Social ‘wanting’ dysfunction in autism: neurobiological underpinnings and treatment implications

Autism is currently defined by impairments in social interactions, communication and restricted interests and behaviors [1]. The core social and communicative impairments (which will probably be collapsed into one category in the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders) can be conceptualized as a set of related skill deficits (including social reciprocity, social perception and memory, joint attention, and perspective-taking). These deficits conspire to make it difficult for people with autism to develop and maintain social relationships [2]. Considering the symptoms of autism spectrum disorders (ASD) as developmental failure to acquire adequate social-communication skills brings into focus the learning processes that underlie ASD. Such skill-based focus has concrete implications for treatment. Currently, there are no FDA-approved medications to treat the core social and communicative skill impairments of ASD. In fact, it is probably naive to expect that a medication is by itself able to remediate a skill deficit, but it clearly might have a role in potentiating or facilitating social skill learning.At present, most interventions targeting social-communicative skill defects and other behavioral problems in ASD rely on the principles of applied behavior analysis (ABA), especially operant techniques, where desired behaviors are reinforced using a variety of rewards (for example, verbal praise, candy, or stickers). Accumulating evidence from over 40 years of research indicates that these reinforcement-based interventions significantly increase both cognitive and social outcomes, and successfully reduce aberrant behaviors [3]. Although it is well established and has proven efficacious at the group level, this approach fails to benefit a substantial number of individuals on the autistic spectrum [4-6]. It is not yet understood how and why behavioral approaches work well for some people with ASD but not for others. As well as