SIGNS OF MILD AUTISM IN ADULTS

Article Updated 08 January 2024

Over the last decade or two, research efforts and awareness have greatly facilitated autism detection in infants and young children, both by the parents and developmental pediatricians, with relative ease. Chances are, there are likely to be many more adults with autism these days who escaped diagnosis during childhood. Investigations into adult autism have revealed that the symptoms are often milder than those seen in children and tend to present differently in men and women.

The following discussion takes a closer look at signs of mild autism in adults, covering its prevalence, symptoms, potential causes and risk factors, diagnosis, and  current treatment options.

Prevalence of Adult Autism

Autism has been largely studied as a developmental disorder affecting children, with a lesser emphasis on adults with autism. This is likely due to its former novelty as a diagnosis, which has changed in recent years. It is now recognized that there are as many adults with autism as there are children.

The prevalence of autism has increased since it was first recognized several decades ago and is thought to affect approximately 1-3% of both children and adults across the global population. The current prevalence among adults could be more than  currently realized. Adults with autism are more likely to be unaware of their condition. One study showed that up to 80% of autistic adults experience difficulty with seeking out medical attention. On the contrary, autistic children are often easier to diagnose due to having more obvious symptoms that can be detected early on by a parent or practitioner.

Gender Prevalence.  Autism is more common in men than in women , with an average 4:1 male to female ratio. Recent research has suggested that this ratio is likely to be equal between men and women and may be ascribed to differences in symptom presentation.

Signs and Symptoms

Signs and symptoms of autism are usually picked up in children first, with adult autism being less easy to diagnose. Symptoms of adult autism are likely to differ in several ways through the course of maturation and lifetime exposures.

Symptoms of adult autism include:

• Communication skill deficits or differences, including a lack of body language, understanding social cues, and a lack of emotional reciprocity during social interactions
• Social anxiety
• Reduced ability to develop or maintain relationships
• Difficulties with switching attention and sustaining focus
• Limited patterns of interest
• Over or under-sensitivity towards the environment, sensory inputs, or finer details
• Requiring a predictable environment and preferring a set schedule or careful planning
• Physical clumsiness or a lack of motor coordination

An Autistic Social Style often lacks what would be considered by most to be a natural emotional component. This is usually reflected through a lack of body language, the use of unusual body language, and eccentric modes of expression. It can be difficult for them to interpret social cues or conventions, which may make them prone to abruptness or non-intentional apparent disinterest. They may also place a different emphasis on the content of a conversation, take statements too literally, or lose focus during a conversation in a way that can promote miscommunication and misunderstanding. In extreme cases, adults with autism can be mistaken for being non-empathetic due to communication difficulties.

Cognitive Differences. Adults with autism may also display differences in their ability to plan, make decisions, time events, and in executing motor skills. As a consequence of their symptoms, autistic adults may find it difficult to maintain a job or social relationships, both of which can increase symptom severity and the risk of comorbidity.

Intellectual Disability or Genius. It is common for children with chromosomal learning disabilities to have autism due to genetic overlap. Despite this, up to 40% of autistic individuals have above average-intelligence and/or extraordinary artistic ability.^[1] In the absence of a misdiagnosis or comorbidity, this is more likely to be true of adults with autism who escaped a diagnosis in childhood than not, as they may have excelled academically or found helpful social coping mechanisms at an early age. In this respect, psychosocial awareness and support can go a long way toward improving symptoms that may interfere with the quality of life of autistic individuals who are not intellectually impaired.

Autistic Females Have Unique Symptom Presentation. Autistic men are known to display more social and behavioral symptoms on average than autistic women. Studies suggest that women are better able to mask their autistic symptoms through social mimicry and that autistic girls are more concerned with social integration than their male counterparts. Women may also have more conventional interests, which may make their symptoms more difficult to diagnose. However, their fixation on their interests still falls in line with male autistic symptoms. Autistic females are more prone to female-biased mental comorbidities such as depression, anorexia, and other eating disorders, as well as female reproductive diseases.^[2]

Common Comorbidities

The limited evidence available suggests that adults with autism are more likely to suffer from mental and physical health problems. These include^[3]:

• Sleep disruptions and disorders
• Gastrointestinal problems
• Epilepsy
• ADD/ADHD
• Anxiety disorders
• Mood and psychotic disorders
• Obsessive-Compulsive Disorder (OCD)
• Female eating disorders

Due to various genetic and brain changes, those with autism may also be at a higher risk for contracting neurodegenerative disorders as they age.

Women with autism are more likely to suffer from eating disorders, endocrine and reproductive disorders, as well as affective disorders than autistic men.

Possible Causes

Autism was previously believed to be caused by childhood social factors that emphasized antisocial behaviors, such as parenting styles. However, it is now widely recognized that autism is likely to be a multi-factorial disorder caused by genetics, lifestyle, and environmental factors. Due to a wide array of genetic inputs and differences across those with Autism, it was redefined as Autism Spectrum Disorder.

• Genetics. According to some studies, children of parents with autism stand a very high chance of being autistic. However, twin studies suggest that inherited genetics only constitute 35-40% of the risk. The remaining 60% has been attributable to genetic changes that occur in utero and during infancy. Aside from familial inheritance of autistic genes, chromosomal disorders such as Fragile X Syndrome and learning disabilities are known to increase the risk for autism, as reflected by higher autism rates amongst these populations.
• Specific Gene Mutations. Different subsets of autism are starting to be delineated in accordance with their unique genetic origins^[4]. However the results are far too varied,^[5] and more research is required before firm conclusions can be drawn with respect to the genetics of autism. Hundreds of mutations have been discovered pertaining to circadian signaling, oxytocin, DNA utilization (methylation and acetylation), vitamin D and A metabolism^[6], synaptic and dendritic formation, neurotransmission, metabolism, and autoimmunity. Despite differences, these gene changes all contribute towards promoting similar brain alterations and symptoms amongst those with autistic spectrum disorders. With more time and research, precision treatment options are likely to emerge that can help to treat autistic symptoms in those with specific subtypes.^[7]
• Brain Changes in Autistic Individuals. Several brain changes have been noted across studies assessing the brain scans of autistic individuals. The findings reveal white and grey matter overgrowth in various brain regions during childhood, followed by atrophy in the same regions during adolescence, that altogether promote alterations in motor and sensory processing as well as cognition. Brain changes may occur in different areas in autistic men and women. Women are also more likely to experience brain endocrine disruption as an additional contributor to their autistic profile (also known as excessive brain masculinization)^[8]. These changes may explain why autistic individuals are more detail-oriented, less receptive towards body language (motion and biological emotive cues), and sensitive towards visual and/or auditory stimuli, as well as less physically coordinated and prone to exhibiting repetitive or distinct behaviors.^[9]
• Neuroinflammation and the Aging Autistic Brain. Over the course of the lifespan, the brain slowly shrinks in size, which places the elderly at an increased risk of contracting a neurodegenerative disease. Following on from the brain changes described above, the brains of those with autism appear to age quicker on average than the brains of the average non-autistic population. A lifelong study published on over 500 individuals with autism revealed that 40-45-year-old autistic men averaged brain sizes comparable with non-autistic 50-year-old men. The study also revealed great differences between autistic individuals, with many experiencing greater brain volumes at both puberty and the age of 50 than the average population, despite the quicker aging rate observed.^[10] More research has highlighted that the quicker rate of decline is linked to mild chronic neuroinflammation and immune differences in autistic individuals. These promote autistic symptoms and are thought to be induced by the wide spectrum of genetic mutations underpinning autism.
• Neurotransmission Anomalies and Neuroexcitation Imbalances. Many studies suggest that autism is indicative of genetic changes that underlie altered synaptic growth patterns as well as excitatory neurotransmission imbalances. It has been theorized that those with autism have deficits in GABA transmission, the main inhibitory neurotransmitter, or excesses in glutamate/glutamine, the main excitatory neurotransmitter, which leads to over-excitability in various brain regions. This excitation imbalance may also increase synaptic growth anomalies or arise as a result of them, contributing to the brain changes described above in some autistic individuals.^[11]
• Other Inflammatory Contributions. The genetic abnormalities that precipitate autism are known to influence other aspects of health, including overall immunity, fatty acid metabolism, hormones, and digestive health. Those with autism typically have a form of chronic low-grade inflammation in tandem with increased gut and blood-brain barrier permeability, as well as gut dysbiosis. These factors can help to promote problems pertaining to fatty acid metabolism, neuroinflammation,^[12] and unbalanced brain development throughout the lifespan.

Risk Factors

The following factors are known to increase the risk of autism by contributing to possible causes:

• Toxin Exposure. It is recognized that some drugs, such as sodium valproate, and exposure to chemicals during pregnancy and early childhood enhance the chance of autism in susceptible individuals. Epidemiological studies indicate that air pollution from industry or dense traffic has been shown to contribute to the incidence of autism. Furthermore, endocrine-disrupting chemicals, pesticides, and herbicides are capable of inducing gene switches that also correspond with promoting autism. These exposures can also increase inflammation, disrupt endocrine signaling, and pose a substantial threat to the microbiome, all of which can affect brain function and development.
• Older Parental Age. Additionally, those conceived of fathers that were 40-50 years of age are up to 5 times more likely to develop autism during childhood than those conceived of younger fathers.
• Congenital Rubella Syndrome. Since the frequent Rubella outbreaks of the 60s, it was shown that as many as 4-13% of children with rubella syndrome developed autism^{[13] [14]} and that pregnant women with rubella infections were at an increased risk of birthing an autistic child. Despite this association, there is no convincing evidence to suggest that the MMR vaccines are associated with an elevated risk for autism.

Diagnosis

Some autistic individuals may not require a diagnosis, while others may benefit. It can often help to provide a better understanding of any problematic symptoms or psychosocial differences to the autistic individual, as well as their families, friends, and colleagues. ^[15]

Receiving a Diagnosis. If an adult displays one or more symptoms of autism and the symptoms substantially impact the quality of his or her life, then it may be a good idea to consult with a qualified practitioner.^[16] A psychologist, pediatrician, or neuropsychologist are all able to assist with diagnosis. There are several diagnostic tests used to assess adult autism, all of which assess social and behavioral symptoms. Adults with autism may be able to trace their symptoms back to childhood in order to aid in acquiring a diagnosis. It may be more difficult to diagnose females than males with autism.

Biological Confirmation. A few companies are offering genetic testing that can offer biological confirmation of an autistic diagnosis, yet this form of testing cannot be used to give an up-front diagnosis. Future diagnostic panels are expected to make use of MRIs and genome sequencing to ascertain distinct autism subtypes as well as individual-specific brain areas that are affected.^[17]

Treatment

There is no known cure for autism as of now. Due to the large number of genetic causes, optimal treatment is going to consist of a personalized protocol that makes use of genomics and precision medicine. More research is required before specific genome-based recommendations can be made with regard to specific autistic profiles.

The following treatment suggestions can help to improve the overall health and well-being of adults with autism, potentially enhancing symptom management. These consist of regular exercise, circadian regulation, consuming a microbiome-oriented diet, psychosocial support, and management of comorbidities.

• Regular Physical Exercise. There are not many studies published on the effects of exercise with respect to adult autism. In childhood, autistic individuals are likely to benefit most from team sports and aerobic exercise, which have been shown to improve social and behavioral symptoms, respectively. Other research suggests that exercise is likely to be helpful in regulating overall metabolism, lowering inflammation, and helping to normalize brain development in those with either child or adult autistic spectrum disorder.^[18] Autistic adults may benefit additionally from group-based exercises that emphasize self-expression and/or group participation, such as dance and physical movement classes. This proved to improve upon social symptoms more than any other cognitive or social therapy.
• Melatonin and Sleep Hygiene. Many with autism have sleep-related symptoms and difficulties with falling asleep, setting a stable bedtime, and sometimes, insomnia. Those with autism are likely to have mutations in genes that regulate circadian signaling, which include those governing melatonin production and the sleep-wake cycle^[19]. Melatonin may be an effective way to treat sleep disturbances in adults with autism, showing great success across many studies. In combination with melatonin, sleep hygiene is important to practice to promote better sleep, especially in adults with autism. Maintaining a consistent bedtime, making use of dim light the hour before sleep for enhancing melatonin production,^[20] and lowering exposure to overly stimulating inputs during this time can all reduce the time it takes to fall asleep and improve its quality.
• Opting for a Balanced Diet Plan. Many studies highlight that children with autism tend to suffer from multiple nutritional deficiencies and microbiome imbalances that affect their overall health. Adults with autism may have a similar profile or may have already made appropriate dietary changes. The diet should be high in fruit and vegetable fiber and nutrients while low in processed foods. Probiotics may have a highly beneficial role in helping to stabilize the microbiome in autistic individuals^[21], as well as dietary omega-3 fats, amino acids, and vitamins A, D and E. Fiber-rich foods with probiotics can improve gut microbe diversity and boost the production of short-chain fats like butyrate that is known to enhance brain health and development, as seen in autistic individuals. Many polyphenol-rich foods are complementary to digestive health and have been shown to help correct inflammatory and behavioral symptoms. Additionally, various supplements are thought to help, including nutrient extracts^[22], N-acetyl-cysteine, choline, B vitamins^[23], vitamin D3, astaxanthin, and carnitine^[24].
• Nutritional Counseling. Autistic children are known to have extremely selective eating habits that often limit their intake of nutrients, which may extend into adulthood and promote GI problems. Adults with autism may wish to get nutritional counseling in order to improve their eating habits and balance their nutrient intake. It is also important, especially for women with autism, to create a consistent healthy diet plan to minimize the risk of disordered eating as well as obsessing over one’s diet.
• Psychosocial Support. Adequate psychosocial support continues to be one of the best treatment avenues for enhancing the social components of autism. Social functioning has been divided into social motivation, anxiety, cognition, and social skills, all of which are known to be affected in those across the autistic spectrum to varying degrees^[25]. In a large review analyzing psychosocial support strategies, it was revealed that autistic adults could benefit from the support that promotes social motivation more than any other aspect of social functioning. As mentioned above, group-based physical activities are one of the best strategies for enhancing overall social functioning, including motivation^[26]. Understanding and support from family and peers can help the individual to understand the value of socializing and to orient positively in the social setting.
• Transcranial Brain Stimulation. Some newer complementary approaches to autism have begun to gain popularity, such as transcranial brain stimulation. These include transcranial magnetic stimulation, electric stimulation, and theta burst stimulation, all of which involve altering brain activity using electromagnetic stimulation. This has been shown to improve symptoms in those with autism in preliminary trials and enhance balanced brain development.^[27]
• Comorbid Treatment. Those with autism are likely to be diagnosed with comorbidities and treated for the same. However, standard treatment may not be advisable for autistic individuals. This is especially true of ADHD and epilepsy, yet may extend towards insomnia, OCD, anxiety disorders, and digestive ailments as well. Hence, adults with autism should be assessed on a case by case basis, with treatment being tailored to the individual. Behavioral, lifestyle and dietary approaches should be tried first before employing a pharmaceutical route.

Conclusion

Autism in adults is more difficult to diagnose due to a lack of awareness and differences in symptom presentation as compared to children. Autistic adults are more likely to have found coping mechanisms that help compensate for their social and behavioral symptoms. This is especially true of autistic women, who tend to mimic social cues better and have a greater tendency to adopt socially oriented interests compared to autistic men. There are hundreds of potential genetic causes that can contribute to unique symptoms across autistic individuals, all of which tend to promote neuroinflammation and problems with brain development that persist throughout adulthood. Depending on the individual, a diagnosis and treatment may or may not be necessary. Treatment usually emphasizes leading a healthy lifestyle, improving sleep quality, and encouraging engagement in social activities that are motivating.

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