of genetic and environmental factors.[5] Risk factors during pregnancy include certain infections, such as rubella, toxins including valproic acid, alcohol, cocaine, pesticides, lead, and air pollution, fetal growth restriction, and autoimmune diseases.[16][17][18] Controversies surround other proposed environmental causes; for example, the vaccine hypothesis, which has been disproven.[19] Autism affects information processing in the brain and how nerve cells and their synapses connect and organize; how this occurs is not well understood.[20] The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), combines autism and less severe forms of the condition, including Asperger syndrome and pervasive developmental disorder not otherwise specified (PDD-NOS) into the diagnosis of autism spectrum disorder (ASD).[4][21]
Early behavioral interventions or speech therapy can help children with autism gain self-care, social, and communication skills.[7][8] Although there is no known cure,[7] there have been cases of children who recovered.[22] Not many autistic adults are able to live independently, though some are successful.[13] An autistic culture has developed, with some individuals seeking a cure and others believing autism should be accepted as a difference to be accommodated instead of cured.[23][24]
Globally, autism is estimated to affect 24.8 million people as of 2015.[14] In the 2000s, the number of people affected was estimated at 1–2 per 1,000 people worldwide.[25] In the developed countries, about 1.5% of children are diagnosed with ASD as of 2017,[26] from 0.7% in 2000 in the United States.[27] It occurs four-to-five times more often in males than females.[27] The number of people diagnosed has increased dramatically since the 1960s, which may be partly due to changes in diagnostic practice.[25] The question of whether actual rates have increased is unresolved.[25]

Contents


Characteristics
Autism is a highly variable, neurodevelopmental disorder[28] whose symptoms first appears during infancy or childhood, and generally follows a steady course without remission.[29] People with autism may be severely impaired in some respects but average, or even superior, in others.[30] Overt symptoms gradually begin after the age of six months, become established by age two or three years[31] and tend to continue through adulthood, although often in more muted form.[32] It is distinguished by a characteristic triad of symptoms: impairments in social interaction, impairments in communication, and repetitive behavior. Other aspects, such as atypical eating, are also common but are not essential for diagnosis.[33] Individual symptoms of autism occur in the general population and appear not to associate highly, without a sharp line separating pathologically severe from common traits.[34]
Social development
Social deficits distinguish autism and the related autism spectrum disorders (ASD; see Classification) from other developmental disorders.[32] People with autism have social impairments and often lack the intuition about others that many people take for granted. Noted autistic Temple Grandin described her inability to understand the social communication of neurotypicals, or people with typical neural development, as leaving her feeling "like an anthropologist on Mars".[35]
Unusual social development becomes apparent early in childhood. Autistic infants show less attention to social stimuli, smile and look at others less often, and respond less to their own name. Autistic toddlers differ more strikingly from social norms; for example, they have less eye contact and turn-taking, and do not have the ability to use simple movements to express themselves, such as pointing at things.[36] Three- to five-year-old children with autism are less likely to exhibit social understanding, approach others spontaneously, imitate and respond to emotions, communicate nonverbally, and take turns with others. However, they do form attachments to their primary caregivers.[37] Most children with autism display moderately less attachment security than neurotypical children, although this difference disappears in children with higher mental development or less pronounced autistic traits.[38] Older children and adults with ASD perform worse on tests of face and emotion recognition[39] although this may be partly due to a lower ability to define a person's own emotions.[40]
Children with high-functioning autism have more intense and frequent loneliness compared to non-autistic peers, despite the common belief that children with autism prefer to be alone. Making and maintaining friendships often proves to be difficult for those with autism. For them, the quality of friendships, not the number of friends, predicts how lonely they feel. Functional friendships, such as those resulting in invitations to parties, may affect the quality of life more deeply.[41]
There are many anecdotal reports, but few systematic studies, of aggression and violence in individuals with ASD. The limited data suggest that, in children with intellectual disability, autism is associated with aggression, destruction of property, and meltdowns.[42]
Communication
About a third to a half of individuals with autism do not develop enough natural speech to meet their daily communication needs.[43] Differences in communication may be present from the first year of life, and may include delayed onset of babbling, unusual gestures, diminished responsiveness, and vocal patterns that are not synchronized with the caregiver. In the second and third years, children with autism have less frequent and less diverse babbling, consonants, words, and word combinations; their gestures are less often integrated with words. Children with autism are less likely to make requests or share experiences, and are more likely to simply repeat others' words (echolalia)[44][45] or reverse pronouns.[46] Joint attention seems to be necessary for functional speech, and deficits in joint attention seem to distinguish infants with ASD.[21] For example, they may look at a pointing hand instead of the pointed-at object,[36][45] and they consistently fail to point at objects in order to comment on or share an experience.[21] Children with autism may have difficulty with imaginative play and with developing symbols into language.[44][45]
In a pair of studies, high-functioning children with autism aged 8–15 performed equally well as, and as adults better than, individually matched controls at basic language tasks involving vocabulary and spelling. Both autistic groups performed worse than controls at complex language tasks such as figurative language, comprehension and inference. As people are often sized up initially from their basic language skills, these studies suggest that people speaking to autistic individuals are more likely to overestimate what their audience comprehends.[47]
Repetitive behavior

A young boy with autism who has arranged his toys in a row
Autistic individuals can display many forms of repetitive or restricted behavior, which the Repetitive Behavior Scale-Revised (RBS-R) categorizes as follows.[48]
  • Stereotyped behaviors: Repetitive movements, such as hand flapping, head rolling, or body rocking.
  • Compulsive behaviors: Time-consuming behaviors intended to reduce anxiety that an individual feels compelled to perform repeatedly or according to rigid rules, such as placing objects in a specific order, checking things, or hand washing.
  • Sameness: Resistance to change; for example, insisting that the furniture not be moved or refusing to be interrupted.
  • Ritualistic behavior: Unvarying pattern of daily activities, such as an unchanging menu or a dressing ritual. This is closely associated with sameness and an independent validation has suggested combining the two factors.[48]
  • Restricted interests: Interests or fixations that are abnormal in theme or intensity of focus, such as preoccupation with a single television program, toy, or game.
  • Self-injury: Behaviors such as eye-poking, skin-picking, hand-biting and head-banging.[21]
No single repetitive or self-injurious behavior seems to be specific to autism, but autism appears to have an elevated pattern of occurrence and severity of these behaviors.[49]
Other symptoms
Autistic individuals may have symptoms that are independent of the diagnosis, but that can affect the individual or the family.[33] An estimated 0.5% to 10% of individuals with ASD show unusual abilities, ranging from splinter skills such as the memorization of trivia to the extraordinarily rare talents of prodigious autistic savants.[50] Many individuals with ASD show superior skills in perception and attention, relative to the general population.[51] Sensory abnormalities are found in over 90% of those with autism, and are considered core features by some,[52] although there is no good evidence that sensory symptoms differentiate autism from other developmental disorders.[53] Differences are greater for under-responsivity (for example, walking into things) than for over-responsivity (for example, distress from loud noises) or for sensation seeking (for example, rhythmic movements).[54] An estimated 60–80% of autistic people have motor signs that include poor muscle tone, poor motor planning, and toe walking;[52] deficits in motor coordination are pervasive across ASD and are greater in autism proper.[55] Unusual eating behavior occurs in about three-quarters of children with ASD, to the extent that it was formerly a diagnostic indicator. Selectivity is the most common problem, although eating rituals and food refusal also occur.[56]
There is tentative evidence that autism occurs more frequently in people with gender dysphoria.[57][58]
Gastrointestinal problems are one of the most commonly associated medical disorders in people with autism.[59] These are linked to greater social impairment, irritability, behavior and sleep problems, language impairments and mood changes.[59][60]
Parents of children with ASD have higher levels of stress.[36] Siblings of children with ASD report greater admiration of and less conflict with the affected sibling than siblings of unaffected children and were similar to siblings of children with Down syndrome in these aspects of the sibling relationship. However, they reported lower levels of closeness and intimacy than siblings of children with Down syndrome; siblings of individuals with ASD have greater risk of negative well-being and poorer sibling relationships as adults.[61]

Causes
Main article: Causes of autism
It has long been presumed that there is a common cause at the genetic, cognitive, and neural levels for autism's characteristic triad of symptoms.[62] However, there is increasing suspicion that autism is instead a complex disorder whose core aspects have distinct causes that often co-occur.[62][63]

Deletion (1), duplication (2) and inversion (3) are all chromosome abnormalities that have been implicated in autism.[64]
Autism has a strong genetic basis, although the genetics of autism are complex and it is unclear whether ASD is explained more by rare mutations with major effects, or by rare multigene interactions of common genetic variants.[65][66] Complexity arises due to interactions among multiple genes, the environment, and epigenetic factors which do not change DNA sequencing but are heritable and influence gene expression.[32] Many genes have been associated with autism through sequencing the genomes of affected individuals and their parents.[67] Studies of twins suggest that heritability is 0.7 for autism and as high as 0.9 for ASD, and siblings of those with autism are about 25 times more likely to be autistic than the general population.[52] However, most of the mutations that increase autism risk have not been identified. Typically, autism cannot be traced to a Mendelian (single-gene) mutation or to a single chromosome abnormality, and none of the genetic syndromes associated with ASDs have been shown to selectively cause ASD.[65] Numerous candidate genes have been located, with only small effects attributable to any particular gene.[65] Most loci individually explain less than 1% of cases of autism.[68] The large number of autistic individuals with unaffected family members may result from spontaneous structural variation—such as deletions, duplications or inversions in genetic material during meiosis.[69][70] Hence, a substantial fraction of autism cases may be traceable to genetic causes that are highly heritable but not inherited: that is, the mutation that causes the autism is not present in the parental genome.[64] Autism may be underdiagnosed in women and girls due to an assumption that it is primarily a male condition,[71] but genetic phenomena such as imprinting and X linkage have the ability to raise the frequency and severity of conditions in males, and theories have been put forward for a genetic reason why males are diagnosed more often, such as the imprinted brain theory and the extreme male brain theory.[72][73][74]
Maternal nutrition and inflammation during preconception and pregnancy influences fetal neurodevelopment. Intrauterine growth restriction is associated with ASD, in both term and preterm infants.[17] Maternal inflammatory and autoimmune diseases may damage fetal tissues, aggravating a genetic problem or damaging the nervous system.[18]
Exposure to air pollution during pregnancy, especially heavy metals and particulates, may increase the risk of autism.[75][76] Environmental factors that have been claimed without evidence to contribute to or exacerbate autism include certain foods, infectious diseases, solvents, PCBs, phthalates and phenols used in plastic products, pesticides, brominated flame retardants, alcohol, smoking, illicit drugs, vaccines,[25] and prenatal stress. Some, such as the MMR vaccine, have been completely disproven.[77][78][79][80]
Parents may first become aware of autistic symptoms in their child around the time of a routine vaccination. This has led to unsupported theories blaming vaccine "overload", a vaccine preservative, or the MMR vaccine for causing autism.[81] The latter theory was supported by a litigation-funded study that has since been shown to have been "an elaborate fraud".[82] Although these theories lack convincing scientific evidence and are biologically implausible,[81] parental concern about a potential vaccine link with autism has led to lower rates of childhood immunizations, outbreaks of previously controlled childhood diseases in some countries, and the preventable deaths of several children.[83][84]

Mechanism
Main article: Mechanism of autism
Autism's symptoms result from maturation-related changes in various systems of the brain. How autism occurs is not well understood. Its mechanism can be divided into two areas: the pathophysiology of brain structures and processes associated with autism, and the neuropsychological linkages between brain structures and behaviors.[85] The behaviors appear to have multiple pathophysiologies.[34]
There is evidence that gut–brain axis abnormalities may be involved.[59][60][86] A 2015 review proposed that immune dysregulation, gastrointestinal inflammation, malfunction of the autonomic nervous system, gut flora alterations, and food metabolites may cause brain neuroinflammation and dysfunction.[60] A 2016 review concludes that enteric nervous system abnormalities might play a role in neurological disorders such as autism. Neural connections and the immune system are a pathway that may allow diseases originated in the intestine to spread to the brain.[86]
Several lines of evidence point to synaptic dysfunction as a cause of autism.[20] Some rare mutations may lead to autism by disrupting some synaptic pathways, such as those involved with cell adhesion.[87] Gene replacement studies in mice suggest that autistic symptoms are closely related to later developmental steps that depend on activity in synapses and on activity-dependent changes.[88] All known teratogens (agents that cause birth defects) related to the risk of autism appear to act during the first eight weeks from conception, and though this does not exclude the possibility that autism can be initiated or affected later, there is strong evidence that autism arises very early in development.[89]

Diagnosis
Diagnosis is based on behavior, not cause or mechanism.[34][90] Under the DSM-5, autism is characterized by persistent deficits in social communication and interaction across multiple contexts, as well as restricted, repetitive patterns of behavior, interests, or activities. These deficits are present in early childhood, typically before age three, and lead to clinically significant functional impairment.[4] Sample symptoms include lack of social or emotional reciprocity, stereotyped and repetitive use of language or idiosyncratic language, and persistent preoccupation with unusual objects. The disturbance must not be better accounted for by Rett syndrome, intellectual disability or global developmental delay.[4] ICD-10 uses essentially the same definition.[29]
Several diagnostic instruments are available. Two are commonly used in autism research: the Autism Diagnostic Interview-Revised (ADI-R) is a semistructured parent interview, and the Autism Diagnostic Observation Schedule (ADOS)[91] uses observation and interaction with the child. The Childhood Autism Rating Scale (CARS) is used widely in clinical environments to assess severity of autism based on observation of children.[36] The Diagnostic interview for social and communication disorders (DISCO) may also be used.[92]
A pediatrician commonly performs a preliminary investigation by taking developmental history and physically examining the child. If warranted, diagnosis and evaluations are conducted with help from ASD specialists, observing and assessing cognitive, communication, family, and other factors using standardized tools, and taking into account any associated medical conditions.[93] A pediatric neuropsychologist is often asked to assess behavior and cognitive skills, both to aid diagnosis and to help recommend educational interventions.[94] A differential diagnosis for ASD at this stage might also consider intellectual disability, hearing impairment, and a specific language impairment[93] such as Landau–Kleffner syndrome.[95] The presence of autism can make it harder to diagnose coexisting psychiatric disorders such as depression.[96]
Clinical genetics evaluations are often done once ASD is diagnosed, particularly when other symptoms already suggest a genetic cause.[97] Although genetic technology allows clinical geneticists to link an estimated 40% of cases to genetic causes,[98] consensus guidelines in the US and UK are limited to high-resolution chromosome and fragile X testing.[97] A genotype-first model of diagnosis has been proposed, which would routinely assess the genome's copy number variations.[99] As new genetic tests are developed several ethical, legal, and social issues will emerge. Commercial availability of tests may precede adequate understanding of how to use test results, given the complexity of autism's genetics.[100] Metabolic and neuroimaging tests are sometimes helpful, but are not routine.[97]
ASD can sometimes be diagnosed by age 14 months, although diagnosis becomes increasingly stable over the first three years of life: for example, a one-year-old who meets diagnostic criteria for ASD is less likely than a three-year-old to continue to do so a few years later.[1] In the UK the National Autism Plan for Children recommends at most 30 weeks from first concern to completed diagnosis and assessment, though few cases are handled that quickly in practice.[93] Although the symptoms of autism and ASD begin early in childhood, they are sometimes missed; years later, adults may seek diagnoses to help them or their friends and family understand themselves, to help their employers make adjustments, or in some locations to claim disability living allowances or other benefits. Girls are often diagnosed later than boys.[101]
Underdiagnosis and overdiagnosis are problems in marginal cases, and much of the recent increase in the number of reported ASD cases is likely due to changes in diagnostic practices. The increasing popularity of drug treatment options and the expansion of benefits has given providers incentives to diagnose ASD, resulting in some overdiagnosis of children with uncertain symptoms. Conversely, the cost of screening and diagnosis and the challenge of obtaining payment can inhibit or delay diagnosis.[102] It is particularly hard to diagnose autism among the visually impaired, partly because some of its diagnostic criteria depend on vision, and partly because autistic symptoms overlap with those of common blindness syndromes or blindisms.[103]
Classification
Autism is one of the five pervasive developmental disorders (PDD), which are characterized by widespread abnormalities of social interactions and communication, and severely restricted interests and highly repetitive behavior.[29] These symptoms do not imply sickness, fragility, or emotional disturbance.[32]
Of the five PDD forms, Asperger syndrome is closest to autism in signs and likely causes; Rett syndrome and childhood disintegrative disorder share several signs with autism, but may have unrelated causes; PDD not otherwise specified (PDD-NOS; also called atypical autism) is diagnosed when the criteria are not met for a more specific disorder.[104] Unlike with autism, people with Asperger syndrome have no substantial delay in language development.[105] The terminology of autism can be bewildering, with autism, Asperger syndrome and PDD-NOS often called the autism spectrum disorders (ASD)[7] or sometimes the autistic disorders,[106] whereas autism itself is often called autistic disorder, childhood autism, or infantile autism. In this article, autism refers to the classic autistic disorder; in clinical practice, though, autism, ASD, and PDD are often used interchangeably.[97] ASD, in turn, is a subset of the broader autism phenotype, which describes individuals who may not have ASD but do have autistic-like traits, such as avoiding eye contact.[107]
Autism can also be divided into syndromal and non-syndromal autism; the syndromal autism is associated with severe or profound intellectual disability or a congenital syndrome with physical symptoms, such as tuberous sclerosis.[108] Although individuals with Asperger syndrome tend to perform better cognitively than those with autism, the extent of the overlap between Asperger syndrome, HFA, and non-syndromal autism is unclear.[109]
Some studies have reported diagnoses of autism in children due to a loss of language or social skills, as opposed to a failure to make progress, typically from 15 to 30 months of age. The validity of this distinction remains controversial; it is possible that regressive autism is a specific subtype,[1][15][44][110] or that there is a continuum of behaviors between autism with and without regression.[111]
Research into causes has been hampered by the inability to identify biologically meaningful subgroups within the autistic population[112] and by the traditional boundaries between the disciplines of psychiatry, psychology, neurology and pediatrics.[113] Newer technologies such as fMRI and diffusion tensor imaging can help identify biologically relevant phenotypes (observable traits) that can be viewed on brain scans, to help further neurogenetic studies of autism;[114] one example is lowered activity in the fusiform face area of the brain, which is associated with impaired perception of people versus objects.[20] It has been proposed to classify autism using genetics as well as behavior.[115]
Spectrum
Autism has long been thought to cover a wide spectrum, ranging from individuals with severe impairments—who may be silent, developmentally disabled, and prone to frequent repetitive behavior such as hand flapping and rocking—to high functioning individuals who may have active but distinctly odd social approaches, narrowly focused interests, and verbose, pedantic communication.[116] Because the behavior spectrum is continuous, boundaries between diagnostic categories are necessarily somewhat arbitrary.[52] Sometimes the syndrome is divided into low-, medium- or high-functioning autism (LFA, MFA, and HFA), based on IQ thresholds.[117] Some people have called for an end to the terms "high-functioning" and "low-functioning" due to lack of nuance and the potential for a person's needs or abilities to be overlooked.[118][119]

Screening
About half of parents of children with ASD notice their child's unusual behaviors by age 18 months, and about four-fifths notice by age 24 months.[1] According to an article, failure to meet any of the following milestones "is an absolute indication to proceed with further evaluations. Delay in referral for such testing may delay early diagnosis and treatment and affect the long-term outcome".[33]
  • No response to name (or eye-to-eye gaze) by 6 months.[120]
  • No babbling by 12 months.
  • No gesturing (pointing, waving, etc.) by 12 months.
  • No single words by 16 months.
  • No two-word (spontaneous, not just echolalic) phrases by 24 months.
  • Loss of any language or social skills, at any age.
The United States Preventive Services Task Force in 2016 found it was unclear if screening was beneficial or harmful among children in whom there is no concerns.[121] The Japanese practice is to screen all children for ASD at 18 and 24 months, using autism-specific formal screening tests. In contrast, in the UK, children whose families or doctors recognize possible signs of autism are screened. It is not known which approach is more effective.[20] Screening tools include the Modified Checklist for Autism in Toddlers (M-CHAT), the Early Screening of Autistic Traits Questionnaire, and the First Year Inventory; initial data on M-CHAT and its predecessor, the Checklist for Autism in Toddlers (CHAT), on children aged 18–30 months suggests that it is best used in a clinical setting and that it has low sensitivity (many false-negatives) but good specificity (few false-positives).[1] It may be more accurate to precede these tests with a broadband screener that does not distinguish ASD from other developmental disorders.[122] Screening tools designed for one culture's norms for behaviors like eye contact may be inappropriate for a different culture.[123] Although genetic screening for autism is generally still impractical, it can be considered in some cases, such as children with neurological symptoms and dysmorphic features.[124]

Prevention
While infection with rubella during pregnancy causes fewer than 1% of cases of autism,[125] vaccination against rubella can prevent many of those cases.[126]

Management
Main article: Autism therapies

A three-year-old with autism points to fish in an aquarium, as part of an experiment on the effect of intensive shared-attention training on language development.[127]
The main goals when treating children with autism are to lessen associated deficits and family distress, and to increase quality of life and functional independence. In general, higher IQs are correlated with greater responsiveness to treatment and improved treatment outcomes.[128][129] No single treatment is best and treatment is typically tailored to the child's needs.[7] Families and the educational system are the main resources for treatment.[20] Services should be carried out by behavior analysts, special education teachers, speech pathologists, and licensed psychologists. Studies of interventions have methodological problems that prevent definitive conclusions about efficacy.[130] However, the development of evidence-based interventions has advanced in recent years.[128] Although many psychosocial interventions have some positive evidence, suggesting that some form of treatment is preferable to no treatment, the methodological quality of systematic reviews of these studies has generally been poor, their clinical results are mostly tentative, and there is little evidence for the relative effectiveness of treatment options.[131] Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, communication, and job skills,[7] and often improve functioning and decrease symptom severity and maladaptive behaviors;[132] claims that intervention by around age three years is crucial are not substantiated.[133] While medications have not been found to help with core symptoms, they may be used for associated symptoms, such as irritability, inattention, or repetitive behavior patterns.[10]
Education
Educational interventions often used include applied behavior analysis (ABA), developmental models, structured teaching, speech and language therapy, social skills therapy, and occupational therapy.[7] Among these approaches, interventions either treat autistic features comprehensively, or focalize treatment on a specific area of deficit.[128] The quality of research for early intensive behavioral intervention (EIBI)—a treatment procedure incorporating over thirty hours per week of the structured type of ABA that is carried out with very young children—is currently low, and more vigorous research designs with larger sample sizes are needed.[134] Two theoretical frameworks outlined for early childhood intervention include structured and naturalistic ABA interventions, and developmental social pragmatic models (DSP).[128] One interventional strategy utilizes a parent training model, which teaches parents how to implement various ABA and DSP techniques, allowing for parents to disseminate interventions themselves.[128] Various DSP programs have been developed to explicitly deliver intervention systems through at-home parent implementation. Despite the recent development of parent training models, these interventions have demonstrated effectiveness in numerous studies, being evaluated as a probable efficacious mode of treatment.[128]
Early, intensive ABA therapy has demonstrated effectiveness in enhancing communication and adaptive functioning in preschool children;[135] it is also well-established for improving the intellectual performance of that age group.[132][135] Similarly, a teacher-implemented intervention that utilizes a more naturalistic form of ABA combined with a developmental social pragmatic approach has been found to be beneficial in improving social-communication skills in young children, although there is less evidence in its treatment of global symptoms.[128] Neuropsychological reports are often poorly communicated to educators, resulting in a gap between what a report recommends and what education is provided.[94] It is not known whether treatment programs for children lead to significant improvements after the children grow up,[132] and the limited research on the effectiveness of adult residential programs shows mixed results.[136] The appropriateness of including children with varying severity of autism spectrum disorders in the general education population is a subject of current debate among educators and researchers.[137]
Medication
Medications may be used to treat ASD symptoms that interfere with integrating a child into home or school when behavioral treatment fails.[8] They may also be used for associated health problems, such as ADHD or anxiety.[8] More than half of US children diagnosed with ASD are prescribed psychoactive drugs or anticonvulsants, with the most common drug classes being antidepressants, stimulants, and antipsychotics.[11][12] The atypical antipsychotic drugs risperidone and aripiprazole are FDA-approved for treating associated aggressive and self-injurious behaviors.[10][32][138] However, their side effects must be weighed against their potential benefits, and people with autism may respond atypically.[10] Side effects, for example, may include weight gain, tiredness, drooling, and aggression.[10] SSRI antidepressants, such as fluoxetine and fluvoxamine, have been shown to be effective in reducing repetitive and ritualistic behaviors, while the stimulant medication methylphenidate is beneficial for some children with co-morbid inattentiveness or hyperactivity.[7] There is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD.[139] No known medication relieves autism's core symptoms of social and communication impairments.[140] Experiments in mice have reversed or reduced some symptoms related to autism by replacing or modulating gene function,[88][141] suggesting the possibility of targeting therapies to specific rare mutations known to cause autism.[87][142]


Society and culture
Main article: Societal and cultural aspects of autism

Autism awareness ribbon
An autistic culture has emerged, accompanied by the autistic rights and neurodiversity movements.[203][204][205] Events include World Autism Awareness Day, Autism Sunday, Autistic Pride Day, Autreat, and others.[206][207][208][209] Organizations dedicated to promoting awareness of autism include Autism Speaks, Autism National Committee, and Autism Society of America.[210] Social-science scholars study those with autism in hopes to learn more about "autism as a culture, transcultural comparisons... and research on social movements."[211] While most autistic individuals do not have savant skills, many have been successful in their fields.[212][213][214]
Autism rights movement
The autism rights movement is a social movement within the context of disability rights that emphasizes the concept of neurodiversity, viewing the autism spectrum as a result of natural variations in the human brain rather than a disorder to be cured.[205] The autism rights movement advocates for including greater acceptance of autistic behaviors; therapies that focus on coping skills rather than on imitating the behaviors of those without autism,[215] and the recognition of the autistic community as a minority group.[215][216] Autism rights or neurodiversity advocates believe that the autism spectrum is genetic and should be accepted as a natural expression of the human genome. This perspective is distinct from two other likewise distinct views: the medical perspective, that autism is caused by a genetic defect and should be addressed by targeting the autism gene(s), and fringe theories that autism is caused by environmental factors such as vaccines.[205] A common criticism against autistic activists is that the majority of them are "high-functioning" or have Asperger syndrome and do not represent the views of "low-functioning" autistic people.[216]
Employment
About half of autistics are unemployed, and one third of those with graduate degrees may be unemployed.[217] Among autistics who find work, most are employed in sheltered settings working for wages below the national minimum.[218] While employers state hiring concerns about productivity and supervision, experienced employers of autistics give positive reports of above average memory and detail orientation as well as a high regard for rules and procedure in autistic employees.[217] A majority of the economic burden of autism is caused by decreased earnings in the job market.[219] Some studies also find decreased earning among parents who care for autistic children.[220][221]

References
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  2. ^ "Autism spectrum disorder - Symptoms and causes". Mayo Clinic. Retrieved 13 July 2019.
  3. ^ a b c "NIMH " Autism Spectrum Disorder". nimh.nih.gov. October 2016. Retrieved 20 April 2017.
  4. ^ a b c d e f Autism Spectrum Disorder, 299.00 (F84.0). In: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing; 2013.
  5. ^ a b Chaste P, Leboyer M (2012). "Autism risk factors: genes, environment, and gene-environment interactions". Dialogues in Clinical Neuroscience. 14 (3): 281–292. PMC 3513682. PMID 23226953.
  6. ^ Corcoran J, Walsh J (9 February 2006). Clinical Assessment and Diagnosis in Social Work Practice. Oxford University Press, New York. p. 72. ISBN 978-0-19-516830-3. LCCN 2005027740. OCLC 466433183.
  7. ^ a b c d e f g h i Myers SM, Johnson CP (November 2007). "Management of children with autism spectrum disorders". Pediatrics. 120 (5): 1162–1182. doi:10.1542/peds.2007-2362. PMID 17967921.
  8. ^ a b c d Sanchack KE, Thomas CA (December 2016). "Autism Spectrum Disorder: Primary Care Principles". American Family Physician. 94 (12): 972–979. PMID 28075089.
  9. ^ Sukhodolsky DG, Bloch MH, Panza KE, Reichow B (November 2013). "Cognitive-behavioral therapy for anxiety in children with high-functioning autism: a meta-analysis". Pediatrics. 132 (5): e1341-50. doi:10.1542/peds.2013-1193. PMC 3813396. PMID 24167175.
  10. ^ a b c d e Ji N, Findling RL (March 2015). "An update on pharmacotherapy for autism spectrum disorder in children and adolescents". Current Opinion in Psychiatry. 28 (2): 91–101. doi:10.1097/YCO.0000000000000132. PMID 25602248.
  11. ^ a b Oswald DP, Sonenklar NA (June 2007). "Medication use among children with autism spectrum disorders". Journal of Child and Adolescent Psychopharmacology. 17 (3): 348–355. doi:10.1089/cap.2006.17303. PMID 17630868.
  12. ^ a b Doyle CA, McDougle CJ (September 2012). "Pharmacologic treatments for the behavioral symptoms associated with autism spectrum disorders across the lifespan". Dialogues in Clinical Neuroscience. 14 (3): 263–279. PMC 3513681. PMID 23226952.
 
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Autism


This article is about the classic autistic disorder. For other conditions sometimes called "autism", see Autism spectrum. For the journal, see Autism (journal).
Autism is a developmental disorder characterized by difficulties with social interaction and communication, and by restricted and repetitive behavior.[4] Parents often notice signs during the first three years of their child's life.[1][4] These signs often develop gradually, though some children with autism experience worsening in their communication and social skills after reaching developmental milestones at a normal pace.[15]
Autism is associated with a combination of genetic and environmental factors.[5] Risk factors during pregnancy include certain infections, such as rubella, toxins including valproic acid, alcohol, cocaine, pesticides, lead, and air pollution, fetal growth restriction, and autoimmune diseases.[16][17][18] Controversies surround other proposed environmental causes; for example, the vaccine hypothesis, which has been disproven.[19] Autism affects information processing in the brain and how nerve cells and their synapses connect and organize; how this occurs is not well understood.[20] The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), combines autism and less severe forms of the condition, including Asperger syndrome and pervasive developmental disorder not otherwise specified (PDD-NOS) into the diagnosis of autism spectrum disorder (ASD).[4][21]
Early behavioral interventions or speech therapy can help children with autism gain self-care, social, and communication skills.[7][8] Although there is no known cure,[7] there have been cases of children who recovered.[22] Not many autistic adults are able to live independently, though some are successful.[13] An autistic culture has developed, with some individuals seeking a cure and others believing autism should be accepted as a difference to be accommodated instead of cured.[23][24]
Globally, autism is estimated to affect 24.8 million people as of 2015.[14] In the 2000s, the number of people affected was estimated at 1–2 per 1,000 people worldwide.[25] In the developed countries, about 1.5% of children are diagnosed with ASD as of 2017,[26] from 0.7% in 2000 in the United States.[27] It occurs four-to-five times more often in males than females.[27] The number of people diagnosed has increased dramatically since the 1960s, which may be partly due to changes in diagnostic practice.[25] The question of whether actual rates have increased is unresolved.[25]

Contents


Characteristics
Autism is a highly variable, neurodevelopmental disorder[28] whose symptoms first appears during infancy or childhood, and generally follows a steady course without remission.[29] People with autism may be severely impaired in some respects but average, or even superior, in others.[30] Overt symptoms gradually begin after the age of six months, become established by age two or three years[31] and tend to continue through adulthood, although often in more muted form.[32] It is distinguished by a characteristic triad of symptoms: impairments in social interaction, impairments in communication, and repetitive behavior. Other aspects, such as atypical eating, are also common but are not essential for diagnosis.[33] Individual symptoms of autism occur in the general population and appear not to associate highly, without a sharp line separating pathologically severe from common traits.[34]
Social development
Social deficits distinguish autism and the related autism spectrum disorders (ASD; see Classification) from other developmental disorders.[32] People with autism have social impairments and often lack the intuition about others that many people take for granted. Noted autistic Temple Grandin described her inability to understand the social communication of neurotypicals, or people with typical neural development, as leaving her feeling "like an anthropologist on Mars".[35]
Unusual social development becomes apparent early in childhood. Autistic infants show less attention to social stimuli, smile and look at others less often, and respond less to their own name. Autistic toddlers differ more strikingly from social norms; for example, they have less eye contact and turn-taking, and do not have the ability to use simple movements to express themselves, such as pointing at things.[36] Three- to five-year-old children with autism are less likely to exhibit social understanding, approach others spontaneously, imitate and respond to emotions, communicate nonverbally, and take turns with others. However, they do form attachments to their primary caregivers.[37] Most children with autism display moderately less attachment security than neurotypical children, although this difference disappears in children with higher mental development or less pronounced autistic traits.[38] Older children and adults with ASD perform worse on tests of face and emotion recognition[39] although this may be partly due to a lower ability to define a person's own emotions.[40]
Children with high-functioning autism have more intense and frequent loneliness compared to non-autistic peers, despite the common belief that children with autism prefer to be alone. Making and maintaining friendships often proves to be difficult for those with autism. For them, the quality of friendships, not the number of friends, predicts how lonely they feel. Functional friendships, such as those resulting in invitations to parties, may affect the quality of life more deeply.[41]
There are many anecdotal reports, but few systematic studies, of aggression and violence in individuals with ASD. The limited data suggest that, in children with intellectual disability, autism is associated with aggression, destruction of property, and meltdowns.[42]
Communication
About a third to a half of individuals with autism do not develop enough natural speech to meet their daily communication needs.[43] Differences in communication may be present from the first year of life, and may include delayed onset of babbling, unusual gestures, diminished responsiveness, and vocal patterns that are not synchronized with the caregiver. In the second and third years, children with autism have less frequent and less diverse babbling, consonants, words, and word combinations; their gestures are less often integrated with words. Children with autism are less likely to make requests or share experiences, and are more likely to simply repeat others' words (echolalia)[44][45] or reverse pronouns.[46] Joint attention seems to be necessary for functional speech, and deficits in joint attention seem to distinguish infants with ASD.[21] For example, they may look at a pointing hand instead of the pointed-at object,[36][45] and they consistently fail to point at objects in order to comment on or share an experience.[21] Children with autism may have difficulty with imaginative play and with developing symbols into language.[44][45]
In a pair of studies, high-functioning children with autism aged 8–15 performed equally well as, and as adults better than, individually matched controls at basic language tasks involving vocabulary and spelling. Both autistic groups performed worse than controls at complex language tasks such as figurative language, comprehension and inference. As people are often sized up initially from their basic language skills, these studies suggest that people speaking to autistic individuals are more likely to overestimate what their audience comprehends.[47]
Repetitive behavior
A young boy with autism who has arranged his toys in a row
Autistic individuals can display many forms of repetitive or restricted behavior, which the Repetitive Behavior Scale-Revised (RBS-R) categorizes as follows.[48]
  • Stereotyped behaviors: Repetitive movements, such as hand flapping, head rolling, or body rocking.
  • Compulsive behaviors: Time-consuming behaviors intended to reduce anxiety that an individual feels compelled to perform repeatedly or according to rigid rules, such as placing objects in a specific order, checking things, or hand washing.
  • Sameness: Resistance to change; for example, insisting that the furniture not be moved or refusing to be interrupted.
  • Ritualistic behavior: Unvarying pattern of daily activities, such as an unchanging menu or a dressing ritual. This is closely associated with sameness and an independent validation has suggested combining the two factors.[48]
  • Restricted interests: Interests or fixations that are abnormal in theme or intensity of focus, such as preoccupation with a single television program, toy, or game.
  • Self-injury: Behaviors such as eye-poking, skin-picking, hand-biting and head-banging.[21]
No single repetitive or self-injurious behavior seems to be specific to autism, but autism appears to have an elevated pattern of occurrence and severity of these behaviors.[49]
Other symptoms
Autistic individuals may have symptoms that are independent of the diagnosis, but that can affect the individual or the family.[33] An estimated 0.5% to 10% of individuals with ASD show unusual abilities, ranging from splinter skills such as the memorization of trivia to the extraordinarily rare talents of prodigious autistic savants.[50] Many individuals with ASD show superior skills in perception and attention, relative to the general population.[51] Sensory abnormalities are found in over 90% of those with autism, and are considered core features by some,[52] although there is no good evidence that sensory symptoms differentiate autism from other developmental disorders.[53] Differences are greater for under-responsivity (for example, walking into things) than for over-responsivity (for example, distress from loud noises) or for sensation seeking (for example, rhythmic movements).[54] An estimated 60–80% of autistic people have motor signs that include poor muscle tone, poor motor planning, and toe walking;[52] deficits in motor coordination are pervasive across ASD and are greater in autism proper.[55] Unusual eating behavior occurs in about three-quarters of children with ASD, to the extent that it was formerly a diagnostic indicator. Selectivity is the most common problem, although eating rituals and food refusal also occur.[56]
There is tentative evidence that autism occurs more frequently in people with gender dysphoria.[57][58]
Gastrointestinal problems are one of the most commonly associated medical disorders in people with autism.[59] These are linked to greater social impairment, irritability, behavior and sleep problems, language impairments and mood changes.[59][60]
Parents of children with ASD have higher levels of stress.[36] Siblings of children with ASD report greater admiration of and less conflict with the affected sibling than siblings of unaffected children and were similar to siblings of children with Down syndrome in these aspects of the sibling relationship. However, they reported lower levels of closeness and intimacy than siblings of children with Down syndrome; siblings of individuals with ASD have greater risk of negative well-being and poorer sibling relationships as adults.[61]

Causes
Main article: Causes of autism
It has long been presumed that there is a common cause at the genetic, cognitive, and neural levels for autism's characteristic triad of symptoms.[62] However, there is increasing suspicion that autism is instead a complex disorder whose core aspects have distinct causes that often co-occur.[62][63]
Deletion (1), duplication (2) and inversion (3) are all chromosome abnormalities that have been implicated in autism.[64]
Autism has a strong genetic basis, although the genetics of autism are complex and it is unclear whether ASD is explained more by rare mutations with major effects, or by rare multigene interactions of common genetic variants.[65][66] Complexity arises due to interactions among multiple genes, the environment, and epigenetic factors which do not change DNA sequencing but are heritable and influence gene expression.[32] Many genes have been associated with autism through sequencing the genomes of affected individuals and their parents.[67] Studies of twins suggest that heritability is 0.7 for autism and as high as 0.9 for ASD, and siblings of those with autism are about 25 times more likely to be autistic than the general population.[52] However, most of the mutations that increase autism risk have not been identified. Typically, autism cannot be traced to a Mendelian (single-gene) mutation or to a single chromosome abnormality, and none of the genetic syndromes associated with ASDs have been shown to selectively cause ASD.[65] Numerous candidate genes have been located, with only small effects attributable to any particular gene.[65] Most loci individually explain less than 1% of cases of autism.[68] The large number of autistic individuals with unaffected family members may result from spontaneous structural variation—such as deletions, duplications or inversions in genetic material during meiosis.[69][70] Hence, a substantial fraction of autism cases may be traceable to genetic causes that are highly heritable but not inherited: that is, the mutation that causes the autism is not present in the parental genome.[64] Autism may be underdiagnosed in women and girls due to an assumption that it is primarily a male condition,[71] but genetic phenomena such as imprinting and X linkage have the ability to raise the frequency and severity of conditions in males, and theories have been put forward for a genetic reason why males are diagnosed more often, such as the imprinted brain theory and the extreme male brain theory.[72][73][74]
Maternal nutrition and inflammation during preconception and pregnancy influences fetal neurodevelopment. Intrauterine growth restriction is associated with ASD, in both term and preterm infants.[17] Maternal inflammatory and autoimmune diseases may damage fetal tissues, aggravating a genetic problem or damaging the nervous system.[18]
Exposure to air pollution during pregnancy, especially heavy metals and particulates, may increase the risk of autism.[75][76] Environmental factors that have been claimed without evidence to contribute to or exacerbate autism include certain foods, infectious diseases, solvents, PCBs, phthalates and phenols used in plastic products, pesticides, brominated flame retardants, alcohol, smoking, illicit drugs, vaccines,[25] and prenatal stress. Some, such as the MMR vaccine, have been completely disproven.[77][78][79][80]
Parents may first become aware of autistic symptoms in their child around the time of a routine vaccination. This has led to unsupported theories blaming vaccine "overload", a vaccine preservative, or the MMR vaccine for causing autism.[81] The latter theory was supported by a litigation-funded study that has since been shown to have been "an elaborate fraud".[82] Although these theories lack convincing scientific evidence and are biologically implausible,[81] parental concern about a potential vaccine link with autism has led to lower rates of childhood immunizations, outbreaks of previously controlled childhood diseases in some countries, and the preventable deaths of several children.[83][84]

Mechanism
Main article: Mechanism of autism
Autism's symptoms result from maturation-related changes in various systems of the brain. How autism occurs is not well understood. Its mechanism can be divided into two areas: the pathophysiology of brain structures and processes associated with autism, and the neuropsychological linkages between brain structures and behaviors.[85] The behaviors appear to have multiple pathophysiologies.[34]
There is evidence that gut–brain axis abnormalities may be involved.[59][60][86] A 2015 review proposed that immune dysregulation, gastrointestinal inflammation, malfunction of the autonomic nervous system, gut flora alterations, and food metabolites may cause brain neuroinflammation and dysfunction.[60] A 2016 review concludes that enteric nervous system abnormalities might play a role in neurological disorders such as autism. Neural connections and the immune system are a pathway that may allow diseases originated in the intestine to spread to the brain.[86]
Several lines of evidence point to synaptic dysfunction as a cause of autism.[20] Some rare mutations may lead to autism by disrupting some synaptic pathways, such as those involved with cell adhesion.[87] Gene replacement studies in mice suggest that autistic symptoms are closely related to later developmental steps that depend on activity in synapses and on activity-dependent changes.[88] All known teratogens (agents that cause birth defects) related to the risk of autism appear to act during the first eight weeks from conception, and though this does not exclude the possibility that autism can be initiated or affected later, there is strong evidence that autism arises very early in development.[89]

Diagnosis
Diagnosis is based on behavior, not cause or mechanism.[34][90] Under the DSM-5, autism is characterized by persistent deficits in social communication and interaction across multiple contexts, as well as restricted, repetitive patterns of behavior, interests, or activities. These deficits are present in early childhood, typically before age three, and lead to clinically significant functional impairment.[4] Sample symptoms include lack of social or emotional reciprocity, stereotyped and repetitive use of language or idiosyncratic language, and persistent preoccupation with unusual objects. The disturbance must not be better accounted for by Rett syndrome, intellectual disability or global developmental delay.[4] ICD-10 uses essentially the same definition.[29]
Several diagnostic instruments are available. Two are commonly used in autism research: the Autism Diagnostic Interview-Revised (ADI-R) is a semistructured parent interview, and the Autism Diagnostic Observation Schedule (ADOS)[91] uses observation and interaction with the child. The Childhood Autism Rating Scale (CARS) is used widely in clinical environments to assess severity of autism based on observation of children.[36] The Diagnostic interview for social and communication disorders (DISCO) may also be used.[92]
A pediatrician commonly performs a preliminary investigation by taking developmental history and physically examining the child. If warranted, diagnosis and evaluations are conducted with help from ASD specialists, observing and assessing cognitive, communication, family, and other factors using standardized tools, and taking into account any associated medical conditions.[93] A pediatric neuropsychologist is often asked to assess behavior and cognitive skills, both to aid diagnosis and to help recommend educational interventions.[94] A differential diagnosis for ASD at this stage might also consider intellectual disability, hearing impairment, and a specific language impairment[93] such as Landau–Kleffner syndrome.[95] The presence of autism can make it harder to diagnose coexisting psychiatric disorders such as depression.[96]
Clinical genetics evaluations are often done once ASD is diagnosed, particularly when other symptoms already suggest a genetic cause.[97] Although genetic technology allows clinical geneticists to link an estimated 40% of cases to genetic causes,[98] consensus guidelines in the US and UK are limited to high-resolution chromosome and fragile X testing.[97] A genotype-first model of diagnosis has been proposed, which would routinely assess the genome's copy number variations.[99] As new genetic tests are developed several ethical, legal, and social issues will emerge. Commercial availability of tests may precede adequate understanding of how to use test results, given the complexity of autism's genetics.[100] Metabolic and neuroimaging tests are sometimes helpful, but are not routine.[97]
ASD can sometimes be diagnosed by age 14 months, although diagnosis becomes increasingly stable over the first three years of life: for example, a one-year-old who meets diagnostic criteria for ASD is less likely than a three-year-old to continue to do so a few years later.[1] In the UK the National Autism Plan for Children recommends at most 30 weeks from first concern to completed diagnosis and assessment, though few cases are handled that quickly in practice.[93] Although the symptoms of autism and ASD begin early in childhood, they are sometimes missed; years later, adults may seek diagnoses to help them or their friends and family understand themselves, to help their employers make adjustments, or in some locations to claim disability living allowances or other benefits. Girls are often diagnosed later than boys.[101]
Underdiagnosis and overdiagnosis are problems in marginal cases, and much of the recent increase in the number of reported ASD cases is likely due to changes in diagnostic practices. The increasing popularity of drug treatment options and the expansion of benefits has given providers incentives to diagnose ASD, resulting in some overdiagnosis of children with uncertain symptoms. Conversely, the cost of screening and diagnosis and the challenge of obtaining payment can inhibit or delay diagnosis.[102] It is particularly hard to diagnose autism among the visually impaired, partly because some of its diagnostic criteria depend on vision, and partly because autistic symptoms overlap with those of common blindness syndromes or blindisms.[103]
Classification
Autism is one of the five pervasive developmental disorders (PDD), which are characterized by widespread abnormalities of social interactions and communication, and severely restricted interests and highly repetitive behavior.[29] These symptoms do not imply sickness, fragility, or emotional disturbance.[32]
Of the five PDD forms, Asperger syndrome is closest to autism in signs and likely causes; Rett syndrome and childhood disintegrative disorder share several signs with autism, but may have unrelated causes; PDD not otherwise specified (PDD-NOS; also called atypical autism) is diagnosed when the criteria are not met for a more specific disorder.[104] Unlike with autism, people with Asperger syndrome have no substantial delay in language development.[105] The terminology of autism can be bewildering, with autism, Asperger syndrome and PDD-NOS often called the autism spectrum disorders (ASD)[7] or sometimes the autistic disorders,[106] whereas autism itself is often called autistic disorder, childhood autism, or infantile autism. In this article, autism refers to the classic autistic disorder; in clinical practice, though, autism, ASD, and PDD are often used interchangeably.[97] ASD, in turn, is a subset of the broader autism phenotype, which describes individuals who may not have ASD but do have autistic-like traits, such as avoiding eye contact.[107]
Autism can also be divided into syndromal and non-syndromal autism; the syndromal autism is associated with severe or profound intellectual disability or a congenital syndrome with physical symptoms, such as tuberous sclerosis.[108] Although individuals with Asperger syndrome tend to perform better cognitively than those with autism, the extent of the overlap between Asperger syndrome, HFA, and non-syndromal autism is unclear.[109]
Some studies have reported diagnoses of autism in children due to a loss of language or social skills, as opposed to a failure to make progress, typically from 15 to 30 months of age. The validity of this distinction remains controversial; it is possible that regressive autism is a specific subtype,[1][15][44][110] or that there is a continuum of behaviors between autism with and without regression.[111]
Research into causes has been hampered by the inability to identify biologically meaningful subgroups within the autistic population[112] and by the traditional boundaries between the disciplines of psychiatry, psychology, neurology and pediatrics.[113] Newer technologies such as fMRI and diffusion tensor imaging can help identify biologically relevant phenotypes (observable traits) that can be viewed on brain scans, to help further neurogenetic studies of autism;[114] one example is lowered activity in the fusiform face area of the brain, which is associated with impaired perception of people versus objects.[20] It has been proposed to classify autism using genetics as well as behavior.[115]
Spectrum
Autism has long been thought to cover a wide spectrum, ranging from individuals with severe impairments—who may be silent, developmentally disabled, and prone to frequent repetitive behavior such as hand flapping and rocking—to high functioning individuals who may have active but distinctly odd social approaches, narrowly focused interests, and verbose, pedantic communication.[116] Because the behavior spectrum is continuous, boundaries between diagnostic categories are necessarily somewhat arbitrary.[52] Sometimes the syndrome is divided into low-, medium- or high-functioning autism (LFA, MFA, and HFA), based on IQ thresholds.[117] Some people have called for an end to the terms "high-functioning" and "low-functioning" due to lack of nuance and the potential for a person's needs or abilities to be overlooked.[118][119]

Screening
About half of parents of children with ASD notice their child's unusual behaviors by age 18 months, and about four-fifths notice by age 24 months.[1] According to an article, failure to meet any of the following milestones "is an absolute indication to proceed with further evaluations. Delay in referral for such testing may delay early diagnosis and treatment and affect the long-term outcome".[33]
  • No response to name (or eye-to-eye gaze) by 6 months.[120]
  • No babbling by 12 months.
  • No gesturing (pointing, waving, etc.) by 12 months.
  • No single words by 16 months.
  • No two-word (spontaneous, not just echolalic) phrases by 24 months.
  • Loss of any language or social skills, at any age.
The United States Preventive Services Task Force in 2016 found it was unclear if screening was beneficial or harmful among children in whom there is no concerns.[121] The Japanese practice is to screen all children for ASD at 18 and 24 months, using autism-specific formal screening tests. In contrast, in the UK, children whose families or doctors recognize possible signs of autism are screened. It is not known which approach is more effective.[20] Screening tools include the Modified Checklist for Autism in Toddlers (M-CHAT), the Early Screening of Autistic Traits Questionnaire, and the First Year Inventory; initial data on M-CHAT and its predecessor, the Checklist for Autism in Toddlers (CHAT), on children aged 18–30 months suggests that it is best used in a clinical setting and that it has low sensitivity (many false-negatives) but good specificity (few false-positives).[1] It may be more accurate to precede these tests with a broadband screener that does not distinguish ASD from other developmental disorders.[122] Screening tools designed for one culture's norms for behaviors like eye contact may be inappropriate for a different culture.[123] Although genetic screening for autism is generally still impractical, it can be considered in some cases, such as children with neurological symptoms and dysmorphic features.[124]

Prevention
While infection with rubella during pregnancy causes fewer than 1% of cases of autism,[125] vaccination against rubella can prevent many of those cases.[126]

Management
Main article: Autism therapies
A three-year-old with autism points to fish in an aquarium, as part of an experiment on the effect of intensive shared-attention training on language development.[127]
The main goals when treating children with autism are to lessen associated deficits and family distress, and to increase quality of life and functional independence. In general, higher IQs are correlated with greater responsiveness to treatment and improved treatment outcomes.[128][129] No single treatment is best and treatment is typically tailored to the child's needs.[7] Families and the educational system are the main resources for treatment.[20] Services should be carried out by behavior analysts, special education teachers, speech pathologists, and licensed psychologists. Studies of interventions have methodological problems that prevent definitive conclusions about efficacy.[130] However, the development of evidence-based interventions has advanced in recent years.[128] Although many psychosocial interventions have some positive evidence, suggesting that some form of treatment is preferable to no treatment, the methodological quality of systematic reviews of these studies has generally been poor, their clinical results are mostly tentative, and there is little evidence for the relative effectiveness of treatment options.[131] Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, communication, and job skills,[7] and often improve functioning and decrease symptom severity and maladaptive behaviors;[132] claims that intervention by around age three years is crucial are not substantiated.[133] While medications have not been found to help with core symptoms, they may be used for associated symptoms, such as irritability, inattention, or repetitive behavior patterns.[10]
Education
Educational interventions often used include applied behavior analysis (ABA), developmental models, structured teaching, speech and language therapy, social skills therapy, and occupational therapy.[7] Among these approaches, interventions either treat autistic features comprehensively, or focalize treatment on a specific area of deficit.[128] The quality of research for early intensive behavioral intervention (EIBI)—a treatment procedure incorporating over thirty hours per week of the structured type of ABA that is carried out with very young children—is currently low, and more vigorous research designs with larger sample sizes are needed.[134] Two theoretical frameworks outlined for early childhood intervention include structured and naturalistic ABA interventions, and developmental social pragmatic models (DSP).[128] One interventional strategy utilizes a parent training model, which teaches parents how to implement various ABA and DSP techniques, allowing for parents to disseminate interventions themselves.[128] Various DSP programs have been developed to explicitly deliver intervention systems through at-home parent implementation. Despite the recent development of parent training models, these interventions have demonstrated effectiveness in numerous studies, being evaluated as a probable efficacious mode of treatment.[128]
Early, intensive ABA therapy has demonstrated effectiveness in enhancing communication and adaptive functioning in preschool children;[135] it is also well-established for improving the intellectual performance of that age group.[132][135] Similarly, a teacher-implemented intervention that utilizes a more naturalistic form of ABA combined with a developmental social pragmatic approach has been found to be beneficial in improving social-communication skills in young children, although there is less evidence in its treatment of global symptoms.[128] Neuropsychological reports are often poorly communicated to educators, resulting in a gap between what a report recommends and what education is provided.[94] It is not known whether treatment programs for children lead to significant improvements after the children grow up,[132] and the limited research on the effectiveness of adult residential programs shows mixed results.[136] The appropriateness of including children with varying severity of autism spectrum disorders in the general education population is a subject of current debate among educators and researchers.[137]
Medication
Medications may be used to treat ASD symptoms that interfere with integrating a child into home or school when behavioral treatment fails.[8] They may also be used for associated health problems, such as ADHD or anxiety.[8] More than half of US children diagnosed with ASD are prescribed psychoactive drugs or anticonvulsants, with the most common drug classes being antidepressants, stimulants, and antipsychotics.[11][12] The atypical antipsychotic drugs risperidone and aripiprazole are FDA-approved for treating associated aggressive and self-injurious behaviors.[10][32][138] However, their side effects must be weighed against their potential benefits, and people with autism may respond atypically.[10] Side effects, for example, may include weight gain, tiredness, drooling, and aggression.[10] SSRI antidepressants, such as fluoxetine and fluvoxamine, have been shown to be effective in reducing repetitive and ritualistic behaviors, while the stimulant medication methylphenidate is beneficial for some children with co-morbid inattentiveness or hyperactivity.[7] There is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD.[139] No known medication relieves autism's core symptoms of social and communication impairments.[140] Experiments in mice have reversed or reduced some symptoms related to autism by replacing or modulating gene function,[88][141] suggesting the possibility of targeting therapies to specific rare mutations known to cause autism.[87][142]


Society and culture
Main article: Societal and cultural aspects of autism
Autism awareness ribbon
An autistic culture has emerged, accompanied by the autistic rights and neurodiversity movements.[203][204][205] Events include World Autism Awareness Day, Autism Sunday, Autistic Pride Day, Autreat, and others.[206][207][208][209] Organizations dedicated to promoting awareness of autism include Autism Speaks, Autism National Committee, and Autism Society of America.[210] Social-science scholars study those with autism in hopes to learn more about "autism as a culture, transcultural comparisons... and research on social movements."[211] While most autistic individuals do not have savant skills, many have been successful in their fields.[212][213][214]
Autism rights movement
The autism rights movement is a social movement within the context of disability rights that emphasizes the concept of neurodiversity, viewing the autism spectrum as a result of natural variations in the human brain rather than a disorder to be cured.[205] The autism rights movement advocates for including greater acceptance of autistic behaviors; therapies that focus on coping skills rather than on imitating the behaviors of those without autism,[215] and the recognition of the autistic community as a minority group.[215][216] Autism rights or neurodiversity advocates believe that the autism spectrum is genetic and should be accepted as a natural expression of the human genome. This perspective is distinct from two other likewise distinct views: the medical perspective, that autism is caused by a genetic defect and should be addressed by targeting the autism gene(s), and fringe theories that autism is caused by environmental factors such as vaccines.[205] A common criticism against autistic activists is that the majority of them are "high-functioning" or have Asperger syndrome and do not represent the views of "low-functioning" autistic people.[216]
Employment
About half of autistics are unemployed, and one third of those with graduate degrees may be unemployed.[217] Among autistics who find work, most are employed in sheltered settings working for wages below the national minimum.[218] While employers state hiring concerns about productivity and supervision, experienced employers of autistics give positive reports of above average memory and detail orientation as well as a high regard for rules and procedure in autistic employees.[217] A majority of the economic burden of autism is caused by decreased earnings in the job market.[219] Some studies also find decreased earning among parents who care for autistic children.[220][221]

References
  1. ^ a b c d e f Landa RJ (2008). "Diagnosis of autism spectrum disorders in the first 3 years of life". Nat Clin Pract Neurol. 4 (3): 138–147. doi:10.1038/ncpneuro0731. PMID 18253102.
  2. ^ "Autism spectrum disorder - Symptoms and causes". Mayo Clinic. Retrieved 13 July 2019.
  3. ^ a b c "NIMH " Autism Spectrum Disorder". nimh.nih.gov. October 2016. Retrieved 20 April 2017.
  4. ^ a b c d e f Autism Spectrum Disorder, 299.00 (F84.0). In: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing; 2013.
  5. ^ a b Chaste P, Leboyer M (2012). "Autism risk factors: genes, environment, and gene-environment interactions". Dialogues in Clinical Neuroscience. 14 (3): 281–292. PMC 3513682. PMID 23226953.
  6. ^ Corcoran J, Walsh J (9 February 2006). Clinical Assessment and Diagnosis in Social Work Practice. Oxford University Press, New York. p. 72. ISBN 978-0-19-516830-3. LCCN 2005027740. OCLC 466433183.
  7. ^ a b c d e f g h i Myers SM, Johnson CP (November 2007). "Management of children with autism spectrum disorders". Pediatrics. 120 (5): 1162–1182. doi:10.1542/peds.2007-2362. PMID 17967921.
  8. ^ a b c d Sanchack KE, Thomas CA (December 2016). "Autism Spectrum Disorder: Primary Care Principles". American Family Physician. 94 (12): 972–979. PMID 28075089.
  9. ^ Sukhodolsky DG, Bloch MH, Panza KE, Reichow B (November 2013). "Cognitive-behavioral therapy for anxiety in children with high-functioning autism: a meta-analysis". Pediatrics. 132 (5): e1341-50. doi:10.1542/peds.2013-1193. PMC 3813396. PMID 24167175.
  10. ^ a b c d e Ji N, Findling RL (March 2015). "An update on pharmacotherapy for autism spectrum disorder in children and adolescents". Current Opinion in Psychiatry. 28 (2): 91–101. doi:10.1097/YCO.0000000000000132. PMID 25602248.
  11. ^ a b Oswald DP, Sonenklar NA (June 2007). "Medication use among children with autism spectrum disorders". Journal of Child and Adolescent Psychopharmacology. 17 (3): 348–355. doi:10.1089/cap.2006.17303. PMID 17630868.
  12. ^ a b Doyle CA, McDougle CJ (September 2012). "Pharmacologic treatments for the behavioral symptoms associated with autism spectrum disorders across the lifespan". Dialogues in Clinical Neuroscience. 14 (3): 263–279. PMC 3513681. PMID 23226952.
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Autism


This article is about the classic autistic disorder. For other conditions sometimes called "autism", see Autism spectrum. For the journal, see Autism (journal).
Autism is a developmental disorder characterized by difficulties with social interaction and communication, and by restricted and repetitive behavior.[4] Parents often notice signs during the first three years of their child's life.[1][4] These signs often develop gradually, though some children with autism experience worsening in their communication and social skills after reaching developmental milestones at a normal pace.[15]
Autism is associated with a combination of genetic and environmental factors.[5] Risk factors during pregnancy include certain infections, such as rubella, toxins including valproic acid, alcohol, cocaine, pesticides, lead, and air pollution, fetal growth restriction, and autoimmune diseases.[16][17][18] Controversies surround other proposed environmental causes; for example, the vaccine hypothesis, which has been disproven.[19] Autism affects information processing in the brain and how nerve cells and their synapses connect and organize; how this occurs is not well understood.[20] The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), combines autism and less severe forms of the condition, including Asperger syndrome and pervasive developmental disorder not otherwise specified (PDD-NOS) into the diagnosis of autism spectrum disorder (ASD).[4][21]
Early behavioral interventions or speech therapy can help children with autism gain self-care, social, and communication skills.[7][8] Although there is no known cure,[7] there have been cases of children who recovered.[22] Not many autistic adults are able to live independently, though some are successful.[13] An autistic culture has developed, with some individuals seeking a cure and others believing autism should be accepted as a difference to be accommodated instead of cured.[23][24]
Globally, autism is estimated to affect 24.8 million people as of 2015.[14] In the 2000s, the number of people affected was estimated at 1–2 per 1,000 people worldwide.[25] In the developed countries, about 1.5% of children are diagnosed with ASD as of 2017,[26] from 0.7% in 2000 in the United States.[27] It occurs four-to-five times more often in males than females.[27] The number of people diagnosed has increased dramatically since the 1960s, which may be partly due to changes in diagnostic practice.[25] The question of whether actual rates have increased is unresolved.[25]

Contents


Characteristics
Autism is a highly variable, neurodevelopmental disorder[28] whose symptoms first appears during infancy or childhood, and generally follows a steady course without remission.[29] People with autism may be severely impaired in some respects but average, or even superior, in others.[30] Overt symptoms gradually begin after the age of six months, become established by age two or three years[31] and tend to continue through adulthood, although often in more muted form.[32] It is distinguished by a characteristic triad of symptoms: impairments in social interaction, impairments in communication, and repetitive behavior. Other aspects, such as atypical eating, are also common but are not essential for diagnosis.[33] Individual symptoms of autism occur in the general population and appear not to associate highly, without a sharp line separating pathologically severe from common traits.[34]
Social development
Social deficits distinguish autism and the related autism spectrum disorders (ASD; see Classification) from other developmental disorders.[32] People with autism have social impairments and often lack the intuition about others that many people take for granted. Noted autistic Temple Grandin described her inability to understand the social communication of neurotypicals, or people with typical neural development, as leaving her feeling "like an anthropologist on Mars".[35]
Unusual social development becomes apparent early in childhood. Autistic infants show less attention to social stimuli, smile and look at others less often, and respond less to their own name. Autistic toddlers differ more strikingly from social norms; for example, they have less eye contact and turn-taking, and do not have the ability to use simple movements to express themselves, such as pointing at things.[36] Three- to five-year-old children with autism are less likely to exhibit social understanding, approach others spontaneously, imitate and respond to emotions, communicate nonverbally, and take turns with others. However, they do form attachments to their primary caregivers.[37] Most children with autism display moderately less attachment security than neurotypical children, although this difference disappears in children with higher mental development or less pronounced autistic traits.[38] Older children and adults with ASD perform worse on tests of face and emotion recognition[39] although this may be partly due to a lower ability to define a person's own emotions.[40]
Children with high-functioning autism have more intense and frequent loneliness compared to non-autistic peers, despite the common belief that children with autism prefer to be alone. Making and maintaining friendships often proves to be difficult for those with autism. For them, the quality of friendships, not the number of friends, predicts how lonely they feel. Functional friendships, such as those resulting in invitations to parties, may affect the quality of life more deeply.[41]
There are many anecdotal reports, but few systematic studies, of aggression and violence in individuals with ASD. The limited data suggest that, in children with intellectual disability, autism is associated with aggression, destruction of property, and meltdowns.[42]
Communication
About a third to a half of individuals with autism do not develop enough natural speech to meet their daily communication needs.[43] Differences in communication may be present from the first year of life, and may include delayed onset of babbling, unusual gestures, diminished responsiveness, and vocal patterns that are not synchronized with the caregiver. In the second and third years, children with autism have less frequent and less diverse babbling, consonants, words, and word combinations; their gestures are less often integrated with words. Children with autism are less likely to make requests or share experiences, and are more likely to simply repeat others' words (echolalia)[44][45] or reverse pronouns.[46] Joint attention seems to be necessary for functional speech, and deficits in joint attention seem to distinguish infants with ASD.[21] For example, they may look at a pointing hand instead of the pointed-at object,[36][45] and they consistently fail to point at objects in order to comment on or share an experience.[21] Children with autism may have difficulty with imaginative play and with developing symbols into language.[44][45]
In a pair of studies, high-functioning children with autism aged 8–15 performed equally well as, and as adults better than, individually matched controls at basic language tasks involving vocabulary and spelling. Both autistic groups performed worse than controls at complex language tasks such as figurative language, comprehension and inference. As people are often sized up initially from their basic language skills, these studies suggest that people speaking to autistic individuals are more likely to overestimate what their audience comprehends.[47]
Repetitive behavior
A young boy with autism who has arranged his toys in a row
Autistic individuals can display many forms of repetitive or restricted behavior, which the Repetitive Behavior Scale-Revised (RBS-R) categorizes as follows.[48]
  • Stereotyped behaviors: Repetitive movements, such as hand flapping, head rolling, or body rocking.
  • Compulsive behaviors: Time-consuming behaviors intended to reduce anxiety that an individual feels compelled to perform repeatedly or according to rigid rules, such as placing objects in a specific order, checking things, or hand washing.
  • Sameness: Resistance to change; for example, insisting that the furniture not be moved or refusing to be interrupted.
  • Ritualistic behavior: Unvarying pattern of daily activities, such as an unchanging menu or a dressing ritual. This is closely associated with sameness and an independent validation has suggested combining the two factors.[48]
  • Restricted interests: Interests or fixations that are abnormal in theme or intensity of focus, such as preoccupation with a single television program, toy, or game.
  • Self-injury: Behaviors such as eye-poking, skin-picking, hand-biting and head-banging.[21]
No single repetitive or self-injurious behavior seems to be specific to autism, but autism appears to have an elevated pattern of occurrence and severity of these behaviors.[49]
Other symptoms
Autistic individuals may have symptoms that are independent of the diagnosis, but that can affect the individual or the family.[33] An estimated 0.5% to 10% of individuals with ASD show unusual abilities, ranging from splinter skills such as the memorization of trivia to the extraordinarily rare talents of prodigious autistic savants.[50] Many individuals with ASD show superior skills in perception and attention, relative to the general population.[51] Sensory abnormalities are found in over 90% of those with autism, and are considered core features by some,[52] although there is no good evidence that sensory symptoms differentiate autism from other developmental disorders.[53] Differences are greater for under-responsivity (for example, walking into things) than for over-responsivity (for example, distress from loud noises) or for sensation seeking (for example, rhythmic movements).[54] An estimated 60–80% of autistic people have motor signs that include poor muscle tone, poor motor planning, and toe walking;[52] deficits in motor coordination are pervasive across ASD and are greater in autism proper.[55] Unusual eating behavior occurs in about three-quarters of children with ASD, to the extent that it was formerly a diagnostic indicator. Selectivity is the most common problem, although eating rituals and food refusal also occur.[56]
There is tentative evidence that autism occurs more frequently in people with gender dysphoria.[57][58]
Gastrointestinal problems are one of the most commonly associated medical disorders in people with autism.[59] These are linked to greater social impairment, irritability, behavior and sleep problems, language impairments and mood changes.[59][60]
Parents of children with ASD have higher levels of stress.[36] Siblings of children with ASD report greater admiration of and less conflict with the affected sibling than siblings of unaffected children and were similar to siblings of children with Down syndrome in these aspects of the sibling relationship. However, they reported lower levels of closeness and intimacy than siblings of children with Down syndrome; siblings of individuals with ASD have greater risk of negative well-being and poorer sibling relationships as adults.[61]

Causes
Main article: Causes of autism
It has long been presumed that there is a common cause at the genetic, cognitive, and neural levels for autism's characteristic triad of symptoms.[62] However, there is increasing suspicion that autism is instead a complex disorder whose core aspects have distinct causes that often co-occur.[62][63]
Deletion (1), duplication (2) and inversion (3) are all chromosome abnormalities that have been implicated in autism.[64]
Autism has a strong genetic basis, although the genetics of autism are complex and it is unclear whether ASD is explained more by rare mutations with major effects, or by rare multigene interactions of common genetic variants.[65][66] Complexity arises due to interactions among multiple genes, the environment, and epigenetic factors which do not change DNA sequencing but are heritable and influence gene expression.[32] Many genes have been associated with autism through sequencing the genomes of affected individuals and their parents.[67] Studies of twins suggest that heritability is 0.7 for autism and as high as 0.9 for ASD, and siblings of those with autism are about 25 times more likely to be autistic than the general population.[52] However, most of the mutations that increase autism risk have not been identified. Typically, autism cannot be traced to a Mendelian (single-gene) mutation or to a single chromosome abnormality, and none of the genetic syndromes associated with ASDs have been shown to selectively cause ASD.[65] Numerous candidate genes have been located, with only small effects attributable to any particular gene.[65] Most loci individually explain less than 1% of cases of autism.[68] The large number of autistic individuals with unaffected family members may result from spontaneous structural variation—such as deletions, duplications or inversions in genetic material during meiosis.[69][70] Hence, a substantial fraction of autism cases may be traceable to genetic causes that are highly heritable but not inherited: that is, the mutation that causes the autism is not present in the parental genome.[64] Autism may be underdiagnosed in women and girls due to an assumption that it is primarily a male condition,[71] but genetic phenomena such as imprinting and X linkage have the ability to raise the frequency and severity of conditions in males, and theories have been put forward for a genetic reason why males are diagnosed more often, such as the imprinted brain theory and the extreme male brain theory.[72][73][74]
Maternal nutrition and inflammation during preconception and pregnancy influences fetal neurodevelopment. Intrauterine growth restriction is associated with ASD, in both term and preterm infants.[17] Maternal inflammatory and autoimmune diseases may damage fetal tissues, aggravating a genetic problem or damaging the nervous system.[18]
Exposure to air pollution during pregnancy, especially heavy metals and particulates, may increase the risk of autism.[75][76] Environmental factors that have been claimed without evidence to contribute to or exacerbate autism include certain foods, infectious diseases, solvents, PCBs, phthalates and phenols used in plastic products, pesticides, brominated flame retardants, alcohol, smoking, illicit drugs, vaccines,[25] and prenatal stress. Some, such as the MMR vaccine, have been completely disproven.[77][78][79][80]
Parents may first become aware of autistic symptoms in their child around the time of a routine vaccination. This has led to unsupported theories blaming vaccine "overload", a vaccine preservative, or the MMR vaccine for causing autism.[81] The latter theory was supported by a litigation-funded study that has since been shown to have been "an elaborate fraud".[82] Although these theories lack convincing scientific evidence and are biologically implausible,[81] parental concern about a potential vaccine link with autism has led to lower rates of childhood immunizations, outbreaks of previously controlled childhood diseases in some countries, and the preventable deaths of several children.[83][84]

Mechanism
Main article: Mechanism of autism
Autism's symptoms result from maturation-related changes in various systems of the brain. How autism occurs is not well understood. Its mechanism can be divided into two areas: the pathophysiology of brain structures and processes associated with autism, and the neuropsychological linkages between brain structures and behaviors.[85] The behaviors appear to have multiple pathophysiologies.[34]
There is evidence that gut–brain axis abnormalities may be involved.[59][60][86] A 2015 review proposed that immune dysregulation, gastrointestinal inflammation, malfunction of the autonomic nervous system, gut flora alterations, and food metabolites may cause brain neuroinflammation and dysfunction.[60] A 2016 review concludes that enteric nervous system abnormalities might play a role in neurological disorders such as autism. Neural connections and the immune system are a pathway that may allow diseases originated in the intestine to spread to the brain.[86]
Several lines of evidence point to synaptic dysfunction as a cause of autism.[20] Some rare mutations may lead to autism by disrupting some synaptic pathways, such as those involved with cell adhesion.[87] Gene replacement studies in mice suggest that autistic symptoms are closely related to later developmental steps that depend on activity in synapses and on activity-dependent changes.[88] All known teratogens (agents that cause birth defects) related to the risk of autism appear to act during the first eight weeks from conception, and though this does not exclude the possibility that autism can be initiated or affected later, there is strong evidence that autism arises very early in development.[89]

Diagnosis
Diagnosis is based on behavior, not cause or mechanism.[34][90] Under the DSM-5, autism is characterized by persistent deficits in social communication and interaction across multiple contexts, as well as restricted, repetitive patterns of behavior, interests, or activities. These deficits are present in early childhood, typically before age three, and lead to clinically significant functional impairment.[4] Sample symptoms include lack of social or emotional reciprocity, stereotyped and repetitive use of language or idiosyncratic language, and persistent preoccupation with unusual objects. The disturbance must not be better accounted for by Rett syndrome, intellectual disability or global developmental delay.[4] ICD-10 uses essentially the same definition.[29]
Several diagnostic instruments are available. Two are commonly used in autism research: the Autism Diagnostic Interview-Revised (ADI-R) is a semistructured parent interview, and the Autism Diagnostic Observation Schedule (ADOS)[91] uses observation and interaction with the child. The Childhood Autism Rating Scale (CARS) is used widely in clinical environments to assess severity of autism based on observation of children.[36] The Diagnostic interview for social and communication disorders (DISCO) may also be used.[92]
A pediatrician commonly performs a preliminary investigation by taking developmental history and physically examining the child. If warranted, diagnosis and evaluations are conducted with help from ASD specialists, observing and assessing cognitive, communication, family, and other factors using standardized tools, and taking into account any associated medical conditions.[93] A pediatric neuropsychologist is often asked to assess behavior and cognitive skills, both to aid diagnosis and to help recommend educational interventions.[94] A differential diagnosis for ASD at this stage might also consider intellectual disability, hearing impairment, and a specific language impairment[93] such as Landau–Kleffner syndrome.[95] The presence of autism can make it harder to diagnose coexisting psychiatric disorders such as depression.[96]
Clinical genetics evaluations are often done once ASD is diagnosed, particularly when other symptoms already suggest a genetic cause.[97] Although genetic technology allows clinical geneticists to link an estimated 40% of cases to genetic causes,[98] consensus guidelines in the US and UK are limited to high-resolution chromosome and fragile X testing.[97] A genotype-first model of diagnosis has been proposed, which would routinely assess the genome's copy number variations.[99] As new genetic tests are developed several ethical, legal, and social issues will emerge. Commercial availability of tests may precede adequate understanding of how to use test results, given the complexity of autism's genetics.[100] Metabolic and neuroimaging tests are sometimes helpful, but are not routine.[97]
ASD can sometimes be diagnosed by age 14 months, although diagnosis becomes increasingly stable over the first three years of life: for example, a one-year-old who meets diagnostic criteria for ASD is less likely than a three-year-old to continue to do so a few years later.[1] In the UK the National Autism Plan for Children recommends at most 30 weeks from first concern to completed diagnosis and assessment, though few cases are handled that quickly in practice.[93] Although the symptoms of autism and ASD begin early in childhood, they are sometimes missed; years later, adults may seek diagnoses to help them or their friends and family understand themselves, to help their employers make adjustments, or in some locations to claim disability living allowances or other benefits. Girls are often diagnosed later than boys.[101]
Underdiagnosis and overdiagnosis are problems in marginal cases, and much of the recent increase in the number of reported ASD cases is likely due to changes in diagnostic practices. The increasing popularity of drug treatment options and the expansion of benefits has given providers incentives to diagnose ASD, resulting in some overdiagnosis of children with uncertain symptoms. Conversely, the cost of screening and diagnosis and the challenge of obtaining payment can inhibit or delay diagnosis.[102] It is particularly hard to diagnose autism among the visually impaired, partly because some of its diagnostic criteria depend on vision, and partly because autistic symptoms overlap with those of common blindness syndromes or blindisms.[103]
Classification
Autism is one of the five pervasive developmental disorders (PDD), which are characterized by widespread abnormalities of social interactions and communication, and severely restricted interests and highly repetitive behavior.[29] These symptoms do not imply sickness, fragility, or emotional disturbance.[32]
Of the five PDD forms, Asperger syndrome is closest to autism in signs and likely causes; Rett syndrome and childhood disintegrative disorder share several signs with autism, but may have unrelated causes; PDD not otherwise specified (PDD-NOS; also called atypical autism) is diagnosed when the criteria are not met for a more specific disorder.[104] Unlike with autism, people with Asperger syndrome have no substantial delay in language development.[105] The terminology of autism can be bewildering, with autism, Asperger syndrome and PDD-NOS often called the autism spectrum disorders (ASD)[7] or sometimes the autistic disorders,[106] whereas autism itself is often called autistic disorder, childhood autism, or infantile autism. In this article, autism refers to the classic autistic disorder; in clinical practice, though, autism, ASD, and PDD are often used interchangeably.[97] ASD, in turn, is a subset of the broader autism phenotype, which describes individuals who may not have ASD but do have autistic-like traits, such as avoiding eye contact.[107]
Autism can also be divided into syndromal and non-syndromal autism; the syndromal autism is associated with severe or profound intellectual disability or a congenital syndrome with physical symptoms, such as tuberous sclerosis.[108] Although individuals with Asperger syndrome tend to perform better cognitively than those with autism, the extent of the overlap between Asperger syndrome, HFA, and non-syndromal autism is unclear.[109]
Some studies have reported diagnoses of autism in children due to a loss of language or social skills, as opposed to a failure to make progress, typically from 15 to 30 months of age. The validity of this distinction remains controversial; it is possible that regressive autism is a specific subtype,[1][15][44][110] or that there is a continuum of behaviors between autism with and without regression.[111]
Research into causes has been hampered by the inability to identify biologically meaningful subgroups within the autistic population[112] and by the traditional boundaries between the disciplines of psychiatry, psychology, neurology and pediatrics.[113] Newer technologies such as fMRI and diffusion tensor imaging can help identify biologically relevant phenotypes (observable traits) that can be viewed on brain scans, to help further neurogenetic studies of autism;[114] one example is lowered activity in the fusiform face area of the brain, which is associated with impaired perception of people versus objects.[20] It has been proposed to classify autism using genetics as well as behavior.[115]
Spectrum
Autism has long been thought to cover a wide spectrum, ranging from individuals with severe impairments—who may be silent, developmentally disabled, and prone to frequent repetitive behavior such as hand flapping and rocking—to high functioning individuals who may have active but distinctly odd social approaches, narrowly focused interests, and verbose, pedantic communication.[116] Because the behavior spectrum is continuous, boundaries between diagnostic categories are necessarily somewhat arbitrary.[52] Sometimes the syndrome is divided into low-, medium- or high-functioning autism (LFA, MFA, and HFA), based on IQ thresholds.[117] Some people have called for an end to the terms "high-functioning" and "low-functioning" due to lack of nuance and the potential for a person's needs or abilities to be overlooked.[118][119]

Screening
About half of parents of children with ASD notice their child's unusual behaviors by age 18 months, and about four-fifths notice by age 24 months.[1] According to an article, failure to meet any of the following milestones "is an absolute indication to proceed with further evaluations. Delay in referral for such testing may delay early diagnosis and treatment and affect the long-term outcome".[33]
  • No response to name (or eye-to-eye gaze) by 6 months.[120]
  • No babbling by 12 months.
  • No gesturing (pointing, waving, etc.) by 12 months.
  • No single words by 16 months.
  • No two-word (spontaneous, not just echolalic) phrases by 24 months.
  • Loss of any language or social skills, at any age.
The United States Preventive Services Task Force in 2016 found it was unclear if screening was beneficial or harmful among children in whom there is no concerns.[121] The Japanese practice is to screen all children for ASD at 18 and 24 months, using autism-specific formal screening tests. In contrast, in the UK, children whose families or doctors recognize possible signs of autism are screened. It is not known which approach is more effective.[20] Screening tools include the Modified Checklist for Autism in Toddlers (M-CHAT), the Early Screening of Autistic Traits Questionnaire, and the First Year Inventory; initial data on M-CHAT and its predecessor, the Checklist for Autism in Toddlers (CHAT), on children aged 18–30 months suggests that it is best used in a clinical setting and that it has low sensitivity (many false-negatives) but good specificity (few false-positives).[1] It may be more accurate to precede these tests with a broadband screener that does not distinguish ASD from other developmental disorders.[122] Screening tools designed for one culture's norms for behaviors like eye contact may be inappropriate for a different culture.[123] Although genetic screening for autism is generally still impractical, it can be considered in some cases, such as children with neurological symptoms and dysmorphic features.[124]

Prevention
While infection with rubella during pregnancy causes fewer than 1% of cases of autism,[125] vaccination against rubella can prevent many of those cases.[126]

Management
Main article: Autism therapies
A three-year-old with autism points to fish in an aquarium, as part of an experiment on the effect of intensive shared-attention training on language development.[127]
The main goals when treating children with autism are to lessen associated deficits and family distress, and to increase quality of life and functional independence. In general, higher IQs are correlated with greater responsiveness to treatment and improved treatment outcomes.[128][129] No single treatment is best and treatment is typically tailored to the child's needs.[7] Families and the educational system are the main resources for treatment.[20] Services should be carried out by behavior analysts, special education teachers, speech pathologists, and licensed psychologists. Studies of interventions have methodological problems that prevent definitive conclusions about efficacy.[130] However, the development of evidence-based interventions has advanced in recent years.[128] Although many psychosocial interventions have some positive evidence, suggesting that some form of treatment is preferable to no treatment, the methodological quality of systematic reviews of these studies has generally been poor, their clinical results are mostly tentative, and there is little evidence for the relative effectiveness of treatment options.[131] Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, communication, and job skills,[7] and often improve functioning and decrease symptom severity and maladaptive behaviors;[132] claims that intervention by around age three years is crucial are not substantiated.[133] While medications have not been found to help with core symptoms, they may be used for associated symptoms, such as irritability, inattention, or repetitive behavior patterns.[10]
Education
Educational interventions often used include applied behavior analysis (ABA), developmental models, structured teaching, speech and language therapy, social skills therapy, and occupational therapy.[7] Among these approaches, interventions either treat autistic features comprehensively, or focalize treatment on a specific area of deficit.[128] The quality of research for early intensive behavioral intervention (EIBI)—a treatment procedure incorporating over thirty hours per week of the structured type of ABA that is carried out with very young children—is currently low, and more vigorous research designs with larger sample sizes are needed.[134] Two theoretical frameworks outlined for early childhood intervention include structured and naturalistic ABA interventions, and developmental social pragmatic models (DSP).[128] One interventional strategy utilizes a parent training model, which teaches parents how to implement various ABA and DSP techniques, allowing for parents to disseminate interventions themselves.[128] Various DSP programs have been developed to explicitly deliver intervention systems through at-home parent implementation. Despite the recent development of parent training models, these interventions have demonstrated effectiveness in numerous studies, being evaluated as a probable efficacious mode of treatment.[128]
Early, intensive ABA therapy has demonstrated effectiveness in enhancing communication and adaptive functioning in preschool children;[135] it is also well-established for improving the intellectual performance of that age group.[132][135] Similarly, a teacher-implemented intervention that utilizes a more naturalistic form of ABA combined with a developmental social pragmatic approach has been found to be beneficial in improving social-communication skills in young children, although there is less evidence in its treatment of global symptoms.[128] Neuropsychological reports are often poorly communicated to educators, resulting in a gap between what a report recommends and what education is provided.[94] It is not known whether treatment programs for children lead to significant improvements after the children grow up,[132] and the limited research on the effectiveness of adult residential programs shows mixed results.[136] The appropriateness of including children with varying severity of autism spectrum disorders in the general education population is a subject of current debate among educators and researchers.[137]
Medication
Medications may be used to treat ASD symptoms that interfere with integrating a child into home or school when behavioral treatment fails.[8] They may also be used for associated health problems, such as ADHD or anxiety.[8] More than half of US children diagnosed with ASD are prescribed psychoactive drugs or anticonvulsants, with the most common drug classes being antidepressants, stimulants, and antipsychotics.[11][12] The atypical antipsychotic drugs risperidone and aripiprazole are FDA-approved for treating associated aggressive and self-injurious behaviors.[10][32][138] However, their side effects must be weighed against their potential benefits, and people with autism may respond atypically.[10] Side effects, for example, may include weight gain, tiredness, drooling, and aggression.[10] SSRI antidepressants, such as fluoxetine and fluvoxamine, have been shown to be effective in reducing repetitive and ritualistic behaviors, while the stimulant medication methylphenidate is beneficial for some children with co-morbid inattentiveness or hyperactivity.[7] There is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD.[139] No known medication relieves autism's core symptoms of social and communication impairments.[140] Experiments in mice have reversed or reduced some symptoms related to autism by replacing or modulating gene function,[88][141] suggesting the possibility of targeting therapies to specific rare mutations known to cause autism.[87][142]


Society and culture
Main article: Societal and cultural aspects of autism
Autism awareness ribbon
An autistic culture has emerged, accompanied by the autistic rights and neurodiversity movements.[203][204][205] Events include World Autism Awareness Day, Autism Sunday, Autistic Pride Day, Autreat, and others.[206][207][208][209] Organizations dedicated to promoting awareness of autism include Autism Speaks, Autism National Committee, and Autism Society of America.[210] Social-science scholars study those with autism in hopes to learn more about "autism as a culture, transcultural comparisons... and research on social movements."[211] While most autistic individuals do not have savant skills, many have been successful in their fields.[212][213][214]
Autism rights movement
The autism rights movement is a social movement within the context of disability rights that emphasizes the concept of neurodiversity, viewing the autism spectrum as a result of natural variations in the human brain rather than a disorder to be cured.[205] The autism rights movement advocates for including greater acceptance of autistic behaviors; therapies that focus on coping skills rather than on imitating the behaviors of those without autism,[215] and the recognition of the autistic community as a minority group.[215][216] Autism rights or neurodiversity advocates believe that the autism spectrum is genetic and should be accepted as a natural expression of the human genome. This perspective is distinct from two other likewise distinct views: the medical perspective, that autism is caused by a genetic defect and should be addressed by targeting the autism gene(s), and fringe theories that autism is caused by environmental factors such as vaccines.[205] A common criticism against autistic activists is that the majority of them are "high-functioning" or have Asperger syndrome and do not represent the views of "low-functioning" autistic people.[216]
Employment
About half of autistics are unemployed, and one third of those with graduate degrees may be unemployed.[217] Among autistics who find work, most are employed in sheltered settings working for wages below the national minimum.[218] While employers state hiring concerns about productivity and supervision, experienced employers of autistics give positive reports of above average memory and detail orientation as well as a high regard for rules and procedure in autistic employees.[217] A majority of the economic burden of autism is caused by decreased earnings in the job market.[219] Some studies also find decreased earning among parents who care for autistic children.[220][221]

References
  1. ^ a b c d e f Landa RJ (2008). "Diagnosis of autism spectrum disorders in the first 3 years of life". Nat Clin Pract Neurol. 4 (3): 138–147. doi:10.1038/ncpneuro0731. PMID 18253102.
  2. ^ "Autism spectrum disorder - Symptoms and causes". Mayo Clinic. Retrieved 13 July 2019.
  3. ^ a b c "NIMH " Autism Spectrum Disorder". nimh.nih.gov. October 2016. Retrieved 20 April 2017.
  4. ^ a b c d e f Autism Spectrum Disorder, 299.00 (F84.0). In: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing; 2013.
  5. ^ a b Chaste P, Leboyer M (2012). "Autism risk factors: genes, environment, and gene-environment interactions". Dialogues in Clinical Neuroscience. 14 (3): 281–292. PMC 3513682. PMID 23226953.
  6. ^ Corcoran J, Walsh J (9 February 2006). Clinical Assessment and Diagnosis in Social Work Practice. Oxford University Press, New York. p. 72. ISBN 978-0-19-516830-3. LCCN 2005027740. OCLC 466433183.
  7. ^ a b c d e f g h i Myers SM, Johnson CP (November 2007). "Management of children with autism spectrum disorders". Pediatrics. 120 (5): 1162–1182. doi:10.1542/peds.2007-2362. PMID 17967921.
  8. ^ a b c d Sanchack KE, Thomas CA (December 2016). "Autism Spectrum Disorder: Primary Care Principles". American Family Physician. 94 (12): 972–979. PMID 28075089.
  9. ^ Sukhodolsky DG, Bloch MH, Panza KE, Reichow B (November 2013). "Cognitive-behavioral therapy for anxiety in children with high-functioning autism: a meta-analysis". Pediatrics. 132 (5): e1341-50. doi:10.1542/peds.2013-1193. PMC 3813396. PMID 24167175.
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  12. ^ a b Doyle CA, McDougle CJ (September 2012). "Pharmacologic treatments for the behavioral symptoms associated with autism spectrum disorders across the lifespan". Dialogues in Clinical Neuroscience. 14 (3): 263–279. PMC 3513681. PMID 23226952.
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