• Fail to identify symptoms until 3-yrs 
• Children present with delayed speech, poor eye contact, hyperactivity, sensory impairments
• High prevalence of perinatal and environmental factors includes Caesarean delivery, pre-term or post-term birth, abnormal birth events

A significant proportion of Sri Lankan parents fail to identify symptoms of the neurodevelopmental disorder, Autism Spectrum Disorder (ASD), until after 36 months of age, while upon diagnosis, families face notable financial and social challenges concerning related therapy and interventions. This situation underlines the need for community-level education on the early signs of ASD, and emphasises the need for public health strategies that promote early diagnosis, intervention, equitable service access, and improve awareness regarding ASD at the society level.

These findings and recommendations were made in an original research paper on the "Characteristics of children with ASD attending the Theeraniyam Open School and Learning Centre, Batticaloa, Eastern Province" which was authored by R. Rashanth, P.P.W. Madushani and H.M.S.H. Madanayaka (all three attached to the Eastern University's Health-Care Sciences Faculty), and R. Sanjeev (Senior Lecturer attached to the same Faculty's Human Biology Department), and published in the Batticaloa Medical Journal's 19th Volume's Second Issue. 

Neurodevelopmental disorders are behavioural and cognitive disorders that arise during the developmental period, and involve significant difficulties in the acquisition and execution of specific intellectual, motor, language, or social functions. ASD constitutes a diverse group of conditions characterised by some degree of difficulty with social communication and reciprocal social interaction, as well as persistent restricted, repetitive, and inflexible patterns of behaviour, interests, or activities. Effective treatment options exist including psychosocial interventions, behavioural interventions, and occupational and speech therapy. For certain diagnoses and age groups, medication may also be considered.

ASD is characteried by persistent impairments in communication, social interaction, and repetitive behaviours (H-Y. Dong, B. Wang, H-H. Li, X-J. Yue and F-Y. Jia's "Correlation between screen time and autistic symptoms as well as development quotients in children With ASD", and an Iranian study). Globally, the estimated prevalence is approximately one in 100 children, with a notable upward trend in recent years (J. Zeidan, E. Fombonne, J. Scorah, A. Ibrahim, M.S. Durkin, S. Saxena, A. Yusuf, A. Shih and M. Elsabbagh's "Global prevalence of autism: A systematic review update"). In line with the global trend, the prevalence of ASD is increasing in Sri Lanka (B. Sivayokan, S. Sivayokan, K. Thirunavukarasu, G. Sathiadas and T. Sivapathamoorthy's "The characteristics of autistic children attending a neurodevelopmental centre in the North"). H. Perera, K. Wijewardena and R. Aluthwelage's "Screening of 18-24-month-old children for autism in a semi-urban community in Sri Lanka" discovered that red flag signs of ASD present in nearly 7.4 per cent of children aged 18–24 months.

Materials and methodology

Rashanth et al. conducted a descriptive, cross-sectional study at the setting of the said School and Centre, from August 2023 to July 2024.

The participants of the study included all 41 parents of children diagnosed with ASD attending the School and Centre during the study period. The diagnosis was confirmed using the Modified Checklist for Autism in Toddlers, Revised, with Follow-Up.

The study instrument was a newly developed, interviewer-administered, validated questionnaire. 

Results

Socio-demographic details

Out of the 41 children, 85.4% were male and 58.5% were the first born. Most were aged between four–nine years (83%). A majority resided in urban areas (87.8%), were Tamil by ethnicity (75.6%), and in 87.8%, the family’s monthly income was more than Rs. 50,000. 

Parental observations and clinical features

Most parents have identified their child’s abnormalities after 36 months of age (43.9%), and the most common initial observation was speech delay (53.7%). 

Most children began speaking between 13–24 months (41.5%) while 24.4% had not started speaking yet.

Poor eye contact was the predominant social interactive feature (73.2%). In terms of behavioural features, 80.5% had hyperactivity, while 68.3% had temper tantrums and 65.9% had stereotyped activities. Most of the children had no complaints regarding sensory issues; but, 51.2% of the children had sensory issues in touch, especially hyperreactivity to touch (46.3%).

The other first observations by a parent regarding their child's abnormality are not responding to being called, the sudden cessation of speech, and poor social interaction. 

Associated factors

A high prevalence of select perinatal and environmental factors was observed, including: Caesarean section - 63.4%, Preterm (less than 37 weeks) or Post-term (more than 40 weeks) - 41.5%, and abnormal birth symptoms - 31.7% (notably 17.1% had meconium aspiration [when a newborn inhales meconium-stained {the earliest stool of a mammalian infant resulting from defecation} amniotic fluid {related to the bag and liquid that surround the embryo, the latter being the unborn offspring in the process of development, in particular a human offspring during the period from approximately the second to the eighth week after fertilisation}] and 14.6% had jaundice {the yellowing of the skin or whites of the eyes, arising from the excess of the pigment bilirubin, the latter being an orange-yellow pigment formed in the liver by the breakdown of haemoglobin [a red protein responsible for transporting oxygen in the blood] and excreted in bile}).

In maternal conditions, 41.5% of the mothers’ maternal age was 30–41 years. Chronic maternal illness was reported only in 17.1%, including 7.3% with asthma (a respiratory condition marked by attacks of spasm in the bronchi [any of the major air passages of the lungs which diverge from the windpipe] of the lungs, causing difficulty in breathing) and who used salbutamol (a synthetic compound related to aspirin [a synthetic compound used to relieve mild or chronic pain and to reduce fever and inflammation], used as a bronchodilator [a drug that causes the widening of the bronchi] in the treatment of asthma and other conditions involving the constriction of the airways). Only 24.4% of the children had comorbidities with ASD, including epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, the loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) (14.6%) and bronchial asthma (7.3%). Most children had more than four hours of daily screen time (61%), and 19.5% had less than two hours or two-four hours.

Parental perceptions regarding therapies and interventions

The majority of the parents reported that speech therapy is the most effective therapy (58.5%) and classroom activities are seen as the most beneficial intervention for their child (43.9%).

Socioeconomic issues

A total of 34% of the parents reported a financial burden, including increased treatment cost (31.7%), increased transport cost (14.6%), with 9.8% of them resorting to loans while caring for the child with ASD.

Social burdens were reported by 41.5%, including backbiting (24.4%), social stigma (22%), exclusion from family events (17.1%), and conflicts with relations (12.2%). A total of 39% of the parents reported that they are facing challenges in taking care of the other children because of the child with ASD (the increasing time taken for care affected the other child's academics, the other child feels lonely, the other child gets jealous, the ASD child gets angry).

Discussion

Among the 41 children, the majority were male (85.4%), which is similar to D.M.A. Dahanayake, Y.M. Rohanachandra and G.S. Wijetunge's "Factors affecting the age at the presentation of ASDs: A descriptive survey from a child mental health clinic at the Lady Ridgeway Hospital for Children, Colombo". Additionally, 87.8% were from urban areas. Most children were aged four-nine years (83%), and 4.9% were aged one-three. In contrast, Dahanayake et al. found that 50% were under three years. This difference is possibly due to the different study setting.

A total of 39% of the mothers had General Certificate of Education (GCE) Advanced Level education, and 39% of the fathers had GCE Ordinary Level education. 

Autism can be diagnosed by 18–24 months, but, 43.9% of the parents in this study recognised the abnormalities only after 36 months. Moreover, speech delay was the commonest first concern (53.7%), which was similar to the findings of Dahanayake et al. (58.5%).

Poor eye contact was the commonest social issue (73.2%), which is similar to the findings of Sivayokan et al. (87.8%). Hyperactivity was the common behavioural feature (80.5%), followed by temper tantrums (68.3%). 

Sivayokan et al. found that 56.1% had touch sensory issues, especially hypo-reactivity to touch (38.2%). On the other hand, in the present study, 51.2% of the children had touch sensory issues, but, in contrast, 46.3% had hyper-reactivity to touch. K.M. Lampi, L. Lehtonen, P.L. Tran, A. Suominen, V. Lehti, P.N. Banerjee, M. Gissler, A.S. Brown and A. Sourander's "Risk of ASDs in low birth weight and small for gestational age infants" linked low birth weight and preterm birth to autism. The present study found that 41.5% were preterm or post-term births. Additionally, lower segment Cesarean section delivery was reported in 63.4% in the present study, similar to 56.1% reported in Sivayokan et al.'s study. 

Abnormal birth symptoms were present in 31.7% of the children, including meconium aspiration (17.1%) and jaundice (14.6%), while the aforementioned Iranian study indicated that 41% of the children with ASD had jaundice and 5.4% had bruising.

In the present study, in 41.5%, the maternal age was 30–41 years and 17.1% mothers had chronic diseases, and of them, 7.3% had bronchial asthma. Similarly, an Algerian study found that advanced maternal age and the presence of maternal chronic pathologies are associated with ASD.

The present study found that 61% of the children were spending more than four hours’ time on screens (smartphones, laptops, the television, etc.).

Children having associated health conditions was 24.4% including epilepsy (14.6%) and asthma (7.3%). In contrast, A. Malek, S. Farhang, S. Amiri, S. Abdi, A.R. Rezaih and M. Asadian's "Risk factors for autistic disorder: A case-control study" mentioned that 7% had microcephaly (abnormal smallness of the head, a congenital condition associated with incomplete brain development). R. Hock, A. Kinsman and A. Ortaglia's "Examining treatment adherence among parents of children with ASD" found that behavioural therapy was the commonest therapy among children with ASD (78.9%). Similarly, 92.7% of the parents in the present study reported that behavioural therapy was the most common mode of treatment for their children. Additionally, C. Gold, T. Wigram and C. Elefant's "Music therapy for ASD" highlighted the benefits of music therapy, and 34.1% of the children in the present study receive it at the said School and Centre.

Conclusion

Children attending the said School and Centre commonly presented with delayed speech, poor eye contact, hyperactivity and sensory impairments. A high prevalence of select perinatal and environmental factors was observed including Caesarean delivery, preterm or post-term birth, abnormal birth events, and prolonged screen time.

Most parents believed that speech therapy and classroom interventions are effective for their child. 

In conclusion, Rashanth et al. made several recommendations: Strengthen public education on early signs and risk factors of ASD; Improve access to diagnostic and therapeutic services across regions; Expand Centres like the Theeraniyam School and Centre nationally; and Provide financial and psychological support systems for the affected families.