This article needs to be updated. The reason given is: some parts of the article do not accurately reflect either the new DSM5 or ICD10 or ICD11 criteria. Please help update this article to reflect recent events or newly available information. (February 2021)
Repetitively stacking or lining up objects is commonly associated with autism.
Kanner autism, or classic autism, is a neurodevelopmental disorder characterized by challenges with social communication, and by restricted and repetitive behaviors. It is now considered part of the wider autism spectrum. The term 'autism' was historically used to refer specifically to Kanner autism, which is the convention used in much of this entry, but it is now more commonly used for the spectrum at large.
Parents often notice signs of autism during the first three years of their child's life. These signs often develop gradually, though some autistic children experience regression in their communication and social skills after reaching developmental milestones at a normal pace.
There is no 'treatment' for autism as such, and many sources advise that this is not an appropriate goal, although treatment of co-occurring conditions remains an important goal. Behavioral, psychological, education, and/or skill-building interventions may be used to assist autistic people to learn life skills necessary for living independently, as well as other social, communication, and language skills. Therapy also aims to reduce challenging behaviors and build upon strengths. Some autistic adults are unable to live independently. An autistic culture has developed, with a minority of individuals seeking a cure, and others believing autism should be accepted as a difference to be accommodated instead of cured.
Globally, classic autism was estimated to affect 24.8 million people as of 2015[update]. The number of people diagnosed had increased considerably since the 1990s, which may be partly due to increased recognition of the condition.
Autism is a highly variable neurodevelopmental disorder whose symptoms first appear during infancy or childhood, and generally follows a steady course without remission. Autistic people may be severely impaired in some respects but average, or even superior, in others. Overt symptoms gradually begin after the age of six months, become established by age two or three years and tend to continue through adulthood, although often in more muted form. It was said to be distinguished by a characteristic triad of symptoms: impairments in social interaction, impairments in communication, and repetitive behavior. Other aspects, such as atypical eating, are also common but are not essential for diagnosis. Individual symptoms of autism occur in the general population and appear not to associate highly, without a sharp line separating pathologically severe from common traits.
Unusual social development becomes apparent early in childhood. Autistic infants show less attention to social stimuli, smile and look at others less often, and respond less to their own name. Autistic toddlers differ more strikingly from social norms; for example, they have less eye contact and turn-taking, and do not have the ability to use simple movements to express themselves, such as pointing at things. Three- to five-year-old autistic children are less likely to exhibit social understanding, approach others spontaneously, imitate and respond to emotions, communicate nonverbally, and take turns with others. However, they do form attachments to their primary caregivers. Most autistic children display moderately less attachment security than neurotypical children, although this difference disappears in children with higher mental development or less pronounced autistic traits. Older children and adults with ASD perform worse on tests of face and emotion recognition although this may be partly due to a lower ability to define a person's own emotions.
Children with high-functioning autism have more intense and frequent loneliness compared to non-autistic peers, despite the common belief that autistic children prefer to be alone. Making and maintaining friendships often proves to be difficult for autistic people. For them, the quality of friendships, not the number of friends, predicts how lonely they feel. Functional friendships, such as those resulting in invitations to parties, may affect the quality of life more deeply.
There are many anecdotal reports, but few systematic studies, of aggression and violence in individuals with ASD. The limited data suggest that, in children with intellectual disability, autism is associated with aggression, destruction of property, and meltdowns.
About one third to half of autistic people do not develop enough natural speech to meet their daily communication needs. Differences in communication may be present from the first year of life, and may include delayed onset of babbling, unusual gestures, diminished responsiveness, and vocal patterns that are not synchronized with the caregiver. In the second and third years, autistic children have less frequent and less diverse babbling, consonants, words, and word combinations; their gestures are less often integrated with words. Autistic children are less likely to make requests or share experiences, and are more likely to simply repeat others' words (echolalia) or reverse pronouns.Joint attention seems to be necessary for functional speech, and deficits in joint attention seem to distinguish infants with ASD. For example, they may look at a pointing hand instead of the object to which the hand is pointing, and they consistently fail to point at objects in order to comment on or share an experience. Autistic children may have difficulty with imaginative play and with developing symbols into language.
In a pair of studies, high-functioning autistic children aged 8–15 performed equally well as, and as adults better than, individually matched controls at basic language tasks involving vocabulary and spelling. Both autistic groups performed worse than controls at complex language tasks such as figurative language, comprehension, and inference. As people are often sized up initially from their basic language skills, these studies suggest that people speaking to autistic individuals are more likely to overestimate what their audience comprehends.[better source needed]
A young autistic boy who has arranged his toys in a row
Autistic individuals can display many forms of repetitive or restricted behavior, which the Repetitive Behavior Scale-Revised (RBS-R) categorizes as follows.
Compulsive behaviors: Time-consuming behaviors intended to reduce the anxiety that an individual feels compelled to perform repeatedly or according to rigid rules, such as placing objects in a specific order, checking things, or handwashing.
Sameness: Resistance to change; for example, insisting that the furniture not be moved or refusing to be interrupted.
Ritualistic behavior: Unvarying pattern of daily activities, such as an unchanging menu or a dressing ritual. This is closely associated with sameness and an independent validation has suggested combining the two factors.
Restricted interests: Interests or fixations that are abnormal in theme or intensity of focus, such as preoccupation with a single television program, toy, or game.
No single repetitive or self-injurious behavior seems to be specific to autism, but autism appears to have an elevated pattern of occurrence and severity of these behaviors.
Autistic individuals may have symptoms that are independent of the diagnosis, but that can affect the individual or the family.
An estimated 0.5% to 10% of individuals with ASD show unusual abilities, ranging from splinter skills such as the memorization of trivia to the extraordinarily rare talents of prodigious autistic savants. Many individuals with ASD show superior skills in perception and attention, relative to the general population.Sensory abnormalities are found in over 90% of autistic people, and are considered core features by some, although there is no good evidence that sensory symptoms differentiate autism from other developmental disorders. Differences are greater for under-responsivity (for example, walking into things) than for over-responsivity (for example, distress from loud noises) or for sensation seeking (for example, rhythmic movements). An estimated 60–80% of autistic people have motor signs that include poor muscle tone, poor motor planning, and toe walking; deficits in motor coordination are pervasive across ASD and are greater in autism proper. Unusual eating behavior occurs in about three-quarters of children with ASD, to the extent that it was formerly a diagnostic indicator. Selectivity is the most common problem, although eating rituals and food refusal also occur.
There is tentative evidence that gender dysphoria occurs more frequently in autistic people (see Autism and LGBT identities). As well as that, a 2021 anonymized online survey of 16-90 year-olds revealed that autistic males are more likely to be bisexual, while autistic females are more likely to be homosexual.
Parents of children with ASD have higher levels of stress. Siblings of children with ASD report greater admiration of and less conflict with the affected sibling than siblings of unaffected children and were similar to siblings of children with Down syndrome in these aspects of the sibling relationship. However, they reported lower levels of closeness and intimacy than siblings of children with Down syndrome; siblings of individuals with ASD have greater likelihood of negative well-being and poorer sibling relationships as adults.
It has long been presumed that there is a common cause at the genetic, cognitive, and neural levels for autism's characteristic triad of symptoms. However, there is increasing suspicion that autism is instead a complex disorder whose core aspects have distinct causes that often co-occur.
Autism has a strong genetic basis, although the genetics of autism are complex and it is unclear whether ASD is explained more by rare mutations with major effects, or by rare multigene interactions of common genetic variants. Complexity arises due to interactions among multiple genes, the environment, and epigenetic factors which do not change DNA sequencing but are heritable and influence gene expression. Many genes have been associated with autism through sequencing the genomes of affected individuals and their parents. Studies of twins suggest that heritability is 0.7 for autism and as high as 0.9 for ASD, and siblings of those with autism are about 25 times more likely to be autistic than the general population. However, most of the mutations that increase the likelihood of a diagnosis of autism have not been identified. Typically, autism cannot be traced to a Mendelian (single-gene) mutation or to a single chromosome abnormality, and none of the genetic syndromes associated with ASDs have been shown to selectively cause ASD. Numerous candidate genes have been located, with only small effects attributable to any particular gene. Most loci individually explain less than 1% of cases of autism. The large number of autistic individuals with unaffected family members may result from spontaneous structural variation—such as deletions, duplications or inversions in genetic material during meiosis. Hence, a substantial fraction of autism cases may be traceable to genetic causes that are highly heritable but not inherited: that is, the mutation that causes the autism is not present in the parental genome. Autism may be underdiagnosed in women and girls due to an assumption that it is primarily a male condition, but genetic phenomena such as imprinting and X linkage have the ability to raise the frequency and severity of conditions in males, and theories have been put forward for a genetic reason why males are diagnosed more often, such as the imprinted brain hypothesis and the extreme male brain theory.
Maternal nutrition and inflammation during preconception and pregnancy influences fetal neurodevelopment. Intrauterine growth restriction is associated with ASD, in both term and preterm infants. Maternal inflammatory and autoimmune diseases may damage fetal tissues, aggravating a genetic problem or damaging the nervous system.
Diagnosis is based on behavior, not cause or mechanism. Under the DSM-5, autism is characterized by persistent deficits in social communication and interaction across multiple contexts, as well as restricted, repetitive patterns of behavior, interests, or activities. These deficits are present in early childhood, typically before age three, and lead to clinically significant functional impairment. Sample symptoms include lack of social or emotional reciprocity, stereotyped and repetitive use of language or idiosyncratic language, and persistent preoccupation with unusual objects. The disturbance must not be better accounted for by Rett syndrome, intellectual disability or global developmental delay.ICD-10 uses essentially the same definition.
Clinical genetics evaluations are often done once ASD is diagnosed, particularly when other symptoms already suggest a genetic cause. Although genetic technology allows clinical geneticists to link an estimated 40% of cases to genetic causes, consensus guidelines in the US and UK are limited to high-resolution chromosome and fragile X testing. A genotype-first model of diagnosis has been proposed, which would routinely assess the genome's copy number variations. As new genetic tests are developed several ethical, legal, and social issues will emerge. Commercial availability of tests may precede adequate understanding of how to use test results, given the complexity of autism's genetics.Metabolic and neuroimaging tests are sometimes helpful, but are not routine.
ASD can sometimes be diagnosed by age 14 months, although diagnosis becomes increasingly stable over the first three years of life: for example, a one-year-old who meets diagnostic criteria for ASD is less likely than a three-year-old to continue to do so a few years later. In the UK the National Autism Plan for Children recommends at most 30 weeks from first concern to completed diagnosis and assessment, though few cases are handled that quickly in practice. Although the symptoms of autism and ASD begin early in childhood, they are sometimes missed; years later, adults may seek diagnoses to help them or their friends and family understand themselves, to help their employers make adjustments, or in some locations to claim disability living allowances or other benefits.
Signs of autism may be more challenging for clinicians to detect in females.[better source needed] Autistic females have been shown to engage in masking more frequently than autistic males. Masking may include making oneself perform normative facial expressions and eye contact.[better source needed] A notable percentage of autistic females may be misdiagnosed, diagnosed after a considerable delay, or not diagnosed at all.
Conversely, the cost of screening and diagnosis and the challenge of obtaining payment can inhibit or delay diagnosis. It is particularly hard to diagnose autism among the visually impaired, partly because some of its diagnostic criteria depend on vision, and partly because autistic symptoms overlap with those of common blindness syndromes or blindisms.
The fourth edition of the American Psychiatric Association's diagnostic manual, DSM-IV, listed autistic disorder as one of the five pervasive developmental disorders (PDD), but these were collapsed into the single diagnosis of Autism Spectrum Disorder in 2013, and the WHO's diagnostic manual ICD-11 (which had listed it as 'childhood autism' in its previous edition) followed suit a few years later. It was said to be characterized by widespread abnormalities of social interactions and communication, severely restricted interests, and highly repetitive behavior. These symptoms do not imply sickness, fragility, or emotional disturbance.
Autism has long been thought to cover a wide spectrum, ranging from individuals with severe impairments—who may be silent, developmentally disabled, and prone to frequent repetitive behavior such as hand flapping and rocking—to high functioning individuals who may have active but distinctly odd social approaches, narrowly focused interests, and verbose, pedantic communication. Because the behavior spectrum is continuous, boundaries between diagnostic categories were necessarily somewhat arbitrary. The autism spectrum, in turn, is sometimes said to be a subset of the broader autism phenotype, which describes individuals who may not have ASD but do have autistic-like traits, such as avoiding eye contact.
An autistic three-year-old points to fish in an aquarium, as part of an experiment on the effect of intensive shared-attention training on language development.
The main goals when treating autistic children are to lessen associated deficits and family distress, and to increase quality of life and functional independence. In general, higher IQs are correlated with greater responsiveness to treatment and improved treatment outcomes. No single treatment is best and treatment is typically tailored to the child's needs. Families and the educational system are the main resources for treatment. Services should be carried out by behavior analysts, special education teachers, speech pathologists, and licensed psychologists. Studies of interventions have methodological problems that prevent definitive conclusions about efficacy. However, the development of evidence-based interventions has advanced in recent years. Although many psychosocial interventions have some positive evidence, suggesting that some form of treatment is preferable to no treatment, the methodological quality of systematic reviews of these studies has generally been poor, their clinical results are mostly tentative, and there is little evidence for the relative effectiveness of treatment options. Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, communication, and job skills, and often improve functioning and decrease symptom severity and maladaptive behaviors; claims that intervention by around age three years is crucial are not substantiated. While medications have not been found to help with core symptoms, they may be used for associated symptoms, such as irritability, inattention, or repetitive behavior patterns.
Educational interventions often used include applied behavior analysis (ABA), developmental models, structured teaching, speech and language therapy, social skills therapy, and occupational therapy and cognitive behavioral interventions in adults without intellectual disability to reduce depression, anxiety, and obsessive-compulsive disorder. Among these approaches, interventions either treat autistic features comprehensively, or focalize treatment on a specific area of deficit. The quality of research for early intensive behavioral intervention (EIBI)—a treatment procedure incorporating over thirty hours per week of the structured type of ABA that is carried out with very young children—is currently low, and more vigorous research designs with larger sample sizes are needed. Two theoretical frameworks outlined for early childhood intervention include structured and naturalistic ABA interventions, and developmental social pragmatic models (DSP). One interventional strategy utilizes a parent training model, which teaches parents how to implement various ABA and DSP techniques, allowing for parents to disseminate interventions themselves. Various DSP programs have been developed to explicitly deliver intervention systems through at-home parent implementation. Despite the recent development of parent training models, these interventions have demonstrated effectiveness in numerous studies, being evaluated as a probable efficacious mode of treatment.
Early, intensive ABA therapy has demonstrated effectiveness in enhancing communication and adaptive functioning in preschool children; it is also well-established for improving the intellectual performance of that age group. Similarly, a teacher-implemented intervention that utilizes a more naturalistic form of ABA combined with a developmental social pragmatic approach has been found to be beneficial in improving social-communication skills in young children, although there is less evidence in its treatment of global symptoms. Neuropsychological reports are often poorly communicated to educators, resulting in a gap between what a report recommends and what education is provided. It is not known whether treatment programs for children lead to significant improvements after the children grow up, and the limited research on the effectiveness of adult residential programs shows mixed results. The appropriateness of including children with varying severity of autism spectrum disorders in the general education population is a subject of current debate among educators and researchers.
Medications may be used to treat ASD symptoms that interfere with integrating a child into home or school when behavioral treatment fails. They may also be used for associated health problems, such as ADHD or anxiety. More than half of US children diagnosed with ASD are prescribed psychoactive drugs or anticonvulsants, with the most common drug classes being antidepressants, stimulants, and antipsychotics. The atypical antipsychotic drugs risperidone and aripiprazole are FDA-approved for treating associated aggressive and self-injurious behaviors. However, their side effects must be weighed against their potential benefits, and autistic people may respond atypically. Side effects, for example, may include weight gain, tiredness, drooling, and aggression.SSRI antidepressants, such as fluoxetine and fluvoxamine, have been shown to be effective in reducing repetitive and ritualistic behaviors, while the stimulant medication methylphenidate is beneficial for some children with co-morbid inattentiveness or hyperactivity. There is scant reliable research about the effectiveness or safety of drug treatments for adolescents and adults with ASD.[medical citation needed] No known medication relieves autism's core symptoms of social and communication impairments.[medical citation needed] Experiments in mice have reversed or reduced some symptoms related to autism by replacing or modulating gene function, suggesting the possibility of targeting therapies to specific rare mutations known to cause autism.
Although many alternative therapies and interventions are available, few are supported by scientific studies. Treatment approaches have little empirical support in quality-of-life contexts, and many programs focus on success measures that lack predictive validity and real-world relevance. Some alternative treatments may place the child at risk. The preference that autistic children have for unconventional foods can lead to reduction in bone cortical thickness with this being greater in those on casein-free diets, as a consequence of the low intake of calcium and vitamin D; however, suboptimal bone development in ASD has also been associated with lack of exercise and gastrointestinal disorders. In 2005, botched chelation therapy killed a five-year-old child with autism. Chelation is not recommended for autistic people since the associated risks outweigh any potential benefits. Another alternative medicine practice with no evidence is CEASE therapy, a mixture of homeopathy, supplements, and 'vaccine detoxing'.[medical citation needed]
Although popularly used as an alternative treatment for autistic people, as of 2018[update] there is no good evidence to recommend a gluten- and casein-free diet as a standard treatment. A 2018 review concluded that it may be a therapeutic option for specific groups of children with autism, such as those with known food intolerances or allergies, or with food intolerance markers. The authors analyzed the prospective trials conducted to date that studied the efficacy of the gluten- and casein-free diet in children with ASD (4 in total). All of them compared gluten- and casein-free diet versus normal diet with a control group (2 double-blind randomized controlled trials, 1 double-blind crossover trial, 1 single-blind trial). In two of the studies, whose duration was 12 and 24 months, a significant improvement in ASD symptoms (efficacy rate 50%) was identified. In the other two studies, whose duration was 3 months, no significant effect was observed. The authors concluded that a longer duration of the diet may be necessary to achieve the improvement of the ASD symptoms. Other problems documented in the trials carried out include transgressions of the diet, small sample size, the heterogeneity of the participants and the possibility of a placebo effect. In the subset of people who have gluten sensitivity there is limited evidence that suggests that a gluten-free diet may improve some autistic behaviors.
Results of a systematic review on interventions to address health outcomes among autistic adults found emerging evidence to support mindfulness-based interventions for improving mental health. This includes decreasing stress, anxiety, ruminating thoughts, anger, and aggression. There is tentative evidence that music therapy may improve social interactions, verbal communication, and non-verbal communication skills.[needs update] There has been early research looking at hyperbaric treatments in children with autism. Studies on pet therapy have shown positive effects.
There is no known cure for autism. The degree of symptoms can decrease, occasionally to the extent that people lose their diagnosis of ASD; this occurs sometimes after intensive treatment and sometimes not. It is not known how often this outcome happens; reported rates in unselected samples have ranged from 3% to 25%. Most autistic children acquire language by age five or younger, though a few have developed communication skills in later years. Many autistic children lack social support, future employment opportunities or self-determination. Although core difficulties tend to persist, symptoms often become less severe with age.
Few high-quality studies address long-term prognosis. Some adults show modest improvement in communication skills, but a few decline; no study has focused on autism after midlife. Acquiring language before age six, having an IQ above 50, and having a marketable skill all predict better outcomes; independent living is unlikely with severe autism.
Many autistic people face significant obstacles in transitioning to adulthood. 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.
Autistic people tend to face increased stress levels related to psychosocial factors, such as stigma, which may increase the rates of mental health issues in the autistic population.
Reports of autism cases per 1,000 children rose considerably in the US from 1996 to 2007. It is unknown how much growth came from changes in rates of autism.
Globally, classic autism was understood to affect an estimated 24.8 million people as of 2015[update]. In the UK, from 1998 to 2018, autism diagnoses increased by 787%. This increase was largely attributable to changes in diagnostic practices, referral patterns, availability of services, age at diagnosis, and public awareness (particularly among women). Vaccination does not cause autism (or ASD) and is not behind any increase in autism prevalence rates, if any change in the rate of autism exists at all.
Males had higher likelihood of being diagnosed with autism than females. The sex ratio averaged 4.3:1 and was greatly modified by cognitive impairment: it may have been close to 2:1 with intellectual disability and more than 5.5:1 without.[obsolete source]
Several other conditions are common in children with autism. They include:
Intellectual disability. The percentage of autistic individuals who also met criteria for intellectual disability has been reported as anywhere from 25% to 70%, a wide variation illustrating the difficulty of assessing intelligence of individuals on the autism spectrum. In comparison, for PDD-NOS the association with intellectual disability was much weaker, and by definition, the diagnosis of Asperger's excluded intellectual disability.
A few examples of autistic symptoms and treatments were described long before autism was named. The Table Talk of Martin Luther, compiled by his notetaker, Mathesius, contains the story of a 12-year-old boy who may have been severely autistic. The earliest well-documented case of autism is that of Hugh Blair of Borgue, as detailed in a 1747 court case in which his brother successfully petitioned to annul Blair's marriage to gain Blair's inheritance. The Wild Boy of Aveyron, a feral child caught in 1798, showed several signs of autism; the medical student Jean Itard treated him with a behavioral program designed to help him form social attachments and to induce speech via imitation.
The New Latin word autismus (English translation autism) was coined by the Swiss psychiatrist Eugen Bleuler in 1910 as he was defining symptoms of schizophrenia. He derived it from the Greek word autós (αὐτός, meaning "self"), and used it to mean morbid self-admiration, referring to "autistic withdrawal of the patient to his fantasies, against which any influence from outside becomes an intolerable disturbance". A Soviet child psychiatrist, Grunya Sukhareva, described a similar syndrome that was published in Russian in 1925, and in German in 1926.
Clinical development and diagnoses
Leo Kanner introduced the label early infantile autism in 1943.
The word autism first took its modern sense in 1938 when Hans Asperger of the Vienna University Hospital adopted Bleuler's terminology autistic psychopaths in a lecture in German about child psychology. Asperger was investigating an ASD now known as Asperger syndrome, though for various reasons it was not widely recognized as a separate diagnosis until 1981.Leo Kanner of the Johns Hopkins Hospital first used autism in its modern sense in English when he introduced the label early infantile autism in a 1943 report of 11 children with striking behavioral similarities. Almost all the characteristics described in Kanner's first paper on the subject, notably "autistic aloneness" and "insistence on sameness", are still regarded as typical of the autistic spectrum of disorders. It is not known whether Kanner derived the term independently of Asperger.
Kanner's reuse of autism led to decades of confused terminology like infantile schizophrenia, and child psychiatry's focus on maternal deprivation led to misconceptions of autism as an infant's response to "refrigerator mothers". Starting in the late 1960s autism was established as a separate syndrome.
Terminology and distinction from schizophrenia
As late as the mid-1970s there was little evidence of a genetic role in autism, while in 2007 it was believed to be one of the most heritable psychiatric conditions. Although the rise of parent organizations and the destigmatization of childhood ASD have affected how ASD is viewed, parents continue to feel social stigma in situations where their child's autistic behavior is perceived negatively, and many primary care physicians and medical specialists express some beliefs consistent with outdated autism research.
It took until 1980 for the DSM-III to differentiate autism from childhood schizophrenia. In 1987, the DSM-III-R provided a checklist for diagnosing autism. In May 2013, the DSM-5 was released, updating the classification for pervasive developmental disorders. The grouping of disorders, including PDD-NOS, autism, Asperger syndrome, Rett syndrome, and CDD, has been removed and replaced with the general term of Autism Spectrum Disorders. The two categories that exist are impaired social communication and/or interaction, and restricted and/or repetitive behaviors.
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 on 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 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.
About half of autistic people are unemployed, and one third of those with graduate degrees may be unemployed. Among those who find work in the United States, 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 autistic people 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 decreased earnings in the job market. Some studies also find decreased earning among parents who care for autistic children.
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^James S, Stevenson SW, Silove N, Williams K (May 2015). James S (ed.). "Chelation for autism spectrum disorder (ASD)". The Cochrane Database of Systematic Reviews (Review) (5): CD010766. doi:10.1002/14651858.CD010766. PMID26106752.
^ abcGogou M, Kolios G (June 2018). "Are therapeutic diets an emerging additional choice in autism spectrum disorder management?". World Journal of Pediatrics (Review). 14 (3): 215–223. doi:10.1007/s12519-018-0164-4. PMID29846886. S2CID44155118. Current literature knowledge provides evidence that ketogenic and casein/gluten-free diet may have their own place in our reserve for the therapeutic management of specific subsets of children with autism. ... More clinical studies about the effect of gluten/caseinfree diet in these patients are available. However, available data arise from studies with small sample size and are still controversial. In general, despite encouraging data, no definite proof still exists. Under this view, the use of therapeutic diets in children with autism should be restricted to specific subgroups, such as children with autism and epilepsy or specific inborn errors of metabolism (ketogenic diet), children with known food intolerance/allergy or even children with food intolerance markers (gluten- and casein-free diet). Their implementation should always be guided by health care practitioners.
^Hyman SL, Stewart PA, Foley J, Cain U, Peck R, Morris DD, et al. (January 2016). "The Gluten-Free/Casein-Free Diet: A Double-Blind Challenge Trial in Children with Autism". Journal of Autism and Developmental Disorders. 46 (1): 205–220. doi:10.1007/s10803-015-2564-9. PMID26343026. S2CID12884691. 20 natural challenges when parents reported that children by mistake consumed foods containing gluten or casein.
^Buie T (May 2013). "The relationship of autism and gluten". Clinical Therapeutics (Review). 35 (5): 578–583. doi:10.1016/j.clinthera.2013.04.011. PMID23688532. At this time, the studies attempting to treat symptoms of autism with diet have not been sufficient to support the general institution of a gluten-free or other diet for all children with autism. There may be a subgroup of patients who might benefit from a gluten-free diet, but the symptom or testing profile of these candidates remains unclear.
^Volta U, Caio G, De Giorgio R, Henriksen C, Skodje G, Lundin KE (June 2015). "Non-celiac gluten sensitivity: a work-in-progress entity in the spectrum of wheat-related disorders". Best Practice & Research. Clinical Gastroenterology. 29 (3): 477–491. doi:10.1016/j.bpg.2015.04.006. PMID26060112. autism spectrum disorders (ASD) have been hypothesized to be associated with [non-celiac gluten sensitivity]. Notably, a gluten- and casein-free diet might have a positive effect in improving hyperactivity and mental confusion in some patients with ASD. This very exciting association between [non-celiac gluten sensitivity] and ASD deserves further study before conclusions can be firmly drawn
^San Mauro Martín I, Garicano Vilar E, Collado Yurrutia L, Ciudad Cabañas MJ (December 2014). "[Is gluten the great etiopathogenic agent of disease in the XXI century?]" [Is gluten the great etiopathogenic agent of disease in the XXI century?]. Nutricion Hospitalaria (in Spanish). 30 (6): 1203–1210. doi:10.3305/nh.2014.30.6.7866. PMID25433099.
^Warren Z, Veenstra-VanderWeele J, Stone W, et al. (April 2011). Therapies for Children With Autism Spectrum Disorders (Report No. 11-EHC029-EF). Agency for Healthcare Research and Quality (US). p. 8. PMID21834171. Hyperbaric therapy, in which oxygen is administered in special chambers that maintain a higher air pressure, has shown possible effects in other chronic neurologic conditions and has also undergone preliminary exploration in ASDs.[needs update]
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^Hendricks DR, Wehman P (24 March 2009). "Transition From School to Adulthood for Youth With Autism Spectrum Disorders: Review and Recommendations". Focus on Autism and Other Developmental Disabilities. 24 (2): 77–88. doi:10.1177/1088357608329827. S2CID14636906.
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^Taylor LE, Swerdfeger AL, Eslick GD (June 2014). "Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies". Vaccine. 32 (29): 3623–3629. doi:10.1016/j.vaccine.2014.04.085. PMID24814559.
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