Feral child

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https://en.wikipedia.org/wiki/Feral_child 

Mowgli was a fictional feral child in Rudyard Kipling's The Jungle Book.

A feral child (also called wild child) is a human child who has lived isolated from human contact from a very young age, and so has had little or no experience of human care, behavior or human language. There are several confirmed cases and other speculative ones. Feral children may have experienced severe abuse or trauma before being abandoned or running away. They are sometimes the subjects of folklore and legends, typically portrayed as having been raised by animals.

Description

Feral children lack the basic social skills that are normally learned in the process of enculturation. For example, they may be unable to learn to use a toilet, have trouble learning to walk upright after walking on fours all their lives, or display a complete lack of interest in the human activity around them. They often seem mentally impaired and have almost insurmountable trouble learning a human language. The impaired ability to learn a natural language after having been isolated for so many years is often attributed to the existence of a critical period for language learning, and taken as evidence in favor of the critical period hypothesis.

There is little scientific knowledge about feral children. One of the best-documented cases has supposedly been that of sisters Amala and Kamala, described by Reverend J. A. L. Singh in 1926 as having been "raised by wolves" in a forest in India. French surgeon Serge Aroles, however, has persuasively argued that the case was a fraud, perpetrated by Singh in order to raise money for his orphanage. Child psychologist Bruno Bettelheim states that Amala and Kamala were born mentally and physically disabled. Yet other scientific studies of feral children exist, such as the case of Genie.

History

Prior to the 1600s, feral and wild children stories were usually limited to myths and legends. In those tales, the depiction of feral children included hunting for food, running on all fours instead of two, and not knowing language. Philosophers and scientists were infatuated with such children, and began to question if these children were part of a different species from the human family.

The question was taken seriously as science tried to name and categorize the development of humans, and the understanding of the natural world in the 18th and 19th century. Around the 20th century, psychologists were attempting to differentiate between behavior and biological culture. Feral children who lived in isolation or with animals provided examples of this dilemma.

Documented cases of feral children

Raised by primates/monkeys

• Marina Chapman claimed to have lived with weeper capuchin monkeys in the Colombian jungle from the age of five to about nine, following a botched kidnapping in about 1954. Unusual for feral children, she went on to marry, have children and live a largely normal life with no persisting problems.
• Robert Mayanja (1982) lost his parents in the Ugandan Civil War at the age of three, when Milton Obote's soldiers raided their village, around 50 miles (80 km) from Kampala. Robert then survived in the wild, presumably with vervet monkeys, for three years until he was found by soldiers of National Resistance Army.
• Saturday Mthiyane (or Mifune) (1987), a boy of around five, was found after spending about a year in the company of monkeys in KwaZulu-Natal, South Africa. He was given the name Saturday after the day he was found, and Mthiyane was the name of the headmistress of the Special School which took him in. In 2005 he died in a fire, at the age of around 17, he could still not talk, and still walked and jumped like a monkey. He never ate cooked food and refused to share or play with other children.
• John Ssebunya, from Uganda, was a toddler when his father killed his mother and hanged himself. Instead of going into a care facility, he went to live with vervet monkeys. For two years he learned how to forage and travel. The monkeys protected him in the wild. When he was around seven years old, he was brought back to civilization. According to a local villager, the only forms of communication he was capable of were crying and demanding food, and he was a "wild boy" whom everyone feared.

Raised by wolves

• Hessian wolf-children (1304, 1341 and 1344) lived with the Eurasian wolf in the forests of Hesse.
• Marcos Rodríguez Pantoja (ca. 1946, Sierra Morena, Spain) lived for 12 years with wolves in the mountains of Southern Spain. He was discovered at age 19. Rodríguez's story was depicted in the 2010 Spanish-German film Entrelobos. For his portrayal of Rodríguez, young actor Manuel Camacho received a Best New Actor nomination at the 2011 Goya Awards.

Raised by dogs

• Oxana Malaya was an eight-year-old Ukrainian girl who lived with Black Russian Terriers for six years. She was found in a kennel with dogs in 1991. She was neglected by her parents who were alcoholics. The three-year-old looking for comfort crawled into the farm and snuggled in with the dogs. Her behavior imitated dogs more than humans. She walked on all fours, bared her teeth, and barked. She was removed from her parents' custody by the social services. As she lacked human contact she did not know any words besides "yes" and "no". Upon adulthood, Oxana has been taught to subdue her dog-like behavior. She learned to speak fluently and intelligently and works at the farm milking cows, but remains somewhat intellectually impaired. Years later, Oxana admitted on a Russian talk show that her story was slightly less dramatic; neglected by her parents, she sought out the company of the dogs and learned to imitate them as they were more responsive than her parents.
• Ivan Mishukov, a six-year-old boy was rescued by the police in 1998 from wild dogs, who he lived with for two years. He ran from his mother and her abusive alcoholic boyfriend at the age of four. He earned the dogs' trust by giving them food and in return the dogs protected him. The boy had risen to being "alpha male" of the pack. When the police found him, they set a trap for him and the dogs by leaving food in a restaurant kitchen. Because he had lived among the dogs for only two years, he relearned language fairly rapidly. He studied in military school and served in the Russian Army.
• A 10-year-old Chilean boy (Dog Boy) was abandoned by his parents, lived with street dogs who hunted for food with him, and may have nursed him. At the age of five, the boy was abandoned by his parents and escaped a child care facility with 15 street dogs. The boy lived in a cave with the stray dogs and searched for food with them. He would search garbage cans to find leftover food to eat. He was raised by dogs since he was little. In 2001, he was found by the police, and he tried to escape by going into the water. However, he was caught and hospitalized.
• Traian Căldărar, Romania (found in 2002) also known as "the Romanian Dog Boy" or "Mowgli". From the ages of four to seven, Traian lived without his family. The boy was found at the age of seven and was described as a three-year-old due to undernutrition. His mother had left her home because of domestic violence, and Traian ran from home sometime after his mother left. He lived in the wild and took shelter in a cardboard box. He suffered from infected wounds, having poor circulation, and a children's disease caused by vitamin D deficiency. Traian was found by Manolescu Ioan, who had been walking across the country after his car broke down. In the surrounding area, a dog that had been eaten was also found. Many assume that the boy was eating the dog to stay alive. When Traian was being cared for, he would usually sleep under the bed and wanted to eat all the time. In 2007, Traian was being taken care of by his grandfather and was doing well in 3rd grade at school.
• Andrei Tolstyk (2004) was raised by dogs in a remote part of Siberia from the age of three months to 7 years. He was neglected by his parents because he had speaking and hearing problems. Social workers who found the boy were curious about why the boy was not admitted to his local school. This boy was not able to talk as he lacked human interaction and had many dog-like characteristics including walking on all fours, biting people, and sniffing his food before eating.
• Madina, a three-year-old girl. Madina lived with dogs from birth until she was three years old. She slept with them in the cold, ate food with them, and played with them. Her father left her after she was born, this caused her mother to become an alcoholic and neglect Madina. When found by social workers in 2013 she was completely nude and engaged in dog like behavior including chewing on bones. Afterwards doctors confirmed that she was still mentally and physically capable despite being neglected for nearly her entire life.

Raised by bears

• The three Lithuanian bear-boys (1657, 1669, 1694) – Serge Aroles shows from the archives of the Queen of Poland (1664–1688) that these are false. There was only one boy who lived in the forests of Lithuania with the Eurasian brown bear, he was found in spring 1663 and then brought to Poland's capital.

Raised by sheep

• An Irish boy brought up by sheep, reported by Nicolaes Tulp in his book Observationes Medicae (1672). Serge Aroles gives evidence that this boy was severely disabled and exhibited for money.
• A 14-year-old boy also known as the sheep boy, was found in the former Soviet Union living in a sheep flock. He was raised by sheep for 8 years. He had no communication skills and could not use the toilet. His parents left to find work and was left with his grandmother. His grandmother took care of him until she died.

Raised by cattle

• The Bamberg boy – who grew up among cattle (late 16th century).

Raised by goats

• Daniel, Andes Goat Boy (1990) lived in the wild for about 8 years. He was discovered in the mountains of Peru and was raised by goats. He walked and ran on all fours with the mountain goats. He drank goat's milk, ate berries, and roots.

Raised by ostriches

• The "ostrich boy" – A boy named Hadara was lost by his parents in the Sahara desert at the age of two, and was adopted by ostriches. At the age of 12, he was rescued and taken back to society and his parents. He later married and had children. The story of Hadara is often told in west Sahara. In 2000, Hadara's son Ahmedu told his father's story to the Swedish author Monica Zak, who compiled it to a book. The book is a mixture of the stories told by Ahmedu and Zak's own fantasy.

Other documented cases

Kaspar Hauser.

• Jean de Liège. Described by natural philosopher Sir Kenelm Digby in his book 'Two Treatises' (1644).
• The girl of Oranienburg (1717).
• The two Pyrenean boys (1719).
• Peter the Wild Boy of Hamelin (1724) – Mentally handicapped boy, affected with Pitt-Hopkins Syndrome. He lived only one year in the wild.
• Victor of Aveyron (1800) – Victor was a feral child in the forests of Aveyron for twelve years. The subject is treated with a certain amount of realism in François Truffaut’s 1970 film L’Enfant Sauvage (UK: The Wild Boy, US: The Wild Child), where a scientist's efforts in trying to rehabilitate a feral boy meet with great difficulty.
• Marie-Angelique Memmie Le Blanc, was a famous feral child of the 18th century in France who was known as The Wild Girl of Champagne, The Maid of Châlons, or The Wild Child of Songy. Marie-Angélique survived for ten years living wild in the forests of France, between the ages of nine and 19, before she was captured by villagers in Songy in Champagne in September 1731. She was likely born in 1712 as a Native American of the Meskwaki (or "Fox") people, and brought to France in 1720; or she was born in an unknown location in 1721. Marie died in Paris in 1775. Documents show that she learned to read and write as an adult, thus making her unique among feral children.
• Hany Istók (a.k.a. Steve of the Marsh) of Kapuvár, Hungary (1749). According to documents stored at the Catholic parish of Kapuvár, an abandoned child was once found in a marshy lakeside forest by two fishermen. He was brought to the town of Kapuvár, where he was christened and received the name Steven. The local governor took him to his castle and tried to raise him, but the boy eventually escaped and ran back to the forest. Later, numerous folk tales developed around his character, depicting him as a "half fish, half human creature" who lived in a nearby lake.
• Kaspar Hauser (early 19th century), portrayed in the 1974 Werner Herzog film The Enigma of Kaspar Hauser (Jeder für sich und Gott gegen alle), who existed but whose account of his own early isolation may well have been a hoax.
• Ramachandra (1970s and 1980s) – First reported in 1973 in the Indian state of Uttar Pradesh, at roughly 12 years old, and as living an amphibian lifestyle in the Kuwano River. He was rescued in 1979 and taken to a nearby village. He only partly adapted to a conventional lifestyle, still preferring raw food, walking with an awkward gait, and spending most of his time alone in nearby rivers and streams. He died in 1982 after approaching a woman who was frightened by him, and who badly scalded Ramachandra with boiling water. Historian Mike Dash speculates that Ramachandra's uncharacteristically bold approach to the woman was sparked by a burgeoning sexual attraction coupled with his ignorance of cultural mores and taboos.
• Cambodian jungle girl (2007) – Alleged to be Rochom P'ngieng, who lived 19 years in the Cambodian jungle. Other sources questioned these claims. In August 2016, after immigration officials spent two weeks reviewing the case, the woman left Cambodia with her family and returned to Vietnam. Vietnamese media reported that her birth father discovered her through photographs on Facebook. The woman never learned to speak while living with her adoptive family in Cambodia, and according to her Vietnamese birth family, she has been that way since birth.
• Name Unknown, Uzbekistan (2007) – A teenage boy found acting like a wild animal and snarling in the mountains of Samarkand after being reported missing in 1998.
• Ng Chhaidy, Theiva near Saiha, Mizoram, India (2012) – She went missing in a jungle aged four, returning 38 years later. When she was first seen, she was naked, long-haired, and with long fingernails, which caused her to be seen as a "wild woman".

Alleged cases of feral children

Raised by pumas

Vicente Caucau (1948) – Chilean boy found in a savage state at age 12, allegedly raised by pumas.

Raised with sheep

The historian Herodotus wrote that Egyptian pharaoh Psammetichus I (Psamtik) sought to discover the origin of language by conducting an experiment with two children. Allegedly, he gave two newborn babies to a shepherd, with the instructions that no one should speak to them, but that the shepherd should feed and care for them while listening to determine their first words. The hypothesis was that the first word would be uttered in the root language of all people. When one of the children cried “bekos” (a sound quite similar to the bleating of sheep) with outstretched arms the shepherd concluded that the word was Phrygian because that was the sound of the Phrygian word for bread. Thus, they concluded that the Phrygians were an older people than the Egyptians.

Other alleged cases

The Lobo Wolf Girl of Devil's River (1845) – A figure in Texas folklore, was captured in 1846, but escaped. She was last spotted at age 17 in 1852.

Raised in confinement

• Isabelle (1938) was almost seven years old when she was discovered. She had spent the first years of her life isolated in a dark room with her deaf-mute mother as her only contact. Only seven months later, she had learned a vocabulary of around 1,500 to 2,000 words. She is reported to have acquired normal linguistic abilities.
• Anna (1938) was six years old when she was found, having been kept in a dark room for most of her life. She was born in March 1932 in Pennsylvania, United States. She was her mother's second illegitimate child. Her mother had tried to give Anna up for several months but no agency was willing to take the financial burden, as this was during the Great Depression. Anna was kept in a store room at least until she was five and half, out of the way of her disapproving grandfather, who was infuriated by her presence. Her mother also resented her, considering her troublesome. She was tied to a broken chair which was too small for her, and is believed to have also been tied to a cot for long periods of time. She was mostly fed milk and was never bathed, trained, or caressed by anyone. When she was found, she was suffering from malnutrition as well as muscle atrophy. She was immobile, expressionless, and indifferent to everything. She was believed to be deaf as she did not respond to others (later it was found that her deafness was functional rather than physical). She could not talk, walk, feed herself, or do anything that showed signs of cognition. Once she was taken away and placed in a foster home, she showed signs of improvement. At the age of nine she began to develop speech. She had started to conform to social norms and was able to feed herself, though only using a spoon. Her teachers described her as having a pleasant disposition. Anna died in August 1942 of hemorrhagic jaundice.
• Genie, discovered 1970 in Los Angeles. Confined to one room without external stimulation of any kind, strapped to a child's toilet and restrained in a makeshift harness for up to 13 hours per day. It was also theorized that Genie's father would beat her with a wooden plank kept in the room if Genie vocalized at all. This abuse continued for approximately 13 years and 6 months. Attempts were made to teach Genie language, but results were limited. Genie's living situation was mostly unstable, often moving between hospitals, foster homes and even an unsuccessful stay with her own mother. As of 2016, Genie is a ward of the state of California.
• Sujit Kumar (1979), named the "Chicken Boy of Fiji" by the media, was born with cerebral palsy and epilepsy. Sujit's mother committed suicide when he was a toddler and his father left him confined under the house to live with the chickens. Sujit was rescued while still a boy and committed to the Samabula Old People's Home where he was confined to his room and tied to his bed. He could not speak and his only verbalisation was clucking; his only interaction with people consisted of outbursts. Sujit remained at the old people's home for 20 years until he was found by Elizabeth Clayton, a wealthy Australian businesswoman who founded the Happy Home Trust to care for Sujit and other at-risk Fijian children. Sujit's behaviour has improved, but it is assumed that he will never learn to speak, and he remains profoundly disabled.
• Danielle Crockett, Plant City, Florida, United States (2007–2008), had been locked in her room and deprived of any human interaction for the first 7 years of her life, causing a variety of severe developmental delays. She was found and adopted and is currently undergoing efforts to acclimate her to human conditioning including learning English and effective communication. As of 2017, Dani now lives in a group home but was unable to learn how to speak.
• Vanya Yudin, ("Russian bird boy"), Russia, (2008), a seven-year-old boy was found who spent his entire life living in a tiny two bedroom apartment surrounded by birds. His mother never spoke to him and treated him as a pet, and when found he was unable to communicate except for chirping and flapping his arms like wings.
• Natasha, Chita, Zabaykalsky Krai, Russia (2009), a five-year-old girl who spent her entire life locked in a room with cats and dogs, and no heat, water, or sewage system. When she was found, she could not speak, would jump at the door and bark as caretakers left, and had "clear attributes of an animal".
• Sasha T., Russia (2012), a two-year-old boy who was kept in a room with goats his entire life by his mother. Having spent all his time in a room with goats and without human contact, he had not learned how to speak, and weighed only about two-thirds as much as a typical child his age when he was discovered by Russian social workers.

Hoaxes

Following the 2008 disclosure by Belgian newspaper Le Soir that the bestselling book Misha: A Mémoire of the Holocaust Years and movie Survivre avec les loups (“Surviving with Wolves”) was a media hoax, the French media debated the credulity with which numerous cases of feral children have been unquestioningly accepted. Although there are numerous books on these children, almost none of them have been based on archives; the authors instead have used dubious second- or third-hand printed information. According to the French surgeon Serge Aroles, who wrote a general study of feral children based on archives (L'Enigme des Enfants-loups or The Enigma of Wolf-children, 2007), many alleged cases are totally fictitious stories:

• The teenager of Kronstadt (1781) – According to the Hungarian document published by Serge Aroles, this case is a hoax: the boy, mentally handicapped, had a goitre and was exhibited for money.
• Syrian Gazelle Boy (1946) – A boy aged around 10 was reported to have been found in the midst of a herd of gazelles in the Syrian desert in the 1950s, and was only rescued with the help of an Iraqi army jeep, because he could run at speeds of up to 50 km/h. However, it was a hoax, as are the other gazelle-boy cases.
• Amala and Kamala – Claimed to have been found in 1920 by missionaries near Midnapore, Calcutta region, India, later proved to be a hoax to gain charity for Rev. Singh's orphanage. Scholars from Japan and France launched a new inquiry about Amala and Kamala, and validated the discoveries and conclusions done by Serge Aroles 20 years before: the story was a hoax.
• Ramu, Lucknow, India, (1954) – A girl taken by a wolf as a baby, and raised in the jungle until the age of seven. Aroles made inquiries on the scene and classifies this as another hoax.
• The bear-girl of Krupina, Slovakia (1767) – Serge Aroles found no traces of her in the Krupina archives.

Legend, fiction, and popular culture

Myths, legends, and fiction have depicted feral children reared by wild animals such as wolves, apes, monkeys, and bears. Famous examples include Romulus and Remus, Ibn Tufail’s Hayy, Ibn al-Nafis’ Kamil, Rudyard Kipling’s Mowgli, Edgar Rice Burroughs’s Tarzan, George of the Jungle and the legends of Atalanta and Enkidu.

The Capitoline Wolf suckling Romulus and Remus

 

Roman legend has it that Romulus and Remus, twin sons of Rhea Silvia and Mars, were suckled by a she-wolf. Rhea Silvia was a priestess, and when it was found that she had been pregnant and had children, King Amulius, who had usurped his brother's throne, ordered her to be buried alive and for the children to be killed. The servant who was given the order set them in a basket on the Tiber river instead, and the children were taken by Tiberinus, the river god, to the shore where a she-wolf found them and raised them until they were discovered as toddlers by a shepherd named Faustulus. He and his wife Acca Larentia, who had always wanted a child but never had one, raised the twins, who would later feature prominently in the events leading up to the founding of Rome (named after Romulus, who eventually killed Remus in a fight over whether the city should be founded on the Palatine Hill or the Aventine Hill).

Legendary and fictional children are often depicted as growing up with relatively normal human intelligence and skills and an innate sense of culture or civilization, coupled with a healthy dose of survival instincts. Their integration into human society is made to seem relatively easy. One notable exception is Mowgli, for whom living with humans proved to be extremely difficult.

The book Knowledge of Angels involves a feral girl found on a fictional island based upon Mallorca. She is the subject of an experiment to see if the knowledge of God is learned or innate. Placed in a convent, while she is there the nuns are instructed not to teach her about God or even mention him in front of her. This is to see whether an atheist who washed up there should be condemned or not.

The 2006 novel "Magic Hour" by Kristin Hannah is about a six-year-old feral child living during her formative years inside a cave in the Olympic National Forest. The girl wanders one day into the fictional small town of Rain Valley, Washington, searching for food and carrying her pet wolf pup and unable to speak. The police chief calls in her psychiatrist sister to teach the girl how to speak and to find the girl's family.

Autism spectrum

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Autism_spectrum 

 

Autism spectrum
Other names	Autism spectrum disorder, autistic spectrum disorder, autism spectrum condition, autistic spectrum condition
Repetitively stacking or lining up objects is associated with autism spectrum
Specialty	Psychiatry, clinical psychology
Symptoms	Problems with communication, social interaction, restricted interests, repetitive behavior
Complications	Social isolation, employment problems, family stress, bullying, self-harm, suicide
Usual onset	By the age of 3 years
Duration	Lifelong or Long-term
Causes	Uncertain
Risk factors	Advanced parental age, exposure to valproate during pregnancy, low birth weight
Diagnostic method	Based on symptoms
Differential diagnosis	Intellectual disability, Rett syndrome, ADHD, selective mutism, childhood-onset schizophrenia
Treatment	Behavioral therapy, psychotropic medication
Frequency	1% of people (62.2 million 2015)

The autism spectrum encompasses a range of neurodevelopmental conditions, including autism and Asperger syndrome, generally known as autism spectrum disorders (ASD). Individuals on the autistic spectrum experience difficulties with social communication and interaction and also exhibit restricted, repetitive patterns of behavior, interests, or activities. Symptoms are typically recognized between one and two years of age. Long-term problems may include difficulties in performing daily tasks, creating and keeping relationships, and maintaining a job.

The cause of autism spectrum conditions is uncertain. Risk factors include having an older parent, a family history of autism, and certain genetic conditions. It is estimated that between 64% and 91% of risk is due to family history. Diagnosis is based on symptoms. In 2013, the Statistical Manual of Mental Disorders version 5 (DSM-5) replaced the previous subgroups of autistic disorder, Asperger syndrome, pervasive developmental disorder not otherwise specified (PDD-NOS), and childhood disintegrative disorder with the single term "autism spectrum disorder".

Treatment efforts are generally individualized and can include behavioural therapy and the teaching of coping skills. Medications may be used to try to help improve symptoms. Evidence to support the use of medications, however, is not very strong.

Autism spectrum is estimated to affect about 1% of people (62.2 million globally) as of 2015. In the United States it is estimated to affect more than 2% of children (about 1.5 million) as of 2016. Males are diagnosed four times more often than females. The term "spectrum" refers to the variation in the type and severity of symptoms. Those in the mild range may function independently, while those with moderate to severe symptoms may require substantial support in their daily lives.

Classification

DSM-IV diagnoses that fall under the umbrella of autism spectrum disorder in DSM-V

Autism forms the core of the autism spectrum disorders. Asperger syndrome is closest to autism in signs and likely causes; unlike autism, people with Asperger syndrome have no significant delay in language development or cognitive development, according to the older DSM-IV criteria. PDD-NOS is diagnosed when the criteria are not met for a more specific disorder. Some sources also include Rett syndrome and childhood disintegrative disorder, which share several signs with autism but may have unrelated causes; other sources differentiate them from ASD, but group all of the above conditions into the pervasive developmental disorders.

Autism, Asperger syndrome, and PDD-NOS are sometimes called the autistic disorders instead of ASD, whereas autism itself is often called autistic disorder, childhood autism, or infantile autism. Although the older term pervasive developmental disorder and the newer term autism spectrum disorder largely or entirely overlap, the earlier was intended to describe a specific set of diagnostic labels, whereas the latter refers to a postulated spectrum disorder linking various conditions. ASD is a subset of the broader autism phenotype (BAP), which describes individuals who may not have ASD but do have autistic-like traits, such as avoiding eye contact.

A revision to autism spectrum disorder (ASD) was presented in the Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM-5), released May 2013. The new diagnosis encompasses previous diagnoses of autistic disorder, Asperger syndrome, childhood disintegrative disorder, and PDD-NOS. Compared with the DSM-IV diagnosis of autistic disorder, the DSM-5 diagnosis of ASD no longer includes communication as a separate criterion, and has merged social interaction and communication into one category. Slightly different diagnostic definitions are used in other countries. For example, the ICD-10 is the most commonly-used diagnostic manual in the UK and European Union. Rather than categorizing these diagnoses, the DSM-5 has adopted a dimensional approach to diagnosing disorders that fall underneath the autism spectrum umbrella. Some have proposed that individuals on the autism spectrum may be better represented as a single diagnostic category. Within this category, the DSM-5 has proposed a framework of differentiating each individual by dimensions of severity, as well as associated features (i.e., known genetic disorders, and intellectual disability).

Another change to the DSM includes collapsing social and communication deficits into one domain. Thus, an individual with an ASD diagnosis will be described in terms of severity of social communication symptoms, severity of fixated or restricted behaviors or interests, hyper- or hyposensitivity to sensory stimuli, and associated features. The restricting of onset age has also been loosened from 3 years of age to "early developmental period", with a note that symptoms may manifest later when social demands exceed capabilities.

Signs and symptoms

Autism spectrum disorder (ASD) is characterized by persistent challenges with social communication and social interaction, and by the presence of restricted, repetitive patterns of behavior, interests, or activities. These symptoms begin in early childhood, and can impact function. There is also a unique disorder called savant syndrome that can co-occur with autism. As many as one in 10 children with autism and savant syndrome can have outstanding skills in music, art, and mathematics. Self-injurious behavior (SIB) is more common and has been found to correlate with intellectual disability. Approximately 50% of those with ASD take part in some type of SIB (head-banging, self-biting).

Other characteristics of ASD include restricted and repetitive behaviors (RRBs). These include a range of gestures and behaviors as defined in the Diagnostic and Statistic Manual for Mental Disorders.

Asperger syndrome was distinguished from autism in the DSM-IV by the lack of delay or deviance in early language development. Additionally, individuals diagnosed with Asperger syndrome did not have significant cognitive delays. PDD-NOS was considered "subthreshold autism" and "atypical autism" because it was often characterized by milder symptoms of autism or symptoms in only one domain (such as social difficulties). The DSM-5 eliminated the four separate diagnoses: Asperger Syndrome, Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS), Childhood Disintegrative Disorder, and Autistic Disorder and combined them under the diagnosis of Autism Spectrum Disorder.

Developmental course

Most parents report that the onset of autism symptoms occur within the first year of life. There are two possible developmental courses of autism spectrum disorder. One course of development is more gradual in nature, in which parents report concerns in development over the first two years of life and diagnosis is made around 3–4 years of age. Some of the early signs of ASDs in this course include decreased looking at faces, failure to turn when name is called, failure to show interests by showing or pointing, and delayed imaginative play.

A second course of development is characterized by normal or near-normal development in the first 15 months to 3 years before onset of regression or loss of skills. Regression may occur in a variety of domains, including communication, social, cognitive, and self-help skills; however, the most common regression is loss of language. Childhood disintegrative disorder, a DSM-IV diagnosis now included under ASD in DSM-V, is characterized by regression after normal development in the first 3 to 4 years of life.

There continues to be a debate over the differential outcomes based on these two developmental courses. Some studies suggest that regression is associated with poorer outcomes and others report no differences between those with early gradual onset and those who experience a regression period. While there is conflicting evidence surrounding language outcomes in ASD, some studies have shown that cognitive and language abilities at age ​2 ¹⁄₂ may help predict language proficiency and production after age 5. Overall, the literature stresses the importance of early intervention in achieving positive longitudinal outcomes.

Social skills

Impairments in social skills present many challenges for individuals with ASD. Deficits in social skills may lead to problems with friendships, romantic relationships, daily living, and vocational success. One study that examined the outcomes of adults with ASD found that, compared to the general population, those with ASD were less likely to be married, but it is unclear whether this outcome was due to deficits in social skills or intellectual impairment.

Prior to 2013, deficits in social function and communication were considered two separate symptoms of autism. The current criteria for Autism diagnosis require individuals to have deficits in three social skills: social-emotional reciprocity, nonverbal communication, and developing and sustaining relationships.

Some of the symptoms related to social reciprocity include:

• Lack of mutual sharing of interests: many children with autism prefer not to play or interact with others.
• Lack of awareness or understanding of other people's thoughts or feelings: a child may get too close to peers without noticing that this makes them uncomfortable.
• Atypical behaviors for attention: a child may push a peer to gain attention before starting a conversation.

People with autism spectrum usually display atypical nonverbal behaviors:

• Poor eye contact: a child with autism may fail to make eye contact when called by name, or they may avoid making eye contact with an observer. Aversion of gaze can also be seen in anxiety disorders, however poor eye contact in autistic children is not due to shyness or anxiety; rather, it is overall diminished in quantity.
• Facial expressions: they often don't know how to recognize emotions from others' facial expressions, or they may not respond with the appropriate facial expressions.
• Unusual speech: at least half of children with autism speak in a flat, monotone voice or they 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.

Communication skills

Communication deficits are due to problems with social-emotional skills like joint attention and social reciprocity. Difficulties with nonverbal communication skills such as poor eye contact, and impaired use of proper facial expressions and gestures are common. Some of the linguistic behaviors in individuals with autism 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. ASD can present with impairments in pragmatic communication skills, such as difficulty initiating a conversation or failure to consider the interests of the listener to sustain a conversation. Language impairment is also common in children with autism, but it is not necessary for the diagnosis. Many children with ASD develop language skills at an uneven pace where they easily acquire some aspects of communication, while never fully developing others. In some cases, individuals remain completely nonverbal throughout their lives, although the accompanying levels of literacy and nonverbal communication skills vary.

They may 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. Similarly, they have trouble recognizing subtle expressions of emotion and identifying what various emotions mean for the conversation. 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. How emotional processing and facial expressions differ between those on the autism spectrum and others is not clear, but emotions are processed differently between different partners.

It is also common for individuals with ASD to communicate strong interest in a specific topic, speaking in lesson-like monologues about their passion instead of enabling reciprocal communication with whomever they are speaking to. What looks like self-involvement or indifference toward others stems from a struggle to recognize or remember that other people have their own personalities, perspectives, and interests. The ability to be focused in on one topic in communication is known as monotropism, and can be compared to "tunnel vision" in the mind for those individuals with ASD. Language expression by those on the autism spectrum is often characterized by repetitive and rigid language. Often children with ASD repeat certain words, numbers, or phrases during an interaction, words unrelated to the topic of conversation. They can also exhibit a condition called echolalia in which they respond to a question by repeating the inquiry instead of answering.

Behavioral characteristics

Autism spectrum disorders include 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. They may develop these difficulties of creating connections due to anxiety or depression, which people with autism are more likely to experience, and as a result isolate themselves. Other behavioral characteristics include abnormal responses to sensations including sights, sounds, touch, and smell, and problems keeping a consistent speech rhythm. The latter problem influences an individual's social skills, leading to potential problems in how they are understood by communication partners. Behavioral characteristics displayed by those with autism spectrum disorder typically influence development, language, and social competence. Behavioral characteristics of those with autism spectrum disorder can be observed as perceptual disturbances, disturbances of development rate, relating, speech and language, and motility.

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, a child must have at least two of the following behaviors:

• Stereotyped behaviors– Most children with autism perform repetitive behaviors such as rocking, hand flapping, finger flicking, head banging, or repeating phrases or sounds. These behaviors may occur constantly or only when the child gets stressed, anxious or upset.
• Resistance to change– Children with autism spectrum also tend to have routines and rituals that they must follow, like eating certain foods in a specific order, or taking the same path to school every day. The child may have a meltdown if there is any change or disruption to his routine.
• Restricted interests– Children may become excessively interested in a particular thing or topic, and devote 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 talk about it constantly.
• Sensory Processing Disorder– Many people with Autism have difficulty processing complex combinations of emotional and sensory stimuli. Their inability to process this information in a timely manner produces an information pile up which will trigger a stress reaction. They must be able to escape the environment causing this information pile up or their stress reaction may escalate to a severe anxiety reaction or panic attack. This will ultimately result in an autistic meltdown.
• Oversensitivity– Many people with autism are overly sensitive to loud sounds, bright lights, strong smells, or being touched.

Self-injury

Self-injurious behaviors (SIB) are common in ASD and include head-banging, self-cutting, self-biting, and hair-pulling. These behaviors can result in serious injury or death. Following are theories about the cause of self-injurious behavior in autistic individuals:

• Frequency and/or continuation of self-injurious behavior can be influenced by environmental factors e.g. reward in return for halting self-injurious behavior. However this theory is not applicable 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 this behavior.
• Higher rates of self-injury are also noted in socially isolated individuals with autism
• Self-injury could be a response to modulate pain perception when chronic pain or other health problems that cause pain are present
• An abnormal basal ganglia connectivity may predispose to self-injurious behavior

Causes

While specific causes of autism spectrum disorders have yet to be found, many risk factors identified in the research literature may contribute to their development. These risk factors include genetics, prenatal and perinatal factors, neuroanatomical abnormalities, and environmental factors. It is possible to identify general risk factors, but much more difficult to pinpoint specific factors. Given the current state of knowledge, prediction can only be of a global nature and therefore requires the use of general markers.

Genetics

Hundreds of different genes are implicated in susceptibility to developing autism, most of which alter the brain structure in a similar way

As of 2018, it appeared that somewhere between 74% and 93% of ASD risk is heritable. After an older child is diagnosed with ASD, 7–20% of subsequent children are likely to be as well. If parents have a child with ASD they have a 2% to 8% chance of having a second child with ASD. If the child with ASD is an identical twin the other will be affected 36 to 95 percent of the time. If they are fraternal twins the other will only be affected up to 31 percent of the time.

As of 2018, 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 people with ASD have such a mutation. Some ASD is associated with clearly genetic conditions, like fragile X syndrome; however only around 2% of people with ASD have fragile X.

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 despite up to 1000 different genes thought to contribute to increased 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 knows to modulate production of the GABA neurotransmitter which is the main inhibitory neurotransmitter in the nervous system. These GABA-related genes are underexpressed 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 overexpressed 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.

All these genetic variants contribute to the development of the autistic spectrum, however, it can not be guaranteed that they are determinants for the development.

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 after first trimester, use of 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. While it is unclear if any single factors during the prenatal phase affect the risk of autism, complications during pregnancy may be a risk.

Low vitamin D levels in early development has been hypothesized as a risk factor for autism.

Disproven vaccine hypothesis

In 1998 Andrew Wakefield led a fraudulent study that suggested that the MMR vaccine may cause autism. This conjecture suggested that autism results from brain damage caused either by the MMR vaccine itself, or by thimerosal, a vaccine preservative. No convincing scientific evidence supports these claims, and further evidence continues to refute them, including the observation that the rate of autism continues to climb despite elimination of thimerosal from routine childhood vaccines. A 2014 meta-analysis examined ten major studies on autism and vaccines involving 1.25 million children worldwide; it concluded that neither the MMR vaccine, which has never contained thimerosal, nor the vaccine components thimerosal or mercury, lead to the development of ASDs.

Pathophysiology

In general, neuroanatomical studies support the concept that autism may involve a combination of brain enlargement in some areas and reduction in others. These studies suggest that autism may be caused by abnormal neuronal growth and pruning during the early stages of prenatal and postnatal brain development, leaving some areas of the brain with too many neurons and other areas with too few neurons. Some research has reported an overall brain enlargement in autism, while others suggest abnormalities in several areas of the brain, including the frontal lobe, the mirror neuron system, the limbic system, the temporal lobe, and the corpus callosum.

In functional neuroimaging studies, when performing theory of mind and facial emotion response tasks, the median person on the autism spectrum exhibits less activation in the primary and secondary somatosensory cortices of the brain than the median member of a properly sampled control population. This finding coincides with reports demonstrating abnormal patterns of cortical thickness and grey matter volume in those regions of autistic persons' brains.

Brain connectivity

Brains of autistic individuals have been observed to have abnormal connectivity and the degree of these abnormalities directly correlates with the severity of autism. Following are some observed abnormal connectivity patterns in autistic individuals:

• Decreased connectivity between different specialized regions of the brain (e.g. lower neuron density in corpus callosum) and relative overconnectivity within specialized regions of the brain by adulthood. Connectivity between different regions of the brain ('long-range' connectivity) is important for integration and global processing of information and comparing incoming sensory information with the existing model of the world within the brain. Connections within each specialized regions ('short-range' connections) are important for processing individual details and modifying the existing model of the world within the brain to more closely reflect incoming sensory information. In infancy, children at high risk for autism that were later diagnosed with autism were observed to have abnormally high long-range connectivity which then decreased through childhood to eventual long-range underconnectivity by adulthood.
• Abnormal preferential processing of information by the left hemisphere of the brain vs. preferential processing of information by right hemisphere in neurotypical individuals. The left hemisphere is associated with processing information related to details whereas the right hemisphere is associated with processing information in a more global and integrated sense that is essential for pattern recognition. For example, visual information like face recognition is normally processed by the right hemisphere which tends to integrate all information from an incoming sensory signal, whereas an ASD brain preferentially processes visual information in the left hemisphere where information tends to be processed for local details of the face rather than the overall configuration of the face. This left lateralization negatively impacts both facial recognition and spatial skills.
• Increased functional connectivity within the left hemisphere which directly correlates with severity of autism. This observation also supports preferential processing of details of individual components of sensory information over global processing of sensory information in an ASD brain.
• Prominent abnormal connectivity in the frontal and occipital regions. In autistic individuals low connectivity in the frontal cortex was observed from infancy through adulthood. This is in contrast to long-range connectivity which is high in infancy and low in adulthood in ASD. Abnormal neural organization is also observed in the Broca's area which is important for speech production.

Neuropathology

Listed below are some characteristic findings in ASD brains on molecular and cellular levels regardless of the specific genetic variation or mutation contributing to autism in a particular individual:

• Limbic system with smaller neurons that are more densely packed together. Given that the limbic system is the main center of emotions and memory in the human brain, this observation may explain social impairment in ASD.
• Fewer and smaller Purkinje neurons in the cerebellum. New research suggest a role of the cerebellum in emotional processing and language.
• Increased number of astrocytes and microglia in the cerebral cortex. These cells provide metabolic and functional support to neurons and act as immune cells in the nervous system, respectively.
• Increased brain size in early childhood causing macrocephaly in 15–20% of ASD individuals. The brain size however normalizes by mid-childhood. This variation in brain size in not uniform in the ASD brain with some parts like the frontal and temporal lobes being larger, some like the parietal and occipital lobes being normal sized, and some like cerebellar vermis, corpus callosum, and basal ganglia being smaller than neurotypical individuals.
• Cell-adhesion molecules (CAMs) that are essential to formation and maintenance of connections between neurons, neuroligins found on postsynaptic neurons that bind presynaptic CAMs, and proteins that anchor CAMs to neurons are all found to be mutated in ASD.

Gut-immune-brain axis

Role of gut-immune-brain axis in autism; BBB – blood brain barrier

Up to 70% of autistic individuals have GI related problems like reflux, diarrhea, constipation, inflammatory bowel disease, and food allergies. The severity of GI symptoms is directly proportional to the severity of autism. It has also been shown that the makeup of gut bacteria in ASD patients is different than that of neurotypical individuals. This has raised the question of influence of gut bacteria on ASD development via inducing an inflammatory state.

Listed below are some research findings on the influence of gut bacteria and abnormal immune responses on brain development:

• Some studies on rodents have shown gut bacteria influencing emotional functions and neurotransmitter balance in the brain, both of which are impacted in ASD.
• The immune system is thought to be the intermediary that modulates the influence of gut bacteria on the brain. Some ASD individuals have a dysfunctional immune system with higher numbers of some types of immune cells, biochemical messengers and modulators, and autoimmune antibodies. Increased inflammatory biomarkers correlate with increased severity of ASD symptoms and there is evidence to support a state of chronic brain inflammation in ASD.
• More pronounced inflammatory responses to bacteria were found in ASD individuals with an abnormal gut microbiota. Additionally IgA antibodies that are central to gut immunity were also found in elevated levels in ASD populations. Some of these antibodies may also attack proteins that support myelination of the brain, a process that is important for robust transmission of neural signal in many nerves.
• Activation of the maternal immune system during pregnancy (by gut bacteria, bacterial toxins, an infection, or non-infectious causes) and gut bacteria in the mother that induce increased levels of Th17, a proinflammatory immune cell, have been associated with an increased risk of autism. Some maternal IgG antibodies that cross the placenta to provide passive immunity to the fetus can also attack the fetal brain. One study found that 12% of mothers of autistic children have IgG that are active against the fetal brain.
• Inflammation within the gut itself does not directly affect brain development. Rather it is the inflammation within the brain promoted by inflammatory responses to harmful gut microbiome that impact brain development.
• Proinflammatory biomessengers IFN-γ, IFN-α, TNF-α, IL-6 and IL-17 have been shown to promote autistic behaviors in animal models. Giving anti-IL-6 and anti-IL-17 along with IL-6 and IL-17, respectively, have been shown to negate this effect in the same animal models.
• Some gut proteins and microbial products can cross the blood-brain barrier (BBB) and activate mast cells in the brain. Mast cells release proinflammatory factors and histamine which further increase BBB permeability and help set up a cycle of chronic inflammation.

Mirror neuron system

The mirror neuron system (MNS) consists of a network of brain areas that have been associated with empathy processes in humans. In humans, the MNS has been identified in the inferior frontal gyrus (IFG) and the inferior parietal lobule (IPL) and is thought to be activated during imitation or observation of behaviors. The connection between mirror neuron dysfunction and autism is tentative, and it remains to be seen how mirror neurons may be related to many of the important characteristics of autism.

"Social brain" interconnectivity

A number of discrete brain regions and networks among regions that are involved in dealing with other people have been discussed together under the rubric of the "social brain". As of 2012, there is a consensus that autism spectrum is likely related to problems with interconnectivity among these regions and networks, rather than problems with any specific region or network.

Temporal lobe

Functions of the temporal lobe are related to many of the deficits observed in individuals with ASDs, such as receptive language, social cognition, joint attention, action observation, and empathy. The temporal lobe also contains the superior temporal sulcus (STS) and the fusiform face area (FFA), which may mediate facial processing. It has been argued that dysfunction in the STS underlies the social deficits that characterize autism. Compared to typically developing individuals, one fMRI study found that individuals with high-functioning autism had reduced activity in the FFA when viewing pictures of faces.

Mitochondria

ASD could be linked to mitochondrial disease (MD), a basic cellular abnormality with the potential to cause disturbances in a wide range of body systems. A 2012 meta-analysis study, as well as other population studies have shown that approximately 5% of children with ASD meet the criteria for classical MD. It is unclear why the MD occurs considering that only 23% of children with both ASD and MD present with mitochondrial DNA (mtDNA) abnormalities.

Serotonin

Serotonin is a major neurotransmitter in the nervous system and contributes to formation of new neurons (neurogenesis), formation of new connections between neurons (synaptogenesis), remodeling of synapses, and survival and migration of neurons, processes that are necessary for a developing brain and some also necessary for learning in the adult brain. 45% of ASD individuals have been found to have increased blood serotonin levels. It has been hypothesized that increased activity of serotonin in the developing brain may facilitate the onset of autism spectrum disorder, with an association found in six out of eight studies between the use of selective serotonin reuptake inhibitors (SSRIs) by the pregnant mother and the development of ASD in the child exposed to SSRI in the antenatal environment. The study could not definitively conclude SSRIs caused the increased risk for ASDs due to the biases found in those studies, and the authors called for more definitive, better conducted studies. Confounding by indication has since then been shown to be likely. However, it is also hypothesized that SSRIs may help reduce symptoms of ASD and even positively affect brain development in some ASD patients.

Diagnosis

Process for screening and diagnosing Autism Spectrum Disorder; ASD – Autism Spectrum Disorder; M-CHAT – Modified Checklist for Autism in Toddlers; (+) – positive test result; (-) – negative test result

ASD can be detected as early as 18 months or even younger in some cases. A reliable diagnosis can usually be made by the age of two years, however, because of delays in seeking and administering assessments, diagnoses often occur much later. The diverse expressions of ASD behavioral and observational symptoms and absence of one specific genetic or molecular marker for the disease pose diagnostic challenges to clinicians who use assessment methods based on symptoms alone. Individuals with an ASD may present at various times of development (e.g., toddler, child, or adolescent), and symptom expression may vary over the course of development. Furthermore, clinicians who use those methods must differentiate among pervasive developmental disorders, and may also consider similar conditions, including intellectual disability not associated with a pervasive developmental disorder, specific language disorders, ADHD, anxiety, and psychotic disorders. Ideally the diagnosis of ASD should be given by a team of professionals from different disciplines (e.g. child psychiatrists, child neurologists, psychologists) and only after the child has been observed in many different settings.

Considering the unique challenges in diagnosing ASD using behavioral and observational assessment, specific practice parameters for its assessment were published by the American Academy of Neurology in the year 2000, the American Academy of Child and Adolescent Psychiatry in 1999, and a consensus panel with representation from various professional societies in 1999. The practice parameters outlined by these societies include an initial screening of children by general practitioners (i.e., "Level 1 screening") and for children who fail the initial screening, a comprehensive diagnostic assessment by experienced clinicians (i.e. "Level 2 evaluation"). Furthermore, it has been suggested that assessments of children with suspected ASD be evaluated within a developmental framework, include multiple informants (e.g., parents and teachers) from diverse contexts (e.g., home and school), and employ a multidisciplinary team of professionals (e.g., clinical psychologists, neuropsychologists, and psychiatrists).

As of 2019, psychologists would wait until a child showed initial evidence of ASD tendencies, then administer various psychological assessment tools to assess for ASD. Among these measurements, the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS) are considered the "gold standards" for assessing autistic children. The ADI-R is a semi-structured parent interview that probes for symptoms of autism by evaluating a child's current behavior and developmental history. The ADOS is a semistructured interactive evaluation of ASD symptoms that is used to measure social and communication abilities by eliciting several opportunities (or "presses") for spontaneous behaviors (e.g., eye contact) in standardized context. Various other questionnaires (e.g., The Childhood Autism Rating Scale, Autism Treatment Evaluation Checklist) and tests of cognitive functioning (e.g., The Peabody Picture Vocabulary Test) are typically included in an ASD assessment battery.

Screening

Screening recommendations for autism in children younger than 3 years are:

• US Preventive Services Task Force (USPSTF) does not recommend universal screen of young children for autism due to poor evidence of benefits of this screening when parents and clinicians have no concerns about ASD. The major concern is a false-positive diagnosis that would burden a family with very time consuming and financially demanding treatment interventions when it is not truly required. USPSTF also did not find any robust studies showing effectiveness of behavioral therapies in reducing ASD symptom severity
• American Academy of Pediatrics recommends ASD screening of all children between the ages if 18 and 24 months. The AAP also recommends that children who screen positive for ASD be referred to ASD treatment services without waiting for a comprehensive diagnostic workup.
• The American Academy of Family Physicians did not find sufficient evidence of benefit of universal early screening for ASD
• The American Academy of Neurology and Child Neurology Society recommends general routine screening for delayed or abnormal development in children followed by screening for ASD only if indicated by the general developmental screening
• Thee American Academy of Child and Adolescent Psychiatry recommend routinely screening autism symptoms in young children
• The UK National Screening Committee does not recommend universal ASD screening in young children. Their main concerns includes higher chances of misdiagnosis at younger ages and lack of evidence of effectiveness of early interventions

Misdiagnosis

There is a concern about significant levels of misdiagnosis of autism in neurodevelopmentally normal children. This is because 18–37% of children diagnosed with ASD eventually lose their diagnosis and this high rate of lost diagnosis cannot be accounted for by successful ASD treatment alone. The common reasons parents understood as the cause of lost ASD diagnosis were new information about child (73.5%), diagnosis given so child could receive ASD treatment services (24.2%) to treat another developmental disorder, ASD treatment success (21%), and incorrect diagnosis (1.9%).

Many of the children who were later found not to meet ASD diagnosis criteria then received diagnosis for another developmental disorder like ADHD (most common), sensory disorders, anxiety, personality disorder, or learning disability. Neurodevelopment and psychiatric disorders that are commonly misdiagnosed as ASD include specific language impairment, social communication disorder, anxiety disorder, reactive attachment disorder, cognitive impairment, visual impairment, hearing impairment and normal behavioral variations. Some normal behavioral variations that resemble autistic traits are repetitive behaviors, sensitivity to change in daily routines, focused interests, and toe-walking. These are considered normal behavioral variations when they do not cause impaired function. Boys are more likely to exhibit repetitive behaviors especially when excited, tired, bored, or stressed. Some ways of distinguishing normal behavioral variations from abnormal behaviors are the ability of the child to suppress these behaviors and the absence of these behaviors during sleep.

Listed below are some risk factors for ASD misdiagnosis:

• Children diagnosed with PDD-NOS or a mild form of ASD which may be harder to distinguish from other developmental delays
• Children diagnosed with ASD whose parents had no concerns about abnormal development in their child
• Initial ASD diagnosis given by generalists (e.g. pediatricians, family physicians etc.), mental health providers, and schools rather than specialists in child neurodevelopmental disorders e.g. child psychiatrists or child neurologists

Prognosis

Few children who are correctly diagnosed with ASD are thought to lose this diagnosis due to treatment or outgrowing their symptoms. Children with poor treatment outcomes also tend to be ones that had moderate to severe forms of ASD, whereas children who appear to have responded to treatment are the ones with milder forms of ASD.

Comorbidity

Autism spectrum disorders tend to be highly comorbid with other disorders. Comorbidity may increase with age and may worsen the course of youth with ASDs and make intervention/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.

• The most common medical condition occurring in individuals with autism spectrum disorders is seizure disorder or epilepsy, which occurs in 11–39% of individuals with ASD.
• 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 individuals with ASDs.
• Intellectual disabilities are some of the most common comorbid disorders with ASDs. Recent estimates suggest that 40–69% of individuals with ASD have some degree of an intellectual disability, more likely to be severe for females. A number of genetic syndromes causing intellectual disability may also be comorbid with ASD, including fragile X, Down, Prader-Willi, Angelman, Williams syndrome and SYNGAP1-related intellectual disability.
• Learning disabilities are also highly comorbid in individuals with an ASD. Approximately 25–75% of individuals with an ASD also have some degree of a learning disability.
• Various anxiety disorders tend to co-occur with autism spectrum disorders, with overall comorbidity rates of 7–84%. Rates of comorbid depression in individuals with an ASD range from 4–58%. 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.
• Deficits in ASD are often linked to behavior problems, such as difficulties following directions, being cooperative, and doing things on other people's terms. Symptoms similar to those of attention deficit hyperactivity disorder (ADHD) can be part of an ASD diagnosis.
• Sensory processing disorder is also comorbid with ASD, with comorbidity rates of 42–88%.
• Starting in adolescence, some people with Asperger syndrome (26% in one sample) fall under the criteria for the similar condition schizoid personality disorder, which is characterised by a lack of interest in social relationships, a tendency towards a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment and apathy. Asperger syndrome was traditionally called "schizoid disorder of childhood".

Treatment

There is no known cure for autism, although those with Asperger syndrome and those who have autism and require little-to-no support are more likely to experience a lessening of symptoms over time. Several interventions can help children with Autism. 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. 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. It has been argued that no single treatment is best and treatment is typically tailored to the child's needs.

 

Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, social, and job skills. Available approaches include applied behavior analysis, developmental models, structured teaching, speech and language therapy, social skills therapy, and occupational therapy. Among these approaches, interventions either treat autistic features comprehensively, or focus treatment on a specific area of deficit. Generally, when educating those with autism, specific tactics may be used to effectively relay information to these individuals. Using as much social interaction as possible is key in targeting the inhibition autistic individuals 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.

There has been increasing attention to the development of evidence-based interventions for young children with ASD. Two theoretical frameworks outlined for early childhood intervention include applied behavioral analysis (ABA) and the developmental social-pragmatic model (DSP). 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. The Journal of Clinical Child and Adolescent Psychology has deemed two early childhood interventions as "well-established": individual comprehensive ABA, and focused teacher-implemented ABA combined with DSP.

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. Various DSP programs have been developed to explicitly deliver intervention systems through at-home parent implementation.

A multitude of unresearched alternative therapies have also been implemented. Many have resulted in harm to autistic people and should not be employed unless proven to be safe. However, a recent 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.

In October 2015, the American Academy of Pediatrics (AAP) proposed new evidence-based recommendations for early interventions in ASD for children under 3. 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. However, a Cochrane review found no evidence that early intensive behavioral intervention (EIBI) is effective in reducing behavioral problems associated with autism in most children with ASD but did help improve IQ and language skills. The Chochrane 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. No advere effects of EIBI treatment were found. Studies on pet therapy have shown positive effects.

Generally speaking, treatment of ASD focuses on behavioral and educational interventions to target its two core symptoms: social communication deficits and restricted, repetitive behaviors. 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. Melatonin for example can be used for sleep problems.

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.

There is some emerging data that show positive effects of risperidone on restricted and repetitive behaviors, but due to the small sample size of these studies and the concerns about its side effects, antipsychotics are not recommended as primary treatment of RRBs.

Epidemiology

While rates of autism spectrum disorders are consistent across cultures, they vary greatly by gender, with boys diagnosed far more frequently than girls. The average male-to-female diagnosis ratio for ASDs is 4.2:1, with 1 in 70 boys, but only 1 in 315 girls. Girls, however, are more likely to have associated cognitive impairment. Among those with an ASD and intellectual disability, the sex ratio may be closer to 2:1. 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.

Autism prevalence has been estimated at 1-2 per 1,000, Asperger syndrome at roughly 0.6 per 1,000, childhood disintegrative disorder at 0.02 per 1,000, and PDD-NOS at 3.7 per 1,000. These rates are consistent across cultures and ethnic groups, as autism is considered a universal disorder.

Using DSM-V criteria 92% of the children diagnosed with a autism spectrum disorder per DSM-IV still meet the diagnostic criteria of an autism spectrum disorder. However if both Autism Spectrum Disorder and Social Communication Disorder categories of DSM-V 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. Relatively mild forms of autism, such as Aspergers as well as other developmental disorders were included in the recent DSM-5 diagnostic criteria. 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. In the US, the rates for diagnosed ASD have been steadily increasing since 2000 when records began being kept. 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.

United States

In the United States it is estimated to affect more than 2% of children (about 1.5 million) as of 2016. According to the latest CDC prevalence reports, 1 in 59 children (1.7%) in the United States had a diagnosis of ASD in 2014, reflecting a 2.5-fold increase from the prevalence rate in 2000. Prevalence is estimated at 6 per 1,000 for autism spectrum disorders as a whole, although prevalence rates vary for each of the developmental disorders in the spectrum.

History

Controversies have surrounded various claims regarding the etiology of autism spectrum disorders. In the 1950s, the "refrigerator mother theory" emerged as an explanation for autism. The hypothesis was based on the idea that autistic behaviors stem from the emotional frigidity, lack of warmth, and cold, distant, rejecting demeanor of a child's mother. Naturally, parents of children with an autism spectrum disorder suffered from blame, guilt, and self-doubt, especially as the theory was embraced by the medical establishment and went largely unchallenged into the mid-1960s. The "refrigerator mother" theory has since continued to be refuted in scientific literature, including a 2015 systematic review which showed no association between caregiver interaction and language outcomes in ASD.

Leo Kanner, a child psychiatrist, was the first person to describe ASD as a neurodevelopmental disorder in 1943 by calling it 'infantile autism' and therefore rejected the 'refrigerator mother' theory.

Another controversial claim suggests that watching extensive amounts of television may cause autism. This hypothesis was largely based on research suggesting that the increasing rates of autism in the 1970s and 1980s were linked to the growth of cable television at this time.

Society and culture

Caregivers

Families who care for an autistic child face added stress from a number of different causes. Parents may struggle to understand the diagnosis and to find appropriate care options. Parents often take a negative view of the diagnosis, and may struggle emotionally. In the words of one parent whose two children were both diagnosed with autism, "In the moment of diagnosis, it feels like the death of your hopes and dreams." More than half of parents over the age of 50 are still living with their child as about 85% of people with ASD have difficulties living independently.

Autism rights movement

The autism rights movement is a social movement within the context of disability rights that emphasizes the concept of neurodiversity, viewing the autism spectrum as a result of natural variations in the human brain rather than a disorder to be cured. 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; and the recognition of the autistic community as a minority group. Autism rights or neurodiversity advocates believe that the autism spectrum is genetic and should be accepted as a natural expression of the human genome. This perspective is distinct from two other likewise distinct views: the medical perspective, that autism is caused by a genetic defect and should be addressed by targeting the autism gene(s), and fringe theories that autism is caused by environmental factors such as vaccines. A common criticism against autistic activists is that the majority of them are "high-functioning" or have Asperger syndrome and do not represent the views of "low-functioning" autistic people.

Academic performance

The number of students identified and served as eligible for autism services in the United States has increased from 5,413 children in 1991–1992 to 370,011 children in the 2010–2011 academic school year. The United States Department of Health and Human Services reported approximately 1 in 68 children at age 8 are diagnosed with autism spectrum disorder (ASD) although onset is typically between ages 2 and 4.

The increasing number of students with ASD in the schools presents significant challenges to teachers, school psychologists, and other school professionals. These challenges include developing a consistent practice that best support the social and cognitive development of the increasing number of students with ASD. Although there is considerable research addressing assessment, identification, and support services for children with ASD, there is a need for further research focused on these topics within the school context. Further research on appropriate support services for students with ASD will provide school psychologists and other education professionals with specific directions for advocacy and service delivery that aim to enhance school outcomes for students with ASD.

Attempts to identify and use best intervention practices for students with autism also pose a challenge due to overdependence on popular or well-known interventions and curricula. Some evidence suggests that although these interventions work for some students, there remains a lack of specificity for which type of student, under what environmental conditions (one-on-one, specialized instruction or general education) and for which targeted deficits they work best. More research is needed to identify what assessment methods are most effective for identifying the level of educational needs for students with ASD.

A difficulty for academic performance in students with ASD, is the tendency to generalize learning. Learning is different for each student, which is the same for students with ASD. To assist in learning, accommodations are commonly put into place for students with differing abilities. The existing schema of these students works in different ways and can be adjusted to best support the educational development for each student.

The cost of educating a student with ASD in the US is about $8,600 a year more than the cost of educating an average student, which is about $12,000.

Employment

About half of people in their 20s with autism are unemployed, and one third of those with graduate degrees may be unemployed. Among those on the autism spectrum who find work, most are employed in sheltered settings working for wages below the national minimum. While employers state hiring concerns about productivity and supervision, experienced employers of autistics give positive reports of above average memory and detail orientation as well as a high regard for rules and procedure in autistic employees. A majority of the economic burden of autism is caused by lost productivity in the job market. Some studies also find decreased earning among parents who care for autistic children. Adding content related to autism in existing diversity training can clarify misconceptions, support employees, and help provide new opportunities for autistics.