AUTISTIC ​BEHAVIORS and developmental, physiological, psychological, and sociological causes and treatments​

Autistic Behaviors and Developmental, Physiological, Psychological, and Sociological Causes and Treatments​
by Lisa R. Macafee
Department of Psychology, California Southern University
PSY 8701 Physiological Psychology
Dr. Lucas
January 15, 2022
 
Behaviors of autism
While not strictly a behavioral disorder, most challenges for individuals with autism stem from managing the behaviors associated with having autism spectrum disorder (ASD). In this paper, ASD will be referred to interchangeably as autism, neurodivergent, or ASD.  Individuals with ASD will be mostly referred to as autistic in this paper instead of the person-first language of ‘person-with-autism’ more commonly used in other disability rights movement.  The autistic disability rights movement generally supports identity-first language because being autistic is core to our neurology and what makes us who we are, autism is not an accessory to who we are, it is an integral part of who we are.  I am diagnosed autistic and will incorporate my own experiences, and those of my two autistic children into this paper. 

To be diagnosed as autistic according to the DSM-V, an individual needs to have, from an early age, significant deficits in social communication and two of the following behaviors: stereotyped or repetitive behaviors, inflexibility or insistence on routines, restricted or fixated interests (called by the autistic community “special interests”), or hyper or hypo-reactivity to sensory stimulus (CDC.gov, 2002).  Core symptoms associated with autism are challenges in social communication, theory-of-mind, emotional control, cognitive function, executive function, perception, and motor control (Nabetani, Mukai, 2022). This paper will focus on the behaviors associated with an autism diagnosis and the developmental, physiological, psychological, and sociological causes, along with traditional and alternative treatments.

Developmental causes
Autism is defined as a developmental disorder.  Pre-dispositions for autism are present from birth and become more apparent as individuals develop.  Approximately 2% of the population has been diagnosed autistic and diagnosis are growing in rate due to broadened diagnostic criteria and increased awareness of differing ways autism can present.  Males are still diagnosed three to four times as often as females, but this gap is shrinking as providers are learning how autism in girls looks different, and autistic girls tend to present with more social aptitude (Weir, Allison, Ong, Baron-Cohen, 2021).  There may be a developmental factor involved in autism in where adaptive autistic traits are inherited independently, but when a threshold is crossed, these traits begin to synergize and reinforce cognitive development and neural connectivity in ways that can be socially maladaptive (Paul, Arora, Midha, Vu, Roy, Belmonte, 2021).

Research demonstrates that higher prenatal androgen exposure correlates with decreased social functioning ability.  This hypothesis explains why there are more males diagnosed with autism than females at a rate of four to one.  This ‘extreme male brain theory’ posits that prenatal exposure to testosterone at critical developmental phases leads to autism.  One metric used to assess prenatal androgen exposure is to measure the digit ratio of the index and ring fingers.  Individuals exposed to more androgen in the womb typically have longer ring fingers and are typically male, but women with autism often have longer ring fingers as well.  Other measurements of prenatal androgen include measurements of masculine traits in facial structure and umbilical cord testosterone levels.  Each metric of androgen exposure leading to higher masculine traits correlates with higher autistic traits.  Androgynous traits have also been correlated with higher rates of autistic traits as autistic females have more masculine faces, but autistic males have less masculine faces than their typical peers.  I am an autistic woman whose ring finger happens to be longer than my index finger.  I also have other masculine physical traits such as broad shoulders, and more masculine personality traits.  This research fascinates me because my friends in school always described me as like a boy with ovaries, and I have to agree!  Getting an autism diagnosis for myself explained so many of the questions I have had about why I was different from typical girls (McKenna, Huang, Vervier, Hofammann, Cafferata, Al-Momani,...  Michaelson, 2021).

Physiological causes
One of the reasons autistic people tend toward routines is that our brains are wired for rule-based systematizing.  While all people have some degree of autistic traits, the threshold for a diagnosis requires that these traits cause significant difficulty in life, and heightened levels of autistic traits scale with heightened levels of brain efficiency.  Apparently, the brains of people with impaired social responsiveness and attention orienting show a greater efficiency of brain-wide functional networks and systematizing in the medial/anterior temporal lobe.  In addition, individuals with higher traits of systematizing and difficulty in social perspective-taking (theory-of-mind) have brains with greater structural network efficiencies, mainly in the right temporoparietal junction.  This greater brain efficiency could mean that autistic minds have specialized to have greater cognitive efficiency in non-social tasks.  For example, I can research autism for hours, but have genuine anxiety about making a phone call and need to script out what to say.  Autistic brains also seem to tend towards higher bottom-up gamma mediated connectivity and reduced top-down beta mediated signaling to information flow which could underlay these autistic brain differences (Paul, Arora, Midha, Vu, Roy, Belmonte, 2021).

Autistic individuals tend to have restricted diets and have increased rates of eating disorders that can range from picky eating, anorexia, restricted food intake disorder, or bulimia.  Autistic females are particularly more likely to engage in emotional eating behaviors and autistic individuals are overrepresented in having food allergies and sensitivities.  Exercise is also challenging for some autistic individuals who may prefer screen time, aren’t as drawn by social motivation for team sports, or have motor control challenges that make playing sports less attractive.  Sleep disturbances are common in autistic youth and adults and is not explained by epilepsy or other seizure disorders.  These factors may explain why autistic individuals have increased rates of obesity and are at greater risk for chronic conditions such as type II diabetes, certain cancers, respiratory conditions, and cardiovascular conditions than their typical peers.  Statistically, autistic individuals tend to have lifespans 16-38.5 years shorter than typical expectations.  The importance of healthy diet, exercise, and sleep is underrated in much of the United States but seems particularly challenging to achieve for autistic individuals (Weir, Allison, Ong, Baron-Cohen, 2021).

Psychological causes
While autism is a developmental disorder and is part of the neurology of each individual, how each person is impacted by having autism varies dramatically.  At times, peer interactions can create cyclical patterns that entrench the autistic individual in more autistic behaviors.  For example, autistic individuals often experience social anxiety because they know they are different and want to have friends, but experience challenges in realizing these relationships.  Negative peer experiences are associated with behaviors that autistic individuals experience when under stress, as will often be the case in social settings.  For example, meltdowns are often experienced when the autistic individual cannot process more information and is being asked to engage with their environment more quickly than they are able to.  When executive function starts to shut down after decision fatigue or masking, many autistic individuals find it difficult to keep up with hygiene demands or simply forget to wear deodorant or change clothes.  As stressors mount, individuals may resort to rigid rule-keeping to maintain control over their situation.  Self-injury may occur when the world is too “loud”, there are too many stimuli, and too many things happening at once.  The difficult part of this is that the more negative peer interactions an individual experiences, the more likely they are to be stressed by social interactions, and the more likely they are to exhibit behaviors that lead to negative peer interactions!  It’s a frustrating cycle for many individuals.  It’s important to give autistic individuals tools to cope with their stressors that are more socially acceptable, such as finding socially appropriate stims (self-soothing or self-stimulating behaviors that allow the individual to manage stress) or finding ways to avoid having meltdowns in front of their peers (giving them a safe place to go and permission from teachers or supervisors to do so).  Establishing routines that incorporate hygiene demands for the day help to both manage executive function stress by having less decisions to make and ensure hygiene is followed while hopefully leaving cognitive space for flexibility with peers, if their executive function is not overtaxed (Adams, Taylor, Bishop, 2020).

Social anxiety disorder occurs at an alarming rate of 50%-70% in autistic adults and social anxiety rates correlate with social skills deficits.  Social anxiety results in intense fear of, and negative evaluation of social situations and social situation avoidance.  Experiencing difficulties with social interaction makes social interaction more anxiety-producing!  This can be a self-reinforcing cycle as avoiding social situations leads to less competence in social situations, more anxiety, and poorer performance, which results in more social anxiety.   Negative social experiences resulting from autistic behaviors increases bullying and rejection rates, while overstimulation from the senses can cause avoidant behaviors and anxiety to social situations as well.  Experiencing social anxiety can lead to more intense behaviors associated with autism and more stress (Bemmer, Boulton, Thomas, Larke, Lah, Hickie, Guastella, 2021).

If stressors are not appropriately managed, it becomes far too common for autistic individuals to experience depression and suicidal ideology.  Having an autism diagnosis is often a protective factor against suicide.  Those most at risk for suicidal thoughts and attempts are adults with a late diagnosis or no diagnosis.  From my own experience of being diagnosed autistic at the age of 37, having that diagnosis was such a relief.  It explained many of the challenges I experienced and allowed me access to others like me who have found coping strategies for the things we often struggle with.  After receiving my own diagnosis, I went back to school to work in a career field that I enjoy, instead of continuing to work in a self-punishing environment.  I allowed myself grace to care for myself and an autism diagnosis allowed me to look at myself as different instead of broken.  Women are particularly underdiagnosed as autistic, and this has a harmful effect on their health as 40.6% of all people who attempted suicide without an autism diagnosis scored above the autism diagnosis cut-off and 45% or women who meet autism diagnostic criteria but are undiagnosed have made a suicide plan. 16% of these women attempted suicide.  11% of people with depression and 15% of women with borderline personality disorder also meet diagnostic criteria for autism and those with comorbid diagnosis are the individuals most at risk for suicide.  I struggled with depression and anxiety when I was younger and wish I had learned more about autism because now I know that most of the pain and trauma I experienced was from now knowing why I was different.  If I had a developmental and neurological fact (an autism diagnosis) to explain this difference, it would have made a great impact on the challenges I experienced (Cassidy, Bradley, Cogger-Ward, Rodgers, 2021).

Sociological causes
Autism is in no small part influenced by society around us.  I have an autistic friend that states with firm belief that they are not internally disabled, only disabled by the way society expects us to react to it.  While it is true that autistic individuals experience social communication and behavior challenges, we are often extremely efficient (I will get my projects done for work even if I’m working for free), trustworthy (I will not lie or betray what I believe is correct, but don’t ask me to lie for you!), reliable (I have called work from the ER to make sure they are doing okay without me and offer to send emails from the hospital!), and cost-effective employees (see all of the above: the hard work, persistence, ethical nature, and pride that drives us).  All of that being said, a majority of autistic young adults have difficulty finding a job because we present differently to the world and employers hesitate at differences.  In the United States, much of our collective concepts of adult self-worth are built around employment, as well as many social networking and friendship opportunities (Solomon, 2020). 

For myself, I feel a great deal of confidence and self-esteem currently because I’ve worked very hard to gain full-time employment (split between two colleges, but it still counts)!  I changed careers five years ago and had difficulty finding employers to trust me with their work.  I ran into supervisors who tried to have me fired through ingenuine employee evaluations.  My assumption is that I made these traditional women uncomfortable by being a non-traditional woman and rather than live with this discomfort, they assumed that their discomfort at my difference was a signal they should listen to and attempt to have me removed.  I fought the evaluation and won, but it’s a terrifying situation to be in to be ostracized for being different.  Some maladaptive autistic behaviors are reinforced by negative experiences in school and the workforce leading to financial insecurity, which can lead to wearing clothing that is not appropriate for the workplace, unhealthy eating habits, and sleeping less due to mental health stressors.  Only 58% of autistic individuals in their 20s were employed in 2015.  These rates are below rates for individuals with learning and intellectual disabilities and those of ex-convicts.  Employers seem to be uneducated about what autism is and how it works, and fear increased costs and declining productivity, when in many cases the opposite would be true if they hired autistic individuals.  Being unemployed often results in social isolation and increased social communication deficits.  For those autistic adults who are employed, it is typically for lower wages and less hours.  In a 2018 CDC study they found that of autistic employees, 80% worked part-time and had a median income of $160 per week (the average American makes $961 per week).  Employment challenges faced by autistic individuals affect mental and physical health of autistic people.  We deserve to work and be able to support ourselves (Solomon, 2020).

Traditional and alternative treatment approaches
Behaviors associated with autism can be difficult to manage.  When autistic individuals experience stressors, it is common for executive function to be increasingly impaired and decision making to suffer.  Thus, when an autistic person is most in need of support, they are least likely to be able to secure it.  There are currently no recommended pharmacological treatments for core autism features of impaired social communication and restricted or repetitive behaviors, only recommendations for how to treat symptoms such as anxiety.  Even treatments for anxiety in autism are not well-researched as to how autistic brains respond differently than neurotypical brains and may need different types or levels of treatments (Aran, Harel, Cassuto, Polyansky, Schnapp, Wattad,… Castellanos, 2021). 

The most commonly used therapy for autism is the controversial and much maligned (in the autism community) applied behavioral analysis (ABA).  There is research on both sides pointing to both the efficacy of ABA, and its abusive factors  This is a topic best left for another paper, but please know that if you are interested in reading more on this topic, there is literature available. One additional support for autism that has been shown as effective in reducing emotional dysregulation and outbursts. and by extension, social communication, is exercise.  Autistic individuals who exercised on a regular basis were shown to have increased emotional regulatory abilities and a reduction in internal and external behavior problems such as stereotypic behaviors, need for stimming (self-stimulating or soothing behaviors), as well as general benefits of increased strength, attention, self-esteem, and self-efficacy (Tse Andy, 2020).

Modified cognitive behavioral therapy (CBT) has been used with great success for autistic individuals experiencing social anxiety.  In one example of a modified CBT session, clients come for ‘café time’ and practice social skills while building group rapport among other autistic individuals.  Social anxiety is a common component of decreased social ability that 50%-70% of autistic adults experience.  CBT can help reduce social anxiety, which reduces other core symptoms and challenging behaviors like restricted or repetitive behaviors that are often stress-induced, while increasing social motivation.  Use of modified CBT also helps improve overall mental health conditions of anxiety, depression, psychological distress, and stress.  In addition to being functional, the recipients spoke favorably about their enjoyment of the CBT process, which is in stark contrast to recipients of ABA.  Overall, increasing mental health and social acuity can reduce the severity of autism as a disability and allow autistic individuals to live more authentic and happy lives with reduced stress (Bemmer, Boulton, Thomas, Larke, Lah, Hickie, Guastella, 2021).

One of the more controversial treatment options for challenging autistic behaviors is cannabis.  Consuming cannabis can reduce hostile feelings that sometimes underlay social communication challenges and enhance interpersonal communication.  Cannabidiol or CBD does not carry the psychoactive or de-motivational characteristics of THC and is being seen increasingly as a beneficial pharmaceutical option.  CBD has also been shown to have antipsychotic, antiepileptic, and neuroprotective properties.  There are also studies showing that individuals with autism seem to have impaired function of the endocannabinoid system of the brain and that CBD may work to restore optimal function.  Research is needed comparing CBD and THC effects and find more optimal treatments for the core symptoms of autism using cannabis (Aran, Harel, Cassuto, Polyansky, Schnapp, Wattad, . . . Castellanos, 2021).

Another possibility in autism therapy could be cell therapy.  Many attempts at treating autism’s core symptoms have been found unsatisfactory.  Researchers have found a connection between aberrant microglial activity and excessive synaptic pruning resulting in less synaptic plasticity often found in autism.  Inflammation due to allergens of other chronic sources can lead to postsynaptic surplus that can also lead to autism behaviors.  With aberrant microglial function in mind, it has been found that autologous cord blood cells can have a protective effect on the impairment of microglia, inflammation, and oxidative stress that researchers have associated with the development of autism traits and use of these blood cells can prompt neurological regeneration.  Human CD34 positive cells release growth factors that affect brain derived neurotrophic factor production whose disruption is often associated with autism.  It is possible that by using these blood cells in treatment of autism, much like they can be used in treatment of those with epilepsy, cell therapies could alter microglial function and immune system responses to assist in treatment of autism (Nabetani, Mukai, 2022).

There is much yet to learn about autism in adults and research into effective treatments to improve quality of life for autistic individuals.  Many of the challenges autistic people face are stressors due to the world’s reaction to our behaviors.  Teaching autistic people how to better manage their mental health and behaviors and teaching the world at large more about autistic people is my goal.  We can all live better lives by learning more about ourselves and each other.

References
Adams, R. E., Taylor, J. L., & Bishop, S. L. (2020). Brief report: ASD-related behavior problems and negative peer experiences among adolescents with ASD in general education settings. Journal of Autism and Developmental Disorders, 50(12), 4548-4552. doi:http://dx.doi.org/10.1007/s10803-020-04508-1

Aran, A., Harel, M., Cassuto, H., Polyansky, L., Schnapp, A., Wattad, N., . . . Castellanos, F. X. (2021). Cannabinoid treatment for autism: A proof-of-concept randomized trial. Molecular Autism, 12, 1-11. doi:http://dx.doi.org/10.1186/s13229-021-00420-2

Bemmer, E. R., Boulton, K. A., Thomas, E. E., Larke, B., Lah, S., Hickie, I. B., & Guastella, A. J. (2021). Modified CBT for social anxiety and social functioning in young adults with autism spectrum disorder. Molecular Autism, 12, 1-15. doi:http://dx.doi.org/10.1186/s13229-021-00418-w

Cassidy, S. A., Bradley, L., Cogger-Ward, H., & Rodgers, J. (2021). Development and validation of the suicidal behaviours questionnaire - autism spectrum conditions in a community sample of autistic, possibly autistic and non-autistic adults. Molecular Autism, 12, 1-22. doi:http://dx.doi.org/10.1186/s13229-021-00449-3

CDC.gov (2020). Autism spectrum disorder (ASD) diagnostic criteria. Centers for Disease Control and Prevention.  Retrieved from https://www.cdc.gov/ncbddd/autism/hcp-dsm.html on January 7th, 2021.

McKenna, B. G., Huang, Y., Vervier, K., Hofammann, D., Cafferata, M., Al-Momani, S., . . . Michaelson, J. J. (2021). Genetic and morphological estimates of androgen exposure predict social deficits in multiple neurodevelopmental disorder cohorts. Molecular Autism, 12, 1-18. doi:http://dx.doi.org/10.1186/s13229-021-00450-w

Nabetani, M., & Mukai, T. (2022). Future perspectives on cell therapy for autism spectrum disorder. Biocell, 46(4), 873-879. doi:http://dx.doi.org/10.32604/biocell.2022.018218

Solomon, C. (2020). Autism and employment: Implications for employers and adults with ASD. Journal of Autism and Developmental Disorders, 50(11), 4209-4217. doi:http://dx.doi.org/10.1007/s10803-020-04537-w

Paul, S., Arora, A., Midha, R., Vu, D., Roy, P. K., & Belmonte, M. K. (2021). Autistic traits and individual brain differences: Functional network efficiency reflects attentional and social impairments, structural nodal efficiencies index systemising and theory-of-mind skills. Molecular Autism, 12, 1-18. doi:http://dx.doi.org/10.1186/s13229-020-00377-8

Tse Andy, C. Y. (2020). Brief report: Impact of a physical exercise intervention on emotion regulation and behavioral functioning in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 50(11), 4191-4198. doi:http://dx.doi.org/10.1007/s10803-020-04418-2

Weir, E., Allison, C., Ong, K. K., & Baron-Cohen, S. (2021). An investigation of the diet, exercise, sleep, BMI, and health outcomes of autistic adults. Molecular Autism, 12, 1-14. doi:http://dx.doi.org/10.1186/s13229-021-00441-x