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Letters to the Editor Indian Pediatrics 2001; 38: 1065-1066 |
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Autism: Some Conceptual Issues |
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The recent study on this subject(1) is probably one of the initial attempts in Indian literature to describe and discuss about one of the most devasting childhood psychiatric disorders. However, further discussion is merited on this report. Firstly, the authors have taken children below the age of 5 years as comprising their sample. This is surprising as autism can present at any age in childhood. This restric-tion of upper age limit poses limitations to the generalizability of the prevalence and clinical presentation of this disorder. Secondly, the authors make an assertion that autism is not uncommon in India. Without actual preva-lence figures, and comparison with preva-lence data on other childhood psychiatric disorders presenting to either pediatric or psychiatric services, it is difficult to sustain this assertion. However, the associated issue, arising out of the above mentioned statement by the authors, assumes significance, i.e., "....reflects the lack of awareness of the problem among pediatricians in our country." This is a very important issue that has been aptly highlighted by the authors and is borne out by the mentioned reasons for referral and that 62.5% children of severe range of autism were not diagnosed so prior to referral. Thirdly, 25% of the cases had normal development up to at least 18 months of age, and thereafter underwent regression in at least the area of acquired language skills. This is an important observation, as it should alert a clinician in ruling out other types of pervasive developmental disorders (PDD) like child-hood disintegrative disorder (CDD) and Rett’s syndrome (RS); apart from autism. Autism can be said to be the commonest and prototypical clinical presentation of PDD(2). But, the hallmark of autism is the develop-mental delay; not developmental regression or loss(3,4). Loss/regression of developmental milestones is more characterstic of CDD or RS(4,5). However, it is conceded that a minority of autistic children can show regres-sion in language development(2). Fourthly, I would tend to differ with the statement that "impairment..... of younger autistic children" (page 388, column 1, para 3). It has been seen that earlier the age of onset (AAO) of childhood psychiatric disorders, more severe is the symptomatology and poorer the outcome(6). It could be possible that the sample so studied had an early AAO, which precluded any significant language development. Details as regards AAO would be helpful in clarifying this issue. Lastly, the authors have provided certain clinical characteristics that facilitate early detection of children with autism. This conclusion needs to be interpreted with caution for the following reasons, i.e., sample was small and clinic-based (hence, not a true representa-tionof the disorder), no comparison with other types of PDD or similar data from previous literature, and lastly, it is known that specific manifestations of characteristic defects in autism change with development of the child(4,7). To conclude, initial most attempts at any research undertaken in this area are bound to be associated with caveats. This brief report is not brief in terms of acting as a building block for database on PDD in India. In fact, it should provide incentive to pediatricians and psychiatrists alike for recognizing and manag-ing this severe and distressing disorder. Nitin Gupta,
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