Intended for healthcare professionals

Clinical Review State of the Art Review

Linking risk factors and outcomes in autism spectrum disorder: is there evidence for resilience?

BMJ 2020; 368 doi: (Published 28 January 2020) Cite this as: BMJ 2020;368:l6880
  1. Mayada Elsabbagh, PhD
  1. Montreal Neurological Institute, Azrieli Centre for Autism Research, McGill University, Montreal, Canada
  1. Correspondence to M Elsabbagh mayada.elsabbagh{at}


Autism spectrum disorder (referred to here as autism) is one of several overlapping neurodevelopmental conditions that have variable impacts on different individuals. This variability results from dynamic interactions between biological and non-biological risk factors, which result in increasing differentiation between individuals over time. Although this differentiation continues well into adulthood, the infancy period is when the brain and behavior develop rapidly, and when the first signs and symptoms of autism emerge. This review discusses advances in our understanding of the causal pathways leading to autism and overlapping neurodevelopmental conditions. Research is also mapping trajectories of brain and behavioral development for some risk groups, namely later born siblings of children with autism and/or infants referred because of developmental concerns. This knowledge has been useful in improving early identification and establishing the feasibility of targeted interventions for infant risk groups before symptoms arise. However, key knowledge gaps remain, such as the discovery of protective factors (biological or environmental) that may mitigate the impact of risk. Also, the dynamic mechanisms that underlie the associations between risk factors and outcomes need further research. These include the processes of resilience, which may explain why some individuals at risk for autism achieve better than expected outcomes. Bridging these knowledge gaps would help to provide tools for early identification and intervention that reflect dynamic developmental pathways from risk to outcomes.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributorship statement: N/A

  • Competing interests The BMJ has judged that there are no disqualifying financial ties to commercial companies. The author declares the following other interests: none.

  • Further details of The BMJ policy on financial interests are here:

  • Provenance and peer review: commissioned; externally peer reviewed.

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