Prognosis of autism

Last updated

There is currently no evidence of a cure for autism. [1] [2] The degree of symptoms can decrease, occasionally to the extent that people lose their diagnosis of autism; [3] [4] this occurs sometimes after intensive treatment [5] and sometimes not. It is not known how often this outcome happens, [6] with reported rates in unselected samples ranging from 3% to 25%. [3] [4] Although core difficulties tend to persist, symptoms often become less severe with age. [7] Acquiring language before age six, having an IQ above 50, and having a marketable skill all predict better outcomes; independent living is unlikely in autistic people with higher support needs. [8]

Contents

Developmental course

There are two possible developmental courses of autism. One course of development is more gradual in nature, with symptoms appearing fairly early in life and persisting. [9] A second course of development is characterized by normal or near-normal development before onset of regression or loss of skills, which is known as regressive autism. [10]

Gradual autism development

Most parents report that the onset of autism features appear within the first or second year of life. [11] [12] This course of development is fairly gradual, in that parents typically report concerns in development over the first two years of life and diagnosis can be made around 3–4 years of age. [9] Overt features gradually begin after the age of six months, become established by age two or three years, [13] and tend to continue through adulthood, although often in more muted form. [7] Some of the early signs of autism in this course include decreased attention at faces, failure to obviously respond when name is called, failure to show interests by showing or pointing, and delayed imaginative play. [14]

Regressive autism development

Regressive autism occurs when a child appears to develop typically but then starts to lose speech and social skills and is subsequently diagnosed with ASD. [15] Other terms used to describe regression in children with autism are autism with regression, autistic regression, setback-type autism, and acquired autistic syndrome. [16]

Within the regressive autism developmental course, there are two patterns. The first pattern is when developmental losses occur in the first 15 months to 3 years. [17] [18] The second pattern, childhood disintegrative disorder (a diagnosis now included under ASD in the DSM, but not the ICD), is characterized by regression after normal development in the first 3 to 4, or even up to 9 years of life. [19]

After the regression, the child follows the standard pattern of autistic neurological development. The term regressive autism refers to the appearance that neurological development has reversed; it is actually only the affected developmental skills, rather than the neurology as a whole, that regresses.

Usually, the apparent onset of regressive autism can be surprising and distressing to parents, who often initially suspect severe hearing loss. [20] Attribution of regression to environmental stress factors may result in a delay in diagnosis. [21]

There is no standard definition for regression. [16] Some children show a mixture of features, with some early delays and some later losses; and there is evidence of a continuous spectrum of behaviors, rather than, or in addition to, a black-and-white distinction, between autism with and without regression. [22] There are several intermediate types of development, which do not neatly fit into either the traditional early onset or the regressive categories, including mixtures of early deficits, failures to progress, subtle diminishment, and obvious losses.

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. [23] [17] [18] Some children lose social development instead of language; some lose both. [22] Skill loss may be quite rapid, or may be slow and preceded by a lengthy period of no skill progression; the loss may be accompanied by reduced social play or increased irritability. [16] The temporarily acquired skills typically amount to a few words of spoken language, and may include some rudimentary social perception. [22]

The prevalence of regression varies depending on the definition used. [22] If regression is defined strictly to require loss of language, it is less common; if defined more broadly, to include cases where language is preserved but social interaction is diminished, it is more common. [22] Although regressive autism is often thought to be a less common (compared with gradual course of autism onset described above), this remains an area of ongoing debate; [23] some evidence suggests that a pattern of regressive autism may be more common than previously thought. [24] There are some who believe that regressive autism is simply early-onset autism which was recognized at a later date. Researchers have conducted studies to determine whether regressive autism is a distinct subset of ASD, but the results of these studies have contradicted one another. [15]

Differential outcomes

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. [25] While there is conflicting evidence surrounding language outcomes in autism, some studies have shown that cognitive and language abilities at age 2+1⁄2 may help predict language proficiency and production after age 5. [26] Overall, the literature stresses the importance of early intervention in achieving positive longitudinal outcomes. [27]

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. [28] The United States Department of Health and Human Services reported approximately 1 in 68 children are diagnosed with autism at age 8, and onset is typically between ages 2 and 4. [28]

The increasing number of students diagnosed with autism in the schools presents significant challenges to teachers, school psychologists, and other school professionals. [28] These challenges include developing a consistent practice that best support the social and cognitive development of the increasing number of autistic students. [28] Although there is considerable research addressing assessment, identification, and support services for autistic children, there is a need for further research focused on these topics within the school context. [28] 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. [28]

Attempts to identify and use best intervention practices for students with autism also pose a challenge due to over dependence on popular or well-known interventions and curricula. [28] 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. [28] More research is needed to identify what assessment methods are most effective for identifying the level of educational needs for students with ASD. Additionally, children living in higher resources settings in the United States tend to experience earlier ASD interventions than children in lower resource settings (e.g. rural areas). [29]

A difficulty for academic performance in students with autism is the tendency to generalize learning. [30] Learning is different for each student, which is the same for students with autism. 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. [31]

The cost of educating a student with autism in the US would be about $20,600 while educating an average student would be about $12,000. [32]

Though much of the focus on early childhood intervention for autism has centered on high-income countries like the United States, some of the most significant unmet needs for autistic individuals are in low- and middle-income countries. [29] In these contexts, research has been more limited but there is evidence to suggest that some comprehensive care plans can be successfully delivered by non-specialists in schools and in the community. [29]

Adulthood

Many autistic people face significant obstacles in transitioning to adulthood. [33] Autistic people may face socialization issues, which may impact relationships such as community participation, employment, independent living, friendships, dating and marriage, and having children. Some autistic adults are unable to live independently. [34]

Employment

The majority of the economic burden of autism is caused by lost productivity in the job market. [35] Compared to the general population, autistic people are more likely to be unemployed and to have never had a job. About half of people in their 20s with autism are not employed. [36]

In various developed countries, the autism unemployment rate can range from 62% to as high as 85%., [37] [38] [39] [40] although in some it can be as low as 25%. [41] 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. [42]

From the perspective of the social model of disability, much of this unemployment is caused by the lack of understanding from employers and coworkers. [43] [44] Adding content related to autism in existing diversity training can clarify misconceptions, support employees, and help provide new opportunities for autistic people. [45] As of 2021, new autism employment initiatives by major employers in the United States continue to grow, as the initiative "Autism at Work" grew to 20 of the largest companies in the United States. [46] However, special hiring programs remain largely limited to entry-level technology positions, such as software testing, and exclude those who have talents outside of technology. An alternative approach is systemic neurodiversity inclusion. Developing organizational systems with enough flexibility and fairness to include autistic employees improves the work experience of all employees. [47] [48]

Related Research Articles

<span class="mw-page-title-main">Asperger syndrome</span> Formerly recognized subtype of autism

Asperger syndrome (AS), also known as Asperger's syndrome or Asperger's, is a diagnosis formerly used to describe a neurodevelopmental condition characterized by significant difficulties in social interaction and nonverbal communication, along with restricted, repetitive patterns of behavior and interests. Asperger syndrome has been merged with other conditions into autism spectrum disorder (ASD) and is no longer a diagnosis in the WHO's ICD-11 or the APA's DSM-5-TR. It was considered milder than other diagnoses which were merged into ASD due to relatively unimpaired spoken language and intelligence.

The diagnostic category pervasive developmental disorders (PDD), as opposed to specific developmental disorders (SDD), was a group of disorders characterized by delays in the development of multiple basic functions including socialization and communication. It was defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM), and the International Classification of Diseases (ICD).

Developmental disorders comprise a group of psychiatric conditions originating in childhood that involve serious impairment in different areas. There are several ways of using this term. The most narrow concept is used in the category "Specific Disorders of Psychological Development" in the ICD-10. These disorders comprise developmental language disorder, learning disorders, developmental coordination disorders, and autism spectrum disorders (ASD). In broader definitions, attention deficit hyperactivity disorder (ADHD) is included, and the term used is neurodevelopmental disorders. Yet others include antisocial behavior and schizophrenia that begins in childhood and continues through life. However, these two latter conditions are not as stable as the other developmental disorders, and there is not the same evidence of a shared genetic liability.

Childhood disintegrative disorder (CDD), also known as Heller's syndrome and disintegrative psychosis, is a rare condition characterized by late onset of developmental delays—or severe and sudden reversals—in language, social engagement, bowel and bladder, play and motor skills. Researchers have not been successful in finding a cause for the disorder. CDD has some similarities to autism and is sometimes considered a low-functioning form of it. In May 2013, CDD, along with other sub-types of PDD, was fused into a single diagnostic term called "autism spectrum disorder" under the new DSM-5 manual.

Diagnoses of autism have become more frequent since the 1980s, which has led to various controversies about both the cause of autism and the nature of the diagnoses themselves. Whether autism has mainly a genetic or developmental cause, and the degree of coincidence between autism and intellectual disability, are all matters of current scientific controversy as well as inquiry. There is also more sociopolitical debate as to whether autism should be considered a disability on its own.

<span class="mw-page-title-main">Conditions comorbid to autism</span> Medical conditions more common in autistic people

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that begins in early childhood, persists throughout adulthood, and is characterized by difficulties in social communication and restricted, repetitive patterns of behavior. There are many conditions comorbid to autism spectrum disorder, such as attention deficit hyperactivity disorder, anxiety disorders, and epilepsy.

<span class="mw-page-title-main">Neurodiversity</span> Non-pathological explanation of variations in mental functions

The neurodiversity paradigm is a framework for understanding human brain function that recognizes the diversity within sensory processing, motor abilities, social comfort, cognition, and focus as neurobiological differences. This diversity falls on a spectrum of neurocognitive differences. The neurodiversity paradigm argues that diversity in human cognition is normal and that some conditions generally classified as disorders, such as autism, are differences and disabilities that are not necessarily pathological. Neurotypical individuals are those who fall within the average range of functioning and thinking.

Ole Ivar Løvaas was a Norwegian-American clinical psychologist and professor at the University of California, Los Angeles. He is most well known for his research on what is now called applied behavior analysis (ABA) to teach autistic children through prompts, modeling, and positive reinforcement. The therapy is also noted for its use of aversives (punishment) to reduce undesired behavior.

Discrete trial training (DTT) is a technique used by practitioners of applied behavior analysis (ABA) that was developed by Ivar Lovaas at the University of California, Los Angeles (UCLA). DTT uses mass instruction and reinforcers that create clear contingencies to shape new skills. Often employed as an early intensive behavioral intervention (EIBI) for up to 25–40 hours per week for children with autism, the technique relies on the use of prompts, modeling, and positive reinforcement strategies to facilitate the child's learning. It previously used aversives to punish unwanted behaviors. DTT has also been referred to as the "Lovaas/UCLA model", "rapid motor imitation antecedent", "listener responding", "errorless learning", and "mass trials".

High-functioning autism (HFA) was historically an autism classification to describe a person who exhibited no intellectual disability but otherwise showed autistic traits, such as difficulty in social interaction and communication, as well as repetitive, restricted patterns of behavior. The term is often applied to autistic people who are fluently verbal and of at least average intelligence. However, many in medical and autistic communities have called to stop using the term, finding it simplistic and unindicative of the difficulties some autistic people face.

<span class="mw-page-title-main">Autism therapies</span> Therapy aimed at autistic people

Autism therapies include a wide variety of therapies that help people with autism, or their families. Such methods of therapy seek to aid autistic people in dealing with difficulties and increase their functional independence.

The epidemiology of autism is the study of the incidence and distribution of autism spectrum disorders (ASD). A 2022 systematic review of global prevalence of autism spectrum disorders found a median prevalence of 1% in children in studies published from 2012 to 2021, with a trend of increasing prevalence over time. However, the study's 1% figure may reflect an underestimate of prevalence in low- and middle-income countries.

The floortime or Developmental, Individual-differences, Relationship-based (DIR) model is a developmental model for assessing and understanding any child's strengths and weaknesses. This model was developed by Stanley Greenspan and first outlined in 1979 in his book Intelligence and Adaptation.

<span class="mw-page-title-main">Classic autism</span> Former neurodevelopmental disorder now classified under autism spectrum disorder

Classic autism, also known as childhood autism, autistic disorder, (early) infantile autism, infantile psychosis, Kanner's autism, Kanner's syndrome, or (formerly) just autism, is a neurodevelopmental condition first described by Leo Kanner in 1943. It is characterized by atypical and impaired development in social interaction and communication as well as restricted, repetitive behaviors, activities, and interests. These symptoms first appear in early childhood and persist throughout life.

Autism or autism spectrum disorder (ASD), is a neurodevelopmental disorder characterized by repetitive, restricted, and inflexible patterns of behavior, interests, and activities, as well as persistent difficulties in social communication and interaction. Autism generally affects a person's ability to understand and connect with others, as well as their adaptability to everyday situations, with its severity and support needs varying widely across the underlying spectrum. For example, some are nonverbal, while others have proficient spoken language.

Nonverbal autism, also called nonspeaking autism, is a subset of autism spectrum disorder (ASD) where the person does not learn how to speak. One study has shown that 64% of autistic children who are nonverbal at age 5 are still nonverbal 10 years later.

John N. Constantino is a child psychiatrist and expert on neurodevelopmental disorders, especially autism spectrum disorders (ASD). Constantino is the inaugural System Chief of Behavioral and Mental Health at Children's Healthcare of Atlanta. He is a Professor of Pediatrics, Psychiatry and Behavioral Sciences and Genetics at the Emory University School of Medicine.

<span class="mw-page-title-main">Autistic masking</span> Suppression of autistic behaviors

Autistic masking, also referred to as camouflaging is the conscious or subconscious suppression of autistic behaviors and compensation of difficulties in social interaction by autistic people with the goal of being perceived as neurotypical. Masking is a learned coping strategy that can be successful from the perspective of autistic people, but can also lead to adverse mental health outcomes.

Daniel S. Messinger is an American interdisciplinary developmental psychologist, and academic. His research works span the field of developmental psychology with a focus on emotional and social development of children and infants, and the interactive behavior of children in preschool inclusive classroom.

The diagnosis of autism is based on a person's reported and directly observed behavior. There are no known biomarkers for autism spectrum conditions that allow for a conclusive diagnosis.

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