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Title Page (Short Communication)

Title of paper: Early identification of autism

Author: Chakrabarti S,

!CP, "!CPC#

Pratibandhi $alyan $endra, $eota, #ooghly, % &engal

Author details: 'ame:Suniti Chakrabarti Address: Pratibandhi $alyan $endra, Abinash P) * +ist, #ooghly %est &engal, P-' ./0/12 Telephone: (122) 032/ 042560235 Email: sunit7doctors,org,uk ukher(ee !oad

Source of funding: 'one Competing interests: 'one %ord count: 88.

Early identification of autism

Abstract

This study 9as carried out to determine the nature and timing of parents: initial concerns and their subse;uent help seeking beha<iour to suggest 9ays to facilitate early identification of autism, -ntroductory part of Autism +iagnostic -nter<ie9=!e<ised 9as used to elicit rele<ant information from parents of children 9ith autism, Concern about speech and language de<elopment 9as the commonest early concern of parents of children subse;uently diagnosed 9ith autism, The mean age of parental recognition of any de<elopmental problem 9as 02,5 months, The mean time lag from first recognition of problem to seeking professional help 9as 5 months and to diagnosis, 20 months, -n 34> of cases the first professional consulted 9as a child specialist,

Key words: Autism, Early identification, Pediatrician:s role

Introduction

Autism is a se<ere de<elopmental disorder characterised by marked impairment of reciprocal social interaction, language and communication and repetiti<e beha<iour (/), There are no pre<alence studies of autism in -ndia, #o9e<er it is recognised that autism is an important problem in our children and there is need for more research in this field (0, 2), Some pertinent research issues are ho9 to identify autism as early as possible and 9hat is the role of the pediatrician in this process in -ndia? The ans9ers to these ;uestions are important because there are currently no @cures: for autism but there is general consensus that early diagnosis and appropriate early inter<ention can impro<e long term outcome of autistic children (5, A),

Methods: A sur<ey 9as conducted in special schools and clinics in %est &engal among parents of children (1=/4 years) diagnosed 9ith autism, %ritten and <erbal information 9ere gi<en to parents 9ho ga<e informed 9ritten consent for inclusion of their children in the study, +etailed medical and de<elopmental history 9as taken of all children in the study focussing on autistic symptomatology and e<olution of autistic beha<iours including any history of de<elopmental regression, A significant number of children in the study 9ere diagnosed 9ith autism in one of the national multidisciplinary centres, '- #A'S in &angalore or the Christian edical College at Bellore ('C30), !esults of these assessments

9ere studied, "or the rest of the children, further direct obser<ation 9as carried out and the teachers consulted about their eDperience and kno9ledge of the children, +iagnosis of autism 9as made in both groups according to +S -B criteria (/),

The introductory part of the Autism +iagnostic -nter<ie9 (!e<ised) (3), 9as used 9ith parents to elicit information about the age at 9hich parents first noticed something abnormal in their child:s de<elopment, the nature of these concerns, the age at 9hich parents first sought ad<ice, 9ho they sought ad<ice from etc, %e also sought additional information rele<ant to the study, A total of /A0 sets of parents 9ere inter<ie9ed 9hose children had a diagnosis of autism, )f these, // cases 9ere eDcluded from further analysis, The reasons for eDclusion 9ere, incomplete inter<ie9 (0 cases), non=fulfilment of age criteria (/ case) and non=fulfilment of +S -B diagnostic criteria for

autism (4 cases), There 9ere thus /5/ children 9ho 9ere considered to be 9ithin the autism spectrum, Statistical analysis of the results using a multi<ariate Eeneral Finear odel,

retaining a p=<alue of 1,1A as the le<el of significance, 9as carried out, Post= hoc &onferroni tests and t tests 9ere used to further in<estigate significant results, Age of first concern and age of consultation 9ere used as dependent <ariables, 'ature of first concern (speech problem, medical6de<elopmental problem, socially isolated beha<iour, general beha<iour problem and autistic beha<iour), child:s gender, mother:s education le<el and child:s <erbal le<el 9ere used as factors,

Results: The main features of the sur<eyed children and families are gi<en in table /, ean age of the children 9as 4,8 years (S+ 2,5), The cause of parents: first concern in A.> of cases of autism 9as absence, significant delay or oddity in their child:s speech and language de<elopment, -n a further 03> of cases speech problem 9as the second most important concern, Thus for 42> of parents, problem in their children:s speech and language de<elopment 9as the commonest concern 9hich made them think that there 9as something not ;uite right about their children:s progress and made them seek help, Barious medical concerns, 9hen present, 9ere of earlier onset but they 9ere 9holly non=specific, Concerns about odd social beha<iour as 9ell as general beha<iour problem such as hyperacti<ity, sleep problem etc, and autistic beha<iours 9ere other initial concerns (table 0), The mean age of first concern 9as at 02,5 months (S+ //,2), The time lag from first concern to seeking help 9as around 5 months (mean age 0.,.m, S+ //,8), There 9as a further gap of 0.,A months to e<entual diagnosis of autism (mean age AA,0m, S+ 0A,3), -n 34> of cases, (83 out of /5/), concerned parents first turned to the pediatrician for help and ad<ice, Statistical analysis re<ealed a significant effect due to first concern reported, for age of concern, "C5,240, pG1,11A, for age of consultation, "C.,210, pG1,11A,

These results 9ere further in<estigated using post=hoc &onferroni tests, This sho9ed a significant effect both for age of first concern (/0,44 months <s 03,A1 months, pG1,11A) and age of consultation (/A,83 months <s 2/,15 months, pG1,11A) respecti<ely for children sho9ing medical problems compared to other children,

Discussion: The study sho9ed a significant delay of 20 months bet9een parents: first recognition of a problem in their child:s de<elopment and e<entual diagnosis of autism, This is <aluable time and a 9indo9 of opportunity for early inter<ention lost by the child and family, )ur study also sho9ed that the pediatrician has an important role in any effort to minimise this delay, as in ma(ority of cases parents turn to the pediatrician first 9ith their concern, +elay and6or de<iance in speech and language de<elopment 9ere the commonest presentation of children 9ith autism, This is in line 9ith findings from European and American studies (.,4), Hnfortunately speech delay is also common in young children 9ho are not autistic (8), The important difference is that in cases of autism speech delay is al9ays associated 9ith other indications of difficulty, in social relatedness, peer interaction, play or repetiti<e beha<iours and also in non=<erbal communication such as gesture or eye contact (/1), These beha<iours may be subtle and may not be immediately apparent in a brief clinic <isit and need to be specifically in;uired into, Parents are good obser<ers of their children (//), They may not be fully a9are of the significance of these beha<iours but, 9hen en;uired, 9ould come forth 9ith good descriptions of the rele<ant beha<iours if they are present, The pediatrician:s (ob is to make sense of these beha<iours for 9hich it is important for the pediatrician to be kno9ledgeable about autism and its early presentation and kno9 9hat beha<iours to look for,

%hat this study adds: )ne of the commonest modes of presentation of autism in childhood is 9ith delay and6or de<iance of speech and language de<elopment, -n ma(ority of cases parents consult the pediatrician first 9ith their concern, -t is important to for the pediatrician to be kno9ledgeable about autism and its early presentation and be able to elicit rele<ant information for early identification,

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Acknowledgements: - 9ould like to eDpress my gratitude to all the parents and children in the study, - am <ery grateful to r Subrata &anner(ee, +irector of Pratibandhi $alyan

$endra, 9ho pro<ided inspiration and practical support for the 9ork, y special thanks to $endra, $olkata, rs rs Anindita Chatter(ee, Chief Psychologist, ano<ikas

allika &anner(ee, +irector of Pradip, $olkata, as 9ell

as to the #eads of the follo9ing centres, !each at $olkata, Child Euidance Centre at Srirampur, S9ambhar at &urd9an, Shelter at &hadres9ar, #ope at +urgapur, Anandam at Asansol, Eoodricke School at Siliguri and Ashar Alo at &ar(ola, &irbhum,

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References:

/, American Psychiatric association, +iagnostic and statistical manual of mental disorders, fourth edition (+S Psychiatric Association, -B), /885, %ashington +C: American

0, 'air

$C, Autism spectrum disorders, -ndian Pediatr 0115I 5/: A5/=A52,

2, Thacker ', Autism spectrum disorder, -ndian Pediatr 011.I 55: 0A/=0A0

5, Euralnick

, The effecti<eness of early inter<ention, &altimore,

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re<ised <ersion of a diagnostic inter<ie9 for caregi<ers of indi<iduals 9ith possible per<asi<e de<elopmental disorder, J Autism +e< +isord /885I 05: 3A8=34A,

., Eiacomo A +e, "ombonne E, Parental recognition of de<elopmental abnormalities in autism, Eur Child Adolesc Psychiatry /884I .(2): /2/=/23,

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anagement of Children 9ith Autism Spectrum +isorders, Pediatrics 011.I /01(A): //30=//40,

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itchell S, &rian J, K9aigenbaum F, !oberts %, SLatmari P, Smith -, et al,

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Table I

Sample features

'umber Gender ale "emale Associated medical condition Children 9ith epilepsy Children 9ithout epilepsy O erall language le el of child Berbal 'on <erbal Mother!s "ducation #e el Hni<ersity graduate #igher secondary school le<el Secondary le<el School le<el $irth order of child "irst born Second born Third born Religious background of family #indu Christian uslim /24 0 / /1. 21 0 /1/ 02 /1 A 38 .1 08 //0 /// 21

Percentage

.4,. > 0/,0 >

0/ > .8 >

58,3 > A1,2 >

.0,3 > /3,A > .> 5>

.. > 00 > />

84 > /,5 1,. >

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Table II Initial sym%toms to raise %arental concern

'umber /, +elay6de<iance in speech6language 0, edical problem (such as seiLures) or 0. /5 4/

Percentage A. >

delayed milestones (other than speech) 2, Abnormal socio=emotional response 5, &eha<iour difficulty not specific to autism (sleep problem, high le<el of acti<ity etc) A, Autistic beha<iour

/8 > /1 >

/1 4

.> A,3 >