The autism spectrum or autistic spectrum describes a range of conditions classified as pervasive developmental disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Pervasive developmental disorders include autism, Asperger syndrome, pervasive developmental disorder not otherwise specified (PDD-NOS), childhood disintegrative disorder, and Rett syndrome, although usually only the first three conditions are considered part of the autism spectrum.^[1] These disorders are typically characterized by social deficits, communication difficulties, stereotyped or repetitive behaviors and interests, and in some cases, cognitive delays. Although these diagnoses share some common features, individuals with these disorders are thought to be "on the spectrum" because of differences in severity across these domains.

Autism is characterized by delays or abnormal functioning before the age of three years in one or more of the following domains: (1) social interaction; (2) communication; and (3) restricted, repetitive, and stereotyped patterns of behavior, interests, and activities.^[2] Social impairments are marked by poor use of nonverbal communication, difficulty in peer relations, lack of social-emotional reciprocity, and lack of shared enjoyment. Communication deficits may include failure to develop speech, use of stereotyped or delayed echolalia, and difficulties maintaining conversations. Social and communication impairments may also cause a lack of symbolic or imaginative play. Restricted and repetitive behaviors may include unusual preoccupations with narrow interests, inflexibility to nonfunctional routines, stereotyped and repetitive mannerisms, and preoccupations with parts of objections.

Asperger syndrome can be distinguished from autism by the lack of delay or deviance in early language development.^[2] Additionally, individuals with Asperger syndrome do not have significant cognitive delays. An individual with Asperger syndrome typically demonstrates obsessive interest in a single topic or activity. Other symptoms include repetitive routines or rituals, peculiarities in speech and language, inappropriate affect or social behavior, problems with non-verbal communication, and clumsy or uncoordinated motor movements.^[3] Because of these difficulties, individuals with Asperger syndrome often have trouble interacting with others.

PDD-NOS is considered "subthreshold autism" and "atypical autism" because it is often characterized by milder symptoms of autism or symptoms in only one domain (such as social difficulties).^[4] Persons with PDD-NOS may demonstrate pervasive deficits in the development of reciprocal social interaction or stereotyped behaviors, but do not meet the criteria for a specific pervasive developmental disorder or other psychological disorders (such as schizophrenia or avoidant personality disorder).^[2]

Autism Spectrum Disorder in the DSM-V[link]

Autism Spectrum Disorder (ASD) is a proposed revision to the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5), which will be released in May 2013.^[5] This new diagnosis will encompass current diagnoses of autistic disorder, Asperger's disorder, childhood disintegrative disorder, and PDD-NOS. Rather than categorizing these diagnoses, the DSM-5 will adopt a dimensional approach to diagnosing disorders that fall underneath the autism spectrum umbrella. It is thought that individuals with ASDs are best represented as a single diagnostic category because they demonstrate similar types of symptoms and are better differentiated by clinical specifiers (i.e., dimensions of severity) and associated features (i.e., known genetic disorders, epilepsy and intellectual disability). An additional change to the DSM includes collapsing social and communication deficits into one domain. Thus, an individual with an ASD diagnosis will be described in terms of severity of social communication symptoms, severity of fixated or restricted behaviors or interests and associated features.

Etiology[link]

While a specific cause or specific causes of autism spectrum disorders has yet to be found, many risk factors have been identified in the research literature that may contribute to the development of an ASD. These risk factors include genetics, prenatal and perinatal factors, neuroanatomical abnormalities, and environmental factors.

Genetic risk factors[link]

The results of family and twin studies suggest that genetic factors play a role in the etiology of autism and other pervasive developmental disorders.^[6] Studies have consistently found that the prevalence of autism in siblings of autistic children is approximately 15 to 30 times greater than the rate in the general population.^[7] In addition, research suggests that there is a much higher concordance rate among monozygotic twins compared to dizygotic twins.^[8] These studies suggest a strong genetic component in autism. It is estimated that autism involves 5-10 genes and possibly more.^[9] It appears that there is no single gene that can account for autism. Instead, there seems to be multiple genes involved, each of which is a risk factor for part of the autism syndrome through various groups.^[10] Possible susceptibility regions include chromosomes 1p, 2q, 7q, 13q, 16p, and 19q.^[9]

Prenatal and perinatal risk factors[link]

A number of prenatal and perinatal complications have been reported as possible risk factors for autism. These risk factors include maternal gestational diabetes, maternal and paternal age over 30, bleeding after first trimester, use of prescription medication during pregnancy, and meconium in the amniotic fluid. While research is not conclusive on the relation of these factors to autism, each of these factors has been identified more frequently in children with autism compared to their non-autistic siblings and other normally developing youth.^[11]

Neuroanatomical findings[link]

In general, neuroanatomical studies support the notion that autism is linked to a combination of brain enlargement in some areas and brain reduction in other areas.^[12] These studies suggest that autism may be caused by abnormal neuronal growth and pruning during the early stages of prenatal and postnatal brain development, leaving some areas of the brain with too many neurons and other areas with too few neurons.^[13] Some research has reported an overall brain enlargement in autism while others suggest abnormalities in several areas of the brain, including the frontal lobe, the mirror neuron system, the limbic system, the temporal lobe, and the corpus callosum.

In neuroanatomical studies, it has been shown that for individuals with Autism spectrum disorder there is reduced activation in the primary and secondary somato-sensory cortices during Theory of Mind and facial emotion response tasks when compared to control. This is consistent with reports of patterns of abnormal cortical thickness and grey matter volume in those regions in individuals with Autism Spectrum Disorder.^[14] (Sugranyes) In normal children, there is a bias of the left lateralized network that is essential for language development, as shown by magnetoencephalography. Specifically, there was a left dominance of parieto-temporal coherence in the theta band that was correlted with higher performance on language related tasks. This was not correlated with head circumference or chronological age.^[15]

Frontal lobe[link]

The frontal lobe is central to many functions that are associated with autism, such as language and executive functions. For instance, Broca's area, which is related to language production, is located in the inferior prefrontal lobe. Other important areas of the frontal lobe include: the prefrontal cortex (involved with aspects of executive function such as working memory, inhibition, planning, organizing, set-shifting and cognitive flexibility), the orbitofrontal cortex (involved in social cognition and theory of mind) and the inferior frontal gyrus (part of the mirror neuron system). Current research suggests that dysfunction in the frontal lobe may be associated with some of the deficits observed in individuals with ASD, including social cognition, imitation, face processing, language, attention, working memory, and problem-solving. For example, it has been found that individuals with autism have decreased concentrations of N-acetyl-asparate (NAA) and reduced glutaminergic neurons in the frontal lobe, suggesting some dysfunction in this region.^[16] Another study using fMRI found that boys with high-functioning autism had reduced activity in the pars opercularis when observing and imitating emotions.^[17] Orbitofrontal cortex deficits have also been implicated with autism, as individuals with high-functioning autism have shown decreased functioning in this area when participating in a task that involved the perception of fearful faces.,^[18] Finally, individuals with ASD have shown decreased activation in the medial prefrontal cortex relative to a control group during a theory of mind task.^[19]

Mirror neuron system[link]

The mirror neuron system (MNS) consists of a network of brain areas that have been associated with empathy processes in both animals^[20] and humans.^[21] In humans, the MNS has been identified in the inferior frontal gyrus (IFG) and the inferior parietal lobule (IPL) and is thought to be activated during imitation or observation of behaviors.^[22] It has been suggested that the MNS generates internal representations of the self and others, which facilitates an understanding of other people. Many researchers have hypothesized that the MNS is related to cognitive processes such as imitative learning, "mind-reading", and empathy; all of which are necessary for social-communication.^[23] Several studies using functional brain-imaging have found evidence of mirror neuron dysfunction in autism,^[24][25] suggesting this neural system is associated with social impairments in individuals with ASDs. Specifically, it has been found that reduced mirror neuron activity and MNS cortical thinning^[26] are highly correlated with autism severity.

Limbic system[link]

Social skills impairments in autism have been theorized to reflect abnormal functioning in the limbic system. In animal models, it has been found that monkeys with lesions in the medial temporal lobe (e.g., the amygdala and hippocampus) demonstrate autistic-like behaviors, such as a failure to develop normal social relationships, stereotyped movements, and poor eye-contact.^[27] Notably, it was found that that the most severe autistic symptoms resulted from lesions in the amygdala and hippocampus whereas less severe forms resulted from lesions to the amygdala alone. Human autopsy studies have also found evidence for limbic system abnormalities in individuals with ASDs. These studies revealed reduced neuronal cell size and increased cell-packing density in the hippocampus and amygdala.^[28] However, MRI studies have not found any evidence for abnormalities in the hippocampus.^[29]

Temporal lobe[link]

Functions of the temporal lobe are related to many of the deficits observed in individuals with ASDs, such as receptive language, social cognition, joint attention, action observation and empathy. The temporal lobe also contains the superior temporal sulcus (STS) which may mediate facial processing. It has been argued that dysfunction in the STS underlie the social deficits that characterize autism. Compared to typically developing individuals, one fMRI study found that individuals with high functioning autism had reduced activity in the STS when viewing pictures of faces.^[30] Other studies have suggested that the role of the STS may be more complex than simple face processing, as research has found that individuals with ASDs have shown reduced functioning when viewing fear-provoking faces; implying that the STS is involved in understanding the emotions of others.^[18] Other areas of the temporal lobe have also been implicated in ASDs. For instance, fMRI research suggests that individuals with ASDs have reduced activity in the right temporoparietal junction and other regions during imitation and observation tasks.^[31]

Corpus callosum[link]

Studies have found evidence of reduced size of the corpus callosum in individuals with autism.^[32] These findings suggest that there may be a link between autism and impaired communication between brain hemispheres.

Environmental risk factors[link]

A wide variety of environmental risk factors have been proposed as contributing to autism. These include gastrointestinal or immune system abnormalities, allergies, and exposure of children to drugs, vaccines, infection, certain foods, or heavy metals. The evidence for these risk factors is anecdotal and has not been confirmed by reliable studies.^[33] The subject remains controversial and extensive further searches for environmental factors are underway.

Controversial theories[link]

There has been a great deal of controversy over the years surrounding various theories of the etiology of autism spectrum disorders. In the 1950s, the "refrigerator mother theory" emerged as an explanation for autism. This theory was based on the idea that autistic behaviors stem from the emotional frigidity, lack of warmth, and cold, distant, rejecting demeanor of a child's mother.^[34] Naturally, parents of children with an autism spectrum disorder suffered from blame, guilt, and self-doubt, especially as the theory was embraced by the medical establishment and went largely unchallenged into the mid-1960s. While the "refrigerator mother theory" has been rejected in the research literature, its effects have lingered into the 21st century. Another controversial theory suggests that watching extensive amounts of television may cause autism. This theory is largely based on research suggesting that the increasing rates of autism in the 1970s and 1980s were due to the growth of cable television at this time.^[35] This theory has not been supported in the research literature. Probably the biggest and most widely circulated controversial theory of autism etiology is the "vaccine theory". This theory suggests that autism results from brain damage caused either by (1) the measles, mumps, rubella (MMR) vaccine itself, or by (2) thimerosal, an MMR vaccine stabilizer that is 50% ethylmercury.^[36] The current scientific consensus is that no convincing scientific evidence supports these claims, based on various lines of evidence including the observation that the rate of autism continues to climb despite elimination of thimerosal from routine childhood vaccines.^[35] Major scientific and medical bodies such as the Institute of Medicine and World Health Organization as well as governmental agencies such as the Food and Drug Administration and the CDC reject any role for thimerosal in autism or other neurodevelopmental disorders.

Language acquisition[link]

Theory of mind tasks assess the ability of an individual to understand the capabilities of others with respect to cognitive abilities and perception. Theory of mind tasks assess attribution of epistemic mental states, intentions and motivations, and affective states.^[37] In the field of cognitive development, these tasks are usually pursued with children over the age of three, in coordination with language development for interaction with the researcher. These tasks are presented as behavioral tasks to the subject. Theory of mind difficulties seem to be universal among individuals that present on the autism spectrum. When asked to differentiate between mental and physical activities, children ages 3–4 had difficulty assessing which was which accurately. Additionally, they tend to have issues understanding figurative speech or appropriate speech with respect to the social context.^[38]

As adults, only half of autistic patients are capable of speech and their linguistic abilities are lower than normal subjects. Autistic children do not seem to acquire language by immersion. Mean length utterance, a measure of linguistic productivity, evolves rapidly in autistic children. A possible rationale is that they do not have enough referential vocabulary to trigger syntax. Referential words, the understanding of what a specific word refers to, is contrasted by relational vocabulary. Limited grammatical acquisition may be attributed to a decreased lexicon of referential words.^[15]

Linguistic and non linguistic elements evolve with isolated and specific social and cognitive elements, with autism there is mutual interference. Gestural means of communication is used by both non-verbal and verbal autistic children. The mother may also have an influence on development of communication.^[39]

There is a division of the Autism spectrum into three categories for patients. Individuals with Asperger who acquire language to a normal degree but with a slight delay in the process of acquisition. Verbal autistic children who show delay in language acquisition and individuals who are never capable of language acquisition, they are considered nonverbal. Difference in language acquisition may be linked to different levels of impairment at theory of mind tasks.^[15]

Developmental course[link]

Although autism spectrum disorders are thought to follow two possible developmental courses, most parents report that symptom onset occurred within the first year of life.^[40] One course of development follows a gradual course of onset in which parents tend to report concerns in development over the first two years of life and diagnosis is made around 3–4 years of age. Some of the early signs of ASDs in this course include decreased looking at faces, failure to turn when name is called, failure to show interests by showing or pointing, and delayed pretend play (see Table 1).^[41] A second course of development is characterized by normal or near-normal development followed by loss of skills or regression in the first 2–3 years. Regression may occur in a variety of domains, including communication, social, cognitive, and self-help skills; however, the most common regression is loss of language.^[41] There continues to be a debate over the differential outcomes based on these two developmental courses. Some studies suggest that regression is associated with poorer outcomes and others report no differences between those with early gradual onset and those who experience a regression period.^[42] Overall, the prognosis for individuals with autism is poor with respect to academic achievement and independent living abilities, particularly for those who have not received early intervention.^[42] However, many individuals show improvements as they grow older. The two best predictors of favorable outcome in autism are the absence of intellectual disability and the development of some communicative speech prior to 5 years of age.^[43] Overall, the literature stresses the importance of early intervention in achieving positive longitudinal outcomes.^[44]

Table 1: Early Symptoms of Autism^[42]

Comorbidity with autism spectrum disorders[link]

Autism spectrum disorders tend to be highly comorbid with other disorders. Comorbidity may increase with age and may worsen the course of youth with ASDs and make intervention/treatment more difficult.^[45] Distinguishing between ASDs and other diagnoses can be challenging because the traits of ASDs often overlap with symptoms of other disorders and the characteristics of ASDs make traditional diagnostic procedures difficult.^{[46] [47]}In spite of these difficulties, comorbid disorders are readily identified and tend to fall into six categories, medical conditions, intellectual disabilities, anxiety disorders, mood disorders, behavior-related disorders, and sensory processing disorders.

Medical conditions[link]

A variety of medical conditions commonly occur in individuals with ASDs. The most common is seizure disorder or epilepsy, which occurs in 11-39% of individuals with ASD.^[48] Typically, onset of epilepsy occurs before age five or during puberty.^[49] and is more common in females and individuals who also have a comorbid intellectual disability. Tic disorder is another common medical condition seen in individuals with ASDs. While only about 6.5% of individuals with an ASD have full blown Tourette syndrome, nearly 30% show some form of tics.^[50] Tuberous sclerosis, a medical condition in which non-malignant tumors grow in the brain and on other vital organs, occurs in 1-4% of individuals with ASDs.^[51] Sleep disorders are also commonly reported by parents of children with ASDs, including late sleep onset, early morning awakening, and poor sleep maintenance.^[49]

Intellectual disabilities[link]

Intellectual disabilities are some of the most common comorbid disorders with ASDs. Recent estimates suggest that 40-69% of individuals with ASD have some degree of mental retardation,^[42] with females more likely to be in severe range of mental retardation. Learning disabilities are also highly comorbid in individuals with an ASD. Approximately 25-75% of individuals with an ASD also have some degree of learning disability,^[52] although the types of learning disability vary depending on the specific strengths and weaknesses of the individual.

Anxiety disorders[link]

A variety of anxiety disorders tend to co-occur with autism spectrum disorders, with overall comorbidity rates of 7-84%.^[42] Specific phobia is the most common comorbid condition over the lifetime for those with ASD, with comorbidity rates of 38-63%.^[45] Common phobias for children with ASD include the fear of certain places or situations, the fear of medically related people, places, or things, and the fear of loud noises.^[53] Obsessive-compulsive disorder (OCD) occurs in 11-35% of individuals with ASD, with 16-81% showing features of the disorder without a full diagnosis. While individuals with ASD exhibit rigid thinking and compulsions, similar to OCD, the repetitive behaviors displayed in ASD (i.e., flapping, spinning, repeating phrases) are distinct and serve alternate functions than the repetitive behaviors displayed in OCD (i.e., checking, cleaning, counting).^[45] Social Phobia or Social Anxiety Disorder is seen in approximately 7.4% of individuals with ASD, but is more common in higher-functioning individuals who have a desire for social interactions, but are also aware of their social deficits.^[45]

Mood disorders[link]

Rates of comorbid depression in individuals with an ASD range from 4–58%.^[54] The presentation of depression in ASDs can depend on level of cognitive functioning, with lower functioning children displaying more behavior issues and higher functioning children displaying more traditional depressive symptoms.^[46] Depression is thought to develop and occur more in high-functioning individuals during adolescence, when they develop greater insight into their differences from others.^[42] Bipolar disorder may also be comorbid with an ASD, although it is far less common than many other disorders. Rates of comorbidity vary greatly, but tend to be around 2-8%.^[53]

Behavior-related disorders[link]

Deficits in ASD are often linked to behavior problems, such as difficulties following directions, being cooperative, and doing things on other people's terms ^[55] These behavior problems are also characteristic of Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD), but the reasons for the behaviors often differ.^[53] For this reason, comorbidity rates of ODD and CD range from 7%^[53] to 73%.^[45] Attention Deficit Hyperactivity Disorder (ADHD) has ASD comorbidity rates of 30-80%; however, current diagnostic guidelines prevent diagnosing ADHD along with ASD.^[53] Rather, ADHD-like symptoms are seen to be part of the ASD diagnosis.^[56]

Sensory processing disorders[link]

Sensory processing disorder is also comorbid with ASD, with comorbidity rates of 42-88%.^[57] Three patterns of sensory processing difficulties are commonly seen, hyperresponsiveness (behavioral over-reactivity to sensory stimuli), hyporesponsiveness (behavioral under-reactivity to sensory stimuli), and sensory-seeking (craving or fascination with certain stimuli). These patterns of processing difficulties may be present with auditory, visual, or tactile stimuli.^[58]

Facial characteristics[link]

Typical characteristic of adolescent with minor Autism spectrum disorder, notice the Latitudinous Philtrum

Facial Phenotypes in Prepubescent boys indicate that the face and brain develop in coordination; researchers have found distinct abnormalities in facial characteristics in a clinically significant percentage of boys with ASD as compared to those of normally developing boys. The distinguishing irregularities are typically: a broader upper face and wider eyes, a shorter middle region of the face, including the cheeks and nose, and a broader mouth and Philtrum.^[59]

Evidenced-based assessment[link]

The diverse expressions of ASD symptoms pose diagnostic challenges to clinicians. Individuals with an ASD may present at various times of development (e.g., toddler, child, or adolescent) and symptom expression may vary over the course of development.^[60] Furthermore, clinicians are required to differentiate among the different pervasive developmental disorders as well as other disorders such as mental retardation not associated with a pervasive developmental disorder, specific developmental disorders (e.g. language), and early onset schizophrenia.

Considering the unique challenges associated with diagnosing ASD, specific practice parameters for the assessment of ASD have been published by the American Academy of Neurology,^[61] the American Academy of Child and Adolescent Psychiatry,^[60] and a consensus panel with representation from various professional societies.^[62] The practice parameters outlined by these societies include an initial screening of children by general practitioners (i.e., "Level 1 screening") and for children who fail the initial screening, a comprehensive diagnostic assessment by experienced clinicians (i.e. "Level 2 evaluation"). Furthermore, it has been suggested that assessments of children with suspected ASD be evaluated within a developmental framework, include multiple informants (e.g., parents and teachers) from diverse contexts (e.g., home and school), and employ a multidisciplinary team of professionals (e.g., clinical psychologists, neuropsychologists, and psychiatrists).^[63]

After a child fails an initial screening, psychologists administer various psychological assessment tools to assess for ASD.^[63] Amongst these measurements, the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS) are considered the "gold standards" for assessing children with autism. The ADI-R is a semi-structured parent interview that probes for symptoms of autism by evaluating a child's current behavior and developmental history. The ADOS is a semistructured interactive evaluation of ASD symptoms that is used to measure social and communication abilities by eliciting a number of opportunities (or "presses") for spontaneous behaviors (e.g., eye contact) in standardized context. Various other questionnaires (e.g., The Childhood Autism Rating Scale) and tests of cognitive functioning (e.g., The Peabody Picture Vocabulary Test) are typically included in an ASD assessment battery.

Therapeutic interventions[link]

Over the past two decades, there has been increasing attention to the development of evidenced-based interventions for young children with ASDs. Additionally, many unresearched alternative therapies have also been implemented (e.g., vitamin therapy and acupuncture). Although evidenced-based interventions for children with autism vary in their methods, many adopt a psychoeducational approach to enhancing cognitive, communication and social skills while minimizing problem behaviors. It has been argued that no single treatment is best and treatment is typically tailored to the child's needs. Available approaches include Treatment and education of autistic and related communication handicapped children (TEACCH Structured Teaching , Picture Exchange Communication Systems (PECS) an Augmentative and Alternative Communication system, Pivotal Response Training (PRT), Discrete Trial Training (DTT), Incidental Teaching, Positive Behavior Supports, Verbal Behavior Analysis (VBA) all of which have roots in applied behavior analysis (ABA); speech and language therapy, social skills therapy, occupational therapy, and parent-communication training.^[64] One of the most empirically supported intervention approaches is ABA, particularly in regard to early intensive home-based therapy. It is recommended that children receiving early intervention ABA therapy receive approximately 40 hours of therapy per week for about two years. This intensive approach underlies the UCLA Young Autism Project, originally developed by Lovaas and colleagues, and children in these programs have demonstrated gains in IQ that are maintained until adolescence.^[65][66] Although ABA therapy has a strong research base, other studies have found that this approach may be limited by diagnostic severity and IQ.^[67][68][69]

ABA AND EIBI

Early Intensive Behavioral Intervention, through the use of Applied Behavioral Analysis, has been researched for over 40 years in its effectiveness. Most EIBI programs recognize that all skills appropriate for each specific age are teachable and should be taught. General curriculum areas that are addressed are language, social skills, play skills, motor skills, pre-academic and academic skills, and independent living skills. ABA models of intervention for preschool age include two main approaches to teaching. "Discrete Trial Teaching" or DTT, includes multiple discrete opportunities that are presented across the day or session. A discrete trial consists of the therapist presenting an instruction, the child responding, and the therapist responding to that by presenting a consequence. If the child responds incorrectly, the reinforcer is not given and the therapist will follow up with a error correction procedure, followed by another trial. A strength of this way of teaching is the child receives a large number of trials in a short time, allowing for a large amount of learning opportunities. A potential weakness may be that the skills learned in this structured setting are not easily generalized in less strict settings. "Natural Environment Teaching" consists of maximizing naturally occurring learning opportunities. It involves a more child-directed format that allows for the child to initiate learning, and the therapist to recognize this and follow it by prompting the child for a desired behavior before giving the reinforcer.^[70]

All successful early intervention programs should focus on the TRIAD of impairments in ASDs.^[71] This includes: a) Joint attention and communication, b) Social understanding and relationships, and c) Flexibility in thinking and behavior. It also includes a strong, positive partnership with parents, siblings, and co-therapists to keep consistency throughout the childs day. Research for more effective treatments should focus on the extent to which E.I Programs are adapting to the child's pattern of strengths and weaknesses and take into account all family circumstances. The importance and effectiveness of treatment (especially ABA formatted treatment) relies heavily on both child and family circumstances. At the child's level the age at entry into treatment and the severity of impairment on a cognitive, language, and behavioral level are crucial. At the family level, Socio-Economic status, level of income, presence of parents and proximity to outside family and resources, organization, extent of stress of the parents and ability to work alongside the therapist are most important for success.^[72]

The Early Start Denver Program integrates applied behavior analysis with relationship and developmental based approaches. Autistic children who participated in the Early Start Denver Program showed significant increase in IQ, adaptive behavior and diagnostic status when compared to community interventions.^[73]

Many popular therapies including auditory integration training, GFCF diets, and chelation are not considered evidence-based practices. Notably, research suggests that children with ASDs on GFCF diets do not differ from control groups in terms of their symptoms.^[74]

Epidemiology[link]

Reviews tend to estimate a prevalence of 6 per 1,000 for autism spectrum disorders as a whole,^[75] however prevalence rates vary for each of the developmental disorders in the spectrum. Autism prevalence has been estimated at 1-2 per 1,000, Asperger syndrome at roughly 0.6 per 1,000, childhood disintegrative disorder at 0.02 per 1,000, and PDD-NOS at 3.7 per 1,000.^[75] These rates are consistent across cultures and ethnic groups, as autism is considered a universal disorder.^[42]

While rates of autism spectrum disorders are consistent across cultures, they vary greatly by gender, with boys being affected far more frequently than girls. The average male-to-female ratio for ASDs is 4.2:1,^[76] affecting 1 in 70 males, but only 1 in 315 females.^[77] Females, however, are more likely to have associated cognitive impairment. Among those with an ASD and mental retardation, the sex ratio may be closer to 2:1.^[78] Prevalence differences might be accounted by gender differences in the expression of clinical symptoms, with females showing less atypical behaviors and, therefore, less likely to receive an ASD diagnosis. ^[79]

See also[link]

• Autism
• Asperger syndrome
• PDD-NOS
• Autism therapies

References[link]

Further reading[link]

• Baron IS. Autism Spectrum Disorder: complex, controversial, and confounding. Neuropsychol Rev. 2008;18(4):271–2. doi:10.1007/s11065-008-9070-1. PMID 18846426.

External links[link]

• Autism spectrum at the Open Directory Project
• For more information about Sensory Integration please visit www.sensoryintegration.org.uk
• For a short documentary about autism see BBC Four's 1992 Video here http://www.youtube.com/thefamilarity#p/u/2/PrViCkYF-lY
• http://www.autismspeaks.org/
• National Autism Center, Provides up to date research on Autism across the country, visit http://www.nationalautismcenter.org/service/

Kathie Lee Gifford
Kathie Lee Gifford at the Emmy Awards, September 21, 2008
Born	Kathryn Lee Epstein (1953-08-16) August 16, 1953 (age 58) Paris, France
Occupation	TV presenter Talk show host Actress Singer-songwriter
Years active	1970–present
Spouse	Paul Johnson (April 1976–1983; divorced) Frank Gifford (October 18, 1986–present; 2 children)
Children	Cody Newton (b. 1990) Cassidy Erin (b. 1993)
Website
www.kathieleegifford.com

Kathie Lee Gifford (born August 16, 1953) is an American television host, singer, songwriter and actress, best known for her 15-year run (1985–2000) on the talk show Live with Regis and Kathie Lee, which she co-hosted with Regis Philbin. She has received 11 Daytime Emmy nominations and won her first Daytime Emmy in 2010 as part of The Today Show team.

Before her long stint in talk shows, Gifford's first television exposure was that of Tom Kennedy's singer/sidekick on Name That Tune, from 1974-78. On April 7, 2008, Gifford began co-hosting the fourth hour of NBC's Today Show, alongside Hoda Kotb.

Early life[link]

Kathie Lee Gifford, born Kathryn Lee Epstein in Paris, France, is the daughter of Joan (née Cuttell; born January 20, 1930), a singer, and Aaron Epstein (March 19, 1924 – November 19, 2002), a musician and former U.S. Navy officer. Aaron Epstein was stationed with his family in France at the time of Gifford's birth.^[1] Gifford grew up in Bowie, Maryland, and attended Bowie High School.^[2] During high school, Gifford was a singer in a folk group, "Pennsylvania Next Right," which performed frequently at school assemblies. During her senior year at high school she dated and went to the prom with Michael Bray, who would later become an anti-abortion activist who was convicted for acts of terrorism.^[3] After high school graduation, Gifford attended Oral Roberts University in Tulsa, Oklahoma, studying drama and music.

Gifford's paternal grandfather was of Russian Jewish descent and her paternal grandmother was of Native American ancestry. Her mother, a relative of writer Rudyard Kipling, was of French Canadian, English and German descent and was raised in a Methodist family.^[4][5] After seeing the Billy Graham-produced film, The Restless Ones at age 12, Gifford became a born-again Christian. She told interviewer Larry King, "I was raised with many Jewish traditions and raised to be very grateful for my Jewish heritage."^[6] Her brother, Rev. David Paul Epstein, is an evangelical Baptist preacher and pastor of Calvary Baptist Church in New York City.

1970s[link]

In 1970, Gifford represented Maryland in America's Junior Miss Pageant.^[7]

During one summer in the early 1970s, she was a live-in secretary/babysitter for Anita Bryant at her home in Miami. Gifford's career took off in the 1970s (during her first marriage to Christian composer/arranger/producer/publisher Paul Johnson) as a vocalist on the game show Name That Tune with Tom Kennedy (she performed the "sing a tune" segment as Kathie Lee Johnson). In 1978, she joined the cast of the short-lived Hee Haw spinoff, Hee Haw Honeys.

She also appeared in television advertisements for Carnival Cruise Lines beginning in 1984. The ads were the first cruise line ads to air on network television.

[edit] Live with Regis and Kathie Lee

Following her divorce from Johnson in 1983, Gifford met sports commentator Frank Gifford (born August 16, 1930) during an episode of ABC's Good Morning America; the couple married in 1986. By that time, she was several months into her most famous television role, as a full-time morning talk show personality. On June 24, 1985, she replaced Ann Abernathy as co-host of The Morning Show on WABC-TV with Regis Philbin. The program went into national broadcast in 1988 as Live with Regis and Kathie Lee, and Gifford became well-known across the country. Throughout the 1990s, millions of morning-TV viewers watched her descriptions of life at home with her sportscaster husband and their two children: Cody Newton Gifford (born in 1990) and Cassidy Erin Gifford (born in 1993). She appeared as a spokesperson for Slim Fast diet shakes after Cody was born.^{[citation needed]} She was also the face of Carnival Cruises in the late 1980s and early 1990s, singing "If my friends could see me now!"

1996 sweatshop scandal[link]

In 1996, the National Labor Committee, a human rights group, reported that sweatshop labor was used to make clothes for the Kathie Lee line, sold at Wal-Mart.^[8] The group reported that a worker in Honduras smuggled a piece of clothing out of the factory, which had a Kathie Lee label on it.^[9] One of the workers, Wendy Diaz, came to the United States to testify about the conditions under which she worked. She commented, "I wish I could talk to [Kathie Lee]. If she's good, she will help us."^[10]

Labor activist Charles Kernaghan spoke to the media and accused Gifford of being responsible for the sweatshop management activity. Gifford addressed Kernaghan's allegations on the air during Live, explaining that she was not involved with hands-on project management in factories.^[11]

Gifford later contacted Federal authorities to investigate the issue and worked with U.S. Federal legislative and executive branch agencies to support and enact laws to protect children against sweat shop conditions. She appeared with President Bill Clinton at the White House in support of the government's initiatives to counter international sweatshop abuses.^{[citation needed]}

Current career[link]

Since Live, Gifford has made guest appearances in films and television series, and has several independently released albums on CD, including 2000's The Heart of a Woman, featuring the single "Love Never Fails".^[12][13]

In September 2005 she became a special correspondent on The Insider, a syndicated entertainment magazine television show, ending her relationship with that program upon her co-hosting role with Today.^[14]

She played the role of Miss Hannigan in a concert performance of Annie at Madison Square Garden in December 2006.^[15]

On March 31, 2008, NBC announced that Gifford was to join its morning show, Today, as co-host of the fourth hour, alongside Hoda Kotb. This marked her return to morning television; in many markets, she now airs directly after her old show, now called Live with Kelly. Because the 4th hour of Today airs live at 10:00am EST, and Live with Kelly airs live at 9:00am EST, Gifford's hour does not compete directly with her former show in most markets.^[16] Kotb and Gifford replaced Ann Curry and Natalie Morales. The show's ratings decreased after Gifford's arrival, having drawn 1.9 million viewers the weeks before her arrival and 1.7 million a few months after, although the network maintains that the drop in viewers was seasonal and unrelated to the on-air talent.^[17] More recently, the 4th hour of Today has averaged 2.148 million total viewers, an increase of 26 percent over those 2008 numbers. ^[18]

She is a recipient of the Mousecar Award (as in "Oscar"), a silver Mickey Mouse statue award that was personally designed by Walt Disney himself. The award was presented personally by Disney's CEO, Michael Eisner, who said that only five had been given out previously.^[19]

On March 27, 2010, she guest starred on The Suite Life on Deck, along with her real-life daughter, Cassidy.

Gifford is a celebrity ambassador for the non-profit organization Childhelp. She regularly makes appearances at fund raisers and events for the child abuse prevention and treatment organization and is an ardent supporter.^[20]

Frank and Kathie Lee Gifford raised the money to build and continue to financially support two shelters in New York City for babies born with HIV or a congenital crack cocaine addiction. These shelters were named in honor of her children, Cody and Cassidy.^[21]

On July 1, 2008, Gifford appeared on NBC's Celebrity Family Feud. She and her friends and family competed against the cast of Dog The Bounty Hunter for their favorite charity. Gifford's family won the $50,000 for The Association to Benefit Children.^[22]

Among her many public gaffes including spilling red wine on her co-star and continually insulting her husband. On May 30, 2012, viewers witnessed perhaps the most awkward exchange between interviewer and guest in television history when she pressed guest Martin Short about his ongoing successful marriage to his wife, who had died two years previously from ovarian cancer. She then went on to apologize to him by twitter, but the account she thought was his was fake and had only one tweet from 2009.

Discography[link]

Musical theatre[link]

In the late 1990s, Gifford began working in musical theatre. She contributed a number of musical numbers to Hats, and wrote and produced Under The Bridge,^[24] based upon the children's book The Family Under The Bridge by Natalie Savage Carlson.

In 2007, she premiered Saving Aimee, a stage musical about evangelist Aimee McPherson, at the Signature Theatre in Arlington, Virginia.^[25][26] The premiere starred Tony-nominated actress Carolee Carmello in the lead role.^[27]

On April 16, 2007, Gifford was a guest presenter at the Washington, DC Helen Hayes Award Ceremony, honoring contributions and professional accomplishments in theatre.^[28]

In 2008, Gifford and David Friedman wrote a junior high school musical entitled Key Pin It Real.^[29] The play depicts a coming-of-age story about a young girl named Key Pin. The first production took place in December 2008 in Kendallville, Indiana at East Noble High School.^[30]

Gifford is currently working on a musical adaptation of It's a Wonderful Life with John McDaniel; McDaniel is composing music while Gifford is writing lyrics.^[31]

References[link]

External links[link]

• Kathie Lee Gifford at the Internet Movie Database
• Kathie Lee Gifford discography (Music City)
• Gifford interview, 2004, The Christian Post
• Gifford interview transcript, Larry King Live, 2000

Jason McElwain, second from left, shakes hands with President George W. Bush in March 2006.

Jason McElwain, ("J-Mac") (born October 1, 1987), is a high-functioning autistic American; he came to fame on national news in 2006 when he played for four minutes during a high school basketball game and scored twenty points.

McElwain had a passion for basketball, so Greece Athena High School basketball coach Jim Johnson appointed him manager of the team.

On February 15, 2006, Greece Athena was playing Spencerport High School for a division title. Greece Athena got a large lead, so Johnson decided to let McElwain play in the last four minutes. After initially missing two shots, McElwain made six three-point shots and one two-pointer. After the final buzzer rang, the crowd dashed onto the court in celebration.

Early life[link]

Jason McElwain was born on October 1, 1987 to David and Debbie McElwain, and was diagnosed with autism at a young age. ^[1][2] Jason and his family lived in Greece, New York, a suburb of Rochester, New York.^[1] He initially struggled when interacting with other children, but began to develop social skills as he grew older.^[3] Although he was placed in special education classes,^[3] McElwain enjoyed basketball, to which he was introduced by his older brother Josh,^[4] and was appointed manager of Greece Athena High School's varsity basketball team.^[3] For the Greece Athena's 2005-2006 basketball season, the 17-year-old McElwain was a senior and slated to graduate in the spring, but he was unable to graduate.^[5]

February 15, 2006 basketball game[link]

Greece Athena High School basketball coach Jim Johnson decided to add McElwain to the roster for the team's February 15 game against Spencerport High School, so McElwain could be given a jersey and sit on the bench for the team's last home game of the season, ^[6]and allow McElwain to play a few minutes if Greece Athena got a comfortable lead.^[6] With four minutes left in the game, Greece Athena had a double-digit lead, so Johnson decided let McElwain play out the last minutes of the game.^[6] When teammates first passed the ball to McElwain he attempted a three-point shot and missed.^[6] McElwain got a second chance to score with a lay-up which he also missed.^[6] McElwain then got "hot as a pistol", shooting six three-pointers and one two-point shot, before the game ended.^[6] The final score was Greece Athena 79, Spencerport 43.^[3] As soon as the final buzzer rang, fans from the stands stormed the court in celebration.^[7]

Reaction[link]

Teacher Andy McCormack was in the audience that night to see the game. McCormack was Jason's Speech/Language Pathologist throughout high school, and Jason had asked his Grandma to be there that night. local news stations picked up on it and followed suit by the next day, and within days the tape reached a national audience. McCormack continued to support Jason over the next few months in school, helping coin alternative language expressions to his now-famous "hot as a pistol" phrase and helping him construct an introduction speech when Magic Johnson came to Johns Hopkins lacrosse to speak to the student body.

In his hometown of Greece, New York, McElwain quickly became a celebrity. The family's home phone was always ringing, and when the McElwains went out for a meal, a group of fans ran into the family, praising Jason.^[3]

McElwain met President George W. Bush on March 14, 2006, when Bush stopped by a nearby airport on his way to Canandaigua^{[disambiguation needed ]}, New York, so he could meet McElwain.^[1] Standing next to McElwain, Bush told reporters "As you can see, a special person has greeted us at the airport, Jason", and then jokingly asked "Can I call you J-Mac?"^[1] Bush went on to praise McElwain, saying "Our country was captivated by an amazing story on the basketball court. It's the story of a young man who found his touch on the basketball court, which, in turn, touched the hearts of citizens all around the country."^[1] Bush also stated that upon seeing McElwain on television, he "wept, just like a lot of other people did".^[1] Indianapolis Colts quarterback Peyton Manning visited Rochester, where he was introduced to McElwain.^[9] Manning invited McElwain and Steve Kerr, another Greece Athena High School athlete to the Colts' training camp for a week, which McElwain accepted.^[9] McElwain later said that Peyton was "one of the nicest guys in sports" and when the Colts won the Super Bowl and Manning raised the Vince Lombardi Trophy, McElwain "had a tear in [his] eye."^[9]

McElwain threw out the opening pitch for the Rochester Red Wings' game against the Charlotte Knights.^[10] The Red Wings also gave away 3,500 free bobblehead dolls that were modeled after McElwain.^[10]

McElwain even won an ESPY Award for the Best Moment in Sports in 2006.^[4] To win that award, McElwain beat out Kobe Bryant's 81-point-game and the George Mason Patriots' run to the Final Four.^[4] The speech that Jason gave upon winning the award was written for him by his older brother.^[9] The theme of the speech was about dreams coming true.^[9] In addition to the many celebrities McElwain met, he also appeared on various talk shows, including The Oprah Winfrey Show, Larry King Live, Good Morning America, and Today.^[9]

In 2007, Topps trading cards produced a Jason McElwain card as part of its retro-themed Allen & Ginter set.

In 2009, he appeared in a commercial for Gatorade as part of their "What is G?" ad campaign. The commercial aired during the Super Bowl.^[11]

McElwain appeared on The Talk in April 2011 as part of the show's month-long series on autism awareness. He told the hosts he was head coach of the 17U East Coast Fusion AAU basketball team. ^[12] His memorable video surfaced once more in 2011, when Facebook users shared a 2006 story featured on CBS Evening News. ^[13]

Radio[link]

Jason had a song dedicated to him and his accomplishments on the court by an artist named Iron Butter. Jason also did several interviews and appeared at the Summerjam concert where his song was performed.

Book[link]

Following his rise to fame, Jason McElwain wrote a book titled The Game of My Life.^[14] The book is written mainly by Jason, but includes sections written by his family, coach, and teammates.^[14] The Game of My Life is 243 pages long and was published on February 5, 2008 by New American Library.^[14] Editorial reviews were left by celebrities such as Magic Johnson, Doug Flutie, Rodney Peete, Holly Robinson Peete, and Tony Dungy.^[14] The book was co-written by Daniel Paisner.^[14]

Film[link]

As early as late February, Jason McElwain and his family started receiving inquiries from over twenty-five film companies, including The Walt Disney Company and Warner Bros., about making a film based on his story.^[2][7] In April 2006, it was announced that Columbia Pictures had bought the rights to produce the film.^[15] Laura Ziskin, producer of the Spider-Man film series, was signed on to produce the film about McElwain's life.^[15] Magic Johnson has also been attached as producer, while two-time Academy Award winner Alvin Sargent is in talks to write the film.^[15] However, there currently is no timetable for the movie as contracts are being finalized and the script is still being written.^[9]

Life after high school[link]

McElwain completed his GED courses and plans to go to college,^[9][16] and has a part-time job at Wegmans Food Markets in Greece, New York.^[9] Jason is often seen, too, at the local Olympia Family Restaurant, in Greece, New York. Occasionally, customers recognize him and ask for an autograph.^[9] McElwain also travels across the United States to help raise funds for autism research and to make media appearances.^[4] With all the activity that is going on his life, Jason admitted that he hasn't been playing as much basketball, but says that, "Occasionally, I'll go and shoot baskets at the YMCA."^[9]

McElwain is also involved in public speaking, including an October 2011 speech at the Jefferson Rehabilitation House's annual dinner. ^[17]

References[link]

External links[link]

• Bush Visits Autistic Teen Hoop Star (CBS News)
• Article and video (CBS - The Early Show)
• Full Video of Shots (MSNBC)
• The Word in Greece (ESPN article)
• Jason McElwain at the Internet Movie Database
• Complete transcript of McElwain's conversation with President Bush