Written by Dr Pratima Giri
There is a general concern that we are seeing more children presenting with autism in India. Prevalence estimates of Autism Spectrum Disorder (ASD) in India are variable, but demonstrate a rising trend recently. Good quality epidemiological studies are needed to estimate true prevalence. In the USA, the Centre for Disease Control estimates an increased prevalence of about 1 in 44 children. This has increased from 1 in 69 children in 2014.
Children with ASD typically show difficulties in communication, socializing and behaviour. The common red flags for ASD include the child not talking at the expected time, not responding to name, displaying repetitive behaviour such as flapping of arms when excited, sensory behaviours like blocking ears to sounds or staring at lights. Children with ASD can show strong and unusual interest in certain objects and play can be unusual.
At this stage, our understanding of the underlying causes of autism is limited. Genetic factors are identified only in about 20% of children with ASD. Often, we do not know what causes ASD but there may be some known risk factors.
Diagnosing autism early is important as problem areas can be identified and early intervention can be provided. There are currently no known biological or genetic markers for ASD. Diagnosing ASD is therefore done by a clinical assessment of development and behaviour and applying diagnostic criteria. Sometimes psychometric assessments such as CARS are used to support or clarify the diagnosis of ASD.
It is very important for experienced clinicians to assess a child with autism carefully as children often present with other problems such as hyperactivity, anxiety and attention problem. An in-depth assessment of development and behaviour including multi-disciplinary assessment is required for a holistic picture of child’s strengths and difficulties. Diagnosis of ASD is not always straightforward. Other conditions such as reactive attachment disorders can mimic autism and hence the need to evaluate these.
The Indian Association of Paediatrics (IAP) recommends screening all children at 18 months for ASD. Children are starting to present early but there are still many that children that present late.
It is important to understand that there is no cure for ASD but there are a range of interventions and evidence of improvement with early interventions.
The interventions help improve communication skills, learning, socialization, sensory integration and behaviour in ASD. These are provided by speech language therapists, early childhood teachers and special educators occupational therapists and psychologist.
Children with autism have a wider issue with speech, i.e. communication. Also, there are many communication skills that develop prior to speech which include intention to communicate, joint attention, eye contact, pointing and gestures. The communication strategies must address pre-verbal communication if these are not already established.
The profile of families of children diagnosed with ASD at Rainbow Hospital has some recurrent themes such as nuclear families with one or both parents working, and children may have had increased screen time and experienced social isolation. With the pandemic and its lockdowns, the latter two factors may have been intensified. The first thousand days in a child’s life is of paramount importance for the overall developmental outcome. We know that children learn to recognize their mother’s face, develop visual and auditory discrimination in the first year. In the context of migration and the larger economic drivers, children are displaced from their wider families and increasingly placed in front of screens and tablets. This raises the question of whether replacing the warm human and parental interaction with the staccato, one-sided and exaggerated tones and visuals of cartoons impair child development. Could these be risk factors for Autism Spectrum Disorder? This will require assessment in a research setting to establish association or causality.
There is a range of intervention programmes, which include behavioural, developmental, naturalistic developmental behavioural (NDBI), sensory, animal-based, TEACCH and technology-assisted. The NDBI approach has the best evidence for improved outcomes. An example of NDBI is the Early Start Denver model.
While interventions can bring about improvements in ASD, they cannot cure the condition. With a lack of clear understanding of causation, it is difficult to develop preventative methods. Can ASD be prevented though? We don’t know this. But as we await information on causality we may need to consider if the risk factors of social isolation and increased screen time observed in our practice be considered a public health concern. Does this then open a window for possible primary prevention?
And should this knowledge translate into influencing public behaviour. Should our young parents be compulsorily educated about the risks of ASD in the antenatal period or even prior to conception? We do not know with certainty that by addressing those risk factors that ASD can be prevented. One of the parents can then opt to be a stay at home parent, work on minimizing screen time and provide a language rich environment for the child.
While we focus on diagnosing and intervening early in children with ASD, efforts need to be in place to raise awareness of the condition and the possible risk factors particularly with young parents and expectant mothers. Maybe it is time to re-think traditional parenting with generous parental leave, involvement of the extended family, especially grandparents and promoting traditional play times and non-screen activities.
DO’s
Provide a language rich environment for the child
Connect with your child and stay involved
Limit Screen time
Encourage socialization and involvement with extended family
Seek pediatrician input if concerned
DON’T’s
Replace parental involvement with screen time
Neglect red flags of ASD
This article was published in association with Rainbow Children’s Hospital.