Autism is a developmental disorder characterized by difficulties with social interaction and communication, and by restricted and repetitive behavior. Parents usually notice signs during the first three years of their child's life. These signs often develop gradually, though some children with autism reach their developmental milestones at a normal pace before worsening. Autism is associated with a combination of genetic and environmental factors. Risk factors during pregnancy include certain infections, such as rubella, toxins including valproic acid, alcohol, cocaine, pesticides and air pollution, fetal growth restriction, and autoimmune diseases. Controversies surround other proposed environmental causes; for example, the vaccine hypothesis, which has been disproven. Autism affects information processing in the brain by altering connections and organization of nerve cells and their synapses. How this occurs is not well understood. In the DSM-5, autism and less severe forms of the condition, including Asperger syndrome and pervasive developmental disorder not otherwise specified (PDD-NOS), have been combined into the diagnosis of autism spectrum disorder (ASD). Early behavioral interventions or speech therapy can help children with autism gain self-care, social, and communication skills. Although there is no known cure, there have been cases of children who recovered. Not many children with autism live independently after reaching adulthood, though some are successful. An autistic culture has developed, with some individuals seeking a cure and others believing autism should be accepted as a difference and not treated as a disorder. Globally, autism is estimated to affect 24.8 million people as of 2015. In the 2000s, the number of people affected was estimated at 1–2 per 1,000 people worldwide. In the developed countries, about 1.5% of children are diagnosed with ASD as of 2017, from 0.7% in 2000 in the United States. It occurs four-to-five times more often in males than females. The number of people diagnosed has increased dramatically since the 1960s, which may be partly due to changes in diagnostic practice. The question of whether actual rates have increased is unresolved. Autism is a highly variable, neurodevelopmental disorder whose symptoms first appears during infancy or childhood, and generally follows a steady course without remission. People with autism may be severely impaired in some respects but normal, or even superior, in others. Overt symptoms gradually begin after the age of six months, become established by age two or three years and tend to continue through adulthood, although often in more muted form. It is distinguished not by a single symptom but by a characteristic triad of symptoms: impairments in social interaction; impairments in communication; and restricted interests and repetitive behavior. Other aspects, such as atypical eating, are also common but are not essential for diagnosis. Individual symptoms of autism occur in the general population and appear not to associate highly, without a sharp line separating pathologically severe from common traits. Social deficits distinguish autism and the related autism spectrum disorders (ASD; see Classification) from other developmental disorders. People with autism have social impairments and often lack the intuition about others that many people take for granted. Noted autistic Temple Grandin described her inability to understand the social communication of neurotypicals, or people with normal neural development, as leaving her feeling 'like an anthropologist on Mars'. Unusual social development becomes apparent early in childhood. Autistic infants show less attention to social stimuli, smile and look at others less often, and respond less to their own name. Autistic toddlers differ more strikingly from social norms; for example, they have less eye contact and turn-taking, and do not have the ability to use simple movements to express themselves, such as pointing at things. Three- to five-year-old children with autism are less likely to exhibit social understanding, approach others spontaneously, imitate and respond to emotions, communicate nonverbally, and take turns with others. However, they do form attachments to their primary caregivers. Most children with autism display moderately less attachment security than neurotypical children, although this difference disappears in children with higher mental development or less severe ASD. Older children and adults with ASD perform worse on tests of face and emotion recognition although this may be partly due to a lower ability to define a person's own emotions.