Let's Talk about Autism It is not a coincidence that we find it more common to hear about autism spectrum disorders (ASD) nowadays, through the years, the media have helped us to understand a little better those who simply have a different way of seeing the world. In addition, the cases of important figures who have accepted to live with this spectrum are visibly increasing. With the passage of time, people have put aside the prejudices and the stereotyped vision they used to have about autism (although there is still a long path to run) and fictional characters have emerged, as is the case of Shaun Murphy, a young surgeon with autism performed by the English actor Freddie Highmore in the TV series ‘The Good Doctor’. But the pioneer in this field was Dustin Hoffman, who played Raymund Babbit in the film ‘Rain Man’, in 1988. The film not only presents a character with autism but also highlights the difficulties that caregivers have to face to contain a person within the spectrum. From that moment, this kind of work started to gain recognition in the entertainment business and films, such as ‘I am Sam’, ‘The Black Balloon’, ‘Mozart and the Whale’, ‘Please Stand By’ and ‘Kia and Cosmos’ were released. “Autism is a complex, lifelong developmental disability that typically appears during early childhood and can impact a person’s social skills, communication, relationships, and self-regulation. Autism is defined by a certain set of behaviors and is a “spectrum condition” that affects people differently and to varying degrees”.[1] According to the World Health Organization, one in 160 children has an autism spectrum disorder. “This estimate represents an average figure, and reported prevalence varies substantially across studies. Some well-controlled studies have, however, reported figures that are substantially higher. The prevalence of ASD in many low- and middle-income countries is so far unknown”.[2] Autism has created a great controversy since its discovery. Children with Autism Spectrum Disorder (ASD) were initially believed to suffer from psychosis and autism was confused with schizophrenia. Moreover, different theories have been developed on its explanation and different forms of the spectrum have changed year by year as new investigations are carried out. It is also known that there is neither a cure for ASD nor an effective treatment to ensure the complete recovery of the patient. So broad is this spectrum that each case is disparate. Symptoms differ among patients; they can range from mild to severe and can change as the individual grows. This makes it difficult to understand ASD and to find effective therapies. “The word Autism was coined after the Latin word Autismus in 1910 by Swiss psychiatrist Eugen Bleuler; however he applied the word to describing schizophrenia. The Latin word was in turn derived from a Greek word, autos, meaning “self”. Once the condition we now know as autism was discovered in 1938, it was labeled with Bleuler’s word because people who are autistic have been observed to be morbidly self-absorbed to the exclusion of everyone else around them”.[3] Autism was originally confused with schizophrenia, nowadays it is known that although people with schizophrenia may show a similar behavior to autism, its symptoms usually do not appear until late adolescence or early adulthood. Most schizophrenia’s patients also have hallucinations and delusions, which are not included in autism. In the 1950s, the "refrigerator mother theory" emerged as an explanation for autism. The hypothesis was based on the idea that an inadequate emotional relationship between child and parents leads to the child’s personality not being normally developed. For a long time it was believed that mothers did not know how to form a proper attachment bond in early childhood. Then, Kanner noticed that his theory did not hold as he observed that siblings of children with autism, raised by the same “not very affectionate” parents, did not have problems in their behavior or in the way they relate to others. Even though nowadays its etiology is not yet clarified, autism spectrum disorders appear to be caused by environmental, biological, and genetic factors. There are different types of ASD. This classification has been modified by the Diagnostic and Statistical Manual of Mental Disorders (DSM), this is the diagnostic “Bible” used by mental health professionals and insurers. In its latest edition, the DSM, published by the American Psychiatric Association (APA) has included five subtypes of autism: classic autism, Asperger syndrome, Childhood Disintegrative Disorder, Pervasive Developmental Disorder – Not Otherwise Specified and Rett syndrome. Autism can also be divided into syndromal and non-syndromal autism; the syndromal autism is associated with severe or profound intellectual disability or a congenital syndrome with physical symptoms, such as tuberous sclerosis. Classic autism is defined as the most serious form of autistic spectrum disorder, it is also known as ’severe autism’, ’Kanner’s Syndrome’ and ’autism disorder’. It is what most people think of when hearing the word “autism”. This manifests as alterations in social interaction and communication skills and a limited number of activities, and unusual behaviors and interests. Many people with autistic disorder also have intellectual disability. Asperger’s syndrome is a mental disorder with generally higher functioning characterized by a significant limitation of social behavior and relationship skills. Classic autism and Asperger syndrome share two key traits: difficulties in social communication processes, and obsessive interests and repetitive actions. But at the same time, there are some features that differentiate them. While many cases of autism have some degree of intellectual impairment, children with Asperger's syndrome show no evidence of cognitive delay and may even do very well on intelligence tests. On the other hand, patients with classic autism show some delay in the acquisition of language skills, while children with Asperger's syndrome acquire an appropriate vocabulary for their age and can even be considered highly intelligent. Finally, both autism and Asperger's patients have a very limited and obsessive area of interest, however, children with Asperger Syndrome show “high-level” interests that can lead them to excel in certain fields of science, such as mathematics or physics. Satoshi Tajiri is one of the most important members of the video games’ industry, he is best known as the creator of ‘Pokémon’, the most profitable license in the entertainment industry, even above 'Star Wars'. Many people do not know but he suffers from Asperger’s syndrome. In his childhood he was fascinated with insects and he enjoyed collecting them, this was an inspiration to create ‘Pokémon’. Some years ago it was confirmed in his biography that he had been diagnosed with this condition, this explains his great obsession with bugs. Furthermore, outstanding thinkers, scientists, and musicians, such as Isaac Newton, Wolfgang Amadeus Mozart, Ludwig Beethoven, Immanuel Kant and Albert Einstein have been studied by Michael Fitzgerald, a British psychiatrist of Trinity College, who has concluded that all of them have also suffered some degree of autism. Childhood disintegrative disorder (CDD), also known as Heller's syndrome and disintegrative psychosis, is a rare condition characterized by late onset of developmental delays in language, social function, and motor skills, which often ends in autistic symptoms after normal development up to two years of age. CDD is frequently associated with more severe symptoms than early-onset autism including deep loss of cognitive abilities resulting in intellectual disability. This condition was discovered by the Austrian educator Theodore Heller in 1908, long before doctors started talking about autism, he used the term ‘dementia infantilis’ to refer to this disorder. So far, the cause of childhood disintegrative disorder is not known with certainty, however, experts are convinced that the loss of acquired skills may be due to a brain disorder such as tuberous sclerosis or a seizure disorder. When the first signs of the CDD appear (between the ages of 2 and 10), the loss of acquired skills is usually quite rapid. In this way, the child begins to have difficulties to carry out tasks and activities that he previously did on his own and the deterioration becomes increasingly evident. These children usually do not fully regain the skills they have lost. They can achieve small improvements with an adequate treatment, although in most of the cases, they will remain dependent on their caregivers. The diagnosis of a Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS) is given to individuals who have difficulties in their development but who do not fully fit with the other specific diagnostic criteria for the categories previously mentioned. This condition includes a wide range of symptoms and each case is unique, therefore, it demands a highly personalized treatment program. A person with this condition involves problems in the areas of social interaction, communication, and stereotypic behavior patterns or interests. Children with PDD-NOS also have specific neurobiological dysfunctions, such as alterations in sensory integration, language disorders or difficulties in executive functions related to planning and working memory. Rett syndrome is a genetic neurological disorder that normally occurs between 6 to 18 months of age particularly in girls and causes severe impairments. It is characterized by normal early growth and development followed by a slowing of development, loss of purposeful use of the hands, distinctive hand movements, slowed brain and head growth, problems with walking, seizures, and intellectual disability. “Rett syndrome is caused by mutations on the X chromosome on a gene called MECP2. There are more than 900 different mutations found on the MECP2 gene. Most of these mutations are found in eight different ‘hot spots’. Rett syndrome is not a degenerative disorder with individuals living to middle age or beyond. It is not inherited. Rett syndrome occurs worldwide in 1 of every 10,000 female births, and is even rarer in boys.”[4] There are people who believe that this syndrome is a developmental disorder, although its classification as ASD is in dispute. Although there is no known cure for Autism Spectrum Disorder, there are many treatments and therapies that can reduce difficulties in communication and social behavior, with a positive effect on the person’s health and quality of life. The earlier intervention during childhood is crucial to promote a favorable development and well-being of people with an ASD. It is recommended that parents carry out daily monitoring of child development and child health care. There are behavioral programs that focus on social skills, attention, sleep, play, anxiety, interaction with parents, and challenging behaviors. Most of these treatments employ trained therapists that work with parents and children and they take place in houses, schools and hospitals. Early intensive behavioral intervention, cognitive behavior therapy and social skills training are types of behavioral therapies. Early intensive behavioral intervention concentrates on the general development of children. Treatments that use cognitive behavior therapies also help patients to cope with their anxiety. Moreover, there is a Skillstreaming program that helps patients to deal with their social skills and there is a Joint Attention Symbolic Play Engagement and Regulation (JASPER) program that has the aim of helping little children with their difficulties for cooperative play. On the other hand, there are treatments that are offered by schools and other teaching centers. They focus on learning and reasoning skills. Most of them are based on the Treatment and Education of Autistic and Related Communication-Handicapped Children method and they use visual resources and arrange the classroom in a way that it is easier for a child with ASD to handle it. There are other methods that use "applied behavioral analysis" strategies in the classroom, such as the positive reinforcement. Moreover, there are some medications that can help to minimize certain symptoms associated with ASD, especially certain behaviors, such as to reduce self-injury or aggression. This allows patients with autism to focus on other things, including learning and communication. Research shows that medication is most effective when used in combination with behavioral therapies. “The U.S. Food and Drug Administration (FDA) has approved the use of some antipsychotic drugs, such as risperidone and aripiprazole, for treating irritability associated with ASD in children between certain ages.”[5] Other drugs are regularly prescribed to help improve symptoms of autism, but they are not authorized by the FDA for this particular function. There are other treatments that are provided for patients with ASD, such as Speech-language therapy, Music therapy, Occupational therapy, Neurofeedback, Nutritional therapy, Parent-mediated therapy, Physical therapy, Education and sleep training, among others. There may be cases where these therapies have helped patients to improve the symptoms, however, they have not been studied enough to know if they are effective or if they have any side effects. Finally, a curious fact that may interest you is that the colour blue symbolizes autism as it is the colour of the sea. Sometimes the sea is calm, but in other opportunities it is rough. The same happens with patients with autism, for that reason the colour blue has become a symbol of Autism Spectrum Disorders. In 2007 the General Assembly of the United Nations appointed April 2 the World Autism Awareness Day. Since then, every year several activities are carried out around the world with the aim of promulgating updated information on ASD and raising awareness about people with this condition. We are living in the 21st century, science has advanced by leaps and bounds but we still do not know the causes of most of these syndromes. There are a lot of children in the world that are misdiagnosed and their parents suffer for not being able to help them. I strongly believe that there is still a long path to run in order to find adequate treatments for these children that are not autistic, they are children with autism. [1] (www.autism-society.org) [2] (World Health Organization, 2019) [3] (Special Learning Inc.) [4] (RettSyndrome.org) [5] (National Institute of Child Health and Human Development, 2019)