Thursday, 3 November 2011

Nature on autism part two

Yesterday I posted a link to the Nature special series on autism spectrum conditions. There was quite a bit of information to take on-board from the various articles and discussion pieces included, but after a little time reading, I feel there are a few issues worthy of some discussion in this separate post.

This was quite a wide-ranging series covering most of the main talking points about autism and where we think we are in terms of things like definition, research and the various aspects on possible aetiology, intervention and politics. With multiple authors and commentators, opinions abound; some to be agreed with, others to be debated depending on your point of view.

So:

The numbers game
For any undergraduate student faced with a question on a term paper like: are cases of autism increasing? the paper by Karen Weintruab gives about as good and up-to-date a picture on prevalence (and incidence) as you might need. The short answer is yes, the numbers of diagnoses have increased over the years, although the reasons for the increase are complex. Covering old favourites like better awareness, diagnostic substitution (changing criteria), parental age [I have a new post on this topic scheduled for the weekend], etc as reasons for the increase, the various commentators included in this article suggest that just over half of the increase in cases of autism might already be explicable. Given my reading of the various research down the years, this estimate might not be too far of the mark. Fine you might say, but what about the remaining 46% of the increase? What about the fact that different weighting to different factors at different time periods might pertain? 'Describe and discuss..' (making sure you use evidence-based critical thinking).

Systemisers, empathisers and assortative mating theory
Historically, the discipline of psychology is replete with generalised theories of people and explanations of their behaviour. I remember my first psychology textbook, Richard Gross 'Psychology: the science of mind and behaviour'. To read it you would assume that humans are perfectly predictable creatures and like the laws of physics (pre-CERN), put us in a specific situation and nod knowingly as we behave as expected. Psychology is however changing. Individual differences, people not living in a vacuum (or a psychology lab), and importantly the old gestalt phrase 'the whole is greater than the sum of its parts' are coming and pushing aside many of those generalised theories. The realisation that just because a person has one condition/issue/diagnosis does not mean that they can't have others which might exert some effect also seems to be in the pipeline.

So many of these concepts appear to align with our current understanding of autism. I think most people have by now figured out that there is probably no global, over-arching theory of autism which covers the entire spectrum of ability and disability. We have seen theories come and go; probably the most widely covered, again from a psychological perspective, has been the suggestion of a lack of theory of mind and the subsequent evolution of such ideas into systemisers and empathisers and to quote Francesca Happé the concept of 'geek chic'. The paper by Lizzie Buchen takes on the various suggestions proposed and comes to about the same conclusions: interesting, and not to say relevant for some on (and off) the autism spectrum, but please don't generalise and bear in mind that the spectrum of autism extends to quite a few people where life is not just about engineering or mathematical prowess.

Autism in the Middle East
Regular readers of this blog probably know that I am more than impressed with the autism research efforts coming out of the Gulf region. If you need to be reminded, have a look at this post and this one, both of which head into some pretty novel areas for further study originating from the Kingdom of Saudi Arabia. Mo Costandi (one of the first to tweet about the Nature special on autism) talks about autism in the Gulf states and also the genetic research goldmine that is consanguineous marriages and very large families. The impression is that autism, research and practice, is starting to take centre stage in Middle Eastern climes and parents and professionals are embracing education and other behavioural interventions for autism alongside social and cultural shifts in the region about autism.

From the limited contact I have had with people involved with autism in places like Saudi Arabia, Kuwait and the UAE, there are lots of good things happening. And unlike the jagged history of autism in more Western nations, the Middle East benefits from what we have learned down the years and also the mistakes we have made (without having to make them all over again).

Other papers discussing the ins and outs of biomarkers for autism for example, included as part of the series have already been covered on this blog.

Asking myself what more could have been said in the Nature series, I perhaps would have a few suggestions which hopefully won't come across as a rant. First, what about comorbidity? The various comorbidities, somatic and psychiatric, and what relationship they might have to autism, indeed to what degree some comorbidities in some cases can be more 'disabling' than the core autistic features. Yes, some of those comorbidities might be a little uncomfortable to discuss but science is science (apparently) and Nature is never one for shying away from uncomfortable issues. Second, talking about education and behavioural intervention is all well and good, but why stop there? How about recognising some of the other data available on the biology / biochemistry of autism as is being done in other conditions, or even things closer to my heart like that on diet and nutrition? No unanimous, universal effect for strategies like the gluten- and casein-free diet but that goes for just about every intervention for autism doesn't it? Finally, genes, SNPs and CNVs. Interesting and dare I say one of the primary ways forward in research bearing in mind recent lessons from other conditions. But how about the bigger picture, genes interacting with environment, as per Tom Insel's oft-quoted piece on the 'Autism Spring'? Environment covers a lot and a lot has changed environmentally over the period of the growth in cases of autism. Maybe a special edition all of its own.

With all things nature and the natural world in mind, I end with a song (it means 'no worries' apparently).