Autism, formally called autism spectrum disorder (ASD) or autism spectrum condition (ASC),[6] is a neurodevelopmental disorder characterized by deficits in social communication and social interaction, and repetitive or restricted patterns of behaviors, interests, or activities, which can include hyper- and hyporeactivity to sensory input. Autism is a spectrum disorder, meaning that it can manifest very differently in each person. For example, some are nonspeaking, while others have proficient spoken language. Because of this, there is wide variation in the support needs of people across the autism spectrum.
Based on combination of clinical observation of behavior and development and comprehensive diagnostic testing completed by a team of qualified professionals (including psychiatrists, clinical psychologists, neuropsychologists, pediatricians, and speech-language pathologists). For adults, the use of a patient's written and oral history of autistic traits becomes more important
There are many theories about what causes autism; it is highly heritable and mainly genetic, but many genes are involved, and environmental factors may also be relevant.[7] The syndrome frequently co-occurs with other conditions, including attention deficit hyperactivity disorder, epilepsy, and intellectual disability. Disagreements persist about what should be included as part of the diagnosis, whether there are meaningful subtypes of autism,[8] and the significance of autism-associated traits in the wider population.[9][10] The combination of broader criteria, increased awareness, and potentially increasing actual prevalence, has led to a trend of steadily increasing estimates of autism prevalence,[11] perpetuating the myth that it is caused by vaccines.[12]
Psychiatry has traditionally classified autism as a mental disorder, and the autism rights movement and a small but increasing number of researchers see autism as part of neurodiversity, the natural diversity in human thinking and experience, with strengths, differences, and weaknesses.[13] From this point of view, autistic people often still have a disability, but need to be accommodated rather than cured.[14][15] This perspective has led to significant controversy among those who are autistic and advocates, practitioners, and charities.[16][17] Some therapies for autism, such as applied behavior analysis, are controversial in the autism rights movement, with many considering them unhelpful and unethical.[18]
There is no known way to prevent or cure autism. Many forms of therapy, such as speech and occupational therapy, have been developed that may help autistic people. Some forms of therapy, such as applied behavior analysis, have been shown to improve certain symptoms of autism, such as socialization, communication, expressive language,[19] intellectual functioning, language development, and acquisition of daily living skills.[20] Intervention can require accommodations such as alternative modes of communication. The use of pharmaceutical medicine is usually focused on associated conditions such as epilepsy or certain symptoms.[21] Research indicates that autistic people are substantially more likely to be LGBT than the general population.[22] They are also significantly more likely to be non-theistic.[23]
Before the DSM-5 (2013) and ICD-11 (2022) diagnostic manuals were adopted, what is now called ASD was found under the diagnostic category pervasive developmental disorder. The previous system relied on a set of closely related and overlapping diagnoses such as Asperger syndrome and Kanner syndrome. This created unclear boundaries between the terms, so for the DSM-5 and ICD-11, a spectrum approach was taken. The new system is also more restrictive, meaning fewer people now qualify for diagnosis.[24]
The DSM-5 and ICD-11 use different categorization tools to define this spectrum. DSM-5 uses a "level" system, which ranks how in need of support the patient is,[25] while the ICD-11 system has two axes, intellectual impairment and language impairment,[26] as these are seen as the most crucial factors.
It is now known that autism is a highly variable neurodevelopmental disorder[27] that is generally thought to cover a broad and deep spectrum, manifesting very differently from one person to another. Some have high support needs, may be non-speaking, and experience developmental delays; this is more likely with other co-existing diagnoses. Others have relatively low support needs; they may have more typical speech-language and intellectual skills but atypical social/conversation skills, narrowly focused interests, and wordy, pedantic communication.[28] They may still require significant support in some areas of their lives. The spectrum model should not be understood as a continuum running from mild to severe, but instead means that autism can present very differently in each person.[29] How a person presents can depend on context, and may vary over time.[30]
While the DSM and ICD greatly influence each other, there are also differences. For example, Rett syndrome was included in ASD in the DSM-5, but in the ICD-11 it was excluded and placed in the chapter on Developmental Anomalies. The ICD and the DSM change over time, and there has been collaborative work toward a convergence of the two since 1980 (when DSM-III was published and ICD-9 was current), including more rigorous biological assessment—in place of historical experience—and a simplification of the classification system.[31][32][33][34]
Autism spectrum disorder is characterised by persistent deficits in the ability to initiate and to sustain reciprocal social interaction and social communication, and by a range of restricted, repetitive, and inflexible patterns of behaviour, interests or activities that are clearly atypical or excessive for the individual's age and sociocultural context. The onset of the disorder occurs during the developmental period, typically in early childhood, but symptoms may not become fully manifest until later, when social demands exceed limited capacities. Deficits are sufficiently severe to cause impairment in personal, family, social, educational, occupational or other important areas of functioning and are usually a pervasive feature of the individual's functioning observable in all settings, although they may vary according to social, educational, or other context. Individuals along the spectrum exhibit a full range of intellectual functioning and language abilities.
— ICD-11, chapter 6, section A02
ICD-11 was produced by professionals from 55 countries out of the 90 involved and is the most widely used reference worldwide.
DSM
The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), released in 2022, is the current version of the DSM. It is the predominant mental health diagnostic system used in the United States and Canada, and is often used in Anglophone countries.
Its fifth edition, DSM-5, released in May 2013, was the first to define ASD as a single diagnosis,[37] which is still the case in the DSM-5-TR.[38] ASD encompasses previous diagnoses, including the four traditional diagnoses of autism—classic Kanner syndrome, Asperger syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS)—and the range of diagnoses that included the word "autism".[39] Rather than distinguishing among these diagnoses, the DSM-5 and DSM-5-TR adopt a dimensional approach to diagnosing disorders that fall underneath the autism spectrum umbrella in one diagnostic category. Within this category, the DSM-5 and the DSM include a framework that differentiates each person by dimensions of symptom severity, as well as by associated features (i.e., the presence of other disorders or factors that likely contribute to the symptoms, other neurodevelopmental or mental disorders, intellectual disability, or language impairment).[38] The symptom domains are social communication and restricted, repetitive behaviors, with the option of a separate severity—the negative impact of the symptoms on the person—being specified for each domain, rather than an overall severity.[40] Before the DSM-5, the DSM separated social deficits and communication deficits into two domains.[41] Further, the DSM-5 changed to an onset age in the early developmental period, with a note that symptoms may manifest later when social demands exceed capabilities, rather than the previous, more restricted three years of age.[42] These changes remain in the DSM-5-TR.[38]
Common characteristics
Pre-diagnosis
For many autistic people, characteristics first appear during infancy or childhood and follow a steady course without remission (different developmental timelines are described in more detail below).[43] Autistic people may be severely impaired in some respects but average, or even superior, in others.[44][45][46]
Clinicians consider assessment for ASD when a patient shows:
regular difficulties in social interaction or communication
restricted or repetitive behaviors (often called "stimming")
resistance to changes or restricted interests
These features are typically assessed with the following, when appropriate:
problems in obtaining or sustaining employment or education
difficulties in initiating or sustaining social relationships
connections with mental health or learning disability services
a history of neurodevelopmental conditions (including learning disabilities and ADHD) or mental health conditions.[47][48]
There are many signs associated with autism; the presentation varies widely:[49][50]
Common signs for autistic spectrum disorder
avoidance of eye-contact
little or no babbling as an infant
not showing interest in indicated objects
delayed language skills (e.g. having a smaller vocabulary than peers or difficulty expressing themselves in words)
reduced interest in other children or caretakers, possibly with more interest in objects
difficulty playing reciprocal games (e.g. peek-a-boo)
hyper- or hypo-sensitivity to or unusual response to the smell, texture, sound, taste, or appearance of things
resistance to changes in routine
repetitive, limited, or otherwise unusual usage of toys (e.g. lining up toys)
The broader autism phenotype (BAP) describes people who may not have ASD but do have autistic traits, such as avoiding eye contact and stimming.[51]
Social and communication skills
In social contexts, autistic people may respond and behave differently than people without ASD.[52]
Impairments in social skills present many challenges for autistic people. Deficits in social skills may lead to problems with friendships, romantic relationships, daily living, and vocational success.[53] One study that examined the outcomes of autistic adults found that, compared to the general population, autistic people were less likely to be married, but it is unclear whether this was because of deficits in social skills, intellectual impairment, or another reason.[54] One factor is likely discrimination against autistic people, which is perpetuated by myths—for example, that they have no empathy.[55][56]
Until 2013, deficits in social function and communication were considered two separate symptom domains of autism.[57] The current social communication domain criteria for autism diagnosis require people to have deficits across three social skills: social-emotional reciprocity, nonverbal communication, and developing and sustaining relationships.[38]
A range of social-emotional reciprocity difficulties (a person's ability to naturally engage in social interactions) may be present. Autistic people may lack mutual sharing of interests; many autistic children prefer not to play or interact with others. They may lack awareness or understanding of other people's thoughts or feelings: a child may get too close to peers (entering their personal space) without noticing that this makes them uncomfortable. They may also engage in atypical behaviors to gain attention: a child may push a peer to gain attention before starting a conversation.[58]
Autistic people experience deficits in their ability to develop, maintain, and understand relationships, as well as difficulties adjusting behavior to fit social contexts.[60] ASD presents with impairments in pragmatic communication skills, such as difficulty initiating a conversation or failure to consider a listener's interests to sustain a conversation.[58][verification needed] The ability to be focused exclusively on one topic in communication is known as monotropism, and can be compared to "tunnel vision". It is common for autistic people to communicate strong interest in a specific topic, speaking in lesson-like monologues about their passion instead of enabling reciprocal communication.[61] What may look like self-involvement or indifference to others stems from a struggle to recognize or remember that other people have their own personalities, perspectives, and interests.[62][63] Another difference in pragmatic communication skills is that autistic people may not recognize the need to control the volume of their voice in different social settings; for example, they may speak loudly in libraries or movie theaters.[64]
Autistic people display atypical nonverbal behaviors or have difficulties with nonverbal communication. They may make infrequent eye contact: an autistic person may not make eye contact when called by name, or may avoid eye contact with an observer. Aversion of gaze can also be seen in anxiety disorders, but poor eye contact in autistic children is not due to shyness or anxiety; rather, it is overall diminished in quantity. Autistic people may struggle with both production and understanding of facial expressions. They often do not know how to recognize emotions from others' facial expressions, or may not respond with appropriate facial expressions. They may have trouble recognizing subtle expressions of emotion and identifying what various emotions mean for the conversation.[65][61] A defining feature is that autistic people have social impairments and often lack intuitions about others that many people take for granted. Temple Grandin, an autistic woman involved in autism activism, 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".[66] They may also not pick up on body language or social cues such as eye contact and facial expressions if they provide more information than the person can process at that time. They struggle with understanding the context and subtext of conversational or printed situations, and have trouble forming resulting conclusions about the content. This also results in a lack of social awareness and atypical language expression.[62] How facial expressions differ between those on the autism spectrum and neurotypical people is not clear.[67] Further, at least half of autistic children have unusual prosody.[64]
Autistic people may also experience difficulties with verbal communication. 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, autistic children have less frequent and less diverse babbling, consonants, words, and word combinations; their gestures are less often integrated with words. Autistic children are less likely to make requests or share experiences, and are more likely to simply repeat others' words (echolalia).[68]Joint attention seems to be necessary for functional speech, and deficits in joint attention seem to distinguish autistic infants.[69] For example, they may look at a pointing hand instead of the object to which the hand is pointing,[70][68] and they consistently fail to point at objects in order to comment on or share an experience.[69] Autistic children may have difficulty with imaginative play and with developing symbols into language.[68] Some autistic linguistic behaviors include repetitive or rigid language, and restricted interests in conversation. For example, a child might repeat words or insist on always talking about the same subject.[58] Echolalia may also be present in autistic people, for example by responding to a question by repeating the inquiry instead of answering.[61] Language impairment is also common in autistic children, but is not part of a diagnosis.[58] Many autistic children develop language skills at an uneven pace where they easily acquire some aspects of communication, while never fully developing others,[61] such as in some cases of hyperlexia. Some people remain completely nonverbal throughout their lives. The CDC estimated that around 40% of autistic children do not speak at all, although the accompanying levels of literacy and nonverbal communication skills vary.[71]
Restricted and repetitive behaviors
A young autistic boy who has arranged his toys in a row
ASD includes a wide variety of characteristics. Some of these include behavioral characteristics which widely range from slow development of social and learning skills to difficulties creating connections with other people. Autistic people may experience these challenges with forming connections due to anxiety or depression, which they are more likely to experience, and as a result isolate themselves.[72][medical citation needed]
Other behavioral characteristics include abnormal responses to sensations (such as sights, sounds, touch, taste and smell) and problems keeping a consistent speech rhythm. The latter problem influences social skills, leading to potential problems in understanding by communication partners. Autistic people's behavioral characteristics typically influence development, language, and social competence. Their behavioral characteristics can be observed as perceptual disturbances, disturbances of development rate, relating, speech and language, and motility.[73]
The second core symptom of autism spectrum is a pattern of restricted and repetitive behaviors, activities, and interests. In order to be diagnosed with ASD under the DSM-5-TR, a person must have at least two of the following behaviors:[38][74]
An older autistic boy arranging brads on a cork coaster.Repetitive behaviors – Repetitive behaviors such as rocking, hand flapping, finger flicking, head banging, or repeating phrases or sounds.[58] These behaviors may occur constantly or only when the person gets stressed, anxious or upset. These behaviors are also known as stimming.
Resistance to change – A strict adherence to routines such as eating certain foods in a specific order or taking the same path to school every day.[58] The person may become distressed if there is a change or disruption to their routine.
Restricted interests – An excessive interest in a particular activity, topic, or hobby, and devoting all their attention to it. For example, young children might completely focus on things that spin and ignore everything else. Older children might try to learn everything about a single topic, such as the weather or sports, and perseverate or talk about it constantly.[58]
Sensory reactivity – An unusual reaction to certain sensory inputs such as having a negative reaction to specific sounds or textures, being fascinated by lights or movements or having an apparent indifference to pain or heat.[75]
Autistic people can display many forms of repetitive or restricted behavior, which the Repetitive Behavior Scale-Revised (RBS-R) categorizes as follows.[76]
Stereotyped behaviors: Repetitive movements, such as hand flapping, head rolling, or body rocking.
Compulsive behaviors: Time-consuming behaviors intended to reduce anxiety, that a person feels compelled to perform repeatedly or according to rigid rules, such as placing objects in a specific order, checking things, or handwashing.
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.[76]
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-injurious behaviors (SIB) are relatively common in autistic people, and can include head-banging, self-cutting, self-biting, and hair-pulling.[77] Some of these can result in serious injury or death.[77] Following are theories about the cause of self-injurious behavior in children with developmental delay, including autistic children:[78]
Frequency and/or continuation of self-injurious behavior can be influenced by environmental factors (e.g. reward in return for halting self-injurious behavior). This theory does not apply to younger children with autism. There is some evidence that frequency of self-injurious behavior can be reduced by removing or modifying environmental factors that reinforce the behavior.[78]: 10–12
Higher rates of self-injury are also noted in socially isolated people with autism. Studies have shown that socialization skills are related factors to self-injurious behavior for people with autism.[79]
Self-injury could be a response to modulate pain perception when chronic pain or other health problems that cause pain are present.[78]: 12–13
An abnormal basal ganglia connectivity may predispose to self-injurious behavior.[78]: 13
The suicide rate for verbal autistics is nine times that of the general population.[80]
Other features
Autistic people may have symptoms that do not contribute to the official diagnosis, but that can affect the person or the family.[81]
Some people with ASD show unusual or notable abilities, ranging from splinter skills (such as the memorization of trivia) to rare talents in mathematics, music, or artistic reproduction, which in exceptional cases are considered a part of the savant syndrome.[82][83][84] One study describes how some people with ASD show superior skills in perception and attention relative to the general population.[85]Sensory abnormalities are found in over 90% of autistic people, and are considered core features by some.[86]
More generally, autistic people tend to show a "spiky skills profile", with strong abilities in some areas contrasting with much weaker abilities in others.[87]
Differences between the previously recognized disorders under the autism spectrum 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).[88] An estimated 60–80% of autistic people have motor signs that include poor muscle tone, poor motor planning, and toe walking;[86][89] deficits in motor coordination are pervasive across ASD and are greater in autism proper.[90][91]
Pathological demand avoidance can occur. People with this set of autistic symptoms are more likely to refuse to do what is asked or expected of them, even to activities they enjoy.
Unusual or atypical eating behavior occurs in about three-quarters of children with ASD, to the extent that it was formerly a diagnostic indicator.[81] Selectivity is the most common problem, although eating rituals and food refusal also occur.[92]
Exactly what causes autism remains unknown.[93][94][95][96] It was long mostly presumed that there is a common cause at the genetic, cognitive, and neural levels for the social and non-social components of ASD's symptoms, described as a triad in the classic autism criteria.[97] But it is increasingly suspected that autism is instead a complex disorder whose core aspects have distinct causes that often cooccur.[97][98] While it is unlikely that ASD has a single cause,[98] many risk factors identified in the research literature may contribute to ASD development. These include genetics, prenatal and perinatal factors (meaning factors during pregnancy or very early infancy), neuroanatomical abnormalities, and environmental factors. It is possible to identify general factors, but much more difficult to pinpoint specific ones. Given the current state of knowledge, prediction can only be of a global nature and therefore requires the use of general markers.[99]
Biological subgroups
Research into causes has been hampered by the inability to identify biologically meaningful subgroups within the autistic population[100] and by the traditional boundaries between the disciplines of psychiatry, psychology, neurology and pediatrics.[101] 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;[102] one example is lowered activity in the fusiform face area of the brain, which is associated with impaired perception of people versus objects.[103] It has been proposed to classify autism using genetics as well as behavior.[104] (For more, see Brett Abrahams.)
Autism spectrum disorder (ASD) can be classified into two categories: "syndromic autism" and "non-syndromic autism."
Syndromic autism refers to cases where ASD is one of the characteristics associated with a broader medical condition or syndrome, representing about 25% of ASD cases. The causes of syndromic autism are often known, and monogenic disorders account for approximately 5% of these cases.
Non-syndromic autism, also known as classic or idiopathic autism, represents the majority of cases, and its cause is typically polygenic and unknown.
Hundreds of different genes are implicated in susceptibility to developing autism,[105] most of which alter the brain structure in a similar way
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 multi-gene interactions of common genetic variants.[106][107] 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.[108] Many genes have been associated with autism through sequencing the genomes of affected people and their parents.[109] But 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 ASD have been shown to selectively cause ASD.[106] Numerous genes have been found, with only small effects attributable to any particular gene.[106] Most loci individually explain less than 1% of cases of autism.[110] As of 2018[update], it appeared that between 74% and 93% of ASD risk is heritable.[74] After an older child is diagnosed with ASD, 7% to 20% of subsequent children are likely to be as well.[74] If parents have one autistic child, they have a 2% to 8% chance of having a second child who is autistic. If the autistic child is an identical twin, the other will be affected 36% to 95% of the time. A fraternal twin is affected up to 31% of the time.[medical citation needed] The large number of autistic people with unaffected family members may result from spontaneous structural variation, such as deletions, duplications or inversions in genetic material during meiosis.[111][112] 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.[113][verification needed]
As of 2018[update], understanding of genetic risk factors had shifted from a focus on a few alleles to an understanding that genetic involvement in ASD is probably diffuse, depending on a large number of variants, some of which are common and have a small effect, and some of which are rare and have a large effect. The most common gene disrupted with large effect rare variants appeared to be CHD8, but less than 0.5% of autistic people have such a mutation. The gene CHD8 encodes the protein chromodomain helicase DNA binding protein 8, which is a chromatin regulator enzyme that is essential during fetal development, CHD8 is an ATP dependent enzyme.[114][115][116] The protein contains an Snf2 helicase domain that is responsible for the hydrolysis of ATP to ADP.[116] CHD8 encodes for a DNA helicase that function as a transcription repressor by remodeling chromatin structure by altering the position of nucleosomes. CHD8 negatively regulates Wnt signaling. Wnt signaling is important in the vertebrate early development and morphogenesis. It is believed that CHD8 also recruits the linker histone H1 and causes the repression of β-catenin and p53 target genes.[114] The importance of CHD8 can be observed in studies where CHD8-knockout mice died after 5.5 embryonic days because of widespread p53 induced apoptosis. Some studies have determined the role of CHD8 in autism spectrum disorder (ASD). CHD8 expression significantly increases during human mid-fetal development.[114] The chromatin remodeling activity and its interaction with transcriptional regulators have shown to play an important role in ASD aetiology.[115] The developing mammalian brain has a conserved CHD8 target regions that are associated with ASD risk genes.[117] The knockdown of CHD8 in human neural stem cells results in dysregulation of ASD risk genes that are targeted by CHD8.[118] Recently CD8 has been associated to the regulation of long non-coding RNAs (lncRNAs),[119] and the regulation of X chromosome inactivation (XCI) initiation, via regulation of Xist long non-coding RNA,[ambiguous] the master regulator of XCI,[ambiguous] though competitive binding to Xist regulatory regions.[120]
Some ASD is associated with clearly genetic conditions, like fragile X syndrome; however, only around 2% of autistic people have fragile X.[74] Hypotheses from evolutionary psychiatry suggest that these genes persist because they are linked to human inventiveness, intelligence or systemising.[121][122]
Current research suggests that genes that increase susceptibility to ASD are ones that control protein synthesis in neuronal cells in response to cell needs, activity and adhesion of neuronal cells, synapse formation and remodeling, and excitatory to inhibitory neurotransmitter balance. Therefore, although up to 1,000 different genes are thought to increase the risk of ASD, all of them eventually affect normal neural development and connectivity between different functional areas of the brain in a similar manner that is characteristic of an ASD brain. Some of these genes are known to modulate production of the GABA neurotransmitter, the nervous system's main inhibitory neurotransmitter. These GABA-related genes are under-expressed in an ASD brain. On the other hand, genes controlling expression of glial and immune cells in the brain, e.g. astrocytes and microglia, respectively, are over-expressed, which correlates with increased number of glial and immune cells found in postmortem ASD brains. Some genes under investigation in ASD pathophysiology are those that affect the mTOR signaling pathway, which supports cell growth and survival.[123]
All these genetic variants contribute to the development of the autistic spectrum, but it cannot be guaranteed that they are determinants for the development.[124]
ASD may be under-diagnosed in women and girls due to an assumption that it is primarily a male condition,[125] 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 hypothesis and the extreme male brain theory.[126][127][128]
Early life
Several prenatal and perinatal complications have been reported as possible risk factors for autism. These risk factors include maternal gestational diabetes, maternal and paternal age over 30, bleeding during pregnancy after the first trimester, use of certain prescription medication (e.g. valproate) during pregnancy, and meconium in the amniotic fluid. While research is not conclusive on the relation of these factors to autism, each of these factors has been identified more frequently in children with autism, compared to their siblings who do not have autism, and other typically developing youth.[129] While it is unclear if any single factors during the prenatal phase affect the risk of autism,[130] complications during pregnancy may be a risk.[130]
There are also studies being done to test whether certain types of regressive autism have an autoimmune basis.[131]
Maternal nutrition and inflammation during preconception and pregnancy influences fetal neurodevelopment. Intrauterine growth restriction is associated with ASD, in both term and preterm infants.[132] Maternal inflammatory and autoimmune diseases may damage fetal tissues, aggravating a genetic problem or damaging the nervous system.[133]
Two versions of the vaccine causation hypothesis were that autism results from brain damage caused by either the MMR vaccine itself, or by mercury used as a vaccine preservative.[147] No convincing scientific evidence supports these claims.[12] They are biologically implausible,[141] and further evidence continues to refute them, including the observation that the rate of autism continues to climb despite elimination of thimerosal from most routine vaccines given to children from birth to 6 years of age.[148][149][150][151][152]
A 2014 meta-analysis examined ten major studies on autism and vaccines involving 1.25 million children worldwide; it concluded that neither the vaccine preservative thimerosal (mercury), nor the MMR vaccine, which has never contained thimerosal,[153] lead to the development of ASDs.[154] Despite this, misplaced parental concern has led to lower rates of childhood immunizations, outbreaks of previously controlled childhood diseases in some countries, and the preventable deaths of several children.[155][156]
Etiological hypotheses
Several hypotheses have been presented that try to explain how and why autism develops by integrating known causes (genetic and environmental effects) and findings (neurobiological and somatic). Some are more comprehensive, such as the Pathogenetic Triad, which proposes and operationalizes three core features (an autistic personality, cognitive compensation, neuropathological burden) that interact to cause autism,[157] and the Intense World Theory, which explains autism through a hyper-active neurobiology that leads to an increased perception, attention, memory, and emotionality.[158] There are also simpler hypotheses that explain only individual parts of the neurobiology or phenotype of autism, such as mind-blindness (a decreased ability for theory of mind), the weak central coherence theory, or the extreme male brain and empathising–systemising theory.
Research exploring the evolutionary benefits of autism and associated genes has suggested that autistic people may have played a "unique role in technological spheres and understanding of natural systems" in the course of human development.[159][160] It has been suggested that it may have arisen as "a slight trade off for other traits that are seen as highly advantageous", providing "advantages in tool making and mechanical thinking", with speculation that the condition may "reveal itself to be the result of a balanced polymorphism, like sickle cell anemia, that is advantageous in a certain mixture of genes and disadvantageous in specific combinations".[161]
In 2011, a paper in Evolutionary Psychology proposed that autistic traits, including increased abilities for spatial intelligence, concentration and memory, could have been naturally selected to enable self-sufficient foraging in a more (although not completely) solitary environment, referred to as the "Solitary Forager Hypothesis".[162][163][164] A 2016 paper examines Asperger syndrome as "an alternative prosocial adaptive strategy" which may have developed as a result of the emergence of "collaborative morality" in the context of small-scale hunter-gathering, i.e. where "a positive social reputation for making a contribution to group wellbeing and survival" becomes more important than complex social understanding.[165]
Conversely, some multidisciplinary research suggests that recent human evolution may be a driving force in the rise of a number of medical conditions in recent human populations, including autism. Studies in evolutionary medicine indicate that as biological evolution becomes outpaced by cultural evolution, disorders linked to bodily dysfunction increase in prevalence due to a lack of contact with pathogens and negative environmental conditions that once widely affected ancestral populations. Because natural selection primarily favors reproduction over health and longevity, the lack of this impetus to adapt to certain harmful circumstances creates a tendency for genes in descendant populations to over-express themselves, which may cause a wide array of maladies, ranging from mental disorders to autoimmune diseases.[166]
Autism is correlated or comorbid with several personality traits/disorders.[103]Comorbidity may increase with age and may worsen the course of youth with ASDs and make intervention and treatment more difficult. Distinguishing between ASDs and other diagnoses can be challenging because the traits of ASDs often overlap with symptoms of other disorders, and the characteristics of ASDs make traditional diagnostic procedures difficult.[167][168]
Correlations
Research indicates that autistic people are significantly more likely to be LGBT than the general population.[22] There is tentative evidence that gender dysphoria occurs more frequently in autistic people.[169][170] A 2021 anonymized online survey of 16- to 90-year-olds revealed that autistic males are more likely to identify as bisexual, while autistic females are more likely to identify as homosexual.[171]
People on the autism spectrum are significantly more likely to be non-theistic than members of the general population.[23]
Comorbidities
The most common medical condition occurring in people with ASDs is seizure disorder or epilepsy, which occurs in 11–39% of autistic people.[172] The risk varies with age, cognitive level, and type of language disorder.[173]
Tuberous sclerosis, an autosomal dominant genetic condition in which non-malignant tumors grow in the brain and on other vital organs, is present in 1–4% of people with ASDs.[174]
Intellectual disabilities are some of the most common comorbid disorders with ASDs. As diagnosis is increasingly being given to people with higher functioning autism, there is a tendency for the proportion with comorbid intellectual disability to decrease over time. In a 2019 study, it was estimated that approximately 30-40% of people diagnosed with ASD also have intellectual disability.[175] Recent research has suggested that autistic people with intellectual disability tend to have rarer, more harmful, genetic mutations than those found in people solely diagnosed with autism.[176] A number of genetic syndromes causing intellectual disability may also be comorbid with ASD, including fragile X, Down, Prader-Willi, Angelman, Williams syndrome,[177]branched-chain keto acid dehydrogenase kinase deficiency,[178][179] and SYNGAP1-related intellectual disability.[180][181]
Learning disabilities are also highly comorbid in people with an ASD. Approximately 25–75% of people with an ASD also have some degree of a learning disability.[182]
Various anxiety disorders tend to co-occur with ASDs, with overall comorbidity rates of 7–84%.[183] They are common among children with ASD; there are no firm data, but studies have reported prevalences ranging from 11% to 84%. Many anxiety disorders have symptoms that are better explained by ASD itself, or are hard to distinguish from ASD's symptoms.[184]
Rates of comorbid depression in people with an ASD range from 4–58%.[185]
The relationship between ASD and schizophrenia remains a controversial subject under continued investigation, and recent meta-analyses have examined genetic, environmental, infectious, and immune risk factors that may be shared between the two conditions.[186][187][188]Oxidative stress, DNA damage and DNA repair have been postulated to play a role in the aetiopathology of both ASD and schizophrenia.[189]
Deficits in ASD are often linked to behavior problems, such as difficulties following directions, being cooperative, and doing things on other people's terms.[190] Symptoms similar to those of attention deficit hyperactivity disorder (ADHD) can be part of an ASD diagnosis.[191]
Starting in adolescence, some people with Asperger syndrome (26% in one sample)[193] fall under the criteria for the similar condition schizoid personality disorder, which is characterized by a lack of interest in social relationships, a tendency towards a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment and apathy.[193][194][195] Asperger syndrome was traditionally called "schizoid disorder of childhood."
Gastrointestinal problems are one of the most commonly co-occurring medical conditions in autistic people.[198] These are linked to greater social impairment, irritability, language impairments, mood changes, and behavior and sleep problems.[198][199][200] A 2015 review proposed that immune, gastrointestinal inflammation, malfunction of the autonomic nervous system, gut flora alterations, and food metabolites may cause brain neuroinflammation and dysfunction.[199] 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.[200]
Sleep problems affect about two-thirds of people with ASD at some point in childhood. These most commonly include symptoms of insomnia, such as difficulty falling asleep, frequent nocturnal awakenings, and early morning awakenings. Sleep problems are associated with difficult behaviors and family stress, and are often a focus of clinical attention over and above the primary ASD diagnosis.[201]
There is no treatment as such for autism,[202] and many sources advise that this is not an appropriate goal,[203][204] although treatment of co-occurring conditions remains an important goal.[205] There is no cure for autism as of 2023, nor can any of the known treatments significantly reduce brain mutations caused by autism, although those who require little to no support are more likely to experience a lessening of symptoms over time.[206][207][208] Several interventions can help children with autism,[209] and no single treatment is best, with treatment typically tailored to the child's needs.[210] Studies of interventions have methodological problems that prevent definitive conclusions about efficacy,[211] but the development of evidence-based interventions has advanced.[212]
The main goals of treatment 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.[213][214] Behavioral, psychological, education, and/or skill-building interventions may be used to assist autistic people to learn life skills necessary for living independently,[215] as well as other social, communication, and language skills. Therapy also aims to reduce challenging behaviors and build upon strengths.[216]
Intensive, sustained special education programs and behavior therapy early in life may help children acquire self-care, language, and job skills.[210] Although evidence-based interventions for autistic children vary in their methods, many adopt a psychoeducational approach to enhancing cognitive, communication, and social skills while minimizing problem behaviors. 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.[217]
Non-pharmacological interventions
Intensive, sustained special education or remedial education programs and behavior therapy early in life may help children acquire self-care, social, and job skills. Available approaches include applied behavior analysis, developmental models, structured teaching, speech and language therapy, cognitive behavioral therapy,[218]social skills therapy, and occupational therapy.[219] Among these approaches, interventions either treat autistic features comprehensively, or focus treatment on a specific area of deficit.[214] Generally, when educating those with autism, specific tactics may be used to effectively relay information to these people. Using as much social interaction as possible is key in targeting the inhibition autistic people experience concerning person-to-person contact. Additionally, research has shown that employing semantic groupings, which involves assigning words to typical conceptual categories, can be beneficial in fostering learning.[220]
There has been increasing attention to the development of evidence-based interventions for autistic young children. Three theoretical frameworks outlined for early childhood intervention include applied behavior analysis (ABA), the developmental social-pragmatic model (DSP) and cognitive behavioral therapy (CBT).[218][214] Although ABA therapy has a strong evidence base, particularly in regard to early intensive home-based therapy, ABA's effectiveness may be limited by diagnostic severity and IQ of the person affected by ASD.[221] The Journal of Clinical Child and Adolescent Psychology has published a paper deeming two early childhood interventions "well-established": individual comprehensive ABA, and focused teacher-implemented ABA combined with DSP.[214]
Another evidence-based intervention that has demonstrated efficacy is a parent training model, which teaches parents how to implement various ABA and DSP techniques themselves.[214] Various DSP programs have been developed to explicitly deliver intervention systems through at-home parent implementation.
In October 2015, the American Academy of Pediatrics (AAP) proposed new evidence-based recommendations for early interventions in ASD for children under 3.[222] These recommendations emphasize early involvement with both developmental and behavioral methods, support by and for parents and caregivers, and a focus on both the core and associated symptoms of ASD.[222] However, a Cochrane review found no evidence that early intensive behavioral intervention (EIBI) is effective in reducing behavioral problems associated with autism in most autistic children but did help improve IQ and language skills.[223] The Cochrane review did acknowledge that this may be due to the low quality of studies currently available on EIBI and therefore providers should recommend EIBI based on their clinical judgement and the family's preferences.[223] No adverse effects of EIBI treatment were found.[223] A meta-analysis in that same database indicates that due to the degrees of severity in ASD, there is variable responses to differing early ABA interventions.[224]
Generally speaking, treatment of ASD focuses on behavioral and educational interventions to target its two core symptoms: social communication deficits and restricted, repetitive behaviors.[225] If symptoms continue after behavioral strategies have been implemented, some medications can be recommended to target specific symptoms or co-existing problems such as restricted and repetitive behaviors (RRBs), anxiety, depression, hyperactivity/inattention and sleep disturbance.[225]Melatonin, for example, can be used for sleep problems.[226]
While there are a number of parent-mediated behavioral therapies to target social communication deficits in children with autism, there is uncertainty regarding the efficacy of interventions to treat RRBs.[227]
Education
An autistic three-year-old points to fish in an aquarium, as part of an experiment on the effect of intensive shared-attention training on language development.[228]
Educational interventions often used include applied behavior analysis (ABA), developmental models, structured teaching, speech and language therapy and social skills therapy.[210] Among these approaches, interventions either treat autistic features comprehensively, or focalize treatment on a specific area of deficit.[212]
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 low; more vigorous research designs with larger sample sizes are needed.[223] Two theoretical frameworks outlined for early childhood intervention include structured and naturalistic ABA interventions, and developmental social pragmatic models (DSP).[212] 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.[212] 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.[212]Early, intensive ABA therapy has demonstrated effectiveness in enhancing communication and adaptive functioning in preschool children;[210] it is also well-established for improving the intellectual performance of that age group.[210]
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.[212] Neuropsychological reports are often poorly communicated to educators, resulting in a gap between what a report recommends and what education is provided.[229] 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.[230]
Pharmacological interventions
Medications may be used to treat ASD symptoms that interfere with integrating a child into home or school when behavioral treatment fails.[231] They may also be used for associated health problems, such as ADHD or anxiety.[231] However, their routine prescription for the core features of ASD is not recommended.[232] 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.[233][234] The atypical antipsychotic drugs risperidone and aripiprazole are FDA-approved for treating associated aggressive and self-injurious behaviors.[217][235] But their side effects must be weighed against their potential benefits, and autistic people may respond atypically.[217] Side effects may include weight gain, tiredness, drooling, and aggression.[217] There is some emerging data that show positive effects of aripiprazole and risperidone on restricted and repetitive behaviors (i.e., stimming; e.g., flapping, twisting, complex whole-body movements),[232] but due to the small sample size and different focus of these studies and the concerns about its side effects, antipsychotics are not recommended as primary treatment of RRBs.[236]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.[210] There is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD.[medical citation needed] No known medication relieves autism's core symptoms of social and communication impairments.[217]
Alternative medicine
A multitude of researched alternative therapies have also been implemented. Many have resulted in harm to autistic people.[219] A 2020 systematic review on adults with autism has provided emerging evidence for decreasing stress, anxiety, ruminating thoughts, anger, and aggression through mindfulness-based interventions for improving mental health.[237]
Although popularly used as an alternative treatment for autistic people, as of 2018[update] there is no good evidence to recommend a gluten- and casein-free diet as a standard treatment.[238][239][240] A 2018 review concluded that it may be a therapeutic option for specific groups of children with autism, such as those with known food intolerances or allergies, or with food intolerance markers. The authors analyzed the prospective trials conducted to date that studied the efficacy of the gluten- and casein-free diet in children with ASD (4 in total). All of them compared gluten- and casein-free diet versus normal diet with a control group (2 double-blind randomized controlled trials, 1 double-blind crossover trial, 1 single-blind trial). In two of the studies, whose duration was 12 and 24 months, a significant improvement in ASD symptoms (efficacy rate 50%) was identified. In the other two studies, whose duration was 3 months, no significant effect was observed.[238] The authors concluded that a longer duration of the diet may be necessary to achieve the improvement of the ASD symptoms.[238] Other problems documented in the trials carried out include transgressions of the diet, small sample size, the heterogeneity of the participants and the possibility of a placebo effect.[240][241][242] In the subset of people who have gluten sensitivity there is limited evidence that suggests that a gluten-free diet may improve some autistic behaviors.[243][244][245]
The preference that autistic children have for unconventional foods can lead to reduction in bone cortical thickness with this risk being greater in those on casein-free diets, as a consequence of the low intake of calcium and vitamin D; however, suboptimal bone development in ASD has also been associated with lack of exercise and gastrointestinal disorders.[246] In 2005, botched chelation therapy killed a five-year-old child with autism.[247][248] Chelation is not recommended for autistic people since the associated risks outweigh any potential benefits.[249] Another alternative medicine practice with no evidence is CEASE therapy, a pseudoscientific mixture of homeopathy, supplements, and "vaccine detoxing".[250]
Results of a systematic review on interventions to address health outcomes among autistic adults found emerging evidence to support mindfulness-based interventions for improving mental health. This includes decreasing stress, anxiety, ruminating thoughts, anger, and aggression.[251] An updated Cochrane review (2022) found evidence that music therapy likely improves social interactions, verbal communication, and nonverbal communication skills.[252] There has been early research on hyperbaric treatments in children with autism.[253] Studies on pet therapy have shown positive effects.[254]
There is no evidence of a cure for autism.[210][103] The degree of symptoms can decrease, occasionally to the extent that people lose their diagnosis of ASD;[257][258] this occurs sometimes after intensive treatment[259] and sometimes not. It is not known how often this outcome happens,[260] with reported rates in unselected samples ranging from 3% to 25%.[257][258] Although core difficulties tend to persist, symptoms often become less severe with age.[108] Acquiring language before age six, having an IQ above 50, and having a marketable skill all predict better outcomes; independent living is unlikely in autistic people with higher support needs.[261]
Reports of autism cases per 1,000 children rose considerably in the US from 1996 to 2007. It is unknown how much growth came from changes in rates of autism.
The World Health Organization (WHO) estimates about 1 in 100 children had autism during the period from 2012 to 2021 as that was the average estimate in studies published during that period with a trend of increasing prevalence over time. However, the study's 1% figure may reflect an underestimate of prevalence in low- and middle-income countries.[5][262] The number of people diagnosed has increased considerably since the 1990s, which may be partly due to increased recognition of the condition.[263]
While rates of ASD are consistent across cultures, they vary greatly by gender, with boys diagnosed far more frequently than girls: 1 in 70 boys, but only 1 in 315 girls at eight years of age.[264] Girls, however, are more likely to have associated cognitive impairment, suggesting that less severe forms of ASD are likely being missed in girls and women.[265] Prevalence differences may be a result of gender differences in expression of clinical symptoms, with women and girls with autism showing less atypical behaviors and, therefore, less likely to receive an ASD diagnosis.[266]
Using DSM-5 criteria, 92% of the children diagnosed per DSM-IV with one of the disorders which is now considered part of ASD will still meet the diagnostic criteria of ASD. However, if both ASD and the social (pragmatic) communication disorder categories of DSM-5 are combined, the prevalence of autism is mostly unchanged from the prevalence per the DSM-IV criteria. The best estimate for prevalence of ASD is 0.7% or 1 child in 143 children.[267] Relatively mild forms of autism, such as Asperger's as well as other developmental disorders, are included in the DSM-5 diagnostic criteria.[268] ASD rates were constant between 2014 and 2016 but twice the rate compared to the time period between 2011 and 2014 (1.25 vs 2.47%). A Canadian meta-analysis from 2019 confirmed these effects as the profiles of people diagnosed with autism became less and less different from the profiles of the general population.[269] In the US, the rates for diagnosed ASD have been steadily increasing since 2000 when records began being kept.[270] While it remains unclear whether this trend represents a true rise in incidence, it likely reflects changes in ASD diagnostic criteria, improved detection, and increased public awareness of autism.[271] In 2012, the NHS estimated that the overall prevalence of autism among adults aged 18 years and over in the UK was 1.1%.[272] A 2016 survey in the United States reported a rate of 25 per 1,000 children for ASD.[273] Rates of autism are poorly understood in many low- and middle-income countries, which affects the accuracy of global ASD prevalence estimates,[274] but it is thought that most autistic people live in low- and middle-income countries.[275]
In the UK, from 1998 to 2018, the autism diagnoses increased by 787%.[263] This increase is largely attributable to changes in diagnostic practices, referral patterns, availability of services, age at diagnosis, and public awareness[276][277][278] (particularly among women),[263] though unidentified environmental risk factors cannot be ruled out.[279] The available evidence does not rule out the possibility that autism's true prevalence has increased;[276] a real increase would suggest directing more attention and funding toward psychosocial factors and changing environmental factors instead of continuing to focus on genetics.[280] It has been established that vaccination is not a risk factor for autism and is not a cause of any increase in autism prevalence rates, if any change in the rate of autism exists at all.[154]
Males have higher likelihood of being diagnosed with ASD than females. The sex ratio averages 4.3:1 and is greatly modified by cognitive impairment: it may be close to 2:1 with intellectual disability and more than 5.5:1 without.[136]Several theories about the higher prevalence in males have been investigated, but the cause of the difference is unconfirmed;[281] one theory is that females are underdiagnosed.[282]
The risk of developing autism is greater with older fathers than with older mothers; two potential explanations are the known increase in mutation burden in older sperm, and the hypothesis that men marry later if they carry genetic liability and show some signs of autism.[27] Most professionals believe that race, ethnicity, and socioeconomic background do not affect the occurrence of autism.[283]
United States
As of 2020[update], CDC prevalence reports show that 1 in 36 children (approximately 4% of boys and 1% of girls) in the United States have a diagnosis of ASD.[284]
Social-science scholars study those with autism in hopes to learn more about "autism as a culture, transcultural comparisons ... and research on social movements."[295] Many autistic people have been successful in their fields.[296]
Neurodiversity movement
Some autistic people, as well as a growing number of researchers,[13] have advocated a shift in attitudes toward the view that autism spectrum disorder is a difference, rather than a disease that must be treated or cured.[297][298] Critics have bemoaned the entrenchment of some of these groups' opinions.[299][300][301][302]
The neurodiversity movement and the autism rights movement are social movements within the context of disability rights, emphasizing the concept of neurodiversity, which describes the autism spectrum as a result of natural variations in the human brain rather than a disorder to be cured.[287][80] The autism rights movement advocates for including greater acceptance of autistic behaviors; therapies that focus on coping skills rather than imitating the behaviors of those without autism;[303] and the recognition of the autistic community as a minority group.[303][304]
Autism rights or neurodiversity advocates believe that the autism spectrum is genetic and should be accepted as a natural variation in the human genome.[287] These movements are not without detractors; a common argument against neurodiversity activists is that most of them have relatively low support needs, or are self-diagnosed, and do not represent the views of autistic people with higher support needs.[304][305][306] Jacquiline den Houting explores this critique, determining that the voices of low-support needs autistics are "some of the most influential within the neurodiversity movement, although admittedly these voices are a minority within the advocacy community"; she suggests this is in part a shortcoming of the wider neurotypical community, referencing non-speaking self-advocate Amy Sequenzia's writing.[307][308][undue weight? – discuss] Pier Jaarsma and Stellan Welin make the argument that only high-functioning autists should be included under the neurodiversity banner, as including low-functioning autists within this concept is deemed problematic, because their condition may rightfully be viewed as a disability.[309] The concept of neurodiversity is contentious in autism advocacy and research groups and has led to infighting.[310][311]
Symbols and flags
Over the years, multiple organizations have tried to capture the essence of autism in symbols. In 1963, the board for the National Autistic Society, led by Gerald Gasson, proposed the "puzzle piece" as a symbol for autism, because it fit their view of autism as a "puzzling condition".[312] In 1999, the Autism Society adopted the puzzle ribbon as the universal sign of autism awareness.[312] In 2004, neurodiversity advocates Amy and Gwen Nelson conjured the "rainbow infinity symbol". It was initially the logo for their website, Aspies for Freedom. Nowadays, the prismatic colors are often associated with the neurodiversity movement in general.[313] The autistic spectrum has also been symbolized by the infinity symbol itself.[314] In 2018, Julian Morgan wrote the article "Light It Up Gold", a response to Autism Speaks's "Light It Up Blue" campaign, launched in 2007.[315][316]Aurum is Latin for gold,[313] and gold has been used to symbolize autism, since both words start with "Au". Though a consensus for a flag to unite autism and neurodiversity has not yet been established, one has gained traction on Reddit.[317] The flag implements a gradient to represent the Pride Movement and incorporates a golden infinity symbol as its focal point.[318] While flags are symbols of solidarity, they may trigger negative associations, such as apparent rivalry among two or more flags.[319] For this reason, flags are sought that can be tailored to the personal preferences of any neurotype.[320][321]
Families who care for an autistic child face added stress from a number of different causes.[70][322] Parents may struggle to understand the diagnosis and to find appropriate care options. They often take a negative view of the diagnosis, and may struggle emotionally.[323] More than half of parents over age 50 are still living with their child, as about 85% of autistic people have difficulties living independently.[324] Some studies also find decreased earnings among parents who care for autistic children.[325][326] Siblings of children with ASD report greater admiration and less conflict with the affected sibling than siblings of unaffected children, like siblings of children with Down syndrome. But they reported lower levels of closeness and intimacy than siblings of children with Down syndrome; siblings of people with ASD have a greater risk of negative well-being and poorer sibling relationships as adults.[327]
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autism, spectrum, autism, formally, called, autism, spectrum, disorder, autism, spectrum, condition, neurodevelopmental, disorder, characterized, deficits, social, communication, social, interaction, repetitive, restricted, patterns, behaviors, interests, acti. Autism formally called autism spectrum disorder ASD or autism spectrum condition ASC 6 is a neurodevelopmental disorder characterized by deficits in social communication and social interaction and repetitive or restricted patterns of behaviors interests or activities which can include hyper and hyporeactivity to sensory input Autism is a spectrum disorder meaning that it can manifest very differently in each person For example some are nonspeaking while others have proficient spoken language Because of this there is wide variation in the support needs of people across the autism spectrum AutismOther namesAutism spectrum condition ASC autism spectrum disorder ASD Formerly Kanner syndrome autistic disorder childhood autism Asperger syndrome AS childhood disintegrative disorder CDD pervasive developmental disorder not otherwise specified PDD NOS Repetitively stacking or lining up objects is a common trait associated with autism SpecialtyPsychiatry clinical psychology pediatrics occupational medicineSymptomsDifficulties in social interaction verbal and nonverbal communication and the presence of repetitive behavior or restricted interestsComplicationsSocial isolation educational and employment problems 1 anxiety 1 stress 1 bullying depression 2 1 self harmOnsetEarly childhoodDurationLifelongCausesMultifactorial with many uncertain factorsRisk factorsFamily history certain genetic conditions having older parents certain prescribed drugs perinatal and neonatal health issuesDiagnostic methodBased on combination of clinical observation of behavior and development and comprehensive diagnostic testing completed by a team of qualified professionals including psychiatrists clinical psychologists neuropsychologists pediatricians and speech language pathologists For adults the use of a patient s written and oral history of autistic traits becomes more importantDifferential diagnosisIntellectual disability anxiety bipolar disorder depression Rett syndrome attention deficit hyperactivity disorder schizoid personality disorder selective mutism schizophrenia obsessive compulsive disorder social anxiety disorder Einstein syndrome PTSD 3 learning disorders mainly speech disorders ManagementApplied behavior analysis cognitive behavioral therapy occupational therapy psychotropic medication 4 speech language pathologyFrequency1 in 100 children 1 worldwide 5 There are many theories about what causes autism it is highly heritable and mainly genetic but many genes are involved and environmental factors may also be relevant 7 The syndrome frequently co occurs with other conditions including attention deficit hyperactivity disorder epilepsy and intellectual disability Disagreements persist about what should be included as part of the diagnosis whether there are meaningful subtypes of autism 8 and the significance of autism associated traits in the wider population 9 10 The combination of broader criteria increased awareness and potentially increasing actual prevalence has led to a trend of steadily increasing estimates of autism prevalence 11 perpetuating the myth that it is caused by vaccines 12 Psychiatry has traditionally classified autism as a mental disorder and the autism rights movement and a small but increasing number of researchers see autism as part of neurodiversity the natural diversity in human thinking and experience with strengths differences and weaknesses 13 From this point of view autistic people often still have a disability but need to be accommodated rather than cured 14 15 This perspective has led to significant controversy among those who are autistic and advocates practitioners and charities 16 17 Some therapies for autism such as applied behavior analysis are controversial in the autism rights movement with many considering them unhelpful and unethical 18 There is no known way to prevent or cure autism Many forms of therapy such as speech and occupational therapy have been developed that may help autistic people Some forms of therapy such as applied behavior analysis have been shown to improve certain symptoms of autism such as socialization communication expressive language 19 intellectual functioning language development and acquisition of daily living skills 20 Intervention can require accommodations such as alternative modes of communication The use of pharmaceutical medicine is usually focused on associated conditions such as epilepsy or certain symptoms 21 Research indicates that autistic people are substantially more likely to be LGBT than the general population 22 They are also significantly more likely to be non theistic 23 Contents 1 Classification 1 1 Spectrum model 1 2 ICD 1 3 DSM 2 Common characteristics 2 1 Pre diagnosis 2 2 Broader autism phenotype 2 3 Social and communication skills 2 4 Restricted and repetitive behaviors 2 4 1 Self injury 2 5 Other features 3 Possible causes 3 1 Biological subgroups 3 1 1 Syndromic autism and non syndromic autism 3 2 Genetics 3 3 Early life 3 3 1 Disproven vaccine hypothesis 3 4 Etiological hypotheses 3 5 Evolutionary hypotheses 4 Pathophysiology 5 Diagnosis 6 Conditions correlated or comorbid to autism 6 1 Correlations 6 2 Comorbidities 7 Management 7 1 Non pharmacological interventions 7 1 1 Education 7 2 Pharmacological interventions 7 3 Alternative medicine 7 4 Prevention 8 Prognosis 9 Epidemiology 9 1 United States 10 History 11 Society and culture 11 1 Neurodiversity movement 11 2 Symbols and flags 11 3 Caregivers 12 See also 13 References 13 1 Sources 14 Further readingClassificationSpectrum model Before the DSM 5 2013 and ICD 11 2022 diagnostic manuals were adopted what is now called ASD was found under the diagnostic category pervasive developmental disorder The previous system relied on a set of closely related and overlapping diagnoses such as Asperger syndrome and Kanner syndrome This created unclear boundaries between the terms so for the DSM 5 and ICD 11 a spectrum approach was taken The new system is also more restrictive meaning fewer people now qualify for diagnosis 24 The DSM 5 and ICD 11 use different categorization tools to define this spectrum DSM 5 uses a level system which ranks how in need of support the patient is 25 while the ICD 11 system has two axes intellectual impairment and language impairment 26 as these are seen as the most crucial factors It is now known that autism is a highly variable neurodevelopmental disorder 27 that is generally thought to cover a broad and deep spectrum manifesting very differently from one person to another Some have high support needs may be non speaking and experience developmental delays this is more likely with other co existing diagnoses Others have relatively low support needs they may have more typical speech language and intellectual skills but atypical social conversation skills narrowly focused interests and wordy pedantic communication 28 They may still require significant support in some areas of their lives The spectrum model should not be understood as a continuum running from mild to severe but instead means that autism can present very differently in each person 29 How a person presents can depend on context and may vary over time 30 While the DSM and ICD greatly influence each other there are also differences For example Rett syndrome was included in ASD in the DSM 5 but in the ICD 11 it was excluded and placed in the chapter on Developmental Anomalies The ICD and the DSM change over time and there has been collaborative work toward a convergence of the two since 1980 when DSM III was published and ICD 9 was current including more rigorous biological assessment in place of historical experience and a simplification of the classification system 31 32 33 34 ICD The World Health Organization s International Classification of Diseases 11th Revision ICD 11 was released in June 2018 and came into full effect as of January 2022 35 31 It describes ASD as follows 36 Autism spectrum disorder is characterised by persistent deficits in the ability to initiate and to sustain reciprocal social interaction and social communication and by a range of restricted repetitive and inflexible patterns of behaviour interests or activities that are clearly atypical or excessive for the individual s age and sociocultural context The onset of the disorder occurs during the developmental period typically in early childhood but symptoms may not become fully manifest until later when social demands exceed limited capacities Deficits are sufficiently severe to cause impairment in personal family social educational occupational or other important areas of functioning and are usually a pervasive feature of the individual s functioning observable in all settings although they may vary according to social educational or other context Individuals along the spectrum exhibit a full range of intellectual functioning and language abilities ICD 11 chapter 6 section A02 ICD 11 was produced by professionals from 55 countries out of the 90 involved and is the most widely used reference worldwide DSM The American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision DSM 5 TR released in 2022 is the current version of the DSM It is the predominant mental health diagnostic system used in the United States and Canada and is often used in Anglophone countries Its fifth edition DSM 5 released in May 2013 was the first to define ASD as a single diagnosis 37 which is still the case in the DSM 5 TR 38 ASD encompasses previous diagnoses including the four traditional diagnoses of autism classic Kanner syndrome Asperger syndrome childhood disintegrative disorder and pervasive developmental disorder not otherwise specified PDD NOS and the range of diagnoses that included the word autism 39 Rather than distinguishing among these diagnoses the DSM 5 and DSM 5 TR adopt a dimensional approach to diagnosing disorders that fall underneath the autism spectrum umbrella in one diagnostic category Within this category the DSM 5 and the DSM include a framework that differentiates each person by dimensions of symptom severity as well as by associated features i e the presence of other disorders or factors that likely contribute to the symptoms other neurodevelopmental or mental disorders intellectual disability or language impairment 38 The symptom domains are social communication and restricted repetitive behaviors with the option of a separate severity the negative impact of the symptoms on the person being specified for each domain rather than an overall severity 40 Before the DSM 5 the DSM separated social deficits and communication deficits into two domains 41 Further the DSM 5 changed to an onset age in the early developmental period with a note that symptoms may manifest later when social demands exceed capabilities rather than the previous more restricted three years of age 42 These changes remain in the DSM 5 TR 38 Common characteristicsPre diagnosis For many autistic people characteristics first appear during infancy or childhood and follow a steady course without remission different developmental timelines are described in more detail below 43 Autistic people may be severely impaired in some respects but average or even superior in others 44 45 46 Clinicians consider assessment for ASD when a patient shows regular difficulties in social interaction or communication restricted or repetitive behaviors often called stimming resistance to changes or restricted interestsThese features are typically assessed with the following when appropriate problems in obtaining or sustaining employment or education difficulties in initiating or sustaining social relationships connections with mental health or learning disability services a history of neurodevelopmental conditions including learning disabilities and ADHD or mental health conditions 47 48 There are many signs associated with autism the presentation varies widely 49 50 Common signs for autistic spectrum disorderavoidance of eye contact little or no babbling as an infant not showing interest in indicated objects delayed language skills e g having a smaller vocabulary than peers or difficulty expressing themselves in words reduced interest in other children or caretakers possibly with more interest in objects difficulty playing reciprocal games e g peek a boo hyper or hypo sensitivity to or unusual response to the smell texture sound taste or appearance of things resistance to changes in routine repetitive limited or otherwise unusual usage of toys e g lining up toys repetition of words or phrases echolalia repetitive motions or movements including stimming self harmingBroader autism phenotype The broader autism phenotype BAP describes people who may not have ASD but do have autistic traits such as avoiding eye contact and stimming 51 Social and communication skills In social contexts autistic people may respond and behave differently than people without ASD 52 Impairments in social skills present many challenges for autistic people Deficits in social skills may lead to problems with friendships romantic relationships daily living and vocational success 53 One study that examined the outcomes of autistic adults found that compared to the general population autistic people were less likely to be married but it is unclear whether this was because of deficits in social skills intellectual impairment or another reason 54 One factor is likely discrimination against autistic people which is perpetuated by myths for example that they have no empathy 55 56 Until 2013 deficits in social function and communication were considered two separate symptom domains of autism 57 The current social communication domain criteria for autism diagnosis require people to have deficits across three social skills social emotional reciprocity nonverbal communication and developing and sustaining relationships 38 A range of social emotional reciprocity difficulties a person s ability to naturally engage in social interactions may be present Autistic people may lack mutual sharing of interests many autistic children prefer not to play or interact with others They may lack awareness or understanding of other people s thoughts or feelings a child may get too close to peers entering their personal space without noticing that this makes them uncomfortable They may also engage in atypical behaviors to gain attention a child may push a peer to gain attention before starting a conversation 58 Older autistic children and adults perform worse on tests of face and emotion recognition than non autistic people although this may be due to the prevalence of alexithymia in autistic people rather than autism itself 59 Autistic people experience deficits in their ability to develop maintain and understand relationships as well as difficulties adjusting behavior to fit social contexts 60 ASD presents with impairments in pragmatic communication skills such as difficulty initiating a conversation or failure to consider a listener s interests to sustain a conversation 58 verification needed The ability to be focused exclusively on one topic in communication is known as monotropism and can be compared to tunnel vision It is common for autistic people to communicate strong interest in a specific topic speaking in lesson like monologues about their passion instead of enabling reciprocal communication 61 What may look like self involvement or indifference to others stems from a struggle to recognize or remember that other people have their own personalities perspectives and interests 62 63 Another difference in pragmatic communication skills is that autistic people may not recognize the need to control the volume of their voice in different social settings for example they may speak loudly in libraries or movie theaters 64 Autistic people display atypical nonverbal behaviors or have difficulties with nonverbal communication They may make infrequent eye contact an autistic person may not make eye contact when called by name or may avoid eye contact with an observer Aversion of gaze can also be seen in anxiety disorders but poor eye contact in autistic children is not due to shyness or anxiety rather it is overall diminished in quantity Autistic people may struggle with both production and understanding of facial expressions They often do not know how to recognize emotions from others facial expressions or may not respond with appropriate facial expressions They may have trouble recognizing subtle expressions of emotion and identifying what various emotions mean for the conversation 65 61 A defining feature is that autistic people have social impairments and often lack intuitions about others that many people take for granted Temple Grandin an autistic woman involved in autism activism 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 66 They may also not pick up on body language or social cues such as eye contact and facial expressions if they provide more information than the person can process at that time They struggle with understanding the context and subtext of conversational or printed situations and have trouble forming resulting conclusions about the content This also results in a lack of social awareness and atypical language expression 62 How facial expressions differ between those on the autism spectrum and neurotypical people is not clear 67 Further at least half of autistic children have unusual prosody 64 Autistic people may also experience difficulties with verbal communication 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 autistic children have less frequent and less diverse babbling consonants words and word combinations their gestures are less often integrated with words Autistic children are less likely to make requests or share experiences and are more likely to simply repeat others words echolalia 68 Joint attention seems to be necessary for functional speech and deficits in joint attention seem to distinguish autistic infants 69 For example they may look at a pointing hand instead of the object to which the hand is pointing 70 68 and they consistently fail to point at objects in order to comment on or share an experience 69 Autistic children may have difficulty with imaginative play and with developing symbols into language 68 Some autistic linguistic behaviors include repetitive or rigid language and restricted interests in conversation For example a child might repeat words or insist on always talking about the same subject 58 Echolalia may also be present in autistic people for example by responding to a question by repeating the inquiry instead of answering 61 Language impairment is also common in autistic children but is not part of a diagnosis 58 Many autistic children develop language skills at an uneven pace where they easily acquire some aspects of communication while never fully developing others 61 such as in some cases of hyperlexia Some people remain completely nonverbal throughout their lives The CDC estimated that around 40 of autistic children do not speak at all although the accompanying levels of literacy and nonverbal communication skills vary 71 Restricted and repetitive behaviors A young autistic boy who has arranged his toys in a rowASD includes a wide variety of characteristics Some of these include behavioral characteristics which widely range from slow development of social and learning skills to difficulties creating connections with other people Autistic people may experience these challenges with forming connections due to anxiety or depression which they are more likely to experience and as a result isolate themselves 72 medical citation needed Other behavioral characteristics include abnormal responses to sensations such as sights sounds touch taste and smell and problems keeping a consistent speech rhythm The latter problem influences social skills leading to potential problems in understanding by communication partners Autistic people s behavioral characteristics typically influence development language and social competence Their behavioral characteristics can be observed as perceptual disturbances disturbances of development rate relating speech and language and motility 73 The second core symptom of autism spectrum is a pattern of restricted and repetitive behaviors activities and interests In order to be diagnosed with ASD under the DSM 5 TR a person must have at least two of the following behaviors 38 74 An older autistic boy arranging brads on a cork coaster Repetitive behaviors Repetitive behaviors such as rocking hand flapping finger flicking head banging or repeating phrases or sounds 58 These behaviors may occur constantly or only when the person gets stressed anxious or upset These behaviors are also known as stimming Resistance to change A strict adherence to routines such as eating certain foods in a specific order or taking the same path to school every day 58 The person may become distressed if there is a change or disruption to their routine Restricted interests An excessive interest in a particular activity topic or hobby and devoting all their attention to it For example young children might completely focus on things that spin and ignore everything else Older children might try to learn everything about a single topic such as the weather or sports and perseverate or talk about it constantly 58 Sensory reactivity An unusual reaction to certain sensory inputs such as having a negative reaction to specific sounds or textures being fascinated by lights or movements or having an apparent indifference to pain or heat 75 Autistic people can display many forms of repetitive or restricted behavior which the Repetitive Behavior Scale Revised RBS R categorizes as follows 76 Stereotyped behaviors Repetitive movements such as hand flapping head rolling or body rocking Compulsive behaviors Time consuming behaviors intended to reduce anxiety that a person feels compelled to perform repeatedly or according to rigid rules such as placing objects in a specific order checking things or handwashing 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 76 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 69 Self injury Self injurious behaviors SIB are relatively common in autistic people and can include head banging self cutting self biting and hair pulling 77 Some of these can result in serious injury or death 77 Following are theories about the cause of self injurious behavior in children with developmental delay including autistic children 78 Frequency and or continuation of self injurious behavior can be influenced by environmental factors e g reward in return for halting self injurious behavior This theory does not apply to younger children with autism There is some evidence that frequency of self injurious behavior can be reduced by removing or modifying environmental factors that reinforce the behavior 78 10 12 Higher rates of self injury are also noted in socially isolated people with autism Studies have shown that socialization skills are related factors to self injurious behavior for people with autism 79 Self injury could be a response to modulate pain perception when chronic pain or other health problems that cause pain are present 78 12 13 An abnormal basal ganglia connectivity may predispose to self injurious behavior 78 13 The suicide rate for verbal autistics is nine times that of the general population 80 Other features Autistic people may have symptoms that do not contribute to the official diagnosis but that can affect the person or the family 81 Some people with ASD show unusual or notable abilities ranging from splinter skills such as the memorization of trivia to rare talents in mathematics music or artistic reproduction which in exceptional cases are considered a part of the savant syndrome 82 83 84 One study describes how some people with ASD show superior skills in perception and attention relative to the general population 85 Sensory abnormalities are found in over 90 of autistic people and are considered core features by some 86 More generally autistic people tend to show a spiky skills profile with strong abilities in some areas contrasting with much weaker abilities in others 87 Differences between the previously recognized disorders under the autism spectrum 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 88 An estimated 60 80 of autistic people have motor signs that include poor muscle tone poor motor planning and toe walking 86 89 deficits in motor coordination are pervasive across ASD and are greater in autism proper 90 91 Pathological demand avoidance can occur People with this set of autistic symptoms are more likely to refuse to do what is asked or expected of them even to activities they enjoy Unusual or atypical eating behavior occurs in about three quarters of children with ASD to the extent that it was formerly a diagnostic indicator 81 Selectivity is the most common problem although eating rituals and food refusal also occur 92 Possible causesMain article Causes of autism Exactly what causes autism remains unknown 93 94 95 96 It was long mostly presumed that there is a common cause at the genetic cognitive and neural levels for the social and non social components of ASD s symptoms described as a triad in the classic autism criteria 97 But it is increasingly suspected that autism is instead a complex disorder whose core aspects have distinct causes that often cooccur 97 98 While it is unlikely that ASD has a single cause 98 many risk factors identified in the research literature may contribute to ASD development These include genetics prenatal and perinatal factors meaning factors during pregnancy or very early infancy neuroanatomical abnormalities and environmental factors It is possible to identify general factors but much more difficult to pinpoint specific ones Given the current state of knowledge prediction can only be of a global nature and therefore requires the use of general markers 99 Biological subgroups Research into causes has been hampered by the inability to identify biologically meaningful subgroups within the autistic population 100 and by the traditional boundaries between the disciplines of psychiatry psychology neurology and pediatrics 101 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 102 one example is lowered activity in the fusiform face area of the brain which is associated with impaired perception of people versus objects 103 It has been proposed to classify autism using genetics as well as behavior 104 For more see Brett Abrahams Syndromic autism and non syndromic autism Main article Syndromic autism Autism spectrum disorder ASD can be classified into two categories syndromic autism and non syndromic autism Syndromic autism refers to cases where ASD is one of the characteristics associated with a broader medical condition or syndrome representing about 25 of ASD cases The causes of syndromic autism are often known and monogenic disorders account for approximately 5 of these cases Non syndromic autism also known as classic or idiopathic autism represents the majority of cases and its cause is typically polygenic and unknown Genetics Main article Heritability of autism See also Missing heritability problem Hundreds of different genes are implicated in susceptibility to developing autism 105 most of which alter the brain structure in a similar wayAutism 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 multi gene interactions of common genetic variants 106 107 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 108 Many genes have been associated with autism through sequencing the genomes of affected people and their parents 109 But 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 ASD have been shown to selectively cause ASD 106 Numerous genes have been found with only small effects attributable to any particular gene 106 Most loci individually explain less than 1 of cases of autism 110 As of 2018 update it appeared that between 74 and 93 of ASD risk is heritable 74 After an older child is diagnosed with ASD 7 to 20 of subsequent children are likely to be as well 74 If parents have one autistic child they have a 2 to 8 chance of having a second child who is autistic If the autistic child is an identical twin the other will be affected 36 to 95 of the time A fraternal twin is affected up to 31 of the time medical citation needed The large number of autistic people with unaffected family members may result from spontaneous structural variation such as deletions duplications or inversions in genetic material during meiosis 111 112 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 113 verification needed As of 2018 update understanding of genetic risk factors had shifted from a focus on a few alleles to an understanding that genetic involvement in ASD is probably diffuse depending on a large number of variants some of which are common and have a small effect and some of which are rare and have a large effect The most common gene disrupted with large effect rare variants appeared to be CHD8 but less than 0 5 of autistic people have such a mutation The gene CHD8 encodes the protein chromodomain helicase DNA binding protein 8 which is a chromatin regulator enzyme that is essential during fetal development CHD8 is an ATP dependent enzyme 114 115 116 The protein contains an Snf2 helicase domain that is responsible for the hydrolysis of ATP to ADP 116 CHD8 encodes for a DNA helicase that function as a transcription repressor by remodeling chromatin structure by altering the position of nucleosomes CHD8 negatively regulates Wnt signaling Wnt signaling is important in the vertebrate early development and morphogenesis It is believed that CHD8 also recruits the linker histone H1 and causes the repression of b catenin and p53 target genes 114 The importance of CHD8 can be observed in studies where CHD8 knockout mice died after 5 5 embryonic days because of widespread p53 induced apoptosis Some studies have determined the role of CHD8 in autism spectrum disorder ASD CHD8 expression significantly increases during human mid fetal development 114 The chromatin remodeling activity and its interaction with transcriptional regulators have shown to play an important role in ASD aetiology 115 The developing mammalian brain has a conserved CHD8 target regions that are associated with ASD risk genes 117 The knockdown of CHD8 in human neural stem cells results in dysregulation of ASD risk genes that are targeted by CHD8 118 Recently CD8 has been associated to the regulation of long non coding RNAs lncRNAs 119 and the regulation of X chromosome inactivation XCI initiation via regulation of Xist long non coding RNA ambiguous the master regulator of XCI ambiguous though competitive binding to Xist regulatory regions 120 Some ASD is associated with clearly genetic conditions like fragile X syndrome however only around 2 of autistic people have fragile X 74 Hypotheses from evolutionary psychiatry suggest that these genes persist because they are linked to human inventiveness intelligence or systemising 121 122 Current research suggests that genes that increase susceptibility to ASD are ones that control protein synthesis in neuronal cells in response to cell needs activity and adhesion of neuronal cells synapse formation and remodeling and excitatory to inhibitory neurotransmitter balance Therefore although up to 1 000 different genes are thought to increase the risk of ASD all of them eventually affect normal neural development and connectivity between different functional areas of the brain in a similar manner that is characteristic of an ASD brain Some of these genes are known to modulate production of the GABA neurotransmitter the nervous system s main inhibitory neurotransmitter These GABA related genes are under expressed in an ASD brain On the other hand genes controlling expression of glial and immune cells in the brain e g astrocytes and microglia respectively are over expressed which correlates with increased number of glial and immune cells found in postmortem ASD brains Some genes under investigation in ASD pathophysiology are those that affect the mTOR signaling pathway which supports cell growth and survival 123 All these genetic variants contribute to the development of the autistic spectrum but it cannot be guaranteed that they are determinants for the development 124 ASD may be under diagnosed in women and girls due to an assumption that it is primarily a male condition 125 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 hypothesis and the extreme male brain theory 126 127 128 Early life Several prenatal and perinatal complications have been reported as possible risk factors for autism These risk factors include maternal gestational diabetes maternal and paternal age over 30 bleeding during pregnancy after the first trimester use of certain prescription medication e g valproate during pregnancy and meconium in the amniotic fluid While research is not conclusive on the relation of these factors to autism each of these factors has been identified more frequently in children with autism compared to their siblings who do not have autism and other typically developing youth 129 While it is unclear if any single factors during the prenatal phase affect the risk of autism 130 complications during pregnancy may be a risk 130 There are also studies being done to test whether certain types of regressive autism have an autoimmune basis 131 Maternal nutrition and inflammation during preconception and pregnancy influences fetal neurodevelopment Intrauterine growth restriction is associated with ASD in both term and preterm infants 132 Maternal inflammatory and autoimmune diseases may damage fetal tissues aggravating a genetic problem or damaging the nervous system 133 Exposure to air pollution during child pregnancy especially heavy metals and particulates may increase the risk of autism 134 135 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 136 and prenatal stress Some such as the MMR vaccine have been completely disproven 137 138 139 140 Disproven vaccine hypothesis Main articles Vaccines and autism and MMR vaccine and autism Parents may first become aware of ASD symptoms in their child around the time of a routine vaccination This has led to unsupported and disproven theories blaming vaccine overload the vaccine preservative thiomersal or the MMR vaccine for causing autism spectrum disorder 141 In 1998 British physician and academic Andrew Wakefield led a fraudulent litigation funded study that suggested that the MMR vaccine may cause autism 142 143 144 145 146 Two versions of the vaccine causation hypothesis were that autism results from brain damage caused by either the MMR vaccine itself or by mercury used as a vaccine preservative 147 No convincing scientific evidence supports these claims 12 They are biologically implausible 141 and further evidence continues to refute them including the observation that the rate of autism continues to climb despite elimination of thimerosal from most routine vaccines given to children from birth to 6 years of age 148 149 150 151 152 A 2014 meta analysis examined ten major studies on autism and vaccines involving 1 25 million children worldwide it concluded that neither the vaccine preservative thimerosal mercury nor the MMR vaccine which has never contained thimerosal 153 lead to the development of ASDs 154 Despite this misplaced parental concern has led to lower rates of childhood immunizations outbreaks of previously controlled childhood diseases in some countries and the preventable deaths of several children 155 156 Etiological hypotheses Several hypotheses have been presented that try to explain how and why autism develops by integrating known causes genetic and environmental effects and findings neurobiological and somatic Some are more comprehensive such as the Pathogenetic Triad which proposes and operationalizes three core features an autistic personality cognitive compensation neuropathological burden that interact to cause autism 157 and the Intense World Theory which explains autism through a hyper active neurobiology that leads to an increased perception attention memory and emotionality 158 There are also simpler hypotheses that explain only individual parts of the neurobiology or phenotype of autism such as mind blindness a decreased ability for theory of mind the weak central coherence theory or the extreme male brain and empathising systemising theory Evolutionary hypotheses See also Evolutionary psychiatry and Evolutionary psychology Research exploring the evolutionary benefits of autism and associated genes has suggested that autistic people may have played a unique role in technological spheres and understanding of natural systems in the course of human development 159 160 It has been suggested that it may have arisen as a slight trade off for other traits that are seen as highly advantageous providing advantages in tool making and mechanical thinking with speculation that the condition may reveal itself to be the result of a balanced polymorphism like sickle cell anemia that is advantageous in a certain mixture of genes and disadvantageous in specific combinations 161 In 2011 a paper in Evolutionary Psychology proposed that autistic traits including increased abilities for spatial intelligence concentration and memory could have been naturally selected to enable self sufficient foraging in a more although not completely solitary environment referred to as the Solitary Forager Hypothesis 162 163 164 A 2016 paper examines Asperger syndrome as an alternative prosocial adaptive strategy which may have developed as a result of the emergence of collaborative morality in the context of small scale hunter gathering i e where a positive social reputation for making a contribution to group wellbeing and survival becomes more important than complex social understanding 165 Conversely some multidisciplinary research suggests that recent human evolution may be a driving force in the rise of a number of medical conditions in recent human populations including autism Studies in evolutionary medicine indicate that as biological evolution becomes outpaced by cultural evolution disorders linked to bodily dysfunction increase in prevalence due to a lack of contact with pathogens and negative environmental conditions that once widely affected ancestral populations Because natural selection primarily favors reproduction over health and longevity the lack of this impetus to adapt to certain harmful circumstances creates a tendency for genes in descendant populations to over express themselves which may cause a wide array of maladies ranging from mental disorders to autoimmune diseases 166 PathophysiologyMain articles Mechanism of autism and Pathophysiology of autismDiagnosisMain article Diagnosis of autismConditions correlated or comorbid to autismMain article Conditions comorbid to autism spectrum disorders An Autistic Pride flag at a Pride is a Protest march in June 2021 Autism is correlated or comorbid with several personality traits disorders 103 Comorbidity may increase with age and may worsen the course of youth with ASDs and make intervention and treatment more difficult Distinguishing between ASDs and other diagnoses can be challenging because the traits of ASDs often overlap with symptoms of other disorders and the characteristics of ASDs make traditional diagnostic procedures difficult 167 168 Correlations Research indicates that autistic people are significantly more likely to be LGBT than the general population 22 There is tentative evidence that gender dysphoria occurs more frequently in autistic people 169 170 A 2021 anonymized online survey of 16 to 90 year olds revealed that autistic males are more likely to identify as bisexual while autistic females are more likely to identify as homosexual 171 People on the autism spectrum are significantly more likely to be non theistic than members of the general population 23 Comorbidities The most common medical condition occurring in people with ASDs is seizure disorder or epilepsy which occurs in 11 39 of autistic people 172 The risk varies with age cognitive level and type of language disorder 173 Tuberous sclerosis an autosomal dominant genetic condition in which non malignant tumors grow in the brain and on other vital organs is present in 1 4 of people with ASDs 174 Intellectual disabilities are some of the most common comorbid disorders with ASDs As diagnosis is increasingly being given to people with higher functioning autism there is a tendency for the proportion with comorbid intellectual disability to decrease over time In a 2019 study it was estimated that approximately 30 40 of people diagnosed with ASD also have intellectual disability 175 Recent research has suggested that autistic people with intellectual disability tend to have rarer more harmful genetic mutations than those found in people solely diagnosed with autism 176 A number of genetic syndromes causing intellectual disability may also be comorbid with ASD including fragile X Down Prader Willi Angelman Williams syndrome 177 branched chain keto acid dehydrogenase kinase deficiency 178 179 and SYNGAP1 related intellectual disability 180 181 Learning disabilities are also highly comorbid in people with an ASD Approximately 25 75 of people with an ASD also have some degree of a learning disability 182 Various anxiety disorders tend to co occur with ASDs with overall comorbidity rates of 7 84 183 They are common among children with ASD there are no firm data but studies have reported prevalences ranging from 11 to 84 Many anxiety disorders have symptoms that are better explained by ASD itself or are hard to distinguish from ASD s symptoms 184 Rates of comorbid depression in people with an ASD range from 4 58 185 The relationship between ASD and schizophrenia remains a controversial subject under continued investigation and recent meta analyses have examined genetic environmental infectious and immune risk factors that may be shared between the two conditions 186 187 188 Oxidative stress DNA damage and DNA repair have been postulated to play a role in the aetiopathology of both ASD and schizophrenia 189 Deficits in ASD are often linked to behavior problems such as difficulties following directions being cooperative and doing things on other people s terms 190 Symptoms similar to those of attention deficit hyperactivity disorder ADHD can be part of an ASD diagnosis 191 Sensory processing disorder is also comorbid with ASD with comorbidity rates of 42 88 192 Starting in adolescence some people with Asperger syndrome 26 in one sample 193 fall under the criteria for the similar condition schizoid personality disorder which is characterized by a lack of interest in social relationships a tendency towards a solitary or sheltered lifestyle secretiveness emotional coldness detachment and apathy 193 194 195 Asperger syndrome was traditionally called schizoid disorder of childhood Genetic disorders about 10 15 of autism cases have an identifiable Mendelian single gene condition chromosome abnormality or other genetic syndromes 196 Several metabolic defects such as phenylketonuria are associated with autistic symptoms 197 verification needed Gastrointestinal problems are one of the most commonly co occurring medical conditions in autistic people 198 These are linked to greater social impairment irritability language impairments mood changes and behavior and sleep problems 198 199 200 A 2015 review proposed that immune gastrointestinal inflammation malfunction of the autonomic nervous system gut flora alterations and food metabolites may cause brain neuroinflammation and dysfunction 199 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 200 Sleep problems affect about two thirds of people with ASD at some point in childhood These most commonly include symptoms of insomnia such as difficulty falling asleep frequent nocturnal awakenings and early morning awakenings Sleep problems are associated with difficult behaviors and family stress and are often a focus of clinical attention over and above the primary ASD diagnosis 201 ManagementMain article Autism therapies There is no treatment as such for autism 202 and many sources advise that this is not an appropriate goal 203 204 although treatment of co occurring conditions remains an important goal 205 There is no cure for autism as of 2023 nor can any of the known treatments significantly reduce brain mutations caused by autism although those who require little to no support are more likely to experience a lessening of symptoms over time 206 207 208 Several interventions can help children with autism 209 and no single treatment is best with treatment typically tailored to the child s needs 210 Studies of interventions have methodological problems that prevent definitive conclusions about efficacy 211 but the development of evidence based interventions has advanced 212 The main goals of treatment 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 213 214 Behavioral psychological education and or skill building interventions may be used to assist autistic people to learn life skills necessary for living independently 215 as well as other social communication and language skills Therapy also aims to reduce challenging behaviors and build upon strengths 216 Intensive sustained special education programs and behavior therapy early in life may help children acquire self care language and job skills 210 Although evidence based interventions for autistic children vary in their methods many adopt a psychoeducational approach to enhancing cognitive communication and social skills while minimizing problem behaviors 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 217 Non pharmacological interventions Intensive sustained special education or remedial education programs and behavior therapy early in life may help children acquire self care social and job skills Available approaches include applied behavior analysis developmental models structured teaching speech and language therapy cognitive behavioral therapy 218 social skills therapy and occupational therapy 219 Among these approaches interventions either treat autistic features comprehensively or focus treatment on a specific area of deficit 214 Generally when educating those with autism specific tactics may be used to effectively relay information to these people Using as much social interaction as possible is key in targeting the inhibition autistic people experience concerning person to person contact Additionally research has shown that employing semantic groupings which involves assigning words to typical conceptual categories can be beneficial in fostering learning 220 There has been increasing attention to the development of evidence based interventions for autistic young children Three theoretical frameworks outlined for early childhood intervention include applied behavior analysis ABA the developmental social pragmatic model DSP and cognitive behavioral therapy CBT 218 214 Although ABA therapy has a strong evidence base particularly in regard to early intensive home based therapy ABA s effectiveness may be limited by diagnostic severity and IQ of the person affected by ASD 221 The Journal of Clinical Child and Adolescent Psychology has published a paper deeming two early childhood interventions well established individual comprehensive ABA and focused teacher implemented ABA combined with DSP 214 Another evidence based intervention that has demonstrated efficacy is a parent training model which teaches parents how to implement various ABA and DSP techniques themselves 214 Various DSP programs have been developed to explicitly deliver intervention systems through at home parent implementation In October 2015 the American Academy of Pediatrics AAP proposed new evidence based recommendations for early interventions in ASD for children under 3 222 These recommendations emphasize early involvement with both developmental and behavioral methods support by and for parents and caregivers and a focus on both the core and associated symptoms of ASD 222 However a Cochrane review found no evidence that early intensive behavioral intervention EIBI is effective in reducing behavioral problems associated with autism in most autistic children but did help improve IQ and language skills 223 The Cochrane review did acknowledge that this may be due to the low quality of studies currently available on EIBI and therefore providers should recommend EIBI based on their clinical judgement and the family s preferences 223 No adverse effects of EIBI treatment were found 223 A meta analysis in that same database indicates that due to the degrees of severity in ASD there is variable responses to differing early ABA interventions 224 Generally speaking treatment of ASD focuses on behavioral and educational interventions to target its two core symptoms social communication deficits and restricted repetitive behaviors 225 If symptoms continue after behavioral strategies have been implemented some medications can be recommended to target specific symptoms or co existing problems such as restricted and repetitive behaviors RRBs anxiety depression hyperactivity inattention and sleep disturbance 225 Melatonin for example can be used for sleep problems 226 While there are a number of parent mediated behavioral therapies to target social communication deficits in children with autism there is uncertainty regarding the efficacy of interventions to treat RRBs 227 Education An autistic three year old points to fish in an aquarium as part of an experiment on the effect of intensive shared attention training on language development 228 Educational interventions often used include applied behavior analysis ABA developmental models structured teaching speech and language therapy and social skills therapy 210 Among these approaches interventions either treat autistic features comprehensively or focalize treatment on a specific area of deficit 212 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 low more vigorous research designs with larger sample sizes are needed 223 Two theoretical frameworks outlined for early childhood intervention include structured and naturalistic ABA interventions and developmental social pragmatic models DSP 212 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 212 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 212 Early intensive ABA therapy has demonstrated effectiveness in enhancing communication and adaptive functioning in preschool children 210 it is also well established for improving the intellectual performance of that age group 210 A 2018 Cochrane meta analysis database concludes how some recent research is beginning to suggest that because of the heterology of ASD there is two varying ABA teaching approaches to acquiring spoken language children with more general expressive language delays respond sufficiently to the naturalistic approach whereas children with receptive language delays require discrete trial training a structured and intensive form of ABA 224 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 212 Neuropsychological reports are often poorly communicated to educators resulting in a gap between what a report recommends and what education is provided 229 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 230 Pharmacological interventions Medications may be used to treat ASD symptoms that interfere with integrating a child into home or school when behavioral treatment fails 231 They may also be used for associated health problems such as ADHD or anxiety 231 However their routine prescription for the core features of ASD is not recommended 232 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 233 234 The atypical antipsychotic drugs risperidone and aripiprazole are FDA approved for treating associated aggressive and self injurious behaviors 217 235 But their side effects must be weighed against their potential benefits and autistic people may respond atypically 217 Side effects may include weight gain tiredness drooling and aggression 217 There is some emerging data that show positive effects of aripiprazole and risperidone on restricted and repetitive behaviors i e stimming e g flapping twisting complex whole body movements 232 but due to the small sample size and different focus of these studies and the concerns about its side effects antipsychotics are not recommended as primary treatment of RRBs 236 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 210 There is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD medical citation needed No known medication relieves autism s core symptoms of social and communication impairments 217 Alternative medicine A multitude of researched alternative therapies have also been implemented Many have resulted in harm to autistic people 219 A 2020 systematic review on adults with autism has provided emerging evidence for decreasing stress anxiety ruminating thoughts anger and aggression through mindfulness based interventions for improving mental health 237 Although popularly used as an alternative treatment for autistic people as of 2018 update there is no good evidence to recommend a gluten and casein free diet as a standard treatment 238 239 240 A 2018 review concluded that it may be a therapeutic option for specific groups of children with autism such as those with known food intolerances or allergies or with food intolerance markers The authors analyzed the prospective trials conducted to date that studied the efficacy of the gluten and casein free diet in children with ASD 4 in total All of them compared gluten and casein free diet versus normal diet with a control group 2 double blind randomized controlled trials 1 double blind crossover trial 1 single blind trial In two of the studies whose duration was 12 and 24 months a significant improvement in ASD symptoms efficacy rate 50 was identified In the other two studies whose duration was 3 months no significant effect was observed 238 The authors concluded that a longer duration of the diet may be necessary to achieve the improvement of the ASD symptoms 238 Other problems documented in the trials carried out include transgressions of the diet small sample size the heterogeneity of the participants and the possibility of a placebo effect 240 241 242 In the subset of people who have gluten sensitivity there is limited evidence that suggests that a gluten free diet may improve some autistic behaviors 243 244 245 The preference that autistic children have for unconventional foods can lead to reduction in bone cortical thickness with this risk being greater in those on casein free diets as a consequence of the low intake of calcium and vitamin D however suboptimal bone development in ASD has also been associated with lack of exercise and gastrointestinal disorders 246 In 2005 botched chelation therapy killed a five year old child with autism 247 248 Chelation is not recommended for autistic people since the associated risks outweigh any potential benefits 249 Another alternative medicine practice with no evidence is CEASE therapy a pseudoscientific mixture of homeopathy supplements and vaccine detoxing 250 Results of a systematic review on interventions to address health outcomes among autistic adults found emerging evidence to support mindfulness based interventions for improving mental health This includes decreasing stress anxiety ruminating thoughts anger and aggression 251 An updated Cochrane review 2022 found evidence that music therapy likely improves social interactions verbal communication and nonverbal communication skills 252 There has been early research on hyperbaric treatments in children with autism 253 Studies on pet therapy have shown positive effects 254 Prevention While infection with rubella during pregnancy causes fewer than 1 of cases of autism 255 vaccination against rubella can prevent many of those cases 256 PrognosisMain article Prognosis of autism There is no evidence of a cure for autism 210 103 The degree of symptoms can decrease occasionally to the extent that people lose their diagnosis of ASD 257 258 this occurs sometimes after intensive treatment 259 and sometimes not It is not known how often this outcome happens 260 with reported rates in unselected samples ranging from 3 to 25 257 258 Although core difficulties tend to persist symptoms often become less severe with age 108 Acquiring language before age six having an IQ above 50 and having a marketable skill all predict better outcomes independent living is unlikely in autistic people with higher support needs 261 The prognosis of autism describes the developmental course gradual autism development regressive autism development differential outcomes academic performance and employment EpidemiologyMain article Epidemiology of autism Reports of autism cases per 1 000 children rose considerably in the US from 1996 to 2007 It is unknown how much growth came from changes in rates of autism The World Health Organization WHO estimates about 1 in 100 children had autism during the period from 2012 to 2021 as that was the average estimate in studies published during that period with a trend of increasing prevalence over time However the study s 1 figure may reflect an underestimate of prevalence in low and middle income countries 5 262 The number of people diagnosed has increased considerably since the 1990s which may be partly due to increased recognition of the condition 263 While rates of ASD are consistent across cultures they vary greatly by gender with boys diagnosed far more frequently than girls 1 in 70 boys but only 1 in 315 girls at eight years of age 264 Girls however are more likely to have associated cognitive impairment suggesting that less severe forms of ASD are likely being missed in girls and women 265 Prevalence differences may be a result of gender differences in expression of clinical symptoms with women and girls with autism showing less atypical behaviors and therefore less likely to receive an ASD diagnosis 266 Using DSM 5 criteria 92 of the children diagnosed per DSM IV with one of the disorders which is now considered part of ASD will still meet the diagnostic criteria of ASD However if both ASD and the social pragmatic communication disorder categories of DSM 5 are combined the prevalence of autism is mostly unchanged from the prevalence per the DSM IV criteria The best estimate for prevalence of ASD is 0 7 or 1 child in 143 children 267 Relatively mild forms of autism such as Asperger s as well as other developmental disorders are included in the DSM 5 diagnostic criteria 268 ASD rates were constant between 2014 and 2016 but twice the rate compared to the time period between 2011 and 2014 1 25 vs 2 47 A Canadian meta analysis from 2019 confirmed these effects as the profiles of people diagnosed with autism became less and less different from the profiles of the general population 269 In the US the rates for diagnosed ASD have been steadily increasing since 2000 when records began being kept 270 While it remains unclear whether this trend represents a true rise in incidence it likely reflects changes in ASD diagnostic criteria improved detection and increased public awareness of autism 271 In 2012 the NHS estimated that the overall prevalence of autism among adults aged 18 years and over in the UK was 1 1 272 A 2016 survey in the United States reported a rate of 25 per 1 000 children for ASD 273 Rates of autism are poorly understood in many low and middle income countries which affects the accuracy of global ASD prevalence estimates 274 but it is thought that most autistic people live in low and middle income countries 275 In the UK from 1998 to 2018 the autism diagnoses increased by 787 263 This increase is largely attributable to changes in diagnostic practices referral patterns availability of services age at diagnosis and public awareness 276 277 278 particularly among women 263 though unidentified environmental risk factors cannot be ruled out 279 The available evidence does not rule out the possibility that autism s true prevalence has increased 276 a real increase would suggest directing more attention and funding toward psychosocial factors and changing environmental factors instead of continuing to focus on genetics 280 It has been established that vaccination is not a risk factor for autism and is not a cause of any increase in autism prevalence rates if any change in the rate of autism exists at all 154 Males have higher likelihood of being diagnosed with ASD than females The sex ratio averages 4 3 1 and is greatly modified by cognitive impairment it may be close to 2 1 with intellectual disability and more than 5 5 1 without 136 Several theories about the higher prevalence in males have been investigated but the cause of the difference is unconfirmed 281 one theory is that females are underdiagnosed 282 The risk of developing autism is greater with older fathers than with older mothers two potential explanations are the known increase in mutation burden in older sperm and the hypothesis that men marry later if they carry genetic liability and show some signs of autism 27 Most professionals believe that race ethnicity and socioeconomic background do not affect the occurrence of autism 283 United States As of 2020 update CDC prevalence reports show that 1 in 36 children approximately 4 of boys and 1 of girls in the United States have a diagnosis of ASD 284 HistoryMain article History of autismSociety and cultureMain article Societal and cultural aspects of autism An autistic culture has emerged accompanied by the autistic rights and neurodiversity movements that argues autism should be accepted as a difference to be accommodated instead of cured 285 286 287 288 289 although a minority of autistic people might still accept a cure 290 Worldwide events related to autism include World Autism Awareness Day Autism Sunday Autistic Pride Day Autreat and others 291 292 293 294 Social science scholars study those with autism in hopes to learn more about autism as a culture transcultural comparisons and research on social movements 295 Many autistic people have been successful in their fields 296 Neurodiversity movement Some autistic people as well as a growing number of researchers 13 have advocated a shift in attitudes toward the view that autism spectrum disorder is a difference rather than a disease that must be treated or cured 297 298 Critics have bemoaned the entrenchment of some of these groups opinions 299 300 301 302 The neurodiversity movement and the autism rights movement are social movements within the context of disability rights emphasizing the concept of neurodiversity which describes the autism spectrum as a result of natural variations in the human brain rather than a disorder to be cured 287 80 The autism rights movement advocates for including greater acceptance of autistic behaviors therapies that focus on coping skills rather than imitating the behaviors of those without autism 303 and the recognition of the autistic community as a minority group 303 304 Autism rights or neurodiversity advocates believe that the autism spectrum is genetic and should be accepted as a natural variation in the human genome 287 These movements are not without detractors a common argument against neurodiversity activists is that most of them have relatively low support needs or are self diagnosed and do not represent the views of autistic people with higher support needs 304 305 306 Jacquiline den Houting explores this critique determining that the voices of low support needs autistics are some of the most influential within the neurodiversity movement although admittedly these voices are a minority within the advocacy community she suggests this is in part a shortcoming of the wider neurotypical community referencing non speaking self advocate Amy Sequenzia s writing 307 308 undue weight discuss Pier Jaarsma and Stellan Welin make the argument that only high functioning autists should be included under the neurodiversity banner as including low functioning autists within this concept is deemed problematic because their condition may rightfully be viewed as a disability 309 The concept of neurodiversity is contentious in autism advocacy and research groups and has led to infighting 310 311 Symbols and flags Over the years multiple organizations have tried to capture the essence of autism in symbols In 1963 the board for the National Autistic Society led by Gerald Gasson proposed the puzzle piece as a symbol for autism because it fit their view of autism as a puzzling condition 312 In 1999 the Autism Society adopted the puzzle ribbon as the universal sign of autism awareness 312 In 2004 neurodiversity advocates Amy and Gwen Nelson conjured the rainbow infinity symbol It was initially the logo for their website Aspies for Freedom Nowadays the prismatic colors are often associated with the neurodiversity movement in general 313 The autistic spectrum has also been symbolized by the infinity symbol itself 314 In 2018 Julian Morgan wrote the article Light It Up Gold a response to Autism Speaks s Light It Up Blue campaign launched in 2007 315 316 Aurum is Latin for gold 313 and gold has been used to symbolize autism since both words start with Au Though a consensus for a flag to unite autism and neurodiversity has not yet been established one has gained traction on Reddit 317 The flag implements a gradient to represent the Pride Movement and incorporates a golden infinity symbol as its focal point 318 While flags are symbols of solidarity they may trigger negative associations such as apparent rivalry among two or more flags 319 For this reason flags are sought that can be tailored to the personal preferences of any neurotype 320 321 Autism infinity symbol Autistic pride flag The puzzle piece symbol as used in the autism awareness ribbon used by Autism SpeaksCaregivers Families who care for an autistic child face added stress from a number of different causes 70 322 Parents may struggle to understand the diagnosis and to find appropriate care options They often take a negative view of the diagnosis and may struggle emotionally 323 More than half of parents over age 50 are still living with their child as about 85 of autistic people have difficulties living independently 324 Some studies also find decreased earnings among parents who care for autistic children 325 326 Siblings of children with ASD report greater admiration and less conflict with the affected sibling than siblings of unaffected children like siblings of children with Down syndrome But they reported lower levels of closeness and intimacy than siblings of children with Down syndrome siblings of people with ASD have a greater risk of negative well being and poorer sibling relationships as adults 327 See alsoOutline of autism Animal model of autism Autism and memory Autism spectrum disorders in the media Autistic art Controversies in autism Global perceptions of autism List of autistic fictional characters List of films about autism Sex and gender differences in autism Violence and autismReferences a b c d Bonati M Cartabia M Clavenna A January 2022 Still too much delay in recognition of autism spectrum disorder Epidemiology and Psychiatric Sciences Cambridge University Press 31 e1 e1 doi 10 1017 S2045796021000822 LCCN 2011243374 OCLC 727338545 PMC 8786613 PMID 35012703 S2CID 245851335 Pezzimenti F Han G T Vasa R A Gotham K 2019 Depression in Youth with Autism Spectrum Disorder Child and Adolescent Psychiatric Clinics of North America 28 3 397 409 doi 10 1016 j chc 2019 02 009 PMC 6512853 PMID 31076116 At the 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149 Supplement 4 e2020049437J doi 10 1542 peds 2020 049437J ISSN 0031 4005 PMID 35363286 A substantial proportion of autistic adolescents and adults are LGBTQIA Autistic people are more likely to be transgender or gender nonconforming compared with non autistic people and findings from a recent autism registry study suggest that among autistic people able to self report on a survey up to 18 of men and 43 of women may be sexual minorities a b Norenzayan Ara Gervais Will M Trzesniewski Kali H 2012 Mentalizing deficits constrain belief in a personal God PLOS ONE 7 5 e36880 doi 10 1371 journal pone 0036880 ISSN 1932 6203 PMC 3364254 PMID 22666332 Why Asperger s Syndrome is no longer listed in the DSM Diagnostic Criteria Autism Spectrum Disorder ASD NCBDDD CDC 2 November 2022 ICD 11 for Mortality and Morbidity Statistics a b Geschwind DH October 2008 Autism many genes common pathways Cell 135 3 391 395 doi 10 1016 j cell 2008 10 016 PMC 2756410 PMID 18984147 Happe F 1999 Understanding 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cause has proven etiological in explaining most cases autism or has been able to account for rising rates of autism a href Template Cite book html title Template Cite book cite book a CS1 maint others link Sauer Ann Katrin Stanton Janelle E Hans Sakshi Grabrucker Andreas M 2021 Autism Spectrum Disorders Etiology and Pathology Written at Brisbane Australia In Grabrucker Andreas M ed Autism spectrum disorders Andreas M Grabrucker Brisbane Exon Publications published 20 August 2021 pp 1 16 doi 10 36255 exonpublications autismspectrumdisorders 2021 etiology ISBN 9780645001785 OCLC 1280592589 PMID 34495611 Archived from the original on 23 April 2023 Retrieved 23 April 2023 The cause of ASD is unknown but several genetic and non genetic risk factors have been characterized that alone or in combination are implicated in the development of ASD Kaluzna Czaplinska Joanna Zurawicz Ewa Jozwik Pruska Jagoda 2018 Focus on the Social Aspect of Autism Journal of Autism and Developmental Disorders 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