Autism is a developmental disorder characterized by troubles with
social interaction and communication, and by restricted and repetitive
behavior. Parents usually notice signs in the first two or three
years of their child's life. These signs often develop
gradually, though some children with autism reach their developmental
milestones at a normal pace and then worsen.
Autism is caused by a combination of genetic and environmental
factors. Risk factors include certain infections during pregnancy
such as rubella as well as valproic acid, alcohol or cocaine use
during pregnancy. Controversies surround other proposed
environmental causes, for example the vaccine hypotheses, which have
Autism affects information processing in the brain
by altering how nerve cells and their synapses connect and organize;
how this occurs is not well understood. In the DSM-5, autism is
included within the autism spectrum (ASDs), along with Asperger
syndrome, which is less severe, and pervasive developmental disorder
not otherwise specified (PDD-NOS).
Early speech or behavioral interventions can help children with autism
gain self-care, social and communication skills. Although there is
no known cure, there have been cases of children who have recovered
from the condition. Not many children with autism live
independently after reaching adulthood, though some are successful.
An autistic culture has developed, with some individuals seeking a
cure and others believing autism should be accepted as a difference
and not treated as a disorder.
Globally, autism is estimated to affect 24.8 million people as of
2015. In the 2000s, the number of people affected was estimated at
1–2 per 1,000 people worldwide. In the developed countries,
about 1.5% of children are diagnosed with ASD as of 2017[update],
a more than doubling from 1 in 150 in 2000 in the United States.
It occurs four to five times more often in boys than girls. The
number of people diagnosed has increased dramatically since the 1960s,
partly due to changes in diagnostic practice; the question of whether
actual rates have increased is unresolved.
1.1 Social development
1.3 Repetitive behavior
1.4 Other symptoms
7.3 Alternative medicine
8 Society and culture
11.1 Clinical development and diagnoses
11.2 Terminology and distinction from schizophrenia
13 External links
Autism is a highly variable neurodevelopmental disorder that first
appears during infancy or childhood, and generally follows a steady
course without remission. People with autism may be severely
impaired in some respects but normal, or even superior, in others.
Overt symptoms gradually begin after the age of six months, become
established by age two or three years and tend to continue through
adulthood, although often in more muted form. It is distinguished
not by a single symptom but by a characteristic triad of symptoms:
impairments in social interaction; impairments in communication; and
restricted interests and repetitive behavior. Other aspects, such as
atypical eating, are also common but are not essential for
diagnosis. Autism's individual symptoms occur in the general
population and appear not to associate highly, without a sharp line
separating pathologically severe from common traits.
Social deficits distinguish autism and the related autism spectrum
disorders (ASD; see Classification) from other developmental
disorders. People with autism have social impairments and often
lack the intuition about others that many people take for granted.
Temple Grandin described her inability to understand
the social communication of neurotypicals, or people with normal
neural development, as leaving her feeling "like an anthropologist on
Unusual social development becomes apparent early in childhood.
Autistic infants show less attention to social stimuli, smile and look
at others less often, and respond less to their own name. Autistic
toddlers differ more strikingly from social norms; for example, they
have less eye contact and turn-taking, and do not have the ability to
use simple movements to express themselves, such as pointing at
things. Three- to five-year-old children with autism are less
likely to exhibit social understanding, approach others spontaneously,
imitate and respond to emotions, communicate nonverbally, and take
turns with others. However, they do form attachments to their primary
caregivers. Most children with autism display moderately less
attachment security than neurotypical children, although this
difference disappears in children with higher mental development or
less severe ASD. Older children and adults with ASD perform worse
on tests of face and emotion recognition although this may be
partly due to a lower ability to define a person's own emotions.
Children with high-functioning autism suffer from more intense and
frequent loneliness compared to non-autistic peers, despite the common
belief that children with autism prefer to be alone. Making and
maintaining friendships often proves to be difficult for those with
autism. For them, the quality of friendships, not the number of
friends, predicts how lonely they feel. Functional friendships, such
as those resulting in invitations to parties, may affect the quality
of life more deeply.
There are many anecdotal reports, but few systematic studies, of
aggression and violence in individuals with ASD. The limited data
suggest that, in children with intellectual disability, autism is
associated with aggression, destruction of property, and tantrums.
About a third to a half of individuals with autism do not develop
enough natural speech to meet their daily communication needs.
Differences in communication may be present from the first year of
life, and may include delayed onset of babbling, unusual gestures,
diminished responsiveness, and vocal patterns that are not
synchronized with the caregiver. In the second and third years,
children with autism have less frequent and less diverse babbling,
consonants, words, and word combinations; their gestures are less
often integrated with words. Children with autism are less likely to
make requests or share experiences, and are more likely to simply
repeat others' words (echolalia) or reverse pronouns.
Joint attention seems to be necessary for functional speech, and
deficits in joint attention seem to distinguish infants with ASD:
for example, they may look at a pointing hand instead of the
pointed-at object, and they consistently fail to point at
objects in order to comment on or share an experience. Children
with autism may have difficulty with imaginative play and with
developing symbols into language.
In a pair of studies, high-functioning children with autism aged
8–15 performed equally well as, and as adults better than,
individually matched controls at basic language tasks involving
vocabulary and spelling. Both autistic groups performed worse than
controls at complex language tasks such as figurative language,
comprehension and inference. As people are often sized up initially
from their basic language skills, these studies suggest that people
speaking to autistic individuals are more likely to overestimate what
their audience comprehends.
A young boy with autism who has arranged his toys in a row
Autistic individuals can display many forms of repetitive or
restricted behavior, which the Repetitive
(RBS-R) categorizes as follows.
Stereotyped behaviors: Repetitive movements, such as hand flapping,
head rolling, or body rocking.
Compulsive behaviors: Time-consuming behaviors intended to reduce
anxiety that an individual feels compelled to perform repeatedly or
according to rigid rules, such as placing objects in a specific order,
checking things, or hand washing.
Sameness: Resistance to change; for example, insisting that the
furniture not be moved or refusing to be interrupted.
Ritualistic behavior: Unvarying pattern of daily activities, such as
an unchanging menu or a dressing ritual. This is closely associated
with sameness and an independent validation has suggested combining
the two factors.
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
No single repetitive or self-injurious behavior seems to be specific
to autism, but autism appears to have an elevated pattern of
occurrence and severity of these behaviors.
A girl with autism.
Autistic individuals may have symptoms that are independent of the
diagnosis, but that can affect the individual or the family. An
estimated 0.5% to 10% of individuals with ASD show unusual abilities,
ranging from splinter skills such as the memorization of trivia to the
extraordinarily rare talents of prodigious autistic savants. Many
individuals with ASD show superior skills in perception and attention,
relative to the general population. Sensory abnormalities are
found in over 90% of those with autism, and are considered core
features by some, although there is no good evidence that sensory
symptoms differentiate autism from other developmental disorders.
Differences are greater for under-responsivity (for example, walking
into things) than for over-responsivity (for example, distress from
loud noises) or for sensation seeking (for example, rhythmic
movements). An estimated 60%–80% of autistic people have motor
signs that include poor muscle tone, poor motor planning, and toe
walking; deficits in motor coordination are pervasive across ASD
and are greater in autism proper.
Unusual eating behavior occurs in about three-quarters of children
with ASD, to the extent that it was formerly a diagnostic indicator.
Selectivity is the most common problem, although eating rituals and
food refusal also occur; this does not appear to result in
malnutrition. Although some children with autism also have
gastrointestinal symptoms, there is a lack of published rigorous data
to support the theory that children with autism have more or different
gastrointestinal symptoms than usual; studies report conflicting
results, and the relationship between gastrointestinal problems and
ASD is unclear.
Parents of children with ASD have higher levels of stress.
Siblings of children with ASD report greater admiration of and less
conflict with the affected sibling than siblings of unaffected
children and were similar to siblings of children with Down syndrome
in these aspects of the sibling relationship. However, they reported
lower levels of closeness and intimacy than siblings of children with
Down syndrome; siblings of individuals with ASD have greater risk of
negative well-being and poorer sibling relationships as adults.
Main article: Causes of autism
It has long been presumed that there is a common cause at the genetic,
cognitive, and neural levels for autism's characteristic triad of
symptoms. However, there is increasing suspicion that autism is
instead a complex disorder whose core aspects have distinct causes
that often co-occur.
Deletion (1), duplication (2) and inversion (3) are all chromosome
abnormalities that have been implicated in autism.
Autism has a strong genetic basis, although the genetics of autism are
complex and it is unclear whether ASD is explained more by rare
mutations with major effects, or by rare multigene interactions of
common genetic variants. Complexity arises due to interactions
among multiple genes, the environment, and epigenetic factors which do
DNA sequencing but are heritable and influence gene
expression. Many genes have been associated with autism through
sequencing the genomes of affected individuals and their parents.
Studies of twins suggest that heritability is 0.7 for autism and as
high as 0.9 for ASD, and siblings of those with autism are about 25
times more likely to be autistic than the general population.
However, most of the mutations that increase autism risk have not been
identified. Typically, autism cannot be traced to a Mendelian
(single-gene) mutation or to a single chromosome abnormality, and none
of the genetic syndromes associated with ASDs have been shown to
selectively cause ASD. Numerous candidate genes have been located,
with only small effects attributable to any particular gene. Most
loci individually explain less than 1% of cases of autism. The
large number of autistic individuals with unaffected family members
may result from spontaneous structural variation — such as
deletions, duplications or inversions in genetic material during
meiosis. 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.
Several lines of evidence point to synaptic dysfunction as a cause of
autism. Some rare mutations may lead to autism by disrupting some
synaptic pathways, such as those involved with cell adhesion. Gene
replacement studies in mice suggest that autistic symptoms are closely
related to later developmental steps that depend on activity in
synapses and on activity-dependent changes. All known teratogens
(agents that cause birth defects) related to the risk of autism appear
to act during the first eight weeks from conception, and though this
does not exclude the possibility that autism can be initiated or
affected later, there is strong evidence that autism arises very early
Exposure to air pollution during pregnancy, especially heavy metals
and particulates, may increase the risk of autism. 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, and prenatal stress. Some such as the MMR vaccine
have been completely disproven.
Parents may first become aware of autistic symptoms in their child
around the time of a routine vaccination. This has led to unsupported
theories blaming vaccine "overload", a vaccine preservative, or the
MMR vaccine for causing autism. The latter theory was supported by
a litigation-funded study that has since been shown to have been "an
elaborate fraud". Although these theories lack convincing
scientific evidence and are biologically implausible, parental
concern about a potential vaccine link with autism has led to lower
rates of childhood immunizations, outbreaks of previously controlled
childhood diseases in some countries, and the preventable deaths of
Autism's symptoms result from maturation-related changes in various
systems of the brain. How autism occurs is not well understood. Its
mechanism can be divided into two areas: the pathophysiology of brain
structures and processes associated with autism, and the
neuropsychological linkages between brain structures and
behaviors. The behaviors appear to have multiple
Autism affects the amygdala, cerebellum, and many other parts of the
Unlike many other brain disorders, such as Parkinson's, autism does
not have a clear unifying mechanism at either the molecular, cellular,
or systems level; it is not known whether autism is a few disorders
caused by mutations converging on a few common molecular pathways, or
is (like intellectual disability) a large set of disorders with
Autism appears to result from developmental
factors that affect many or all functional brain systems, and to
disturb the timing of brain development more than the final
Neuroanatomical studies and the associations with
teratogens strongly suggest that autism's mechanism includes
alteration of brain development soon after conception. This
anomaly appears to start a cascade of pathological events in the brain
that are significantly influenced by environmental factors. Just
after birth, the brains of children with autism tend to grow faster
than usual, followed by normal or relatively slower growth in
childhood. It is not known whether early overgrowth occurs in all
children with autism. It seems to be most prominent in brain areas
underlying the development of higher cognitive specialization.
Hypotheses for the cellular and molecular bases of pathological early
overgrowth include the following:
An excess of neurons that causes local overconnectivity in key brain
Disturbed neuronal migration during early gestation.
Unbalanced excitatory–inhibitory networks.
Abnormal formation of synapses and dendritic spines, for example,
by modulation of the neurexin–neuroligin cell-adhesion system,
or by poorly regulated synthesis of synaptic proteins.
Disrupted synaptic development may also contribute to epilepsy, which
may explain why the two conditions are associated.
The immune system is thought to play an important role in autism.
Children with autism have been found by researchers to have
inflammation of both the peripheral and central immune systems as
indicated by increased levels of pro-inflammatory cytokines and
significant activation of microglia. Biomarkers of
abnormal immune function have also been associated with increased
impairments in behaviors that are characteristic of the core features
of autism such as deficits in social interactions and
communication. Interactions between the immune system and the
nervous system begin early during the embryonic stage of life, and
successful neurodevelopment depends on a balanced immune response. It
is thought that activation of a pregnant mother's immune system such
as from environmental toxicants or infection can contribute to causing
autism through causing a disruption of brain development.
This is supported by recent studies that have found that infection
during pregnancy is associated with an increased risk of
The relationship of neurochemicals to autism is not well understood;
several have been investigated, with the most evidence for the role of
serotonin and of genetic differences in its transport. The role of
group I metabotropic glutamate receptors (mGluR) in the pathogenesis
of fragile X syndrome, the most common identified genetic cause of
autism, has led to interest in the possible implications for future
autism research into this pathway. Some data suggests neuronal
overgrowth potentially related to an increase in several growth
hormones or to impaired regulation of growth factor receptors.
Also, some inborn errors of metabolism are associated with autism, but
probably account for less than 5% of cases.
The mirror neuron system (MNS) theory of autism hypothesizes that
distortion in the development of the MNS interferes with imitation and
leads to autism's core features of social impairment and communication
difficulties. The MNS operates when an animal performs an action or
observes another animal perform the same action. The MNS may
contribute to an individual's understanding of other people by
enabling the modeling of their behavior via embodied simulation of
their actions, intentions, and emotions. Several studies have
tested this hypothesis by demonstrating structural abnormalities in
MNS regions of individuals with ASD, delay in the activation in the
core circuit for imitation in individuals with Asperger syndrome, and
a correlation between reduced MNS activity and severity of the
syndrome in children with ASD. However, individuals with autism
also have abnormal brain activation in many circuits outside the
MNS and the MNS theory does not explain the normal performance of
children with autism on imitation tasks that involve a goal or
Autistic individuals tend to use different areas of the brain (yellow)
for a movement task compared to a control group (blue).
ASD-related patterns of low function and aberrant activation in the
brain differ depending on whether the brain is doing social or
nonsocial tasks. In autism there is evidence for reduced
functional connectivity of the default network, a large-scale brain
network involved in social and emotional processing, with intact
connectivity of the task-positive network, used in sustained attention
and goal-directed thinking[clarification needed]. In people with
autism the two networks are not negatively correlated in time,
suggesting an imbalance in toggling between the two networks, possibly
reflecting a disturbance of self-referential thought.
The underconnectivity theory of autism hypothesizes that autism is
marked by underfunctioning high-level neural connections and
synchronization, along with an excess of low-level processes.
Evidence for this theory has been found in functional neuroimaging
studies on autistic individuals and by a brainwave study that
suggested that adults with ASD have local overconnectivity in the
cortex and weak functional connections between the frontal lobe and
the rest of the cortex. Other evidence suggests the
underconnectivity is mainly within each hemisphere of the cortex and
that autism is a disorder of the association cortex.
From studies based on event-related potentials, transient changes to
the brain's electrical activity in response to stimuli, there is
considerable evidence for differences in autistic individuals with
respect to attention, orientation to auditory and visual stimuli,
novelty detection, language and face processing, and information
storage; several studies have found a preference for nonsocial
stimuli. For example, magnetoencephalography studies have found
evidence in children with autism of delayed responses in the brain's
processing of auditory signals.
In the genetic area, relations have been found between autism and
schizophrenia based on duplications and deletions of chromosomes;
research showed that schizophrenia and autism are significantly more
common in combination with 1q21.1 deletion syndrome. Research on
autism/schizophrenia relations for chromosome 15 (15q13.3), chromosome
16 (16p13.1) and chromosome 17 (17p12) are inconclusive.
Functional connectivity studies have found both hypo- and
hyper-connectivity in brains of people with autism. Hypo-connectivity
seems to dominate, especially for interhemispheric and
cortico-cortical functional connectivity.
Two major categories of cognitive theories have been proposed about
the links between autistic brains and behavior.
The first category focuses on deficits in social cognition. Simon
Baron-Cohen's empathizing–systemizing theory postulates that
autistic individuals can systemize—that is, they can develop
internal rules of operation to handle events inside the brain—but
are less effective at empathizing by handling events generated by
other agents. An extension, the extreme male brain theory,
hypothesizes that autism is an extreme case of the male brain, defined
psychometrically as individuals in whom systemizing is better than
empathizing. These theories are somewhat related to Baron-Cohen's
earlier theory of mind approach, which hypothesizes that autistic
behavior arises from an inability to ascribe mental states to oneself
and others. The theory of mind hypothesis is supported by the atypical
responses of children with autism to the
Sally–Anne test for
reasoning about others' motivations, and the mirror neuron system
theory of autism described in
Pathophysiology maps well to the
hypothesis. However, most studies have found no evidence of
impairment in autistic individuals' ability to understand other
people's basic intentions or goals; instead, data suggests that
impairments are found in understanding more complex social emotions or
in considering others' viewpoints.
The second category focuses on nonsocial or general processing: the
executive functions such as working memory, planning, inhibition. In
his review, Kenworthy states that "the claim of executive dysfunction
as a causal factor in autism is controversial", however, "it is clear
that executive dysfunction plays a role in the social and cognitive
deficits observed in individuals with autism". Tests of core
executive processes such as eye movement tasks indicate improvement
from late childhood to adolescence, but performance never reaches
typical adult levels. A strength of the theory is predicting
stereotyped behavior and narrow interests; two weaknesses are
that executive function is hard to measure and that executive
function deficits have not been found in young children with
Weak central coherence theory hypothesizes that a limited ability to
see the big picture underlies the central disturbance in autism. One
strength of this theory is predicting special talents and peaks in
performance in autistic people. A related theory—enhanced
perceptual functioning—focuses more on the superiority of locally
oriented and perceptual operations in autistic individuals. Yet
another, monotropism, posits that autism stems from a different
cognitive style, tending to focus attention (or processing resources)
intensely, to the exclusion of other stimuli. These theories map
well from the underconnectivity theory of autism.
Neither category is satisfactory on its own; social cognition theories
poorly address autism's rigid and repetitive behaviors, while the
nonsocial theories have difficulty explaining social impairment and
communication difficulties. A combined theory based on multiple
deficits may prove to be more useful.
Diagnosis is based on behavior, not cause or mechanism. Under
the DSM-5, autism is characterized by persistent deficits in social
communication and interaction across multiple contexts, as well as
restricted, repetitive patterns of behavior, interests, or activities.
These deficits are present in early childhood, typically before age
three, and lead to clinically significant functional impairment.
Sample symptoms include lack of social or emotional reciprocity,
stereotyped and repetitive use of language or idiosyncratic language,
and persistent preoccupation with unusual objects. The disturbance
must not be better accounted for by Rett syndrome, intellectual
disability or global developmental delay.
ICD-10 uses essentially
the same definition.
Several diagnostic instruments are available. Two are commonly used in
autism research: the
Autism Diagnostic Interview-Revised (ADI-R) is a
semistructured parent interview, and the
Autism Diagnostic Observation
Schedule (ADOS) uses observation and interaction with the child.
Autism Rating Scale (CARS) is used widely in clinical
environments to assess severity of autism based on observation of
children. The Diagnostic interview for social and communication
disorders (DISCO) may also be used.
A pediatrician commonly performs a preliminary investigation by taking
developmental history and physically examining the child. If
warranted, diagnosis and evaluations are conducted with help from ASD
specialists, observing and assessing cognitive, communication, family,
and other factors using standardized tools, and taking into account
any associated medical conditions. A pediatric neuropsychologist
is often asked to assess behavior and cognitive skills, both to aid
diagnosis and to help recommend educational interventions. A
differential diagnosis for ASD at this stage might also consider
intellectual disability, hearing impairment, and a specific language
impairment such as Landau–Kleffner syndrome. The presence
of autism can make it harder to diagnose coexisting psychiatric
disorders such as depression.
Clinical genetics evaluations are often done once ASD is diagnosed,
particularly when other symptoms already suggest a genetic cause.
Although genetic technology allows clinical geneticists to link an
estimated 40% of cases to genetic causes, consensus guidelines in
the US and UK are limited to high-resolution chromosome and fragile X
testing. A genotype-first model of diagnosis has been proposed,
which would routinely assess the genome's copy number variations.
As new genetic tests are developed several ethical, legal, and social
issues will emerge. Commercial availability of tests may precede
adequate understanding of how to use test results, given the
complexity of autism's genetics.
Metabolic and neuroimaging tests
are sometimes helpful, but are not routine.
ASD can sometimes be diagnosed by age 14 months, although diagnosis
becomes increasingly stable over the first three years of life: for
example, a one-year-old who meets diagnostic criteria for ASD is less
likely than a three-year-old to continue to do so a few years
later. In the UK the National
Autism Plan for Children recommends
at most 30 weeks from first concern to completed diagnosis and
assessment, though few cases are handled that quickly in
practice. Although the symptoms of autism and ASD begin early in
childhood, they are sometimes missed; years later, adults may seek
diagnoses to help them or their friends and family understand
themselves, to help their employers make adjustments, or in some
locations to claim disability living allowances or other benefits.
Girls are often diagnosed later than boys.
Underdiagnosis and overdiagnosis are problems in marginal cases, and
much of the recent increase in the number of reported ASD cases is
likely due to changes in diagnostic practices. The increasing
popularity of drug treatment options and the expansion of benefits has
given providers incentives to diagnose ASD, resulting in some
overdiagnosis of children with uncertain symptoms. Conversely, the
cost of screening and diagnosis and the challenge of obtaining payment
can inhibit or delay diagnosis. It is particularly hard to
diagnose autism among the visually impaired, partly because some of
its diagnostic criteria depend on vision, and partly because autistic
symptoms overlap with those of common blindness syndromes or
Autism is one of the five pervasive developmental disorders (PDD),
which are characterized by widespread abnormalities of social
interactions and communication, and severely restricted interests and
highly repetitive behavior. These symptoms do not imply sickness,
fragility, or emotional disturbance.
Of the five PDD forms,
Asperger syndrome is closest to autism in signs
and likely causes;
Rett syndrome and childhood disintegrative disorder
share several signs with autism, but may have unrelated causes; PDD
not otherwise specified (PDD-NOS; also called atypical autism) is
diagnosed when the criteria are not met for a more specific
disorder. Unlike with autism, people with
Asperger syndrome have
no substantial delay in language development. The terminology of
autism can be bewildering, with autism,
Asperger syndrome and PDD-NOS
often called the autism spectrum disorders (ASD) or sometimes the
autistic disorders, whereas autism itself is often called
autistic disorder, childhood autism, or infantile autism. In this
article, autism refers to the classic autistic disorder; in clinical
practice, though, autism, ASD, and PDD are often used
interchangeably. ASD, in turn, is a subset of the broader autism
phenotype, which describes individuals who may not have ASD but do
have autistic-like traits, such as avoiding eye contact.
The manifestations of autism cover a wide spectrum, ranging from
individuals with severe impairments—who may be silent,
developmentally disabled, and locked into hand flapping and
rocking—to high functioning individuals who may have active but
distinctly odd social approaches, narrowly focused interests, and
verbose, pedantic communication. Because the behavior spectrum is
continuous, boundaries between diagnostic categories are necessarily
somewhat arbitrary. Sometimes the syndrome is divided into low-,
medium- or high-functioning autism (LFA, MFA, and HFA), based on IQ
thresholds, or on how much support the individual requires in
daily life; these subdivisions are not standardized and are
Autism can also be divided into syndromal and
non-syndromal autism; the syndromal autism is associated with severe
or profound intellectual disability or a congenital syndrome with
physical symptoms, such as tuberous sclerosis. Although
Asperger syndrome tend to perform better cognitively
than those with autism, the extent of the overlap between Asperger
syndrome, HFA, and non-syndromal autism is unclear.
Some studies have reported diagnoses of autism in children due to a
loss of language or social skills, as opposed to a failure to make
progress, typically from 15 to 30 months of age. The validity of this
distinction remains controversial; it is possible that regressive
autism is a specific subtype, or that there is a
continuum of behaviors between autism with and without
Research into causes has been hampered by the inability to identify
biologically meaningful subgroups within the autistic population
and by the traditional boundaries between the disciplines of
psychiatry, psychology, neurology and pediatrics. 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; one example is lowered activity in the fusiform face area
of the brain, which is associated with impaired perception of people
versus objects. It has been proposed to classify autism using
genetics as well as behavior.
About half of parents of children with ASD notice their child's
unusual behaviors by age 18 months, and about four-fifths notice by
age 24 months. According to an article, failure to meet any of the
following milestones "is an absolute indication to proceed with
further evaluations. Delay in referral for such testing may delay
early diagnosis and treatment and affect the long-term outcome".
No babbling by 12 months.
No gesturing (pointing, waving, etc.) by 12 months.
No single words by 16 months.
No two-word (spontaneous, not just echolalic) phrases by 24 months.
Any loss of any language or social skills, at any age.
United States Preventive Services Task Force in 2016 found it was
unclear if screening was beneficial or harmful among children in whom
there is no concerns. The Japanese practice is to screen all
children for ASD at 18 and 24 months, using autism-specific formal
screening tests. In contrast, in the UK, children whose families or
doctors recognize possible signs of autism are screened. It is not
known which approach is more effective. Screening tools include
Modified Checklist for Autism in Toddlers
Modified Checklist for Autism in Toddlers (M-CHAT), the Early
Screening of Autistic Traits Questionnaire, and the First Year
Inventory; initial data on M-CHAT and its predecessor, the Checklist
Autism in Toddlers (CHAT), on children aged 18–30 months
suggests that it is best used in a clinical setting and that it has
low sensitivity (many false-negatives) but good specificity (few
false-positives). It may be more accurate to precede these tests
with a broadband screener that does not distinguish ASD from other
developmental disorders. Screening tools designed for one
culture's norms for behaviors like eye contact may be inappropriate
for a different culture. Although genetic screening for autism is
generally still impractical, it can be considered in some cases, such
as children with neurological symptoms and dysmorphic features.
While infection with rubella during pregnancy causes fewer than 1% of
cases of autism, vaccination against rubella can prevent many of
A three-year-old with autism points to fish in an aquarium, as part of
an experiment on the effect of intensive shared-attention training on
The main goals when treating children with autism are to lessen
associated deficits and family distress, and to increase quality of
life and functional independence. In general, higher IQs are
correlated with greater responsiveness to treatment and improved
treatment outcomes. No single treatment is best and
treatment is typically tailored to the child's needs. Families and
the educational system are the main resources for treatment.
Studies of interventions have methodological problems that prevent
definitive conclusions about efficacy, however the development of
evidence-based interventions has advanced in recent years.
Although many psychosocial interventions have some positive evidence,
suggesting that some form of treatment is preferable to no treatment,
the methodological quality of systematic reviews of these studies has
generally been poor, their clinical results are mostly tentative, and
there is little evidence for the relative effectiveness of treatment
options. Intensive, sustained special education programs and
behavior therapy early in life can help children acquire self-care,
social, and job skills, and often improve functioning and decrease
symptom severity and maladaptive behaviors; claims that
intervention by around age three years is crucial are not
substantiated. Available approaches include applied behavior
analysis (ABA), developmental models, structured teaching, speech and
language therapy, social skills therapy, and occupational therapy.
Among these approaches, interventions either treat autistic features
comprehensively, or focalize treatment on a specific area of
deficit. There is some evidence that early intensive behavioral
intervention (EIBI), an early intervention model based on ABA for 20
to 40 hours a week for multiple years, is an effective treatment
for some children with ASD. Two theoretical frameworks outlined
for early childhood intervention include applied behavioral analysis
(ABA) and developmental social pragmatic models (DSP). 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.
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.
Educational interventions can be effective to varying degrees in most
children: intensive ABA treatment has demonstrated effectiveness in
enhancing global functioning in preschool children and is
well-established for improving intellectual performance of young
children. Similarly, teacher-implemented intervention that
utilizes an ABA combined with a developmental social pragmatic
approach has been found to be a well-established treatment in
improving social-communication skills in young children, although
there is less evidence in its treatment of global symptoms.
Neuropsychological reports are often poorly communicated to educators,
resulting in a gap between what a report recommends and what education
is provided. It is not known whether treatment programs for
children lead to significant improvements after the children grow
up, and the limited research on the effectiveness of adult
residential programs shows mixed results. 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.
Many medications are used to treat ASD symptoms that interfere with
integrating a child into home or school when behavioral treatment
fails. 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. Antipsychotics, such as risperidone and
aripiprazole, have been found to be useful for treating irritability,
repetitive behavior, and sleeplessness that often occurs with autism,
however their side effects must be weighed against their potential
benefits, and people with autism may respond atypically. There is
scant reliable research about the effectiveness or safety of drug
treatments for adolescents and adults with ASD. No known
medication relieves autism's core symptoms of social and communication
impairments. Experiments in mice have reversed or reduced some
symptoms related to autism by replacing or modulating gene
function, suggesting the possibility of targeting therapies to
specific rare mutations known to cause autism.
Although many alternative therapies and interventions are available,
few are supported by scientific studies. Treatment approaches
have little empirical support in quality-of-life contexts, and many
programs focus on success measures that lack predictive validity and
real-world relevance. Scientific evidence appears to matter less
to service providers than program marketing, training availability,
and parent requests. Some alternative treatments may place the
child at risk. A 2008 study found that compared to their peers,
autistic boys have significantly thinner bones if on casein-free
diets; in 2005, botched chelation therapy killed a five-year-old
child with autism. There has been early research looking at
hyperbaric treatments in children with autism.
Although popularly used as an alternative treatment for people with
autism, there is no good evidence that a gluten-free diet is of
benefit. 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.
Society and culture
Main article: Sociological and cultural aspects of autism
The emergence of the autism rights movement has served as an attempt
to encourage people to be more tolerant of those with autism.
Through this movement, people hope to cause others to think of autism
as a difference instead of a disease. Proponents of this movement wish
to seek "acceptance, not cures." There have also been many
worldwide events promoting autism awareness such as World Autism
Awareness Day, Light It Up Blue,
Autism Sunday, Autistic Pride Day,
Autreat, and others. There have also been
many organizations dedicated to increasing the awareness of autism and
the effects that autism has on someone's life. These organizations
Autism National Committee,
Autism Society of
America, and many others. Social-science scholars have had an
increased focused on studying those with autism in hopes to learn more
about "autism as a culture, transcultural comparisons... and research
on social movements." Media has had an influence on how the
public perceives those with autism. Rain Man, a film that won 4 Oscars
including Best Picture, depicts a character with autism who has
incredible talents and abilities. While many autistics don't have
these special abilities, there are some autistic individuals who have
been successful in their fields.
Treatment is expensive; indirect costs are more so. For someone born
in 2000, a US study estimated an average lifetime cost of
$4.2 million (net present value in 2017 dollars,
inflation-adjusted from 2003 estimate), with about 10% medical
care, 30% extra education and other care, and 60% lost economic
productivity. Publicly supported programs are often inadequate or
inappropriate for a given child, and unreimbursed out-of-pocket
medical or therapy expenses are associated with likelihood of family
financial problems; one 2008 US study found a 14% average loss of
annual income in families of children with ASD, and a related
study found that ASD is associated with higher probability that child
care problems will greatly affect parental employment. US states
increasingly require private health insurance to cover autism
services, shifting costs from publicly funded education programs to
privately funded health insurance. After childhood, key treatment
issues include residential care, job training and placement,
sexuality, social skills, and estate planning.
There is no known cure. Children recover occasionally, so that
they lose their diagnosis of ASD; this occurs sometimes after
intensive treatment and sometimes not. It is not known how often
recovery happens; reported rates in unselected samples of
children with ASD have ranged from 3% to 25%. Most children with
autism acquire language by age five or younger, though a few have
developed communication skills in later years. Most children with
autism lack social support, meaningful relationships, future
employment opportunities or self-determination. Although core
difficulties tend to persist, symptoms often become less severe with
Few high-quality studies address long-term prognosis. Some adults show
modest improvement in communication skills, but a few decline; no
study has focused on autism after midlife. Acquiring language
before age six, having an IQ above 50, and having a marketable skill
all predict better outcomes; independent living is unlikely with
severe autism. Most people with autism face significant obstacles
in transitioning to adulthood.
Main article: Epidemiology of autism
Reports of autism cases per 1,000 children grew dramatically in the US
from 1996 to 2007. It is unknown how much, if any, growth came from
changes in rates of autism.
Most recent reviews tend to estimate a prevalence of 1–2 per 1,000
for autism and close to 6 per 1,000 for ASD, and 11 per 1,000
children in the United States for ASD as of 2008; because of
inadequate data, these numbers may underestimate ASD's true rate.
Globally, autism affects an estimated 24.8 million people as of 2015,
Asperger syndrome affects a further 37.2 million. In 2012,
the NHS estimated that the overall prevalence of autism among adults
aged 18 years and over in the UK was 1.1%. Rates of PDD-NOS's has
been estimated at 3.7 per 1,000,
Asperger syndrome at roughly 0.6 per
1,000, and childhood disintegrative disorder at 0.02 per 1,000.
CDC's most recent estimate is that 1 out of every 68 children, or 14.7
per 1,000, has an ASD as of 2010.
The number of reported cases of autism increased dramatically in the
1990s and early 2000s. This increase is largely attributable to
changes in diagnostic practices, referral patterns, availability of
services, age at diagnosis, and public awareness, though
unidentified environmental risk factors cannot be ruled out. The
available evidence does not rule out the possibility that autism's
true prevalence has increased; a real increase would suggest
directing more attention and funding toward changing environmental
factors instead of continuing to focus on genetics.
Boys are at higher risk for ASD than girls. 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.
Several theories about the higher prevalence in males have been
investigated, but the cause of the difference is unconfirmed; one
theory is that females are underdiagnosed.
Although the evidence does not implicate any single pregnancy-related
risk factor as a cause of autism, the risk of autism is associated
with advanced age in either parent, and with diabetes, bleeding, and
use of psychiatric drugs in the mother during pregnancy. The
risk 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. Most
professionals believe that race, ethnicity, and socioeconomic
background do not affect the occurrence of autism.
Several other conditions are common in children with autism. They
Genetic disorders. About 10–15% of autism cases have an identifiable
Mendelian (single-gene) condition, chromosome abnormality, or other
genetic syndrome, and ASD is associated with several genetic
Intellectual disability. The percentage of autistic individuals who
also meet criteria for intellectual disability has been reported as
anywhere from 25% to 70%, a wide variation illustrating the difficulty
of assessing intelligence of individuals on the autism spectrum.
In comparison, for
PDD-NOS the association with intellectual
disability is much weaker, and by definition, the diagnosis of
Asperger's excludes intellectual disability.
Anxiety disorders 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.
Epilepsy, with variations in risk of epilepsy due to age, cognitive
level, and type of language disorder.
Several metabolic defects, such as phenylketonuria, are associated
with autistic symptoms.
Minor physical anomalies are significantly increased in the autistic
Preempted diagnoses. Although the DSM-IV rules out concurrent
diagnosis of many other conditions along with autism, the full
Attention deficit hyperactivity disorder
Attention deficit hyperactivity disorder (ADHD), Tourette
syndrome, and other of these conditions are often present and these
comorbid diagnoses are increasingly accepted.
Sleep problems affect about two-thirds of individuals with ASD at some
point in childhood. These most commonly include symptoms of insomnia
such as difficulty in 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.
Further information: History of Asperger syndrome
Leo Kanner introduced the label early infantile autism in 1943.
A few examples of autistic symptoms and treatments were described long
before autism was named. The Table
Talk of Martin Luther, compiled by
his notetaker, Mathesius, contains the story of a 12-year-old boy who
may have been severely autistic. Luther reportedly thought the
boy was a soulless mass of flesh possessed by the devil, and suggested
that he be suffocated, although a later critic has cast doubt on the
veracity of this report. The earliest well-documented case of
autism is that of Hugh Blair of Borgue, as detailed in a 1747 court
case in which his brother successfully petitioned to annul Blair's
marriage to gain Blair's inheritance. The Wild Boy of Aveyron, a
feral child caught in 1798, showed several signs of autism; the
medical student Jean Itard treated him with a behavioral program
designed to help him form social attachments and to induce speech via
New Latin word autismus (English translation autism) was coined by
the Swiss psychiatrist
Eugen Bleuler in 1910 as he was defining
symptoms of schizophrenia. He derived it from the Greek word autós
(αὐτός, meaning "self"), and used it to mean morbid
self-admiration, referring to "autistic withdrawal of the patient to
his fantasies, against which any influence from outside becomes an
Clinical development and diagnoses
The word autism first took its modern sense in 1938 when Hans Asperger
of the Vienna University Hospital adopted Bleuler's terminology
autistic psychopaths in a lecture in German about child
psychology. Asperger was investigating an ASD now known as
Asperger syndrome, though for various reasons it was not widely
recognized as a separate diagnosis until 1981.
Leo Kanner of the
Johns Hopkins Hospital
Johns Hopkins Hospital first used autism in its modern sense in
English when he introduced the label early infantile autism in a 1943
report of 11 children with striking behavioral similarities.
Almost all the characteristics described in Kanner's first paper on
the subject, notably "autistic aloneness" and "insistence on
sameness", are still regarded as typical of the autistic spectrum of
disorders. It is not known whether Kanner derived the term
independently of Asperger.
Donald Triplett was the first person diagnosed with autism. He
was diagnosed by
Leo Kanner after being first examined in 1938, and
was labeled as "case 1". Triplett was noted for his savant
abilities, particularly being able to name musical notes played on a
piano and to mentally multiply numbers. His father, Oliver, described
him as socially withdrawn but interested in number patterns, music
notes, letters of the alphabet, and U.S. president pictures. By the
age of 2, he had the ability to recite the 23rd Psalm and memorized 25
questions and answers from the Presbyterian catechism. He was also
interested in creating musical chords.
Kanner's reuse of autism led to decades of confused terminology like
infantile schizophrenia, and child psychiatry's focus on maternal
deprivation led to misconceptions of autism as an infant's response to
"refrigerator mothers". Starting in the late 1960s autism was
established as a separate syndrome.
Terminology and distinction from schizophrenia
As late as the mid-1970s there was little evidence of a genetic role
in autism; while in 2007 it was believed to be one of the most
heritable psychiatric conditions. Although the rise of parent
organizations and the destigmatization of childhood ASD have affected
how ASD is viewed, parents continue to feel social stigma in
situations where their child's autistic behavior is perceived
negatively, and many primary care physicians and medical
specialists express some beliefs consistent with outdated autism
It took until 1980 for the
DSM-III to differentiate autism from
childhood schizophrenia. In 1987, the
DSM-III-R provided a checklist
for diagnosing autism. In May 2013, the
DSM-5 was released, updating
the classification for pervasive developmental disorders. The grouping
of disorders, including PDD-NOS, Autism, Asperger Syndrome, Rett
Syndrome, and CDD, has been removed and replaced with the general term
Autism Spectrum Disorders. The two categories that exist are
impaired social communication and/or interaction, and restricted
and/or repetitive behaviors.
The Internet has helped autistic individuals bypass nonverbal cues and
emotional sharing that they find so hard to deal with, and has given
them a way to form online communities and work remotely.
Sociological and cultural aspects of autism
Sociological and cultural aspects of autism have developed: some in
the community seek a cure, while others believe that autism is simply
another way of being.
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PMID 21834171. Hyperbaric therapy, in which oxygen is
administered in special chambers that maintain a higher air pressure,
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PMID 23688532. At this time, the studies attempting to treat
symptoms of autism with diet have not been sufficient to support the
general institution of a gluten-free or other diet for all children
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and casein-free diet might have a positive effect in improving
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very exciting association between NCGS and ASD deserves further study
before conclusions can be firmly drawn.
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The Accidental Teacher: Life Lessons from My Silent Son
Aspergirls: Empowering Females with Asperger's Syndrome
Animals in Translation
In a Different Key
Autism's False Prophets
Freaks, Geeks, and Asperger Syndrome: A User Guide to Adolescence
Like Colour to the Blind
Look Me in the Eye
Son-Rise: The Miracle Continues
Extreme Love: Autism
The Mu Rhythm Bluff
The Curious Incident of the Dog in the Night-Time
Speed of Dark
The Winter Journey
With the Light
For younger people
Everybody Is Different: A Book for Young People Who Have Brothers or
Sisters With Autism
Ian's Walk: A Story about Autism
Marcelo in the Real World
Rage: A Love Story
Autism and Developmental Disorders
Autism Spectrum Disorders
Autism Every Day
Autism Is a World
Autism: The Musical
Best Kept Secret
Children of the Stars
Dad's in Heaven with Nixon
The Horse Boy
How to Dance in Ohio
Normal People Scare Me
Recovered: Journeys Through the
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Too Sane for This World
The Wall or psychoanalysis put to the test for autism
Docudrama and biopic
Cries from the Heart
Son-Rise: A Miracle of Love
Wretches & Jabberers
The Black Balloon
Bless the Child
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A Child Is Waiting
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House of Cards
I Am Sam
Koi... Mil Gaya
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Midwinter Night's Dream
Mozart and the Whale
My Name Is Khan
Nightworld: Lost Souls
The Other Sister
Run Wild, Run Free
Salmon Fishing in the Yemen
Season of Miracles
The Story of Luke
Under the Piano
When the Bough Breaks