U.S. countries have approached 1% of the population, with similar estimates in child and adult samples. It remains unclear whether higher rates reﬂect an expansion of the diag- nostic criteria of DSM-IV to include subthreshold cases, increased awareness, differences in study methodology, or a true increase in the frequency of autism spectrum disorder.
The age and pattern of onset also should be noted for autism spectrum disorder. Symptoms are typically recognized during the second year of life (12—24 months of age) but may be seen earlier than 12 months if developmental delays are severe, or noted later than 24 months if symptoms are more subtle. The pattern of onset description might include information about early developmental delays or any losses of social or language skills. In cases where skills have been lost, parents or caregivers may give a history of a gradual or relatively rapid deterioration in social behaviors or language skills. Typically, this would occur be- tween 12 and 24 months of age and is distinguished from the rare instances of developmen- tal regression occurring after at least 2 years of normal development (previously described as childhood disintegrative disorder).
The behavioral features of autism spectrum disorder first become evident in early childhood, with some cases presenting a lack of interest in social interaction in the first year of life. Some children with autism spectrum disorder experience developmental pla- teaus or regression, with a gradual or relatively rapid deterioration in social behaviors or use of language, often during the first 2 years of life. Such losses are rare in other disor- ders and may be a useful "red ﬂag" for autism spectrum disorder. Much more unusual and warranting more extensive medical investigation are losses of skills beyond social communication (e.g., loss of self—care, toileting, motor skills) or those occurring after the second birthday (see also Rett syndrome in the section ”Differential Diagnosis” for this disorder).
First symptoms of autism spectrum disorder frequently involve delayed language de- velopment, often accompanied by lack of social interest or unusual social interactions (e.g., pulling individuals by the hand without any attempt to look at them), odd play patterns (e.g., carrying toys around but never playing with them), and unusual communication patterns (e.g., knowing the alphabet but not responding to own name). Deafness may be suspected but is typically ruled out. During the second year, odd and repetitive behaviors and the absence of typical play become more apparent. Since many typically developing young children have strong preferences and enjoy repetition (e.g., eating the same foods, watching the same video multiple times), distinguishing restricted and repetitive behav- iors that are diagnostic of autism spectrum disorder can be difficult in preschoolers. The clinical distinction is based on the type, frequency, and intensity of the behavior (e.g., a child who daily lines up objects for hours and is very distressed if any item is moved).
Autism spectrum disorder is not a degenerative disorder, and it is typical for learning and compensation to continue throughout life. Symptoms are often most marked in early childhood and early school years, with developmental gains typical in later childhood in at least some areas (e.g., increased interest in social interaction). A small proportion of in— dividuals deteriorate behaviorally during adolescence, whereas most others improve.
Only a minority of individuals with autism spectrum disorder live and work indepen- dently in adulthood; those who do tend to have superior language and intellectual abilities and are able to find a niche that matches their special interests and skills. In general, indi- viduals with lower levels of impairment may be better able to function independently.
However, even these individuals may remain socially naive and vulnerable, have difficul- ties organizing practical demands without aid, and are prone to anxiety and depression.
Many adults report using compensation strategies and coping mechanisms to mask their difficulties in public but suffer from the stress and effort of maintaining a socially accept- able facade. Scarcely anything is known about old age in autism spectrum disorder.