**3. How ASD symptoms change during lifetime**

All professionals who treat children and adolescents, both coming from health care as well as from education must know how behaviors can normally change during the normal neuro‐ psychological development. In other words: there is an ontogenetic evolution on each one of the behavioral manifestations in the normally developed children.

For example: in terms of gender versus behavior, usually hyperactivity is more prevalent in normal boys when compared with normal girls. The humor control, the language skills and the social competence usually improves in normally developed children as long as time passes. Usually, normal girls tend to improve faster their language skills and their social competence when compared with normal boys. This knowledge is crucial to identify how different behavioral symptoms change during lifetime in ASD patients.

When the issue is childhood autism symptoms, there are no major problems in terms of information, because of most of the available publications are directed to pediatric patients. As a consequence, adult ASD symptoms are less frequently accessed in the available literature.

slight superiority in language skills in the AD patient group (Mawhood, Howlin, and

The restrictive repertoire of activities and interests do not change in intensity as long as time passes, but certainly the type of interest do change during lifetime. Only few studies address the restrictive repertoire of interests. According with Rutter and colleagues (1967), in a cohort study, although some improvement was identified, all of patients with repetitive behaviors during infancy continued presenting it 10 years later, with a trend to increasing frequency and intensity of such symptoms (Rutter, Greenfeld, and Lockyer 1967). Subsequent research showed that near of 90% of adolescents and adults with autism persisted with restrictive

Another recurrent preoccupation in ASD follow up is regarding the Intellectual Quotient (IQ). Although some studies revealed lifelong IQ stability, it seem to have a performance IQ decline and a verbal IQ increase as time pass. In reality, there is a paucity of studies regarding IQ changes lifelong in ASD patients. In patients with verbal and performance IQ above 70, these

occur

There are few epidemiologic studies of the ASD-associated comorbidities changes as time pass.

In general, the comorbidities found in classic autism are different from the identified in Asperger patients, which is probably associated with cognition. As a result, classic autism is more associated to violent behavior, and psychosis. By the other side, Asperger disorder can

The more prevalent psychiatric diagnosis in ASD patients is depression that seems to become more intense with age and frequently associated with anxiety (Howlin, Mawhood, and Rutter 2000). In our experience, the dyad depression/anxiety is more frequent in intelligencepreserved ASD patients, such as those with Asperger disorder. Additionally, anxiety seems to increase in stress situations and also during lifetime (Gottfried and Riesgo 2011). Because of their ability to identify their own difficulties (Cederlund, Hagberg, and Gillberg 2010), patients

Persistence of social deficits. A discrete improvement can

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Persists in 90%. Uncommon concerns and complex stereotypies can decrease. The focus of interests can vary

Can improve, but some deficits persists

repertoire of activities and interests (Seltzer et al. 2003; Howlin et al. 2004).

changes seem to be less intense (Howlin et al. 2004).

Social deficits Persistence of social deficits. A

Communication deficits Can improve, but some deficits persists

complexity

**Table 1.** How ASD core symptoms change during lifetime.

be more linked to anxiety and/or depression.

with Asperger are more prone to became depressed.

Restrict repetitive behavior

**Core symptom In adolescence In adulthood**

Increase in frequency and

**3.2. How ASD-associated symptoms change with time**

Consequently, to date any estimate need to be taken with caution.

discrete improvement can occur

Rutter 2000; Howlin et al. 2004).

Researchers had noted that the prevalence of adult ASD may be underestimating and most of these patients reach adulthood without any diagnosis or treatment. This is especially true to patients with Asperger. (Szatmari et al. 1995; Arora et al. 2011).

More recently, an increasing interest is observed in prevalence and clinical presentation of ASD in adults. The few available prospective studies indicate a diagnostic stability through life (Billstedt, Gillberg, and Gillberg 2005), and near of 80% of individuals with ASD diagnosed in childhood continues to present scores within this spectrum during adolescence and adulthood (Rutter, Greenfeld, and Lockyer 1967).

It is important to mention the difficulties in making diagnosis of ASD in adult patients, because many of them have no information regarding their first years of life. If the diag‐ nosis of ASD is hard to be made in adults, then the prognosis is equally affected. The prognostic studies in adults with ASD had includes patients with very different levels of cognitive, linguistic, social, and behavioral functioning (Howlin et al. 2004). Additionally, most of available the prognostic studies in adult ASD use small samples, which make impossible to obtain definitive conclusions.

Where searching literature regarding how ASD symptoms change during lifetime, a paucity of published information is promptly identified. Although the lack of publications, at least two different timelines could be identified in ASD patients: a) how ASD core symptoms change as time pass; b) how ASD-associated symptoms change with time.

#### **3.1. How ASD core symptoms change during lifetime**

The three core symptoms of ASD, the so-called "triad of Wing" are the following: social deficits, communication deficits, and restrict and repetitive behavior.

The social deficits persist as an important problem in adolescence and adult age and usually are accessed by the Autism Diagnostic Interview (ADI) and also by the Vineland Adaptive Behavior Scale (VABS). Our group translated into Brazilian Portuguese the ADI-R, considered the "gold-standard" in autism diagnosis and is extremely useful identifying social deficits (Becker et al. 2012). One study found that only 16.7% of adults with autism presented high scores in social domain of VABS. Additionally, more than half of patients had no social contact at all and one third showed strange social contact (Howlin, Mawhood, and Rutter 2000). In general, social deficits do not improve significantly as time pass.

The communication skills tend to improve. As a group, ASD patients tend to keep al‐ most unchanged the idiosyncratic use of language as well as the inappropriate patterns of communication in adulthood. More recent research had shown that more than half of ASD patients present language below the level of ten years of age, when adults. When comparing ASD versus AD patients with similar age and cognition, it is identified a slight superiority in language skills in the AD patient group (Mawhood, Howlin, and Rutter 2000; Howlin et al. 2004).

The restrictive repertoire of activities and interests do not change in intensity as long as time passes, but certainly the type of interest do change during lifetime. Only few studies address the restrictive repertoire of interests. According with Rutter and colleagues (1967), in a cohort study, although some improvement was identified, all of patients with repetitive behaviors during infancy continued presenting it 10 years later, with a trend to increasing frequency and intensity of such symptoms (Rutter, Greenfeld, and Lockyer 1967). Subsequent research showed that near of 90% of adolescents and adults with autism persisted with restrictive repertoire of activities and interests (Seltzer et al. 2003; Howlin et al. 2004).

Another recurrent preoccupation in ASD follow up is regarding the Intellectual Quotient (IQ). Although some studies revealed lifelong IQ stability, it seem to have a performance IQ decline and a verbal IQ increase as time pass. In reality, there is a paucity of studies regarding IQ changes lifelong in ASD patients. In patients with verbal and performance IQ above 70, these changes seem to be less intense (Howlin et al. 2004).


**Table 1.** How ASD core symptoms change during lifetime.

When the issue is childhood autism symptoms, there are no major problems in terms of information, because of most of the available publications are directed to pediatric patients. As a consequence, adult ASD symptoms are less frequently accessed in the available literature.

Researchers had noted that the prevalence of adult ASD may be underestimating and most of these patients reach adulthood without any diagnosis or treatment. This is especially true to

More recently, an increasing interest is observed in prevalence and clinical presentation of ASD in adults. The few available prospective studies indicate a diagnostic stability through life (Billstedt, Gillberg, and Gillberg 2005), and near of 80% of individuals with ASD diagnosed in childhood continues to present scores within this spectrum during adolescence and

It is important to mention the difficulties in making diagnosis of ASD in adult patients, because many of them have no information regarding their first years of life. If the diag‐ nosis of ASD is hard to be made in adults, then the prognosis is equally affected. The prognostic studies in adults with ASD had includes patients with very different levels of cognitive, linguistic, social, and behavioral functioning (Howlin et al. 2004). Additionally, most of available the prognostic studies in adult ASD use small samples, which make

Where searching literature regarding how ASD symptoms change during lifetime, a paucity of published information is promptly identified. Although the lack of publications, at least two different timelines could be identified in ASD patients: a) how ASD core symptoms change as

The three core symptoms of ASD, the so-called "triad of Wing" are the following: social deficits,

The social deficits persist as an important problem in adolescence and adult age and usually are accessed by the Autism Diagnostic Interview (ADI) and also by the Vineland Adaptive Behavior Scale (VABS). Our group translated into Brazilian Portuguese the ADI-R, considered the "gold-standard" in autism diagnosis and is extremely useful identifying social deficits (Becker et al. 2012). One study found that only 16.7% of adults with autism presented high scores in social domain of VABS. Additionally, more than half of patients had no social contact at all and one third showed strange social contact (Howlin, Mawhood, and Rutter 2000). In

The communication skills tend to improve. As a group, ASD patients tend to keep al‐ most unchanged the idiosyncratic use of language as well as the inappropriate patterns of communication in adulthood. More recent research had shown that more than half of ASD patients present language below the level of ten years of age, when adults. When comparing ASD versus AD patients with similar age and cognition, it is identified a

patients with Asperger. (Szatmari et al. 1995; Arora et al. 2011).

time pass; b) how ASD-associated symptoms change with time.

communication deficits, and restrict and repetitive behavior.

general, social deficits do not improve significantly as time pass.

**3.1. How ASD core symptoms change during lifetime**

adulthood (Rutter, Greenfeld, and Lockyer 1967).

636 Recent Advances in Autism Spectrum Disorders - Volume I

impossible to obtain definitive conclusions.

#### **3.2. How ASD-associated symptoms change with time**

There are few epidemiologic studies of the ASD-associated comorbidities changes as time pass. Consequently, to date any estimate need to be taken with caution.

In general, the comorbidities found in classic autism are different from the identified in Asperger patients, which is probably associated with cognition. As a result, classic autism is more associated to violent behavior, and psychosis. By the other side, Asperger disorder can be more linked to anxiety and/or depression.

The more prevalent psychiatric diagnosis in ASD patients is depression that seems to become more intense with age and frequently associated with anxiety (Howlin, Mawhood, and Rutter 2000). In our experience, the dyad depression/anxiety is more frequent in intelligencepreserved ASD patients, such as those with Asperger disorder. Additionally, anxiety seems to increase in stress situations and also during lifetime (Gottfried and Riesgo 2011). Because of their ability to identify their own difficulties (Cederlund, Hagberg, and Gillberg 2010), patients with Asperger are more prone to became depressed.

The second more frequent psychiatric disorder in ASD patients is probably bipolar disorder (Howlin, Mawhood, and Rutter 2000). Young ASD children experience more difficulties in mood stabilization. In addition, mood's changes occur more rapidly in children when com‐ pared with adults. As a result, in very young ASD children the humor can change almost instantaneously.

sion, etc. Actually, medication is frequently required to decrease the "noise" surrounding autism, including a wide range of maladaptive behaviors and/or associated problems (Benvenuto et al. 2012). To our knowledge, psychopharmacotherapy can eventually improve

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In our experience, we usually identify 2-5 ASD associated symptoms and/or diagnosis, including epilepsy. We have found disruptive behavior more frequently in ASD patients with cognitive impairment, as well as symptoms related with depression and/or anxiety in pre‐ served intelligence ASD children (Gottfried and Riesgo 2011). Other related symptoms are: aggression, self-injury, impulsivity, decreased attention, anxiety, depression, and sleep

Because ASD are chronic and markedly impairing situations in many cases, there is justifiably a high desire for effective treatments. By the other side, it is important to mention that there is a paucity of well conducted evidence-based studies of medications used in ASD patients. Not infrequently, this desire leads to premature enthusiasm for agents and interventions that appear promising in early reports but later do not withstand the rigor of randomized controlled

Another critical issue is the co-occurrence of epilepsy in ASD patients which is almost twenty times more frequent when ASD patients are compared with children with typical develop‐ ment. The management of combined epilepsy can represent a challenge for clinicians. Several anti-epileptic drugs can determine an exacerbation of behavioral symptoms, and some psychotropic medications used in ASD patients may lower the seizure threshold (Benvenuto et al. 2012). In our experience, risperidone can be safely used up to 3mg/Kg/day, and higher doses can lead to seizures in susceptible patients. That is the reason why we prefer to perform an electroencephalogram before using psychoactive drugs in ASD children (Gottfried and Riesgo 2011). Therefore, it's mandatory to search a treatment strategy with the minor negative

It should be noted that most psychotropic use in ASD is actually off-label, as currently there are only two medications approved for use in ASD children by the FDA (Food and Drug Administration). These drugs are risperidone and aripiprazole, which are effective to associated behaviors, but not to autism itself. The general principles for the pharmaco‐ therapy in ASD are similar to the used in other neuropsychiatric conditions (Weinssman

In summary, the use of psychotropic medications, alone or in combination, should follow some guidelines, such as: be focused on specific targets, be used at the minimum effective dosage, as well as be used for short period of time (Benvenuto et al. 2012). Ideally, medications should

Disruptive behaviors in ASD children may include irritability, aggression, explosive outbursts (tantrums), and/or self-injury. These symptoms can be identified in almost two thirds of ASD patients and certainly have the biggest impact on the care of affected individuals, as well as

be initiated only after behavioral and educational interventions are in place.

adhesion to non-medical treatment of ASD patients (Gottfried and Riesgo 2011).

disruption, among others.

impact on this subgroup of patients

and Bridgemohan 2012).

**4.1. Disruptive behaviors**

trial (RTC).

The prevalence of bipolar disorders as a whole can reach up to 33% in ASD patients (Abramson et al. 1992). Obsessive and compulsive symptoms are frequently identified in ASD, although is difficult to distinguish the pure obsessive-compulsive disorder from bizarre concerns common in patients with autism (Howlin, Mawhood, and Rutter 2000).

Adults with Asperger disorder can experience occasional episodes of psychosis, such as persecutory ideas, auditory hallucinations, paranoid idea or delusional thoughts. But schizo‐ phrenia is not common and must remain as a differential diagnosis (Howlin, Mawhood, and Rutter 2000). The abovementioned episodes of psychosis can be identified in up to 15% of Asperger patients after adolescence (Hofvander et al. 2009).

Hyperactivity is a frequent symptom in children with ASD, is more prevalent in boys than in girls, and can decrease as time passes. Although the concomitant aggressiveness itself usually decrease with aging, the consequences of aggressiveness can be worse with age increasing in patients with autism because of their increase of muscle strength. An overlap between ADHD and ASD is relatively common in childhood, but this association is rarely described in manuscripts with ASD adults (Stahlberg et al. 2004).

#### **3.3. Prognosis for ASD patients in adulthood**

Although there are no doubts regarding a substantial improvement in the management of autism in the last three decades, unfortunately even nowadays a minority of adults with autism is able to work, to live independently, as well to develop appropriate social skills. Most of these patients still live with their parents or other caregivers (Howlin et al. 2004).

It is known by far that the most important prognostic value is defined by the cognitive functioning in childhood. In this sense, the clinical problem eventually is to access intelligence in non-verbal ASD children. According with literature, children with autism and IQ above 70 had better global prognosis in adulthood (Howlin et al. 2004).

The ability to acquire functional language until the age of six years is also another prognostic landmark (Howlin et al. 2004). Better language and more preserved cognition are the two probably reasons to explain the best prognosis in Asperger disorder when compared with classical forms of autism.
