Autism as emergent and transactional

Abstract

The current epistemology of autism as a phenotype derives from the consistency of historical accounts and decades of work within the tradition of descriptive epidemiology, culminating in current categorical descriptions within DSM and ICD nosologies and the concept of “prototypical autism.” The demonstrated high heritability of this phenotype has led to an essentialist theory of autism as a biological entity and the concerted search within the developmental brain and genetic science for discrete biological markers. This search has not revealed simple markers explaining autistic outcomes and has led to moves towards a more dimensional account. This article proposes an alternative transactional approach. It proposes to understand autistic states as an emergent property within a complex developmental system; as the neurodivergent brain, and mind and body, encounter their social and physical environment within early development. Key evidence in support of this approach comes from random allocation intervention trials based on such transactional development theory, both in the infancy pre-diagnostic prodrome and the early post-diagnostic period. In replicated evidence, these intervention trials show that a targeted alteration in the quality of social transactional environment available for the child leads to significant, predictable, and sustained alterations in the outcome dimensional autistic phenotype over time; and further, in one prodromal trial, to a significant reduction in later categorical classification status. The inference from this evidence is that the prototypical autistic phenotype is to a degree malleable with a changed experienced social environment and that it is emergent from its constituent traits. Such a transactional approach enlarges our notion of the phenotype and brings the study of autism within mainstream individual difference developmental science. It challenges essentialist views, for instance as to intrinsic autistic “social avoidance” or theory of mind empathy deficits, integrates dimensional and categorical perspectives, and is consistent with the lived experience of autistic people and their advocacy for improved understanding within a social model.

Debate: Neurodiversity, autism and healthcare

“…This should now be I suggest the focus of early intervention; not aiming to change or normalise autism behaviour as it has been in the past but to optimise the environment around the child so that their neurodifference can flourish in the best possible way; an approach that evidence suggests is the most effective (Sandbank et al., 2020), as well as ethical way of proceeding. The outcomes of such an approach in turn can illuminate autistic ability (for instance around sociability) and support some re‐evaluation, through phenomenology, of the phenotype as currently understood (Green, 2022 and see below).…”

“…Fundamental questions have consequently arisen as to 'what is autism'; with the meaning (and ownership) of the term increasingly contested and threatening to fragment (Green, 2022). There is on the one hand the familiar clinical concept of "autism" underpinning diagnostic practice (although challenged by the notion of the spectrum).…”

“…Given all these developments, we need to work together at this time across the clinical, scientific and expert‐by‐experience communities to recast and refine our understanding of autism within the idea of neurodiversity, and the place of healthcare within it. I have suggested (Green, 2022) a model of the autism phenotype, built on contemporary developmental and intervention science, as emergent and transactional . This is a trajectory which starts with the individual brain differences underlying neurodiversity, and then a behavioural phenotype emergent over the first few years of life (or later) from a developmental transaction between these brain differences and the child or young person's experience in the world.…”

Does the current state of biomarker discovery in autism reflect the limits of reductionism in precision medicine? Suggestions for an integrative approach that considers dynamic mechanisms between brain, body, and the social environment

“…A systems biology approach to precision medicine aims to take into account and integrate information from multiple sources, including genes and the environment, and different 'parts' of brain and body, to make predictions about an individual. The question is then how properties emerge from the addition and/or interactions of multiple components in particular conditions, and over time [see also (85)]. This may help us to understand how even a rare variant (e.g., SHANK3 point mutation) can lead to different clinical or behavioural presentations in different people depending on their genomic background (86), environmental and/or stochastic factors, or why identical twins can be discordant for autism or differ in their presentation of autistic features (87).…”

“…Transactional models highlight the role of the dynamics between child and caregivers (and significant others) in the emergence of autism (85). Parents of infants with higher familial likelihood for autism have been shown to adjust to their child in various ways, by offering less social input, or by using more directive or enriched styles to scaffold their child (107).…”