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Mark Germine, MD
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Katie and others, I am a psychiatrist with many years experience diagnosing and treating autism spectrum disorders. Severe cases of autistic disorder are very difficult to miss because of the profound language impairment, but the language criteria can be much more subtle, and such cases can be missed, and often are. One example is a the case of an 14 year old adolescent who obviously had autistic disorder, but it had been missed for ten years in multiple evaluations be psychiatrists, psychologists, and other mental health professionals. So, for me, the real test of whether autism is, in fact, increasing in prevalence, would be the prevalence of these more severe cases. In my own experience, I have rediagnosed patients I originally diagnosed as having Asperger's Disorder with Autistic Disorder based on further history and observation. These rediagnosed individuals may be said to belong the "broader phenotype," with less severe signs, symptoms, and impairments. As a whole, it appears to me that the ASDs are still vastly underdiagnosed. I have diagnosed Asperger's for the first time in individuals who had previous psychiatric evaluations in the elderly, and have seen provound cases of autism in young adults with previous evaluations, in whom the diagnosis has been formerly missed. While autism seems to be primarily genetic, the concordance in identical twins ranges in studies from 36 to 96%, and perinatal stress seems to be a factor in those sets of twins. While autism and the ASDs are not curable, it is not untreatable, partial remediation can and does make a big difference. Remediation in the development of language is crucial is preventing life-long impairments is those severely afflicted. Social functions can, to a large extent, be learned, but this requires expert and educational resources. There seems to be an autistic phase of development in infant symbiosis. In this phase it is crucial that the mother and/or other care providers consistently and lovingly nurture the infant. While this may no prevent ASDs, it is likely to effect the severity and degree of impairment. There are many other adverse effects of inadequate or pathological symbiosis. Mothers are being asked or forced to go back to work as soon as 2 weeks after birth. By impacting severity, problems with symbiosis may increase recognition. The breakdown of the nuclear and extended families, the current need for two working parents, and the advent of things like infant television is a factor that may lead to some developmental arrest in symbiosis, and, given the genetics of ASDs, may impact the severity of these disorders. It is my professional opinion, based on experience and what I know of infant and child development, that mothers should be encouraged and enabled to nurture there infants and tottlers, with a full year of supported leave. It is my professional opinion that a host of psychopathologies and cultural problems have arisen as a result of misplaced priorities that detract from the necessary predicates of infant and child development. It is very easy to say, for example, that the clusters of autism in cities in individuals who are highly educated are the result of higher recognition, but this theory does not have a firm, evidentiary basis. It may be that the careers, parenting practice, and urban cultures are involved, again, in the severity of these illness, which then lends itself to recognition. There is a simple rule of statistics and epidemiology - association does not imply causation - that seems to be lost here. Mark Germine, MD