Autism also referred to autism spectrum disorder (ASD) constitutes a diverse group of conditions related to development of brain. ASD is characterized by some degree of difficulty with social interaction and communication. Characteristics may be detected in early childhood, but autism is often not diagnosed until much later. As per World Health Organisation (WHO), it is estimated that worldwide about one in 100 children has autism.  

In conversation with Rising Kashmir’s senior health correspondent, Mansoor Peer, senior pediatrician of GMC Srinagar, Dr Suhail Naik, talks about the scenario in Kashmir and what should parents do to treat their children as some people with autism can live independently, while others having severe disabilities require life-long care and support.

What is ASD?

Autism term was coined by Leo Kanner, a psychiatrist at Johns Hopkins University, literally meaning coming from within. Autism is a non-progressive neurodevelopmental disorder in which child has issues in two domains of neurodevelopment. One is social and communication domain and the second is they have repetitive and restricted behaviors. 

These kids have poor verbal and non-verbal communication and they don’t interact with people even with their parents and family members. These symptoms are present in them from the early developmental period.

The basic and first problem in these kids is reduced social interaction and engagement and reduced engagement leads to poor development in social behavior, non-verbal and verbal communication. So, genetically these babies lack the ability to interact with people and environment and others behaviors are consequence and not problem in themselves.

Therefore, to ameliorate the symptoms of ASD, the first step is to increase and intensify social interaction with suspected or diagnosed kids. Interaction by different family members is essential to get them engaged and to develop verbal and non-verbal communication. 

Why autism is called a “spectrum” disorder?

The symptoms and characteristics of autism can present themselves in a wide variety of combinations, from mild to severe and symptoms can also change over a period of time. 

What are the causes of ASD? 

The disorder results from disrupted neural connectivity in group of neurons in limbic system, which we can call as microprocessors of brain for social interaction, in genetically predisposed persons. Numerous genes involved in brain development have been implicated in ASD. It is very important to understand that environmental contribution to ASD influencing intrauterine environment to postnatal environment. 

What are early symptoms of ASD or red flag signs?

As early recognition of autism will lead to early intervention, that can improve outcome markedly. There is currently no diagnostic biomarker for ASD. 

Therefore accurate diagnosis needs knowledge about disorder. The infant starts interacting with its surroundings as soon as born. Over a period of time normally developing baby starts relating things and finds there are interacting humans and non-interacting objects around him.

The baby starts interacting with mother and pays more and more attention towards human faces and activities. The baby starts recognizing mother and family and by 6 months of age he/she understands who is a stranger. With this immense social interaction, baby develops non-verbal communication like facial expressions, gestures and later on verbal communication. 

The parents should suspect ASD in their kid if he or she is socially inert or freezed, doesn't recognize mother’s sounds, no interaction at all and no social smile. Social smile is response to familiar and pleasant stimulus. Looking at wall and smiling is not social smile.

These kids don’t respond to their own name despite normal hearing. They don’t show response to mothers play, lack social smile and don’t respond to facial expressions of parents.

Reduced eye contact, lack of facial expressions and gestures, and joint attention are other prominent features in symptomatology.

They remain in their own world and have particular set of interests and behaviours. They follow those rituals very rigidly like jumping, spinning their body, opening and closing doors, aligning toys in a fixed pattern, spending whole day with pet animal like dog. 

They have difficulties in developing, maintaining and understanding relationships. They reject cuddles, hugging initiated by parents and usually show negative response to requests of others. 

They develop delay in speech and their speech has unusual features like vocalizations, frequent repetition of set of words and use of single words.

Further, these children typically have restricted and repetitive pattern of behavior, activities and interests.

Stereotyped motor movements, use of objects, speech, insistence on sameness, inflexible adherence to ritualized patterns of verbal or non-verbal behaviors.

Do we report such cases in Kashmir, if yes then what is the scenario?

Centres for Disease Control (CDC) and Prevention data indicated a 2014 prevalence of 1 in 59 (1 in 37 boys and 1 in 151 in girls). The prevalence has increased significantly over past 20 years primarily due to improved diagnosis and case finding.

ASD is very much prevalent disease in Kashmir. The scenario is same as across the globe. From last few years, huge numbers of kids were diagnosed and that is due to increased awareness, increased ability of parents and teachers to recognize the problem.

Further, increased prevalence of ASD may be contributed to changes in society rather than changes in genes. The shifting from joint families to nuclear families, engaging domestic helps with different language, increased use of electronic devices like mobile phones, tablets, laptops, might have increased frequency as these kids don’t interact with parents for prolonged time.

It seems immense interaction of infant in joint families might have cured cases mild ASD. Today, unfortunately, a 3-month baby is put on device to calm him. Sounds without social interactions are patterns for a growing baby and they invariably delay their language. 

When after 2 years of age, child is labelled as ASD, all the blame is put on mother by telling her that there was problem in your raising and rearing the child.

What should parents do in such a situation?

It is responsibility of family and parents, in particular, to intimately interact with baby immensely. I request parents be a child, a cartoon or a joker with your baby for his or her proper development.

You can’t behave as serious CEO or great doctor with your baby and hamper his development. Jump up and down, be joker and dance for your child.

Give them lot of love, hug them, cuddle and kiss them and that all is very important for brain development and synaptic connections in brain. Don't let the child in you die and that is very important for your child’s development.

How can parents monitor child development and screen for ASD? 

Parents in Kashmir usually focus on weight of baby and whether he or she has neck holding, sitting, walking and running at appropriate development ages. That is all right and I do appreciate this health-seeking behaviour of parents.

But keeping the prevalence of ASD in context, it is high time that the parents and teachers should know that any child who has impaired social interaction, frozen behaviour, social communication, prefers loneliness, fails to make eye contact, as deficits in non-verbal communication, difficulties in making, maintaining and understanding relationship plus restricted and repetitive patterns of behaviour can be suffering from ASD.

There is a simple 20 questions screening test available on Google known as MCHART R/F, which can be easily used by parents and accurately access the development of their kid.

There is clear guideline from American Academy of Pediatrics (AAP) that all children should be screened for ASD at 18 months, 24 months and 30 months of age by MCHAT R/ F. A 20 question M CHART R /F means Modified Checklist for Autism in Toddlers, Revised with follow up is most commonly used screening questionnaire.

When there is a concern for ASD, the parents should immediately consult a pediatrician or developmental pediatrician in order to go for another level of testing to diagnose and grade severity of ASD so that early diagnosis and early intervention is started. 

Is autism treatable? 

Early diagnosis and early intervention are basic pillars to treat ASD and early behaviour intervention improves outcome markedly. When parents come to know that basic problem with their child is that he or she lacks intimate social interaction and rest all spectrum is a consequence, they immediately develop tacit understanding that first and foremost thing is to increase social interaction with baby for a prolonged time. These kids need behavioral and educational programming. Intensive behavioral therapies have strong evidence. 

Early treatment and higher intensity of treatment are associated with better outcomes. We all know that with early intensive behavioral therapy, the behavior of lion (king of jungle) can be drastically modified so that he became the animal of circus.

Therefore parents should have strong hope that early intervention can control and change the behavior of ASD kids because after genetics there is epigenetics which can change the plasticity and function of genes.