Brain repair, protection, or optimization: what is biologically possible in level 3 autisms?

 

Piano tuning vs Brain tuning

Discussions about brain repair often mix together very different biological processes. This leads to confusion, unrealistic expectations, and unhelpful metaphors—most notably the idea that autism reflects “miswired” brains that must somehow be rewired. A more useful approach is to distinguish between construction, protection, repair, and optimization, and to recognise that each dominates at different stages of life and in different conditions.

This discussion focuses primarily on level 3 autism, where early developmental vulnerability, high support needs, and biological stressors play a central role in shaping long-term outcome.

 

Why “brain wiring” is a misleading analogy — and why fine-tuning is better

Autism is frequently described using the language of wiring: faulty circuits, miswired connections, or incorrect neural networks. While intuitively appealing to some, this metaphor is biologically misleading and ultimately unhelpful when discussing development, intervention, or long-term outcome.

The brain does not contain fixed wires. Neurons are living cells embedded in a biochemical, metabolic, and immunological environment that is in constant flux. Synapses strengthen and weaken, receptors are trafficked in and out of membranes, ion gradients shift, myelination adapts to activity, and neuromodulators continuously reshape how information is processed. Even in adulthood, neural networks are not static structures but dynamic systems.

The problem with the wiring metaphor is not that it is entirely wrong, but that it implies permanence and rigidity. Wires, once laid incorrectly, must be physically replaced. This framing naturally leads either to pessimism (“the brain is miswired and cannot be fixed”) or to unrealistic repair narratives (“we must rewire it”). Neither reflects how brains actually function.

A more accurate analogy is fine-tuning or calibration.

In many forms of autism—particularly outside of early severe neuronal loss—the core issue is not missing connections, but suboptimal parameter settings within otherwise intact networks. These include excitatory–inhibitory balance, timing and synchrony, sensory gain control, neuromodulatory tone, and signal-to-noise ratios. These parameters are continuously adjustable across the lifespan.

Fine-tuning implies adjustment rather than reconstruction, optimization rather than replacement. It explains why meaningful improvement remains possible in adulthood, while also acknowledging that early developmental constraints can limit what is achievable later.

In level 3 autism, early neuronal loss or failure of maturation can impose hard structural constraints. In such cases, fine-tuning cannot recreate missing cell populations or replay early construction. But even here, the remaining networks still require calibration. Early protection raises the ceiling; later tuning determines how close that ceiling is reached.

This distinction underlies the rest of this discussion.

 

Neuroblasts: builders, not repair workers

Neuroblasts play a central role during early development. They generate neuronal populations, migrate to appropriate regions, and differentiate into specific cell types. In doing so, they establish the cellular and developmental context in which later plasticity operates.

Outside of development, however, their role is limited. In adulthood, neuroblast generation is sparse and restricted to specific niches, and their contribution to functional recovery after injury (such as stroke) is modest and local. Neuroblasts are therefore best understood as developmental builders, not as the primary agents of ongoing brain repair or optimization.

This distinction matters, because many neurodevelopmental conditions arise from a developmental vulnerability during periods of rapid growth and high metabolic demand.

 

Early vulnerability, degeneration, and plateau

Several severe neurodevelopmental disorders share a common pattern: early disruption or selective neuronal loss followed by long-term stability rather than ongoing degeneration.

Examples include Rett syndrome, CASK-related disorders, certain mitochondrial diseases, and some forms of regressive autism. In these conditions, neurons are lost or fail to mature during early life, when metabolic demand is high and protective systems are immature. Once development slows, the system stabilises and a plateau is reached.

This pattern is often misinterpreted as neurodegeneration. In reality, it reflects failure to complete development under stress, not a progressive destructive process.

 

Mild autism: intact structure, altered tuning

In contrast, many individuals diagnosed with milder forms of autism show preserved gross brain structure, intact cellular populations, and no widespread neuronal loss. Here, the challenge is not repair in the sense of replacing lost neurons, but optimization—particularly of inhibitory timing, neuromodulatory balance, sensory gain control, and network signal-to-noise.

Because the underlying structure is intact, interventions can remain effective across the lifespan without implying reconstruction of early development.

 

The problem with an ever-broadening autism spectrum

The autism spectrum has value as a descriptive and administrative category. However, as it has broadened, it has become increasingly biologically heterogeneous. Conditions with very different mechanisms, trajectories, and therapeutic constraints are now grouped under a single label.

 

Why timing matters in level 3 autism

In level 3 autism, timing is as important as mechanism. This group is enriched for syndromic, regressive, epileptic, and metabolically vulnerable forms of autism, all of which place exceptional stress on the developing brain. Early life combines high energetic demand with immature antioxidant defenses, immune regulation, and microglial control.

For this reason, the earlier developmental stress is reduced, the better the long-term functional ceiling is likely to be. Interventions that reduce oxidative stress, dampen maladaptive neuroinflammation, support mitochondrial function, and stabilize microglial behavior are most likely to have their greatest impact when introduced early—before cumulative stress fixes a lower developmental plateau.

The goal is not to reverse development or guarantee recovery, but to preserve functional substrate. Earlier protection raises the ceiling for later fine-tuning.

 

How developmental stress leads to neuronal loss

In level 3 autism, neuronal loss is not random and not degenerative in the adult sense. It reflects convergence of several stress-driven mechanisms.

 

·        Calcium dysregulation

Excess calcium influx via NMDA receptors and voltage-gated channels overwhelms immature buffering systems, disrupts mitochondria, activates destructive enzymes, and triggers apoptotic pathways.

·        Mitochondrial failure

Calcium overload impairs ATP production and increases reactive oxygen species. Falling ATP worsens ion pump failure, reinforcing calcium toxicity.

·        Oxidative stress

Developing neurons have weak antioxidant defenses. Excess ROS damages membranes, ion channels, and DNA, further impairing energy and calcium control.

 

·        Neuroinflammation and microglia

Microglia guide normal synaptic pruning, but under inflammatory conditions they amplify excitotoxicity and misdirect refinement. Even low-grade, episodic inflammation during critical windows can have lasting effects.

Why loss plateaus

These mechanisms are most dangerous during early development. Once growth slows and protective capacity improves, neuronal loss largely halts, producing a stable—but impaired—plateau.

 

Examples of biologically distinct subtypes currently grouped under “autism”

Condition / subtype	Primary biological issue	Timing of disruption	Neuronal loss	Developmental course	What “repair” realistically means
CASK-related disorders	Early cerebellar vulnerability; impaired synaptic and metabolic support (especially Purkinje cells)	Prenatal / early infancy	Yes, selective and early	Early impairment → plateau	Protection and optimization of remaining circuits
Rett syndrome (MECP2)	Failure of activity-dependent maturation and gene regulation	Infancy / early childhood	Minimal true degeneration	Regression → long-term stability	Restoring plasticity conditions, not cell replacement
Mitochondrial disease with autistic features	Energy failure during periods of high developmental demand	Variable, often early	Often selective	Stress-related regression → relative stability	Metabolic protection and stress reduction
Regressive autism (non-syndromic)	Disrupted synaptic refinement under immune or metabolic stress	Toddler years	Usually no widespread loss	Regression → plateau	Stabilization and plasticity optimization
Mild / non-regressive autism	Altered inhibitory balance, neuromodulation, network noise	Early development, subtle	No	Lifelong, non-degenerative	Optimization and tuning
Stroke (contrast)	Acute focal neuronal loss in mature brain	Adulthood	Yes, focal	Partial recovery	Compensation and plasticity, not rebuilding
Dementia (contrast)	Progressive neuronal loss and toxic protein accumulation	Late adulthood	Yes, progressive	Ongoing decline	Protection and slowing progression

 

Intervention strategies aligned with underlying biology

Biological context	Primary therapeutic goal	What helps most	What has limited value	Why this matters
CASK-related disorders	Preserve remaining function	Neuroprotection, metabolic support, seizure control, supportive therapies	Neurogenesis-based repair narratives	Early cell loss is irreversible
Rett syndrome	Improve functional plasticity	Neuromodulation, activity-dependent therapies, metabolic/redox support	Structural repair strategies	Neurons are present but constrained
Mitochondrial disease	Reduce energetic stress	Metabolic optimization, pacing, stress avoidance	Forcing high-demand plasticity	Energy limits learning capacity
Regressive autism	Stabilize development	Reducing excitotoxicity/inflammation, inhibitory balance, structured learning	Assuming ongoing degeneration	Regression ≠ progressive loss
Mild autism	Network optimization	Inhibitory tuning, sensory modulation, learning-based plasticity	Repair or replacement framing	Structure largely intact
Stroke	Functional recovery	Task-specific training, neuromodulation	Expectation of neuronal replacement	Compensation dominates
Dementia	Slow decline	Neuroprotection, risk reduction	Plasticity-driven optimization	Degeneration overwhelms repair

 

Core biological mechanisms and intervention logic

Core mechanism	What goes wrong developmentally	Downstream consequence	Intervention logic (conceptual)	Why timing matters
Excitatory–inhibitory imbalance	Excess excitation or delayed inhibitory maturation	Network noise, seizures, impaired synaptic refinement	Improve inhibitory timing and reduce excessive excitation	Early imbalance amplifies developmental stress
Calcium dysregulation	Excess Ca²⁺ influx via NMDA and voltage-gated channels	Mitochondrial overload, enzyme activation, cell injury	Reduce excitotoxic stress and improve buffering capacity	Developing neurons have limited calcium buffering
Mitochondrial dysfunction	ATP production cannot meet developmental demand	Energy collapse, impaired ion homeostasis	Support mitochondrial function and reduce energy demand	Energy failure during development causes irreversible loss
Oxidative stress	ROS exceed immature antioxidant defenses	Lipid, protein, and DNA damage	Improve redox balance and reduce ROS generation	Early oxidative damage compounds over time
Neuroinflammation	Maladaptive cytokine signaling and glial activation	Synaptic mis-pruning, excitotoxic amplification	Dampen maladaptive inflammatory signaling	Microglia are most influential during early refinement
Microglial dysregulation	Abnormal synaptic pruning and immune signaling	Long-term circuit instability	Stabilize microglial state and timing	Early pruning errors cannot be fully undone
Sleep and circadian disruption	Reduced restorative and clearance processes	Increased metabolic and oxidative stress	Stabilize sleep–wake rhythms	Sleep is critical for early brain resilience
Metabolic stress (systemic)	Illness, fever, nutrient insufficiency	Regression or stalled development	Reduce cumulative physiological stress	Repeated stress fixes lower developmental plateaus

An example - Phase 1 intervention in CASK: protection before optimization

In CASK-related disorders, early selective neuronal vulnerability—especially of Purkinje cells—imposes hard limits on later outcome.

A hypothetical Phase 1 approach does not aim to replace neurons or reconstruct development. Its goals are to:

• Reduce excitotoxic and metabolic stress
• Support mitochondrial and redox balance
• Stabilize microglial behavior
• Preserve remaining neuronal populations

My thinking suggested

• NAC
• Magnesium
• Atorvastatin 
• Pioglitazone or telmisartan
• Verapamil

Phase 1 targets these upstream injury pathways simultaneously. N-acetylcysteine (NAC) Provides foundational redox protection by restoring glutathione, the brain’s primary antioxidant. This reduces oxidative damage, dampens inflammation, and indirectly limits excitotoxic injury. NAC has also been trialed in autism for irritability and agitation, consistent with reduced neuronal stress. Magnesium acts as an excitotoxicity buffer by modulating NMDA receptor activity and limiting pathological calcium influx. Magnesium supports network stability and sleep, and reduces calcium-driven mitochondrial injury. Verapamil complements magnesium by directly blocking L-type voltage-gated calcium channels, acting as a gatekeeper against intracellular calcium overload. This protects mitochondria, reduces neuronal hyperexcitability, and targets one of the fastest pathways to neuron injury. Atorvastatin is included for its pleiotropic anti-inflammatory effects, not lipid lowering. Statins suppress microglial activation, reduce pro-inflammatory cytokines, and improve endothelial and mitochondrial function—mechanisms relevant to chronic neuroinflammation observed in severe autism.  Pioglitazone or Telmisartan (PPAR-γ axis) targets metabolic-inflammatory signaling at the transcriptional level. Pioglitazone provides full PPAR-γ activation and has been trialed in autism, while telmisartan offers gentler, chronic partial PPAR-γ agonism with CNS penetration. This pathway suppresses microglial activation, improves mitochondrial efficiency, and reduces inflammation-driven excitotoxic vulnerability. 

Phase 1 is therefore protective, not reparative. By lowering early stress, it raises the ceiling for later optimization, even though it cannot undo early loss.

Can past critical periods be revisited?

Critical periods in brain development do not simply disappear; they are actively closed by inhibitory maturation, perineuronal nets, myelination, and epigenetic repression.

Early structural events—migration, layering, cell fate—cannot be replayed. What can be revisited, partially, are the rules governing plasticity. Improving inhibitory balance, metabolic support, and network stability can temporarily create a more permissive learning state.

This is functional reopening, not developmental replay.

 

A unifying perspective

Whether the brain can be repaired, protected, or optimized depends less on diagnostic labels and more on timing, cell loss, and the state of plasticity. Neuroblasts are crucial during construction, marginal during adult recovery, and largely irrelevant once degeneration becomes progressive.

In level 3 autism, early reduction of oxidative, inflammatory, microglial, and metabolic stress is likely to improve long-term outcome by preserving developmental capacity—even if it cannot entirely prevent disability. Later intervention remains valuable for fine-tuning within the biological constraints that remain.

 

Game Changer or Fine Tuning? It depends on severity of Autism

 

There are so many possible autism interventions discussed in this blog, it clearly is not always easy to know their relative merit.

There are so many people now diagnosed with autism it is no longer such a meaningful term.  The most extreme autism I think I will have to start calling really severe autism.  A scale of 1 to 100 would be much more helpful than the current levels 1, 2 or 3. I suppose Elon Musk and Greta are level 1.

One reader did recent describe the effects of bumetanide in his child as being game changing.  I think it is an excellent description to use.  For our reader Roger, Leucovorin was a game changer.

Another reader wrote to me to give an update about his three year old

“After 3 months of bumetanide treatment I've seen improvement on his cognition, like, he is now able to finish an apple and take the end to the trash by himself or enter in his room, turn the lights on, take some toy, turn lights off and close the door or eat his lunch by himself. He is smarter now.”

This reader is well on his way to finding the additional elements for his son’s personalized polytherapy and the way he is going about it is likely to yield optimal results. Most of what you need is tucked away in this blog somewhere.  It is a case of who dares wins.

Using my scale of 1 to 100, with Elon and Greta in low single digits and many people referred to at the blog of the US National Council of Severe Autism mainly at 80-100, we can put interventions into a bit more perspective.

It is still far from perfect because most people with really severe autism reach a plateau in development at a very young age.  This matters because as a three year old they do not look/behave so differently to a typical child, but by the time they reach 18 years old, the difference is gigantic.

If you could delay the onset of this developmental plateau for a decade the result would be transformative.  Based on the longitudinal studies to adulthood, it looks like about 80% of severe autism reaches a plateau at the level of a 2-3 year old.  The other 20% continue to learn, but at a slower rate than typical children. 

In the case of the autism which is <10, like Greta and Elon, very small issues can still become very troubling.  There was inevitably bullying at school from mild to severe, there likely was (and still is) anxiety, perhaps an eating disorder, perhaps some self harming or even suicidal thoughts.

If you fine tune the brain a little to reduce anxiety and improve social/emotional responsiveness, you can trim someone’s score from a 15 to a 9 and make them feel much better.  Job done.

For someone with an IQ of 50 (i.e. severe intellectual disability), non-verbal, non-literate, who is sometimes aggressive and exhibits autistic behaviors, you are going to need much more than fine tuning, you need a game changer.  Then you can go on and fine tune things to give further incremental improvement.

One doctor reader did suggest to me that, in effect, five moderately effective interventions might equal one game changer.

In the case of autism that I deal with, the most important step was raising cognitive function, not treating what people consider to be autism.  I think that this applies to almost all people with a score 50 to 100.  Even if it was never actually diagnosed, the barrier to progress is low cognitive function and a severely reduced ability to learn and acquire new skills.  This has to be fixed and for many people the tools already exist.

 

Improving cognitive function

Game Changer

·      Bumetanide  (also Azosemide, KBr and, possibly, Betaine with the same effect of lowering chloride inside neurons)

Fine tuning

·      Atorvastatin, reducing cognitive inhibition

·      Micro-dose Clonazepam, shift E/I imbalance

·      Low-dose Roflumilast, raising IQ

 

Reducing autistic behaviors

Fine tuning

·      NAC

·      Sulforaphane

·      Verapamil

·      Oxytocin

·      BHB

·      Pentoxifylline

·      Agmatine

·      Clemastine

·      DMF

·      Leucovorin (Calcium Folinate)

 

Interventions with a slow course of action

Some interventions, for example pro-myelinating therapies (like clemastine and Tyler’s N-acetylglucosamine), or pro-autophagy therapies, may take a long time to show effect. I think you may need to first see very tangible results from other therapies, which are much easier to assess.

As Roger will want to point out, in the case of Cerebral Folate Deficiency Leucovorin was the game changer.

In the case of other metabolic autisms, a single therapy may also be the game changer, like the Greek boy for whom high dose biotin resolved his previously severe autism.

In the case of Fragile-X, there seem to be potential game changers galore.  The latest is plugging the leaky membrane in mitochondria that is allowing ATP to leak out, using a research drug dexpramipexole, or potentially the related and already approved variant Mirapex ER (pramipexole).  Mirapex is used to treat the symptoms of Parkinson Disease and Restless Legs Syndrome. 

If our occasional reader and bio-statistician Knut Wittkowski is correct, Mefenamic Acid (the NSAID Ponstan) could be a real game changer, if taken around 2-3 years of age.  He suggests this will block the progression to severe non-verbal autism. Knut has been upsetting YouTube with some of his interviews about Covid-19 and his deal with Q-Biomed to develop Mefenamic Acid fell through. You can buy Ponstan very cheaply, outside of the US, even as a pediatric syrup.

Hopefully, Dr Naviaux's Suramin will be a game changer for some.  More of that in the coming post on leaky ATP.

Conclusion

I am told where we live that Monty’s autism is “fixed”, or by one autism Grandad we know, “he’s 80% fixed”.

If you started life with (really) severe autism, even 80% fixed means you are still pretty autistic, much more so than Elon and Greta, but far less so than the now adult “children” over at the National Council for Severe Autism, who have really severe autism and often had a very early plateau in development.

Monty has finished his year-end exams.  Overall, the grades of his NT classmates are pretty terrible, maybe due to Covid disruptions.  I told Monty’s assistant that if he can come somewhere in the middle, without her doing the tests for him or having extra time, that is a great result, regardless of the grade itself.  In all his subjects he comes in the middle. In the English educational system, Monty is now a C student, maybe even with the odd B or D; so not something to boast about.  What really is amazing  is this person could not figure out  9 – 2 = 7,  at the age of 9 years old, prior to starting bumetanide and his Polypill therapy.  Now he is nearly 18 years old.

If you find that your young child is a genuine bumetanide responder, but later struggle to source it, take a close look at what untreated severe autism looks like by adulthood.  Then you may choose to redouble your efforts to get hold of your game changer. Some readers are getting it from Egypt, Pakistan, Nigeria, China, Austria and many from Mexico and Spain.  In Brazil you can buy it only in a compounding pharmacy. The lucky ones get it at their local pharmacy, which is what should be possible for everyone and one day that might even happen.

There are countless fine-tuning therapies that may be potentially effective in a particular person.  They are certainly worth having; you just have to look at what is available and cost effective.

There will soon be a post about leaky ATP in Fragile X and autism.

Two readers have highlighted the research suggesting that Betaine might have a similar effect to Bumetanide.  It does not block the NKCC1 transporter, but it may reduce the mRNA that produces them, so the net effect may potentially be similar.  At much lower doses, Betaine is a common autism supplement.  This will be covered in the next post.