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How redefining autism could improve research on the condition

Expert

Ami Klin

Director , Marcus Autism Center in Atlanta, Georgia

Autism is typically thought of as a collection of traits: restricted interests, repetitive behaviors and difficulty with social communication. But by the time those traits can be detected and a child diagnosed with autism — around the age of 4, on average, in the United States — she has missed out on months, if not years, of therapy when her brain is most flexible.

Despite more than a decade of research aimed at improving early detection, the average age of autism diagnosis has not budged. Part of the problem lies with how the condition is defined, says Ami Klin, director of the Marcus Autism Center in Atlanta, Georgia.

In a paper published in September, Klin and his colleagues call for autism to be redefined based on the latest scientific evidence, which indicates that it is highly heritable and present from birth. Rather than thinking of autism as a collection of traits, Klin says, researchers, clinicians and policymakers should think about it as a genetic condition that alters how a child perceives and interacts with others, one in which early life experiences can shape the severity of its core traits.

Klin spoke with Spectrum about how adopting this new definition of autism might foster earlier diagnosis and treatment.

Spectrum: What inspired you to try to redefine autism?

Ami Klin: There is a major gap between our societal investments in early autism diagnosis and treatment, and the science of early brain development. My colleagues and I follow babies from the time that they’re born, and we see them monthly until they are diagnosed with autism, or not. We see the immense change that happens during that period and the enormous impact that interventions have. And yet most autistic children cannot access services or interventions until after they receive a diagnosis — and after this period of maximum brain plasticity has ended.

The problem is that the way we have defined autism over the years makes it seem like an inevitable outcome. But what the science has been showing to us is the opposite: Autism is a trait that is genetically based. And with that trait comes an attenuated ability to interact with others, which can disrupt early social experiences and eventually lead to symptoms that we now call ‘autism spectrum disorder.’ But whether or not that genetic risk results in a lifetime of disabilities is critically dependent on early life experiences.

S: What led to the ‘inevitable’ view of the condition?

AK: By necessity we had to define autism as a collection of behavioral traits so that we could all diagnose autism in a uniform way, and so that autistic people could receive treatment and services. That makes complete sense in clinical practice.

But if you instead consider autism to be something like your level of sociability as a baby, then that is not necessarily something that I want to treat. It’s a trait; it’s just a way of being in this world.

What we do want is to ensure that that trait does not lead to other things that are disabilities. For example, not having language, being intellectually disabled, or having severe behavior challenges such as self-injury and aggression. Our focus should be on the opportunities that we have to ensure that those early genetic ‘risks’ don’t become disabilities for the rest of these children’s lives.

S: Why is it important to have a definition of autism that encourages early diagnosis and treatment?

AK: Babies come ready to interact. As they interact, they acquire experiences. Those experiences shape the babies’ brains. A child accrues hundreds, if not thousands, of learning experiences in the first month of life, and the way that the brain is being shaped by those experiences is going to make it ready for the next level of learning and brain development.

What my colleagues and I want others to recognize is that autism breaks this process. Our studies have shown that autistic infants may be missing hundreds of social learning experiences over the course of six months. Every experience they miss was an opportunity to move brain development forward.

If they miss too much, eventually, they will be on a different developmental trajectory. That means not only socializing less, but also doing other things that eventually come to resemble the classic traits of autism.

That’s why we can only identify autism in the second year of life, and stably by the end of the second year of life. But that doesn’t mean the process begins there. You begin with a disruption. And what we are seeing when children are diagnosed is the culmination of that disruption, not the onset.

S: How do socioeconomic disparities play into this problem?

AK: Autistic children originating from communities that are traditionally underserved — in particular minority, low-income and rural populations — are identified later than their white peers. And we see the result of that: By age 8, the rate of intellectual disability among [autistic] Black children is almost double that of [autistic] white children. There is little evidence to suggest that this is due to genetic differences, and a lot of evidence indicating that this might have to do with early access to services.

These disparities are only a reflection of the healthcare disparities that exist across the board, across different races and different socioeconomic sectors. However, because autism is a trait that is instantiated in the early experiences of the child, that environment ends up aggravating the expression of the condition. But if you consider autism an immutable condition, then neither positive experiences nor bad experiences are going to mediate the expression of that genetic risk.

S: How might your redefinition of autism shape research?

AK: What I would like scientists to take away from this paper is that we need not wait for discoveries of autism’s causes in order to have the greatest positive impact for autistic children and their families.

If we take our current science of early brain development seriously, then we need to better understand how genetic risk interacts with environment factors. We need a much better understanding of the active ingredients that disrupt social development, and better ways of ameliorating it.

We also need to make sure that we strengthen the evidence basis of early intervention. Unfortunately, that literature is still not robust enough.

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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

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Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
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We are not required to agree to a restriction that you may request. If we agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your health provider.

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upon request, even if you have agreed to accept this notice electronically.
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You may contact our Privacy Officer at (704) 824-7800 for further information about the complaint process.

This notice was published and becomes effective on August l, 2011.