"and some will be largely free from symptoms of the disorder by adulthood"

The quote heading this post - "and some will be largely free from symptoms of the disorder by adulthood"- comes from a seminar article published in The Lancet by Catherine Lord and colleagues [1] on the topic of autism spectrum disorder (ASD). It follows a series of review and seminar articles published in this journal down the years on the topic of autism; covering various different angles, viewpoints and opinions.

I decided to work this quote up into a short blog entry because there are a couple of important implications stemming from such sentiments that coincide with other independent research findings. Not least are the ideas that: (a) for some, autism is not a life-long condition/state/diagnosis/disorder (see here) and (b) far from being static, the presentation of autism can and does change for whatever reason(s) (see here).

There are some caveats to those 'ideas' I've just described. Not least is the 'sweeping generalisation' caution that is required when it comes to autism, and it's very, very heterogeneous nature. Autism for most/many people is a life-long condition. For many people, particularly those who are profoundly autistic, symptoms/traits/characteristics are always going to be present to a significant degree and affect their (and others) lives every single day. This is a statement of fact.

But the sentiments expressed by Lord et al recognise that even where childhood autistic symptom presentation were often severe and 'disabling', that does not mean that this will always be so for some people as they age and mature. It draws attention to the idea that whether through the process of maturation, results of intervention or other increasingly used terms like 'masking', the presentation of autistic signs and symptoms can and do change both in frequency and intensity. This idea of 'fluidity' in the presentation of autism is something that is beginning to percolate through the peer-reviewed domain. Whilst there is probably going to be a sizable contribution from issues like masking autistic signs and symptoms, there is also a realisation that people change and adapt whether in behaviour or cognitive style depending on issues such as their environment.

This line of thinking has implications. It has implications for the use of the term 'autistic identity' where people see the label/diagnosis as an essential part of who they are; much in the same way that discussions about autism and sexuality seem to be converging in a similar manner. It has implications for the provision of services, particularly those 'bean counter' discussions about autism costs over a lifetime (see here) and eligibility criteria for an increasingly finite pot of money and resources. It also has implications for the idea that autism rarely exists in some sort of diagnostic vacuum (see here), and an intriguing question about whether, as overtly presented autism signs and symptoms wane for some, other important symptoms/conditions instead become more prominent. Y'know, like anxiety (see here) and/or depression (see here) or others (see here and see here)? And I'll again throw in some research on how 'being largely free from symptoms' might also impact on other important issues related to autism (see here) mentioned in a post not-so-long-ago on the topic of depression and autism (see here).

Oh, and there's more longitudinal investigation from this research group [2] too, including the quote: "Findings suggest that some older adolescents and adults with ASD may not exhibit the same difficulties observed in young children with ASD". Discuss.

----------

[1] Lord C. et al. Autism spectrum disorder. Lancet. 2018 Aug 2. pii: S0140-6736(18)31129-2.

[2] Bal VH. et al. Autism spectrum disorder symptoms from ages 2 to 19 years: Implications for diagnosing adolescents and young adult. Autism Res. 2018. Aug 12.

----------

Autism diagnoses (and diagnostic stability) in Germany

"From 2006 to 2012, the prevalence of autism spectrum disorder diagnoses in 0- to 24-year-olds increased from 0.22% to 0.38%."

That was one of the details included in the rather interesting paper by Christian Bachmann and colleagues [1] who provided some introductory information on the the trends in autism diagnoses in Germany. I say 'introductory information' because it appears that autism or autism spectrum disorder (ASD) has not exactly received the research attention in Germany that it perhaps has in other similarly developed nations such as the United States or here in Blighty. Indeed, as Bachmann et al note: "Due to the only available study to date, the prevalence of ASD in Germany is estimated to be about 0.25% in 0- to 24-year-olds in 2009" and even that was taken from another study by the author [2].

This time around, the authors listed two primary aims for their research: (a) "to establish the time trends in the administrative prevalence of autism spectrum disorder diagnoses" and (b) "to assess the stability of autism spectrum disorder diagnoses over time." I'm interested in both these areas on this blog (see here for example). Data for the time trends part of this research came from "the German statutory health insurance company Allgemeine Ortskrankenkassen (AOK) from the years 2006 to 2012" where a diagnosis of ASD was registered by ICD-10 definition. Data for the stability side of their research was via a "cohort with a first-time diagnosis of autism spectrum disorder in 2007 through 2012, investigating the percentage of retained autism spectrum disorder diagnoses."

Results: well as per the opening sentence to this post, the only way is up when it comes to the estimated prevalence of autism or ASD despite the figures being a tad lower than those for other countries. Those percentages were based on nearly 15,000 ASD diagnoses being recorded in 2006 out of 6.9 million insurees, and nearly 22,000 ASD diagnoses in 2012 out of 6.4 million insurees. Males were quite a bit more likely to be diagnosed with autism/ASD and prevalence peaked for the age group 6-11 year olds.

Then to that stability part of the study and from "3927 patients (mean age: 8.7 years, 68.9% males)" with a specific ASD diagnosis in 2007 only a third 'carried on' with a specific diagnosis by 2012. The authors note: "This figure is lower than the usual persistence for ASD diagnoses, which is about 73%–100%." Lower? Yes, I'd say. The reasons for this quite notable lack of diagnostic stability? Well, the authors note that there is probably going to be more than one (before anyone makes any sweeping generalisations). They talk about the lack of "specialised mental health services that are competent to diagnose ASD according to international standards and guidelines" as one factor. They talk about diagnoses "often made by paediatricians or occupational therapists, without employing diagnostic gold standards like Autism Diagnostic Observation Schedule (ADOS)." They even talk about diagnostic switching between ASD subgroups as potentially also being a factor to consider. And then another possibility: "Other reasons include improvement of symptoms because of successful therapeutic interventions" without any specific mention of what types of therapeutic intervention might be involved. Sounds very 'optimal outcome' to me (see here). In short, it's probably going to be complicated.

Bearing in mind those diagnostic stability figures and the authors reliance on a database that relied on those unstable figures for prevalence estimates, this is interesting research. It shows that even a social and economic powerhouse like Germany still has some way to go in many areas not least with that related to autism. Where next? Well, as per the authors suggestion: "one possible option could be to establish standardised diagnostic algorithms and certify ASD diagnostic centres who employ these standards." Sounds good but in amongst the chatter about autism 'misdiagnosis' and seemingly 'ill-trained' professionals diagnosing, I do wonder whether further, more detailed, investigations are needed on the autism diagnostic stability figures of Germany and whether it's all just due to administrative errors...

Music to close, and this guy was/is apparently quite big in Germany...  Permit denied!

----------

[1] Bachmann CJ. et al. Diagnoses of autism spectrum disorders in Germany: Time trends in administrative prevalence and diagnostic stability. Autism. 2016. Dec 20.

[2] Bachmann CJ. et al. Psychopharmacological treatment in children and adolescents with autism spectrum disorders in Germany. Res Dev Disabil. 2013 Sep;34(9):2551-63.

----------

Christian J Bachmann, Bettina Gerste, & Falk Hoffmann (2016). Diagnoses of autism spectrum disorders in Germany: Time trends in administrative prevalence and diagnostic stability Autism: International Journal of Research & Practice : 10.1177/1362361316673977

Autism, ESSENCE and the question of reassessment

I talked about ESSENCE - Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations - only yesterday (see here) and here I am covering the topic again on this blog. There is good reason however that this concept appears once more, as I draw your attention to the paper by Anne-Katrin Kantzer and colleagues [1] and the specific observation that: "Co-existence with other conditions was the rule" when it comes to the diagnosis of autism.

OK, it's nothing new to say that the label of autism rarely appears in some sort of diagnostic vacuum (see here). Indeed, if there is anything that has been learned about autism over the years it is that aside from the incredible heterogeneity present across the spectrum in terms of clinical presentation, many grand theories 'about autism' have been scuppered as a consequence of their assumptions on autism being some sort of stand-alone label. A case in point: theory of mind (ToM); that even some of the major proponents of this theory have come to realise [2] has seen a "a widening of interest to other clinical groups." Indeed it has (see here for example), indeed it has. And other grand theories appear also to be following suit [3]...

The Kantzer paper - including some notable names on the authorship list - set out to examine the diagnostic outcomes of some 96 children "initially assessed for suspected ASD [autism spectrum disorder] at an average age of 2.9 years" who were followed up some two years later. There is an important word included in the Kantzer study: prospectively; as opposed to retrospectively, meaning that participants were assessed and followed in real-time (rather than solely relying on the examination of previous historical records). Various behavioural and psychometric measures were employed by the authors as part of a "broad neurodevelopmental examination... by a multi-professional team" and some rather interesting details emerged.

So: "In a cohort of young children who screened positive for autism spectrum symptoms, 93% of all with an Autism spectrum disorder (ASD) at time1 (T1) had ASD two years later." What this tell us is that in the most part, the diagnosis of autism/ASD over 2 years in young children is fairly stable. Other data has highlighted similar things. But then the question: what about the ~7% where an ASD diagnosis perhaps wasn't as stable? I've covered this topic a few times on this blog (see here and see here), where for whatever reason, the diagnosis of autism is not necessarily a lifelong label for everyone. The still controversial idea that around 9% of those originally diagnosed with autism might 'lose' their diagnosis (see here) and indeed any/many 'broader autism features' (see here) could be pertinent here accepting that in the Kantzer data we are told: "The children who did not meet criteria for ASD at T2 had symptoms of or met criteria for other neurodevelopmental/neuropsychiatric disorders in combination with marked autistic traits." I might also draw your attention to other work from members of the Kantzer group that indicated that even into adulthood, diagnoses along the autism spectrum might similarly not always be 'lifelong' for whatever reason(s) (see here).

Next: "The vast majority of children with ASD also had other neurodevelopmental symptoms or diagnoses." This kinda reiterates the notion of ESSENCE, as details such as: "Hyperactivity was observed in 42% of children with ASD at T2, and Intellectual Developmental Disorder in 30%" provide some diagnostic flesh on the bones of what ESSENCE might look like in clinical terms. Indeed, although the topic of continued debate [4] insofar as how one screens for something like attention-deficit hyperactivity disorder (ADHD) in autism, the overlap between the conditions is likely to be significant (see here).

Finally: "The risk of “over-diagnosis” of ESSENCE/ASD problems by screening for ASD at 2.5 years appears to be minimal." Accepting that important changes to the way that autism is diagnosed by at least one schedule is likely to produce some important differences in who fulfils criteria (see here), the authors seem to be fairly confident that early diagnosis might actually be (a) possible and (b) pretty accurate. The stress is most definitely on 'early diagnosis' save any charges of further health inequalities facing those on the autism spectrum.

I titled this post  'Autism, ESSENCE and the question of reassessment' because I do also want to pass some brief comment about the value of reassessment picked up by the authors: "Reassessments covering the whole range of these conditions are necessary for an optimized intervention—adapted to the individual child’s needs." This is going to take quite a huge shift in thinking and practice insofar as ensuring that a diagnostic assessment for autism does not just include an ADOS or something related but rather includes a wider spread of behavioural and psychometric instruments pertinent to various other labels/features. I can see there being objections to this line of thought; not least that in these austere times we live in when waiting times for an initial assessment can already be quite long (see here) and money and resources are stretched thin on the ground for autism, screening for a range of potential additional issues is likely to further burden limited resources. The idea also that not hitting diagnostic thresholds for autism at one point does not rule out a child hitting them at a later time point is also something likely to impact on screening and assessment services. I suppose it all depends on whether policy-makers and purse-string holders value detail or value cost-saving?

Either way, the Kantzer paper once again highlights that a diagnosis of autism rarely exists in a diagnostic vacuum.

Music to close (it's been a while) and an 80's blast from the past: Billy Ocean - Get Outta My Dreams, Get Into My Car (although please, do not get into a car with someone you don't know, no matter how well they serenade you).

----------

[1] Kantzer A-K. et al. Young children who screen positive for autism: Stability, change and “comorbidity” over two years. Research in Developmental Disabilities. 2016. Nov 3.

[2] Happé F. & Conway JR. Recent progress in understanding skills and impairments in social cognition. Curr Opin Pediatr. 2016 Dec;28(6):736-742.

[3] Dajani DR. et al. Heterogeneity of executive functions among comorbid neurodevelopmental disorders. Sci Rep. 2016 Nov 9;6:36566.

[4] Yerys BE. et al. Evaluation of the ADHD Rating Scale in Youth with Autism. J Autism Dev Disord. 2016 Oct 13.

----------

Kantzer, A., Fernell, E., Westerlund, J., Hagberg, B., Gillberg, C., & Miniscalco, C. (2016). Young children who screen positive for autism: Stability, change and “comorbidity” over two years Research in Developmental Disabilities DOI: 10.1016/j.ridd.2016.10.004

The stability of an Asperger syndrome diagnosis continued

"The subsample that no longer fulfilled an autism spectrum disorder had full-time jobs or studies (10/11), independent living (100%), and reported having two or more friends (100%)."

So said the paper by Adam Helles and colleagues [1] continuing a research theme from this authorship group on what happens to autism, or rather Asperger syndrome, in the longer-term (see here). Indeed, if you have the time, the thesis from Helles covering this area of study is well worth a read (see here).

This time around the focus was on the often fuzzy concept called 'quality of life' (see here) in terms of "work, academic success, living situation, relationships, support system" for 50 males "with Asperger syndrome diagnosed in childhood and followed prospectively over two decades." Alongside those 'objective' measures of quality of life (QoL), Helles et al also sought some information about more 'subjective' reports of QoL with the use of the "Sense of Coherence and Short-Form Health Survey-36" schedules.

As per the opening sentence to this post, I've initially focused in on those participants where diagnosis was not stable (i.e. the sub-group who did not continue to fulfil criteria for Asperger syndrome) as providing yet more evidence [2] on how objective outcomes were seemingly improved compared to those who still reached diagnostic thresholds. Allied to other work by other independent research groups (see here), these findings continue to demonstrate just how heterogeneous the autism spectrum is and that dogma about autism being a 'lifelong condition' might not necessarily be applicable to everyone who at one time or another met diagnostic thresholds. I know such a line of thought is not always received well by all, but I am of the opinion that remitting autism is at least as likely and important as remitting schizophrenia or remitting depression for example. As to the mechanisms, well, I don't want to speculate too much at this time but 'autisms' (plural) is a word that springs to mind as a first thought when it comes to such experiences (see here).

When compared to this subgroup of those no longer meeting diagnostic criteria, those who remained within the diagnostic boundaries of Asperger syndrome did not appear to fare so well on those objective measures of QoL: "41% had full-time job or studies, 51% lived independently, and 33% reported two or more friends, and a significant minority had specialized employments, lived with support from the government, or had no friends." I say that bearing in mind the difference in participant numbers falling into one or other grouping.

In terms of those subjective measures of QoL, we are also told that: "Stability of autism spectrum disorder diagnosis was associated with objective but not subjective quality of life" and that "psychiatric comorbidity was associated with subjective but not objective quality of life." This is perhaps not unexpected as per the growing body of research suggesting that various psychiatric comorbidity might be over-represented when a diagnosis of autism is received (see here) and how some of it can be truly disabling (see here). It's not then beyond the realms of possibility that one could have (and hold down) a job for example (objective QoL), but feel that one's subjective QoL is still poor as a result of said comorbidity and its impact on areas of life like employment. Indeed, I'd perhaps forward a research case for how what we term 'comorbidity' might actual be more central to the presentation of various types of autism (see here) outside of being just another add-on diagnosis.

I don't want to come across as being too focused on outcomes around diagnostic instability when it comes to the autism spectrum because for the majority of people the diagnosis, whilst liable to fluctuation with regards to certain facets and skills, is very much a lifelong thing. That also definitions of long-term outcome and QoL say little about important concepts such as happiness and life satisfaction is another important point to make (see here). But the accumulating longitudinal work from Helles and others is providing something of an important window into autism in the long-term and how, wearing the cold, objective spectacles of science, the remittance of core symptoms might not be an unfavourable outcome for some...

----------

[1] Helles A. et al. Asperger syndrome in males over two decades: Quality of life in relation to diagnostic stability and psychiatric comorbidity. Autism. 2016 May 26. pii: 1362361316650090.

[2] Gillberg IC. et al. Boys with Asperger Syndrome Grow Up: Psychiatric and Neurodevelopmental Disorders 20 Years After Initial Diagnosis. J Autism Dev Disord. 2016 Jan;46(1):74-82.

----------

Helles A, Gillberg IC, Gillberg C, & Billstedt E (2016). Asperger syndrome in males over two decades: Quality of life in relation to diagnostic stability and psychiatric comorbidity. Autism : the international journal of research and practice PMID: 27233289

The stability of an Asperger syndrome diagnosis

"Asperger Syndrome, when considered as an ASD/PDD [autism spectrum disorder/pervasive developmental disorder] diagnosis, was fairly stable into adulthood, but there was a significant increase over time in cases no longer meeting criteria for an ASD diagnosis according to the DSM-IV, or AS according to the Gillberg criteria".

The night is darkest just before the dawn.

That was one of the primary conclusions made in the paper by Adam Helles and colleagues [1] who prospectively followed a group of males diagnosed with Asperger syndrome (AS) in childhood into adulthood covering a period of some 20 years. I believe the starting point of this study has been seen before in the peer-reviewed literature in the paper by Cederlund & Gillberg [2] (open-access here) (a paper which takes me back to my own PhD days with it's important influence to some of my work). Other follow-ups have also been reported [3].

Looking at the diagnostic stability of AS, Helles et al noted that compared with baseline where all participants fulfilled diagnostic criteria, at follow-up (two follow-ups actually) there was a "significant decrease in the rate of cases fulfilling any PDD diagnosis according to the DSM-IV, from 91% at T1 [time 1] to 76% at T2 [time 2] in the 47 cases followed up twice". The decline in cases according to the Gillberg criteria was even more stark (82% at T1 and 44% at T2).

Researchers also noted a few other potentially important points in their findings such that: "Severity of autism spectrum symptoms at T1 was the main predictor of diagnostic stability at T2" and a fifth of those who met criteria for DSM-IV criteria for a PDD diagnosis "did not meet DSM-5 ASD criteria although they had marked difficulties in everyday life". This last point has been mentioned by other authors (see here).

There are a few ways one could take the Helles findings. One could see it as further evidence of the fluidity of presented symptoms when it comes to the autism spectrum as per other discussions in this area (see here). You might even view it as an extension of all that chatter on something like differing developmental trajectories along the autism spectrum (see here) or 'optimal outcome' and autism (see here) albeit without the focus on early intervention as potentially being involved (see here) as far as we know. Indeed, one has to wonder whether for those not meeting the diagnostic criteria as they age and mature, this may in part be because of the various strategies learned over a lifetime to overcome some of the barriers posed by the diagnosis?

But I can also see how for some people such research might be less well-received particularly when added to the 'disappearance' of the term Asperger syndrome from the latest revision of DSM (DSM-V). The paper by Spillers and colleagues [4] described concerns about "identity, community, the cure movement, and services" following the DSM-5 changes when talking to people on the autism spectrum. I wonder how the Helles findings on 'falling out of the spectrum' diagnostically speaking for some, might have similar tones if and when discussed.

Accepting that the Helles findings were eventually based on quite a small participant group and their insinuation that not reaching the diagnostic thresholds for something like Asperger syndrome does not imply a life free of some of the more 'disabling' aspects on and around the diagnosis (yes, including various comorbidity), I do think there is more to see in this area. The realisation that we know so little about the autism spectrum in the long-term [5] and how behaviours ebb and flow, that our systems of diagnosis might not necessarily be as robust as we want them to be (see here) and the continued alliance between diagnosis and service receipt excluding many at the diagnostic periphery all come into play. With all the research data collected down the years, one suspects that with a little bit of organisation and willingness to plough some financial and other resources into this issue, further insight into exactly how stable an autism diagnosis might be and for who should be fairly readily available...

Music to close, and having enjoyed the impressive tones of Sheryl Crow last evening, a song most parents will have a heard a few times: Real Gone.

----------

[1] Helles A. et al. Asperger syndrome in males over two decades: stability and predictors of diagnosis. Journal of Child Psychology and Psychiatry. 2014. 3 October.

[2] Cederlund M. & Gillberg C. One hundred males with Asperger syndrome: a clinical study of background and associated factors. Dev Med Child Neurol. 2004 Oct;46(10):652-60.

[3] Cederlund M. et al. Asperger syndrome and autism: a comparative longitudinal follow-up study more than 5 years after original diagnosis. J Autism Dev Disord. 2008 Jan;38(1):72-85.

[4] Spillers JL. et al. Concerns about identity and services among people with autism and Asperger's regarding DSM-5 changes. J Soc Work Disabil Rehabil. 2014;13(3):247-60.

[5] Howlin P. et al. Cognitive and language skills in adults with autism: a 40-year follow-up. J Child Psychol Psychiatry. 2014 Jan;55(1):49-58.

----------

Adam Helles, Carina I. Gillberg, Christopher Gillberg, & Eva Billstedt (2014). sperger syndrome in males over two decades: stability and predictors of diagnosis Journal of Child Psychology and Psychiatry : doi: 10.1111/jcpp.12334

Family processes and trajectory in autism

The paper by Woodman and colleagues [1] looking at trajectory and autism in adolescents and adults is the source material for today's post (another micropost). Concluding that: "Overall, autism symptoms and maladaptive behaviors were observed to improve over the study period" of about 8 years, the authors also reported that "greater improvements were associated with higher levels of maternal praise (based on maternal speech samples) and higher quality mother-child relationships". If I remember correctly, that last sentence on maternal praise being linked to outcome was the topic of some discussion at IMFAR (2014) this year (see here). That alongside some concerns about healthcare provision for adults with autism (see here) which ties in well with the recent revision to the Treating Autism document on health comorbidity in autism (see here).

A word of warning from Alnwick Castle

Whilst treading a little bit carefully in this area, I find the Woodman paper to be intriguing. Not only because their findings provide further support for the fluidity of presentation in autism tied into the concept of stability (see here), but also because of that association between presentation and environment [2].

A quick trawl through the peer-reviewed literature on this topic reveals that family context is something previously covered by this authorship group as per other papers [3]. Some of their other discussions [4] looking at the role of families on autism carry some pearls of wisdom, as for example: "It is important to note that within any family system, transactions among family members are bidirectional. As such, in addition to risks for parental health due to stressful caregiving, high levels of family distress also can create difficulties for the individual with autism". That last paper also talked about the use of a "multi-family group psychoeducation" intervention model (see here) as a means to improve the family dynamic which is something I'd like to see quite a bit more research into.

Music to close, and what else but Praise You by Fatboy Slim...

----------

[1] Woodman AC. et al. Change in Autism Symptoms and Maladaptive Behaviors in Adolescence and Adulthood: The Role of Positive Family Processes. J Autism Dev Disord. 2014 Jul 29.

[2] Smith LE. et al. Symptoms and behavior problems of adolescents and adults with autism: effects of mother-child relationship quality, warmth, and praise. Am J Ment Retard. 2008 Sep;113(5):387-402.

[3] Smith LE. et al. The family context of autism spectrum disorders: influence on the behavioral phenotype and quality of life. Child Adolesc Psychiatr Clin N Am. 2014 Jan;23(1):143-55.

[4] Smith LE. et al. Adults with autism: outcomes, family effects, and the multi-family group psychoeducation model. Curr Psychiatry Rep. 2012 Dec;14(6):732-8.

----------

Woodman AC, Smith LE, Greenberg JS, & Mailick MR (2014). Change in Autism Symptoms and Maladaptive Behaviors in Adolescence and Adulthood: The Role of Positive Family Processes. Journal of autism and developmental disorders PMID: 25070471

What factors influence the age of autism diagnosis?

Old man @ Wikipedia 

The paper by Ram Mishaal and colleagues [1] examining some of the multitude of variables which might influence how early or late a child receives a diagnosis of autism provides the starting point for today's post. Based on the analysis of over 500 children diagnosed with an autism spectrum disorder (ASD), the authors found that: "the severity of the social interaction impairment reported by the parents and having a history of developmental regression was associated with an earlier age of ASD diagnosis". They also reported that a child having an older sibling was associated with earlier diagnosis. Conversely, they concluded that: "the severity of the restricted and repetitive behaviors was associated with delayed age of ASD diagnosis". I'll come back to some of these points shortly.

In these days of calls for ever earlier identification, diagnosis and intervention where autism is concerned, it is still a stark reality for many that autism [in childhood] is diagnosed at a much later point from where initial concerns were raised/detected. Of course, one has to take into account issues around the plurality of autism (see here) and that there may be stability issues with the early days of some autism presentation (see here). But still diagnosis can be a long and drawn out process; sometimes even adversely influenced by the views and opinions of clinicians themselves (see here) despite there being some [very] NICE guidance available, at least for parts of the UK.

During the early years of my research career I remember my go-to study on the topic of age at autism diagnosis was the report by Howlin & Asgharian [2] and their findings: "In the 'autism group' the average age when diagnosis was confirmed was around 5.5 years; in the 'Asperger group' it was 11 years" based on a UK-based sample of nearly 800 families in the late 1990s. Unfortunately, even in the following years, things seem to have got only marginally better when it comes to age at diagnosis as per the report by Mandell and colleagues [3] (64.9 months for all ASDs) and indeed, some of our own data [4]. The latest CDC estimates of autism in the US (see here) reported by Wingate and colleagues [5] does however hint that things might be continuing to move in the right direction as per their findings: "Although ASD is sometimes diagnosed by 2 years of age, the median age of the first ASD diagnosis remains older than age 4 years in the ADDM Network communities". This bearing in mind the different geographical locations of these studies and different processes in place leading up to diagnostic assessment.

To the question then of what factors might influence age of diagnosis outside of just resource issues (similar to the diagnosis of autism in adults), there are some clues from the collected literature which I'm gonna cherry pick. Bear in mind though, that there is no one-size-fits-all formula when it comes to answering this important question.

• Daniels & Mandell [6] surveyed some of the collected literature in this area. Perhaps unsurprisingly "greater symptom severity" was one of the core factors associated with earlier diagnosis. Some of this authorship group have gone into further detail about which symptoms might affect age and diagnosis [7]. On that occasion they concluded that: "Children with severe language deficits received a diagnosis an average of 1.2 years earlier than other children. Hand flapping, toe walking, and sustained odd play were associated with a decrease in the age of diagnosis, whereas oversensitivity to pain and hearing impairment were associated with an increase".
• Frenette and colleagues [8] in their study reported that: "a one year increase in maternal age at delivery was associated with a 0.06 decrease in age at ASD diagnosis". So there might be something of a correlation between older mums and earlier diagnosis. This suggests one or more factors might pertain: (a) older mums with more 'life experience' and perhaps with a greater likelihood of having other children, might be more sensitive to symptoms, or (b) younger mums with less 'life experience' might be less sensitive to symptoms. Right or wrong, that's my interpretation anyway, and certainly, it was something noted by Fountain and colleagues [9] (open-access here).
• The paper by Rosenberg and colleagues [10] (open-access here) did not find any one factor as being linked to age at diagnosis. That being said they did suggest that: "Both ID [intellectual disability] and history of autistic regression were associated with earlier AOD [age of initial diagnosis]". They similarly noted the differences in age at diagnosis between different diagnoses on the autism spectrum. Race and gender was also picked up.
• Ethnicity was also something picked up in the study by Coo and colleagues [11] (open-access here). They noted that: "rural residence, diagnosis in more recent years, and foreign birthplace were associated with a later age at diagnosis". They continue: "Children who are visible minorities or who have siblings with ASD were more likely to be diagnosed earlier". Not everyone however agrees with those sentiments as per the paper by Valicenti-McDermott and colleagues [12].

I think what we can take from this collected data is that there are many influences pushing and pulling at the age of diagnosis of autism outside of the levels of resources available and other population factors. Presentation of symptoms in terms of timing and severity are the obvious factors which seem to influence age at diagnosis. Regression in symptoms, as I've talked about a few times on this blog (see here and see here) probably depends on how severe the regression was and when it happened.

Outside of the continued need for early and accurate diagnosis, there are other important implications from any change in age at diagnosis. So for example, the potential to affect autism prevalence estimates as per the conclusions by Parner and colleagues [13] is something to consider. Whether also early diagnosis and by assumption, early intervention might also have some important effects on say, the likelihood of joining that optimal outcome group (see here) is another consideration too.

Music to close. Please do not mention the football. Or as someone noted for fans of the England football (soccer) team "that familiar sense of utter disappointment. Hello old friend". So instead a 'sit back and enjoy the summer' song: Waves.

----------

[1] Mishaal RA. et al. Age of autism spectrum disorder diagnosis is associated with child's variables and parental experience. Res Autism Spect Disord. 2014; 8: 873-880.

[2] Howlin P. & Asgharian A. The diagnosis of autism and Asperger syndrome: findings from a survey of 770 families. Dev Med Child Neurol. 1999 Dec;41(12):834-9.

[3] Mandell DS. et al. Age of diagnosis among Medicaid-enrolled children with autism, 2001-2004. Psychiatr Serv. 2010 Aug;61(8):822-9.

[4] Whiteley P. et al. Trends in Developmental, Behavioral and Somatic Factors by Diagnostic Sub-group in Pervasive Developmental Disorders: A Follow-up Analysis. Autism Insights. 2009; 1: 3-17.

[5] Wingate M. et al. Prevalence of autism spectrum disorder among children aged 8 years - autism and developmental disabilities monitoring network, 11 sites, United States, 2010. MMWR Surveill Summ. 2014 Mar 28;63(2):1-21.

[6] Daniels AM. & Mandell DS. Explaining differences in age at autism spectrum disorder diagnosis: A critical review. Autism. 2013 Jun 20.

[7] Mandell DS. et al. Factors associated with age of diagnosis among children with autism spectrum disorders. Pediatrics. 2005 Dec;116(6):1480-6.

[8] Frenette P. et al. Factors affecting the age at diagnosis of autism spectrum disorders in Nova Scotia, Canada. Autism. 2013 Mar;17(2):184-95.

[9] Fountain C. et al. Age of diagnosis for autism: individual and community factors across 10 birth cohorts. J Epidemiol Community Health. 2011 Jun;65(6):503-10.

[10] Rosenberg RE. et al. Factors affecting age at initial autism spectrum disorder diagnosis in a national survey. Autism Res Treat. 2011;2011:874619.

[11] Coo H. et al. Correlates of age at diagnosis of autism spectrum disorders in six Canadian regions. Chronic Dis Inj Can. 2012 Mar;32(2):90-100.

[12] Valicenti-McDermott M. et al. Age at diagnosis of autism spectrum disorders. J Pediatr. 2012 Sep;161(3):554-6.

[13] Parner ET. et al. Autism prevalence trends over time in Denmark: changes in prevalence and age at diagnosis. Arch Pediatr Adolesc Med. 2008 Dec;162(12):1150-6.

----------

Mishaal, R., Ben-Itzchak, E., & Zachor, D. (2014). Age of autism spectrum disorder diagnosis is associated with child's variables and parental experience Research in Autism Spectrum Disorders, 8 (7), 873-880 DOI: 10.1016/j.rasd.2014.04.001

Autism and the [changing] preschool developmental profile

I'd like to begin with a quote from the paper by Hedvall and colleagues* who reported findings based on a study of developmental trajectory for 208 preschoolers diagnosed with an autism spectrum condition: "Changes in developmental profiles during preschool years are common in children with ASD".

Seasons: Autumn @ Wikipedia 

Their naturalistic study suggested that the very early years of autism, at least some autism, and its presentation are characterised by "considerable change over time" and the requirement for "follow-up assessments" in order to more accurately measure where the sands of autism have settled prior to the start of school.

Their reporting that intellectual disability (ID) also might have a maturational aspect to its appearance alongside cases of autism (i.e. not common in early diagnosis but present in about 50% of cases at follow-up) also provides some food for thought in terms of whether this reflects a specific comorbidity or indeed, something more central to specific types of autism (yes, the autisms), though carrying a different timescale of presentation.

I'm not altogether sure but I think we might have seen the Hedvall cohort used in another study by Fernell and colleagues** during their study looking at early intervention and autism. In that paper, the same number of preschoolers with autism (N=208) were followed "in a naturalistic fashion" and their various experiences of an ABA (applied behaviour analysis) program recorded. If it is one and same cohort, it's likely then that we are probably not talking about developmental changes occurring just spontaneously in some sort of intervention vacuum. Sort of what happens in real-life.

I've talked before on this blog about diagnostic stability and instability when it comes to autism (see here). Whilst accepting that 'universals' when it comes to autism are generally few and far between outside of the almighty diagnostic criteria, the conclusion reached on that post was that stability with regards to a diagnosis of autism is surprisingly, quite an unstable thing. When particularly applied to the early years and their growing importance when it comes to autism (see here) one might speculate that such instability presents its own issues particularly in these times when chatter about really early autism diagnosis is becoming more frequent and louder and louder. Discussion about the important issue of regression which might also interfere with any notion of a universal prenatal or early autism diagnostic test is also worth noting. That also different children on the autism spectrum might present with different developmental trajectories is an important point to emphasise, particularly in these times of optimal outcomers for example (see here).

Whilst the Hedvall data provides a cautionary tale that we should be mindful of how dynamic autism might be in the early years (and perhaps even beyond), I'd like to think that it won't be used as an excuse for delaying assessment and diagnosis too much and the subsequent impact that can have....

----------

* Hedvall A. et al. Autism and developmental profiles in preschoolers: stability and change over time. Acta Paediatr. 2013 Oct 8. doi: 10.1111/apa.12455.

** Fernell E. et al. Early intervention in 208 Swedish preschoolers with autism spectrum disorder. A prospective naturalistic study. Res Dev Disabil. 2011 Nov-Dec;32(6):2092-101.

----------

Hedvall A, Westerlund J, Fernell E, Holm A, Gillberg C, & Billstedt E (2013). Autism and developmental profiles in preschoolers: stability and change over time. Acta paediatrica (Oslo, Norway : 1992) PMID: 24237479

More autism developmental trajectory research

Bloomers. No not the clothing variety, but the group described by Christine Fountain and colleagues* (open-access) in their paper on developmental trajectories in autism covered in this post. The bloomers grouping describing a specific group of children with autism who "experienced rapid gains, moving from severely affected to high functioning".

Crateva religiosa @ Wikipedia  

The whole idea of looking at children in the here and now and trying to predict where they will be in X years time seems to be gaining some ground in autism research circles.

The paper by Katherine Gotham and colleagues**, she of the revised algorithm*** for everyone's best loved gold standard autism assessment instrument, the ADOS, joins the crystal-ball reading, based as one might expect on longitudinal ADOS scores.

In brief:

• The aim was to plot developmental trajectory in cases of autism. The hypothesis: "a substantial minority of children will show marked changes in ASD severity over time, with “Improvers” demonstrating the highest mean baseline and rate of growth in verbal IQ (VIQ)". The speculation: a link between autism 'functioning' and verbal intelligence, accepting that functioning means different things to different people.
• Quite a large group of children (N=345) were examined, with at least one 'estimate' of an autism diagnosis at some point between the ages of 2 - 15 years and who received more than one ADOS session.
• Results: move over Christine Fountain and your six developmental trajectories, Gotham et al describe a statistical model made up of 4 classes which best represented the observed data.
• The majority of participant stuck to their allocated class based on severity of symptoms according to ADOS, although participants allocated to two of the classes showed increasing and decreasing severity of symptoms over development. As hypothesised, verbal intelligence was an important factor in predicting class membership increasing "at the greatest rate in the improving class".
• Discussions start to turn to a possible role for trajectories in terms of endophentotypes and further delineation of the autism spectrum.

Once again, I'm really quite interested in this research and indeed this whole area of investigation. I've kinda said it before about how autism is, in some cases, actually quite an unstable diagnosis and how, given this instability combined with the heterogeneity and elevated risk for comorbidity noted across the autism spectrum, we need to find new ways to look at autism research outside of just an autism diagnosis as a starting point. In that respect it's good to see that people are starting to look into this issue (and not just the MIND Institute and their Autism Phenome Project).

Using ADOS to measure symptoms longitudinally is by no means a new phenomenon as per other articles from the authorship team such as this one from Lord and colleagues**** who reported again on four trajectory classes and again highlighted verbal ability as being involved. Elizabeth Pellicano***** likewise reported on developmental trajectory (using ADOS) and also detailed instances of 'diagnostic discontinuity'.

The suggestion that verbal intelligence might be a key part of predicting where a child with autism might be in X years time is also not a new concept. Gillespie-Lynch and colleagues****** (open-access) followed twenty participants with autism from child- to adulthood suggesting that "both early childhood language and RJA [responsiveness to joint attention] predicted adult social functioning". I'm sure that the movers and shakers of the new DSM-V 'social affect' bundling  with autism in mind were very happy to read this. Language and verbal intelligence it appears are pretty crucial to how autism progresses, bearing in mind what is known about verbal intelligence outside of autism.

There's not too much more to add to this post and topic of investigation. I should perhaps mention that when we talk about bloomers and improvers with autism spectrum disorders in mind, there is still a little bit of a gap as to the potential effects from intervention on certain cases. Research which I have been involved with for example, suggested that ADOS scores can also change alongside the adoption of dietary intervention at least in some cases of autism. I hold back from saying that this is 'proof' of any change in clinical presentation, but one does wonder exactly what effects interventions like those based in education or behavioural programs (early intervention?) might have for the current studies in this area.

Oh, and the idea that autism is actually autisms...

To finish, a spot of the fiddles is in order as Bellowhead go Ten Thousand Miles Away. Land ho!

---------


* Fountain C. et al. Six developmental trajectories characterize children with autism. Pediatrics. 2012; 12: e1112-20.

** Gotham K. et al. Trajectories of autism severity in children using standardized ADOS scores. Pediatrics. October 2012.

*** Gotham K. et al. The Autism Diagnostic Observation Schedule: revised algorithms for improved diagnostic validity. J Autism Dev Disord. 2007; 37: 613-27.

**** Lord C. et al. Patterns of developmental trajectories in toddlers with autism spectrum disorder. J Consult Clin Psychol. 2012; 80: 477-489.

***** Pellicano E. Do autistic symptoms persist across time? Evidence of substantial change in symptomatology over a 3-year period in cognitively able children with autism. Am J Intellect Dev Disabil. 2012; 117: 156-166.

****** Gillespie-Lynch K. et al. Early childhood predictors of the social competence of adults with autism. J Autism Dev Disord.  2012; 42: 161-174.


----------

Gotham, K., Pickles, A., & Lord, C. (2012). Trajectories of Autism Severity in Children Using Standardized ADOS Scores PEDIATRICS, 130 (5) DOI: 10.1542/peds.2011-3668

Can you grow out of autism?

An intriguing question to open this post commenting on this study by Heather Close and colleagues* on comorbid conditions and the stability of autism as a diagnosis. In essence the paper suggests two things: (1) autism is rarely a stand-alone condition; a recurring theme on this blog, and (2) autism is not a static condition (see my previous post on diagnostic instability).

To summarise:

• Based on the 2007 National Survey of Children's Health, over 90,000 parents of children aged up to 17 years old were contacted. 
• Of the total population, 1,366 children were identified via parental report as having either a past or current diagnosis of an autism spectrum condition. 453 parents said their child had a diagnosis of autism but didn't anymore.
• Based on age divisions (young children, 3-5 years old), children (6-11 years old) and adolescents (12-17 years old), the authors analysed various responses of background information and the presence of comorbid conditions to ascertain whether there were any differences between those who had a current diagnosis of an autism spectrum condition (ASC) compared with those who had a past but not current (PBNC) diagnosis of an ASC. There were in effect 3 experiments running comparing those with a current diagnosis with those who 'lost' their diagnosis, across the 3 age groupings.
• The findings: youngest children with a current diagnosis of an ASC were more likely (a lot more likely) to have a concurrent learning disability or delayed development compared with the PBNC group. In the 6-11 age bracket, current diagnosis children were more likely to have past speech and hearing problems and concurrent anxiety issues than the PBNC group. In adolescents, past hearing problems and current speech and epilepsy issues were more likely in the current diagnosis group. Currently diagnosed children across the age groups were also more likely to have more comorbidities than the PBNC group. 
• The authors suggest that the presentation of these comorbid features, past or current presentation, likely influences whether or not a diagnosis is retained or 'outgrown'.

There are a few media reports and opinions about this work already. WebMD.com has the headline 'Why some children may 'grow out' of autism'.

Whilst very interested in these results, I find myself in a bit of a quandary. On the one hand is the pretty persistent line presented over the years that autism is a 'lifelong condition' which whilst exemplified by the changing/fluctuating presentation of symptoms as a consequence of things like maturation, in essence is immutable in terms of whether someone has autism or not. On the other hand, we have parents reporting in this study that some of their children having had an autism diagnosis, were no longer considered to have a current diagnosis. I suppose one could argue that the authors were not able to independently test these assumptions out either when diagnosis was originally given or after diagnosis was 'done away with' so a degree of subjectivity should be expected. One perhaps cannot also rule out the subclinical presentation of symptoms such like the ideas on the broader autism phenotype.

Having said that, quite a few people over the years have reported similar things in terms of their child no longer appearing to present on the autism spectrum. Few of these cases have been spontaneous; more often that not associated with some kind of intervention or following mis-diagnosis. I make no value judgements on either of these factors.

One of the authors of the current study, Andrew Zimmerman has quite an extensive autism research career which it has to be said, is perhaps slanted more towards the possibility that other factors/conditions/comorbidities seem to be associated with autism. So for example, familial autoimmunity and medical risk of autism, issues related to inflammation and neuroinflammation, and even a role for fever in abating some of the symptoms of autism. The current findings perhaps extend his interest.

What this latest study does reiterate is that a diagnosis of autism should not be the end-point to determining why a person behaves the way they do. Given recent posts on SPAD, CFD and all manner of other conditions potentially more prevalent in cases of autism (glutathione issues?), a diagnosis of autism should really be the starting point to try and ascertain whether these and/or other conditions contribute to the presentation of autism or at least whether they can adversely affect quality of life. Whilst token mention has been made about the impact of intervention on some cases of autism in this current paper, it does not seem beyond the realms of possibility that intervention might have had a role to play (with the caveat that much more targeted research is needed).

So the question remains: can you grow out of autism?

* Close H. et al. Co-occurring conditions and change in diagnosis in autism spectrum disorders. Pediatrics. January 2012.

Stability of autistic traits in the general population

In a post a few weeks back, I discussed the relative stability, or instability, of autistic traits from a diagnostic point of view. The take-home message from that post was that autism taken as a population whole, can be a fairly unstable concept in terms of symptom presentation both in the short- and long-term as a function of lots of different factors. Much like everyone else, people with autism and their symptoms change with maturity and experience.

A recent paper appearing in PLoS ONE offers some further insight into this process, long-term. The paper (open-text here) by Whitehouse and colleagues* sought to measure autistic traits among typically-developing toddlers and the degree to which such traits were predictive of things a couple of decades later. It is important to realise that this was not a study looking at children with a diagnosis of autism, but rather the overlap of traits in the general population. Longitudinal research to the extreme!

Without repeating the paper rote fashion, here's a summary of what they did and found:

• 2900 mums-to-be were recruited for a study looking at the repeated effects of ultra-sound during gestation. 2868 children were invited to take part in a follow-up study involving various assessments during their childhood and young adult years.
• When children were aged approximately 2 years, their parents completed the pervasive developmental problem sub-scale derived from the Childhood Behaviour Checklist (CBCL) on behalf of their child. The scale looks at social and non-social autistic traits. Participants were followed-up some 17-18 years later and completed the self-report Autism Spectrum Quotient. The scoring schedules whilst not exactly the same, were compared and various potential sources of bias taken into account (most of which occurred during gestation).
• The results from participants (males: 360, females: 400) are presented with correlations between the two instrument scores. A significance value of p<0.006 was used as a result of some statistical adjustment made for the multiple comparisons used.
• Males showed the greatest positive correlations between the testing sessions with several associations surpassing the significance boundaries set in areas of total score and social autistic trait score combinations. Having said that the R-squared values (measure of predictive correlation) were not exactly brilliant (0.16-0.17), where 0 is no predictive value and 1 is absolutely predictive. Non-social autistic traits in males showed nothing in particular across the study. Females scores across social and non-social autistic traits over the study period again showed nothing in particular.

Although there are elements to this study which might raise an eyebrow of many scientific sorts out there, I have to say that I do like this study. I like it because it was prospective and it had a large participant group. I also like the fact after so many years a good percentage of the original group were still willing to volunteer, albeit perhaps from a higher socio-economically advantaged group. Of course we are 'almost' dealing with apples and oranges in terms of the different scales used over the study period and the different informants (parents vs. participants), so these need to be kept in mind.

The gender differences are interesting. Interesting because of the various debates around diagnosis of autism in males and females. The current results hinting that autistic traits in typically-developing young girls were not the same or predictive of the same group in early adulthood may imply either different biological mechanisms or different social factors are at work in modifying such behaviours compared with boys. How this might translate into autism and presentation by gender, I don't know.

The authors are quite reserved in their interpretation of their findings despite the significance values obtained. 'Modest' is a word used quite a bit throughout the article, and to me, that sounds about right. Kudos to them for the work they have put it and the results obtained.

* Whitehouse AJO. et al. Are autistic traits in the general population stable across development? PLoS ONE. August 2011.

Diagnostic stability and instability in autism

Stability (and instability) has many different meanings depending on what area you are looking at. For the purposes of this post, I am talking about what happens to a diagnosis of autism/Asperger syndrome/ASD or PDD-NOS as a function of changes to presented symptoms; and in particular, the factors potentially affecting diagnostic stability such as age, co-morbidity, symptom severity and various interventions.

I use the words 'potentially affecting' because as with many things, it is very difficult (impossible?) to say definitively that one or other factor alone/combinatorially contributed to change something, bearing in mind the basis of science being probability not absolutes.

Stability with regards to autism diagnoses is a surprisingly unstable thing. Think about it: we diagnose on the basis of a prescribed pattern of symptoms being present and observable and occurring within a set chronological time frame. On the basis of such controlled but ultimately subjective judgements we specify 'autism', 'Asperger syndrome' or one of the other sub-diagnoses as being present as detailed in the DSM or ICD schedules.

OK, you're right, we do have various standardised schedules to aid diagnosis (ADI, ADOS, etc) but remember, these are only complementary to the diagnostic (or assessment) process and not confirmatory per se.

Final diagnosis is therefore dependent on factors such as who makes the diagnostic decision (their skill, experience and diligence), where and under what circumstances the diagnosis is made (home, school, clinic, all of the above), what kind of contributory assessment tools were used, and at what age the diagnosis is made (young or older age). Lots of different variables and lots of room for variability to occur.

As I posted in my previous entry on the proposed DSM revisions, there is nothing currently or in the planned revisions to the diagnostic manuals to say that an autism diagnosis is anything but a fixed feature; autism is after all a lifelong condition according to organisations such as the National Autistic Society.

Taking the issue of chronological age first, there are a few things worth noting. Autism research has, frankly become quite obsessed with early diagnosis. Lots of different studies have been conducted to look for the 'magical' set of behaviours and characteristics which would allow screening or assessment measures to universally identify the 'autistic child' at 3 months, 6 months or 12 months, etc of age.

Why you may ask? Well because there is a suggestion (and it is quite a strong suggestion) that the earlier that symptoms are identified and a diagnosis given, the earlier that intervention can be adopted in order to somehow influence the course of development. Given the proposed plasticity of organs such as the brain at these critical early developmental periods, the logic is that through play, speech and language and other therapies and interventions (mainstream and complementary), it may be possible to affect brain development, directly or peripherally, and hence potentially affect symptoms presentation.

There appears to be little wrong with this logic given the evidence available for its component parts: the brain for example during early infancy is a busy little bee adding (and pruning) various neural connections at a pretty spectacular rate over those early years. One side-effect from this whole order of developmental events is perhaps the conflict with the view of autism 'being a purely genetic condition'; whereby genes, and only genes, dictate the course of developmental events and because they are genes, they are somehow immovable.

The contrary logic of early diagnosis and early intervention presenting behaviour as plastic and malleable suggest pre-determination may not be 'the' key element of autism or at least 'some' autisms (perhaps a blog entry of its own on this topic is merited).

The reality is that we do not have a universally clear idea of early autism presentation (we need only look at studies on tools such as the CHAT and M-CHAT to know this) accepting also that age is a modifying variable on autism symptom presentation and diagnosis. Several studies have shown that there is quite a large degree of diagnostic instability as a function of age, particularly in the early months/years; most probably as a function of the rapid changes in physical and psychological development that occur during these formative years.

Moving on to co-morbidity. We know that autism can occur alongside several other linked / non-linked conditions, some of which may have a significant effect on how and what symptoms are presented. Learning disability (LD) is perhaps the most widely cited co-morbidity but things like epilepsy / seizure-type disorders have also been noted. Like autism, LD ebbs and flows in terms of presentation. Epilepsy also is not a static entity with a suggestion that it can impact on autistic symptom presentation (although the nature of the relationship still requires further study).

The severity of symptoms and the connection to which diagnosis is given has also been suggested to further contribute to diagnostic instability. Recent meta-analysis has suggested that greater variability in symptom presentation is evident amongst the ASD / PDD-NOS diagnosis when compared to classical autism. Does this mean that classical 'Kanner' autism is governed more by immovable genetics than environment when compared to other sub-diagnoses?

Finally we have the potential role of intervention on diagnostic stability. There are many different types of intervention or management strategies suggested for autism; educational, behavioural, pharmacotherapy, etc. all with varying degrees of evidence for efficacy (and importantly safety). Time and time again reports similarly emerge of children whose symptoms abate (disappear?) and what interventions might be contributory. I am not getting into the nitty-gritty of whether such reports are accurate or not (I am hardly in a position to question a parent's view of their own child). What such reports do suggest is that movement across the diagnostic autism spectrum is potentially possible (at least in some cases) and correlates with intervention (remembering of course that correlation does not imply causation).

So there we have it; lots of different factors pulling, yanking, tearing at a diagnosis. I will finish with a reiteration: stability with regards to autism diagnoses is a surprisingly unstable thing.