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Autism spectrum article: redraft

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The autism spectrum includes a range of neurodevelopmental differences, commonly referred to as autism and officially designated autism spectrum disorder (ASD). Autistic people are said to have difficulties with social interactions, and to show rigid and repetitive behaviours and interests. They are also likely to have unusual responses to sensory input, including high or low sensitivity.

A spectrum disorder is one that can manifest very differently from person to person: any given person is likely to show some, but not all of the characteristics associated with it, and may show them to very different degrees. Different autistic people might show strikingly different he same person may also present differently at different times[1]. The autism spectrum was historically divided into sub-categories, but there were persistent questions over the validity of these divisions[1][2], and the most recent editions of the diagnostic manuals, Diagnostic and Statistical Manual of Mental Disorders (DSM-5, published in 2013) and International Classification of Diseases (ICD-11, released in 2021[3]) both list ASD as a single disorder.[4][5]

There is some dispute over the appropriateness of the term 'disorder',[6] and many sources prefer to use the terms autism,[7] or autism spectrum conditions (ASC),[8][9] rather than ASD. While psychiatry traditionally classifies autism as a neurodevelopmental disorder, some see autism as part of neurodiversity, the natural diversity in human thinking and experience.[10] On this view, promoted by the autism rights movement, there is not necessarily anything wrong with an autistic person. but this does not preclude their being disabled and potentially having high support needs.[11] This relatively positive view of autism has sometimes led to friction between autistic advocates and autism charities,[citation needed] who have often promoted the search for a 'cure' for autism, and therapies designed to make autistic children more like their peers.

Other controversies in autism include scientific ones, political and philosophical ones, and many which have aspects of all three. Scientists are still trying to determine what causes autism; it is highly heritable and believed to be mainly genetic, but there are many genes involved, and environmental factors may also be relevant. It is unclear why autism commonly co-occurs with ADHD, intellectual disabilities, epilepsy and a range of other conditions. There are ongoing disagreements about what should be included as part of the autism spectrum, whether meaningful sub-types of autism exist, and the significance of autism-associated traits in the wider population. The combination of broader criteria and increased awareness has led to a trend of steadily increasing estimates of autism prevalence, causing a common misconception that there is an 'autism epidemic'[12] and feeding the myth that this is caused by vaccines.

[end of lead]

Partly thanks to the variety of definitions of autism (and autism spectrum disorder) that have been used at different times and in different places, estimates of autism prevalence vary by a large margin, and have tended to increase over time. This should not be taken as evidence that more autistic people exist than previously however, as the increase in recorded prevalence could be fully explained by the combination of changing diagnostic criteria, and steadily increasing awareness of autism.

The autism spectrum is an umbrella term covering a range of neurodevelopmental differences, commonly referred to as autism and officially designated Autism Spectrum Disorder (ASD). Autistic people are said to have difficulties with social interactions, and show rigid and repetitive behaviours and interests. They are also likely to have unusual responses to sensory input, including high or low sensitivity.

A spectrum disorder is one that can manifest very differently from person to person: any given person is likely to show some, but not all of the characteristics associated with it, and may show them to very different degrees. The same person may also present differently at different times[13]. The autism spectrum was historically divided into sub-categories, but there were questions over the validity of these divisions[13][14], and the most recent editions of the diagnostic manuals, Diagnostic and Statistical Manual of Mental Disorders (DSM-5, published in 2013) and International Classification of Diseases (ICD-11, released in 2021[15] ) both list ASD as a single disorder. They do include sub-divisions, but these are not categorical.

pausing there for now. Final sentence there is clunky; there's a subtlety that's hard to convey in simple terms, and I'm wondering about deferring it till later.

is defined in to cover a wider group of conditions and differences in the type and perceived severity of symptoms;[16][17] an alternative term, autism spectrum conditions, has been used by some to avoid perceived negativity associated with the word disorder.[18][19] Asperger syndrome is included in the term autism spectrum disorder. The 11th, released in January 2021,characterises ASD with deficits in the ability of an individual to begin and sustain two-way social communication and restricted or repetitive behavior unusual for the individual's age or situation (see Classification). Although linked with early childhood, the symptoms can appear later, frequently associated with increased social interaction. With considerable variation, also dependent on the context, deficits can cause impediments in personal, family, social, educational and occupational situations; those diagnosed with ASD range from the independent and gifted to the very challenged and needy requiring intervention and long-term support.[20][21][22][23] Related to ASD is the broad autism phenotype (BAP), in which individuals have some of the symptoms of ASD, but an insufficient number or intensity of symptoms to justify an ASD diagnosis; BAP is particularly prevalent in close blood relatives of individuals with ASD.[24]

Symptoms can be detected before the age of two and experienced practitioners can give a reliable diagnosis by that age. However, a diagnosis may not occur until much older, even well into adulthood. The signs are many and can include: specific or repeated behaviors, enhanced sensitivity to materials, being upset by changes in routine, appearing to show reduced interest in others, avoiding eye-contact and limitations in social situations and with verbal communication. When social interaction becomes more important, some whose condition might have been overlooked suffer social and other exclusion and are more likely to have coexisting mental and physical conditions.[22][25] Long-term problems include difficulties in daily living such as managing schedules, hypersensitivities (e.g. to foods, noises, fabric textures), initiating and sustaining relationships and maintaining jobs.[26][27]

The causes of autism spectrum conditions remain uncertain. Genetic and neuroscientific studies have identified patterns of risk but with little that is of current practical benefit.[28][29] Research on twins demonstrates a greater likelihood of heritability of the condition over environmental factors. Studies comparing data from multiple countries also indicate a genetic link.[30][31][32] Risk factors can include a family history of ASD, having an older parent, certain genetic conditions, certain prescribed drugs taken during pregnancy and general compromises in perinatal and neonatal health.[33][34][35][36][37]

Diagnosis is based on observation of behavior and development. Many, especially girls and those who have good verbal skills, may have been misdiagnosed with other conditions. The assessment of children involves carers, the child if capable, physicians and a core team of professionals including pediatricians, child psychiatrists, speech-and-language therapists and clinical/educational psychologists.[38][39][26] For adults, clinicians identify neurodevelopmental history, behaviors, difficulties in communication, limited interests and problems in education, employment and social relationships. Challenging behavior may be assessed with functional analysis to identify the triggers causing it.[29]

Autistic spectrum disorder is considered a lifelong condition with no simple test or cure.[26][21] Few of the many different treatments have been independently scientifically evaluated. Support efforts include teaching social and behavioral skills, monitoring, factoring-in co-existing conditions, and guidance for the carers, family, educators and employers.[26][40] There is no specific medication for ASD; drugs can be prescribed for symptoms such as anxiety but there are significant risks. A study in 2019[41] found that the management of challenging behaviors was generally of low quality, with little support for long-term usage of psychotropic drugs, and concerns about their inappropriate prescription.[42][43] Genetic research has improved understanding of molecular pathways in ASD and animal research has pointed to the reversibility of phenotypes but the studies are at an early stage.[33]

The reported prevalence of ASD worldwide is variable, affected by access, research, data-collection, assessment tools, record-completeness, and geographical coverage, as well as cultural differences and funding.[44][45][46] Most data comes from high-income countries; there is a paucity of data from Africa[47][48] and South America.[49] A 2019 population study of children in Denmark, Finland, Iceland and France showed means of 1.26%, 0.77%, 3.13% and (up to) 0.73% in France respectively with ASD.[50] The USA (2016) had a mean of 1.9% (3.0% of boys and 0.7% of girls)[44] and Canada (2018) 1.5% (2.39% of boys and 0.6% of girls);[51] Irish estimates (2018) showed 1.5% had ASD, similar to the UK, Norway and Italy but lower than South Korea at 2.64%.[52] Meta-analysis from China (2016) gave a low mean of 0.39%, possibly due to different screening tools.[53] Apparent increases in the prevalence of ASD have been attributed to changes in reporting practices.[54][55] Males are diagnosed with ASD about four times more often than females.[27][56] The reasons for this are unclear, with suggestions including a higher testosterone level in utero, different presentation of symptoms in females (leading to misdiagnosis) or simply gender-bias.[57][58]

Advocacy groups have emerged, some as part of the autism rights movement, offering support and challenging healthcare professionals.[46][59][60] The groups encompass those for or against drug treatment, biogenetic research, behavioural therapy, educational and societal change or beliefs about envirotoxins. Terms such as neurodiversity and neurotypical have been popularized and sometimes used in medical literature. Critics, including those on the spectrum, have bemoaned the entrenchment of some groups' opinions.[59][61][62][63] In this process, disagreements have been exposed in the interpretation of ASD by experts from different countries, with some regarding diagnostic changes since 2000 as an "American" phenomenon.[46]


Autism spectrum article: changes needed

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As per Averixus's suggestion under Talk:Autism spectrum#Plan of action, I wanted to start a list of things that need changing on the Autism spectrum page. I'm dealing with a hostile editor threatening to revert any changes I make, so proceeding cautiously here. I will move this list to the main Talk page when it's ready.

"Autistic" redirects here. Not to be confused with Autism.

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It doesn't make sense to suggest that people might confuse this with autism. Either 'autism' refers to the exact same thing, or (historically, and very rarely in contemporary use) it refers to a sub-category of ASD.

The autism spectrum is an umbrella term...

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This first paragraph should start by explaining what the term means in broad strokes, before introducing the other names it is known by (including 'autism') and explaining what is meant by a 'spectrum' (the existing explanation is unclear, and reads like it may have made a bit more sense before some earlier text was rewritten). As an opening paragraph, this is considerably longer than it should be. There should be a brief account of the previously separate diagnoses that were collapsed into this in DSM-5 and ICD-11, and how the new manuals divide the ASD category, but I think this warrants its own paragraph.

Symptoms can be detected before the age of two

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There was a requirement of 'onset prior to age 3 years' for a diagnosis of 'autistic disorder' in DSM-IV, but not for Autism Spectrum Disorders more broadly, and the requirement seems to be entirely absent from DSM-5. The uncited claim that 'experienced practitioners can give a reliable diagnosis' is obviously wrong in many cases.

The causes of autism spectrum conditions remain uncertain

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They really, really do, and I don't think it's helpful to have a substantial paragraph on this before we get to the Contents table. This should be fully dealt with in the separate section below; a single sentence in the introductory sentence would be sufficient.

Diagnosis is based on observation of behavior and development

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Is this the right place for this? It's quite detailed when it comes to childhood diagnoses, and I'm fairly sure many of those details will vary from country to country, which is not made clear here.

Autistic spectrum disorder is considered a lifelong condition with no simple test or cure

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This paragraph relatively solid, although again I'm not sure this level of detail belongs in the opening section. If we're talking about cures, it's probably worth mentioning that as far as the best evidence we have goes, most autistic people don't want one; or, given that this question hasn't been researched as much as it should be, at least that many autistic people have said they wouldn't want to be cured. I don't think the sentence on research that has 'pointed to the reversibility of phenotypes' belongs here; this is a very strong claim, and would require strong evidence.

The reported prevalence of ASD worldwide is variable

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This should be dealt with in a section on prevalence, and expand considerably on the fact that 'Apparent increases in the prevalence of ASD have been attributed to changes in reporting practices': there is an important and dangerous misconception that actual prevalence has skyrocketed, and it deserves to be addressed seriously.

Advocacy groups have emerged, some as part of the autism rights movement

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A bit odd to mention the autism rights movement (autistic rights movement) but not the huge charities set up by parents, given that the rest of the paragraph is talking at least as much about the big charities. A casual reader might get the very wrong idea that parts of the autistic rights movement promote drug treatment, biogenetic research, behavioural therapy, and 'beliefs about envirotoxins', when these are all things that have been largely opposed (or at least selectively resisted) by autistic-led organisations. I'm amused by how obviously this sentence was written by someone with an axe to grind: "Critics, including those on the spectrum, have bemoaned the entrenchment of some groups' opinions". Also, that Washington Post article is really misleading. Someone ought to take a careful look at the other links too, at some point.

Contents

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Six screens down! Still, better late than never.

Classification

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On a skim read, this bit looks reasonably solid. Someone's made a valiant effort to condense the latest diagnostic manuals into 2-3 paragraphs each!

We might want to lose 'Further information: Autism § Classification' which starts 'Autism is one of the five pervasive developmental disorders (PDD)'. Historical information like that obviously needs to be marked as such, and anyway this is the kind of needless redundancy that makes duplication of pages like this such a chore.

Signs and symptoms

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This is obviously written from a 100% medical lens, with little regard for the perspective of autistic people, which I flag up here as something worth thinking about critically. I acknowledge that there are challenges to maintaining NPOV while respecting subjective experiences, and ASD is of course a clinical diagnosis, and in some sense that is our focus here. So I'm not proposing any changes here except for the following:

people with ASD can exhibit notable ability

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If we're bringing this up, we ought to talk about 'spiky skills profiles' more broadly, and possibly 'splinter skills'. Depending on what you think counts as a 'notable ability', I'm not sure that only a small percentage of autistic people have them. But then, a lot of people have one or more notable abilities! Especially people with intense interests.

There are two possible developmental courses of ASD

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Exactly two? Really? This seems a bold claim. This next one is less tenuous, but it's pre-DSM-5, with much of the data cited being much older still; I'd want to know if it holds up at all since they removed the strict requirement for signs to be evident before the age of 3: 'Most parents report that the onset of autism symptoms occur within the first year of life.'

Regressive autism

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There's a paragraph on 'regressive autism' before the section on it starts, presumably missed in the recent merger. We have five paragraphs on this, but they say surprisingly little of real substance. No mention is made of autistic burnout (c.f. Raymaker et al), or other examples of the occasional loss of abilities reported by many autistic adults. No kind of explanation is pointed to at all, really; I know of several proposed mechanisms, but this is obviously not an area that has seen conclusive research. My sense is that this material should be cut down and/or moved out of 'Signs and symptoms' into its own, subsequent section. This is a lot of detail, and we haven't even got to 'social skills' yet.

Social and communication skills

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The 'double empathy problem' should be brought in right at the start here; there's plenty of evidence at this point that it's misleading at best to suggest that 'Impairments in social skills present many challenges'. c.f. CJ Crompton, K DeBrabander, B Heasman (2021) and DEM Milton (2012), as well as Crompton et al (2020) and MA Gernsbacher, M Yergeau (2019). In short, the assumption that the social difficulties autistic people experience are the result of deficits in the person is not supported by the available evidence. This section should be rewritten to account for this new evidence and long-standing methodological critique; the current framing is not scientifically supported.

Behavioural characteristics

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Many of these are not behavioural characteristics. 'They may develop these difficulties of creating connections due to anxiety or depression' is an interesting suggestion, why not the other way round? Seems simplistic.

I don't think 'abnormal responses to sensations including sights, sounds, touch, taste and smell' stands up as a behavioural characteristic when the sensations themselves, and the way they're processed, are different.

The second core symptom of autism spectrum

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Probably best to mention what the first one is supposed to be before getting on to this. This section as a whole could be better structured.

Self-injury

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I'm not convinced this belongs under 'signs and symptoms' at all. It's also currently full of inadequately sourced claims, and doesn't explicitly make the obvious links with stimming, with meltdowns, or with distress, aside from chronic pain. In fact, there seems to be no mention of autistic people's distress anywhere in this article, in so many words, which is... interesting. There's only one mention, in passing, of meltdowns. Nothing on shutdowns, catatonia or even inertia, either.

If we're going to have a section on self-injury, can we make sure not portray it as if it's just a thing that happens sometimes when you're autistic? That's harmful. It's important that people at least try to understand the reasons.

Causes of autism

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I question the need for four screenfuls on causes when there is also a separate entry on this, and when we could pretty much summarise the state of scientific knowledge of causes as 'it seems to be overwhelmingly genetic, but highly polygenic, and there is ambiguous evidence for a large number of possible environmental factors. It's definitely not vaccines though, this is conclusive.'

Most of the studies on so-called 'risk factors' fail to account for likely confounding factors, notoriously the high likelihood that parents are autistic themselves (but frequently undiagnosed) and being autistic causes environmental factors. As discussed elsewhere, autistic people are far more likely to be unemployed and isolated, for example. There is no point citing any studies on risk factors unless they have carefully accounted for this kind of thing (and preferably been independently replicated).

Pathophysiology

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I'm not going to go into this, but I think it could benefit from the attention of someone with a critical eye and limited patience for preliminary findings.

Also, if the Autism article is supposed to be about 'classic autism', it can not be the main article on the pathophysiology of the autism spectrum at large. If it has somehow ended up being, then that section needs to be removed from there and merged in here, or - better - moved into a separate entry on the biology of autism and updated to reflect modern understandings.

Mirror neurons

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I think this one's been directly refuted in the 13 years since the most recent cited study on it. Possibly of interest in a history of science kind of way, but maybe not worth a paragraph here.

As of 2012, there is a consensus

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How strong was this consensus? How strong is it now? The citation given doesn't mention a consensus. The abstract says 'We suggest that the social brain, and its dysfunction and recovery, must be understood not in terms of specific structures, but rather in terms of their interaction in large-scale networks'.

Temporal lobe

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'It has been argued' ... 'one fMRI study' ...does this warrant a paragraph? There are a lot of other things we could be learning about here. Similarly 'ASD could be linked to mitochondrial disease'... is it, though? If so, how? Is 5% of autistic kids meeting the criteria a lot? If it is, what does that tell us?

Serotonin

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Interesting stuff, but still seems to be super speculative. Entry claims '45% of ASD individuals have been found to have increased blood serotonin levels' but study actually states up to 45%. Mulder et al. (2004) suggested 'at least 25%'.


That's it for now.

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ABA redraft: ABA is controversial within and outside of the autism rights movement for a number of reasons. ABA practitioners are often seen as authorities on autism, but they are not generally required to learn about autism. There is a perception that ABA emphasizes indistinguishability instead of acceptance,[1] and there is a history of the use of aversives such as electric shocks,[2][3] which is still defended at conferences of Association for Behavior Analysis International.[4] It is also controversial due to its relatively weak evidence base,[5] and researchers' failure to investigate possible harms[6][7] and disclose conflicts of interest.[8][9][10]

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  9. ^ Bottema-Beutel, Kristen; Crowley, Shannon (2021). "Pervasive Undisclosed Conflicts of Interest in Applied Behavior Analysis Autism Literature". Frontiers in Psychology. 12: 676303. doi:10.3389/fpsyg.2021.676303. ISSN 1664-1078. PMC 8131529. PMID 34025538.
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