Accessibility and the Indian setup

Dr Sharat Chandra Pani

A noisy crowded market, the sound of blaring horns, vegetable vendors and the thick fumes from buses, cars and two wheelers. On the first floor of an old building stands a dental clinic. To a stranger this may seem like the beginning of a rustic travelogue; except that it holds good for any Indian city or town. The past ten years have seen the true emergence of dentistry in India. As the number of dentists has grown so have the number of clinics. Yet most of these clinics are located in buildings which; by all western standards; fail any test of accessibility. Narrow crowded lanes, narrower corridors, steep staircases, narrow doors... the list is endless. And yet are they truly inaccessible? The crowds in the waiting areas would disagree. Apply this scenario to any city or town you like; the clinic with the greatest inflow of patients will most probably be located in a location similar to the one described above. Does this mean that the concept of accessibility is flawed? Or that we have gotten used to the idea of poor infrastructure? Before we answer any of those questions we might do well to take another look at how we define accessibility.

Accessibility: Physical or Economical?

If we choose to define accessibility in its conventional sense, as physical access to dental care, then we would have to agree that dental clinics in India (most of them anyway) would fail even the most lenient evaluation of access. However if you were to look at access more holistically, then you would find that the clinics described above are surprisingly accessible. Consider the case of a practice located in a small town, catering  largely to patients from nearby villages. A clinic in the crowded market next to the bus stand is much easier to access(and also cheaper) than a clinic in relatively  calm surroundings that require the patient to travel a little further. We should perhaps be forgiven for assuming that a patient who has travelled maybe 10 to 20 Km over bad roads, in a bus that has no special accessibility features would not mind climbing 10 steps up a narrow corridor. If accessibility features require the dentist to move out of the crowded market then the very fact that his/her patients have to travel the extra distance negates any benefit the features offer. If the dentist can save on his operating costs by renting space on the first floor, then surely the effort the patient has to make to climb that extra flight of stairs is offset by the resulting reduction in the cost of care. And to talk about parking space in a country where less than 1% of the population drives a car is surely hypocritical. So should we sit back and accept things the way they are? Absolutely not.

Incorporating Access

“Sometimes we stare so long at a door that is closing that we see too late the one that is open.”

-Alexander Graham Bell

 If the process of access is considered once you have built a building or set up a clinic then it is often too expensive to implement. But if you consider access at the time of construction then the costs are not significantly higher. Putting in a wider door, or setting up the chair and other fittings so as to allow the movement of a wheelchair is not that difficult. Even once the clinic is set up access can be greatly improved by considering these few simple and inexpensive points;

• Grab Rails:  These are small metal railings, similar to a towel stand you put up in the bathroom. When put up along the walls of the clinic or adjacent to the chair they allow the patient to get a firm grip to move him/herself from the wheelchair onto the dental chair.

• Reduce clutter: Simple as this may sound, moving a bulky cupboard to a corner or rearranging a chest of drawers can give you much greater room for the placement of a wheel chair.
  

• Place Kick Boards on your doors:  A kick board is a piece of metal that is nailed to the lower part of the door. The kick board allows a person in a wheelchair to kick the door open without damaging the door. 
• A tap with a single twist and large handle: These taps are easier to use than the turn taps, and can be operated even by people with poor hand strength and/or coordination

The steps mentioned here are just a few simple inexpensive methods to make your clinic more accessible. We at DCSN recognize that accessibility is a complex problem that requires improvement not only on our part but also in the way our society views the needs of differently abled individuals. However the steps mentioned above can greatly help a person without any real increase in cost to either the dentist or the patient. I would be wise to remember that more than an open door, access requires an open mind.

ADHD and it's Implications for Dental Care

Dr Sharat Chandra Pani

While much has been found in recent dental literature on the behaviour management of children with ADHD, the disease itself remains an enigma to many. The diagnosis of the disease is still a point of controversy, with both over-diagnosis and under-diagnosis being problems.

Furthermore, once the disease is diagnosed, the dentist is perplexed about where to refer the patient, especially in India, where there is little support for patients with ADHD. In this series of posts, DCSN follows the diagnosis, management and follow up of children with ADHD.

History 

Diagnosing ADHD

Can you diagnose a child with ADHD? And what do you do next?

Preparing yourself to treat a child with ADHD

ADHD support and counselling centers in India

History of ADHD

It began with a Poem 

Seeing a child who can't sit still is not an abnormal finding, but how do we differentiate between a normal active child and one who has ADHD? In 1845 Dr. Heinrich Hoffman, a German physician and psychiatrist was disillusioned with the children's literature of the time. In an attempt to find a suitable poem for his 3 year old son, he wrote the "Story of Fidgety Phillip" a poem in German about a boy who was always running about knocking things down. The description of "Fidgety Phillip" is the first written account of the classical symptoms of ADHD. Although the poem described ADHD the first scientific description of the disorder is credited to Sir George F. Still, who in 1902  published a series of lectures to the Royal College of Physicians in England in which he described a group of impulsive children with significant behavioral problems, caused by a genetic dysfunction and not by poor child rearing—children who today would be easily recognized as having ADHD. Since then, several thousand scientific papers on the disorder have been published, providing information on its nature, course, causes, impairments, and treatments.

Diagnosing a Child with ADHD

The principal characteristics of ADHD are inattention, hyperactivity, and impulsivity. These symptoms appear early in a child’s life. Because many normal children may have these symptoms, but at a low level, or the symptoms may be caused by another disorder, it is important that the child receive a thorough examination and appropriate diagnosis by a well-qualified professional.

Symptoms of ADHD will appear over the course of many months, often with the symptoms of impulsiveness and hyperactivity preceding those of inattention, which may not emerge for a year or more. Different symptoms may appear in different settings, depending on the demands the situation may pose for the child’s self-control. A child who “can’t sit still” or is otherwise disruptive will be noticeable in school, but the inattentive daydreamer may be overlooked. The impulsive child who acts before thinking may be considered just a “discipline problem,” while the child who is passive or sluggish may be viewed as merely unmotivated. Yet both may have different types of ADHD. All children are sometimes restless, sometimes act without thinking, sometimes daydream the time away. When the child’s hyperactivity, distractibility, poor concentration, or impulsivity begin to affect performance in school, social relationships with other children, or behavior at home, ADHD may be suspected. But because the symptoms vary so much across settings, ADHD is not easy to diagnose. This is especially true when inattentiveness is the primary symptom.

DSM-IV Criteria for ADHD
I. Either A or B:

1. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

Inattention

1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

2. Often has trouble keeping attention on tasks or play activities.

3. Often does not seem to listen when spoken to directly.

4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

5. Often has trouble organizing activities.

6. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

8. Is often easily distracted.

9. Is often forgetful in daily activities.

2. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Hyperactivity

1. Often fidgets with hands or feet or squirms in seat.

2. Often gets up from seat when remaining in seat is expected.

3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

4. Often has trouble playing or enjoying leisure activities quietly.

5. Is often "on the go" or often acts as if "driven by a motor".

6. Often talks excessively.

Impulsivity

1. Often blurts out answers before questions have been finished.

2. Often has trouble waiting one's turn.

3. Often interrupts or intrudes on others (e.g., butts into conversations or games).

2. Some symptoms that cause impairment were present before age 7 years.

3. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

4. There must be clear evidence of significant impairment in social, school, or work functioning.

5. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on these criteria, three types of ADHD are identified:

1. ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months

2. ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months 

3. ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

Can you diagnose a child with ADHD? And what do you do next?

While it is one thing to talk fashionably about the DSM criteria, making a diagnosis of ADHD remains a challenge, not only to a dentist but also to Pediatricians and even experienced clinical psychologists. As Prof Malavika Kapur, one of India's leading psychologists told us, " We took a group of trained teachers and asked them to diagnose 300 students for signs of hyperactivity, of the 30 children diagnosed by them, only 10 had ADHD". It has often been reported that the chances of either under-diagnosing or over-diagnosing ADHD are indeed high. So what can we do.

Patients who are Known to suffer from ADHD

In such cases the dentist can gear up to treat the child and be prepared to handle the hyperactivity or absence of attention. See section on treating a child with ADHD

Patients whom you suspect of having ADHD

Telling any parent their child may not be normal can be a daunting task. Telling them this when there is a good chance you may be wrong makes the task even scarier. The anxiety of telling the parent can be greatly reduced by adding a few questions to your history.

"What Class is your child studying in?" This seemingly innocent question will give you a good idea if the child is having trouble keeping up with lessons. Or if the child is continuously fidgeting, then a ,"Is he like this in school?" is often enough to get the parent talking about the child's problem. A surprisingly large number of parents actually want to talk about the difficulty their child is having with a doctor. But it is important to note that a parental history of the child being a bit overactive is not diagnostic of ADHD.

If however you still feel the child has the signs and symptoms of ADHD then you are better off referring the child to an experienced clinical psychologist. In India a visit to the Psychiatrist or Psychologist is still viewed as a sign of madness. It is therefore better to put the matter as gently as possible and explain to the parent that ADHD is not mental retardation and in most cases it does not persist into adulthood. If all else fails then of course you can always point out the example of the  man who is arguably the most famous ADHD sufferer of all time : Micheal Phelps

Preparing yourself to treat a child with ADHD

There is little available literature as to a definite protocol for treating children with ADHD. Before treating the child with ADHD however it is important for the dentist to be aware of a few basic facts...

What are the dental problems of children with ADHD?

The dental problems of children with ADHD are largely non specific, that is they are a result of poor oral care. A higher caries rate, neglect of oral health needs and bleeding gums are some of the most commonly reprted disorders. A higher prevalence of bruxism and oral trauma have also been reported.  These signs are suggestive of a lack of oral hygeine and difficulty in managing the child on the dental chair. Interestingly  studies that have found increased behaviour management problems in these children also found that there was no increase in dental fear in children with ADHD.Bruxism induced TMJ disorders have also been reported in these children.

What medication is the child taking and how does this affect oral health or treatment?

A good drug history is imporatant to the Pediatric Dentist treating a child with ADHD. Firstly, drugs such as amphetamines can cause gingival enlargement in children. Secondly, it is important to remeber that while the medication is often given to treat hyperactivity, it is still the dentist's job to get the patient's attention. The most commonly used drug in the management of ADHD is a CNS stimulant such as Methyl Phenidiate (ritalin) . To view all the different drugs used in the treatment of ADHD click here

Are there any special precautions you must take or protocol you must follow before you treat a child with ADHD?

While no commonly accepted guidelines exist for the management of children with ADHD, we have tried to best summarize the little that exists in the literature on dentistry for children with ADHD. 

Behaviour Management

The report by the NIMH suggests that the underlying condition of children with ADHD prediposes them to behaviour management problems. Keeping in mind articles that have expressed contrasting views on the subject we suggest that children with ADHD should be treated as normal children who show behaviour problems. We do not advocate sedation or management under general anesthesia unless all other forms of behaviour management have failed.

Dental Caries 

While children with ADHD have a definitely higher caries rate this is due to poor oral hygiene rather than any underlying disorder. We recommend that the Pediatric Dentist be actively involved with the child's guidance counsellor or therapist to generate an interest in oral hygeine. The use of glove puppets or dolls in the clinic can greatly influence the child's interest in brushing or mainatainence of oral hygeine.

Gingival Disease

While the increased accumulation of deposits and bleeding from the gums can be attributed to  poor oral hygeine it is important that the dentist be aware of the chances of amphetamine induced gingival hyperplasia. Even though the number of children actually medicated for the disease is low it is essential that the pediatric dentist be aware of the potential problem.

Dental Traumatic Injury(DTI)

An article published in Dental Traumatology  reviewed the different literature available and goes as far as to suggest that the increased prevalence of traumatic dental injury in these children is a direct result of ADHD. DCSN agrees with the view of the authors that ADHD is a predisposing factor for DTI and that increased awareness and close collaboration between different disciplines involved are essential to prevent DTI in chidren with ADHD.

For a detailed account of ADHD and the mechanisms involved we would reccomend the booklet published by the National Institute of Mental Health (NIMH) to download the entire booklet click here

The suggestions expressed above are the views of DCSN and are a means to open the discusion on the best way to manage patients with ADHD. Due to the paucity of literature on the topic we welcome any improvements or additions.

Suggested Reading

Oral characteristics of children with attention-deficit hyperactivity disorder.

Bimstein E, Wilson J, Guelmann M, Primosch R.

Spec Care Dentist. 2008 May-Jun;28(3):107-10.

Swedish children with ADHD do not have a higher experience of dental caries compared to children without an ADHD diagnosis, in spite of showing poor dietary and oral hygiene patterns.

Maupome G.

J Evid Based Dent Pract. 2008 Mar;8(1):35-6. No abstract available.

Dental caries and oral health behavior in children with attention deficit hyperactivity disorder.

Blomqvist M, Holmberg K, Fernell E, Ek U, Dahllöf G.

Eur J Oral Sci. 2007 Jun;115(3):186-91.

The pathophysiology, medical management and dental implications of adult attention-deficit/hyperactivity disorder.

Friedlander AH, Yagiela JA, Mahler ME, Rubin R.

J Am Dent Assoc. 2007 Apr;138(4):475-82; quiz 535, 537. Review.

                  Traumatic dental injuries and attention-deficit/hyperactivity disorder: is there a link?

          Sabuncuoglu O.

              Dent Traumatol. 2007 Jun;23(3):137-42. Review.

Inside the mind of a special child

Child psychology is probably the one part of the Pediatric Dental curriculum that is feared, if not actually hated by student and teacher alike. Often seen as an abstract field or a waste of time it is, in most cases, brushed under the carpet or taught half heartedly. However understanding the psyche of a special child could be the key to getting inside the mind of a special child. Dr Malavika Kapur is one of the most experienced child psychologists in India.In the course of over four decades of clinical, teaching and research experience, she has been a clinical psychologist of the National health Services, Scotland, Senior Research Associate of the University of Edinburgh, and on the Faculty of KMC Hospital, Manipal. Professor Kapur has undertaken various projects on behalf of organizations and offered consultancies to the World Health Organization, the National Council of Educational Research in Training the Indian Council of Medical Research, the Indian Council of Social Science Research and University Grants Commission. She is on the editorial committees of several Professional Journals. She has been awarded the Scholar in residency at the Study and conference Centre in Italy by the Rockefeller Foundation for the preparation of her book Mental Health in Indian Schools. She is the author of two books, editor of three books, contributor of 20 chapters to books, and has more than 70 publications to her credit in national and international journals. Her area of interest are developmental psychopathology and school mental health. She has initiated a project on Child Mental Health service delivery in rural areas utilizing available infrastructure in the settings such as primary health care, schools and anganawadis.She is currently a Professor at the National Institute of Advanced Studies, Bangalore.In this exclusive interview, Dr Kapur shares her ideas on the practical side of child psychology.

How did you get into the field?

My association with child psychology dates back to the early 1960’s when, as a PUC student, I first read the works of (Sigmund) Freud. In 1962 I joined the National Institute of Mental Health, which was then the only institute offering a course in clinical psychology. I have been practicing psychology since 1965. I then did a stint at the University of Edinburgh where I was dealing with both adolescents as well as patients who had psychiatric problems. When I came back to India in 1976 I was again dealing with adults who had psychiatric problems. At that time we were counseling 1000 disabled and around 1000 patients with psychiatric problems a year. But then I suddenly realized that we were only seeing patients who were  already diagnosed with a problem, no one was doing anything for the thousands of children in schools who needed help. So since the 1980’s I’ve been actively involved with child psychology at the school level.

In Dentistry, even though child psychology is a part of the curriculum, many dentists shy away from it. What do you think is the cause?

It’s not just dentistry; you find the same is the case with medicine. And it’s not just India, even in the United States pediatricians shy away from psychology. Over the years things have only gotten worse. In the old days, a bedside manner was a very important part of a doctor’s armamentarium. They may not have applied classic theories of psychology but they followed one of the most important principles; “talk to your patient”. I can give you the example of bed wetting. Most doctors who are faced with a child who is bed wetting place the child on medication without making the effort to find out what stress the child is under and talking to the child and finding out what is bothering him.

So if you had to give a piece of advice to doctors in general what would it be?

Talk to your patients. Psychology is much more than knowing a few theories. It is a knack that you pick up. Communication with the child is the most important practical aspect of child psychology. Unfortunately in most places rules exist for the comfort of the doctor or the dentist. No one wants to put the child at the center of the problem. I am reminded of a very beautiful quote by Anna Freud, who was a teacher who extensively applied Freud’s theories to children;

“You have to insinuate yourself into the child’s affection, become an ally of the child and only then can you treat the child.”

Make your approach child centered. Don’t be scared to come down to the level of the child or even play with the child. A box of toys in your office may not cost much but they will go a long way in making a child your ally. The true application of child psychology lies in using its principles to make the child comfortable. It is not enough to know that children have an innate fear of separation or a fear of the unknown. Using techniques to overcome these fears is the true application of psychology.

What about children with special needs?

I feel that a child with special needs is just a younger child. A mentally retarded child of 10 would be as cooperative as a child of 2. If the doctor is able to judge the mental age of the child, he will find that the principles psychology apply to them just as they would apply to any other child. What happens with autistic children for example is that doctors have this urge to sedate them. It may not always be necessary. Talk to them, try to communicate, you may still fail in certain severe cases and may have to resort to sedation, but you have to make the effort.

So if you had to pick a theory of psychology that was most applicable to Indian Children which theory would it be?

I would say that to be effective you need to employ a judicious mixture of cognitive and behavioural techniques. No one theory can be said to be most applicable. In fact if you were to ask me the one thing you could do to effectively counsel a child it would be to make the child the center of the whole process. The same holds true for our schools we should put the child at the center of our education system, instead of making marks the sole purpose of an education.

You are passionate about bringing psychology to the level of the schools...

Yes. You see we tend to view psychology as a treatment for a disorder, no one realizes that every normal child goes through certain psychological problems. There are over 500 schools in Bangalore today, yet no one caters to them. It is only when you talk to teachers and train them to identify signs of disorders such as attention deficit and hyperactivity can you really begin to help children.

On the topic of attention defecit, what do you make of the recent increase in ADHD cases in India?

ADHD is being diagnosed in a lot of children these days, In fact over the last few years there have been several MPhil and PhD theses on the topic at NIMHANS. Anyone who wishes to treat a child with ADHD must realize that it is both a behavioural problem as well as a response to a psychosocial problem. It must be remembered that even if your patient is on medication, the medication only treats the hyperactivity, it does not treat the attention deficiency. It is important to recognize the activity that engages the child. This could be in the form of playing, coloring or music. In fact in rural areas we suggest sorting of different types of grain, anything to keep the child occupied. And you will find the child's attention improving. For dentists I can suggest Hand puppets. You have a colorful hand puppet that depicts the teeth and you show the procedure you are about to perform on the puppet and you will find that the child automatically becomes interested in the puppet, and therefore the procedure

So you are not for medicating the child?

It is not that i am am for or against medication, the correct diagnosis is very important. For example out of a class of 300 students, the teachers referred 10 children to us with suspected ADHD. Only 1 of the 10 actually had ADHD. And this problem of accurate diagnosis exists worldwide. In the UK for example, doctors are reluctant to medicate a child and do not diagnose many cases of ADHD, whereas in the US there is a tendency to over diagnose the condition and thus we have an increased number of children placed under medication. Judicious use of medication can reduce the hyperactivity, but i still maintain that an activity  that engages the child is the only cure for the attention deficit.

So where do you see the field of child psychology in India?

I'm afraid that like much of our education sector, special ed in India is a money making venture. Except for the little work that is being done in the government hospitals, there is little else being done either for normal children who need guidance or for children with special needs.

Professor Kapur runs a free clinic for the diagnosis and management of children with Attention Disorders, Behavioural Problems and Learning Disability from 2pm to 5pm on Saturdays (except for major holidays) and can be contacted at;

Child Guidance Centre

at Prasanna Counselling Centre

Ajita Shree

8/28, Bull Temple Road

Bangalore 560004

Autism - The disease and Implications for Dental Care

Dr Sharat Chandra Pani

Autism is a severe developmental disorder that affects the way a child sees and interacts with the rest of the world. It limits their ability to interact with others socially, in fact many autism suffers avoid human contact. Autism is part of a larger group of disorders called pervasive developmental disorders (PDD).

In 1911 a  Swiss psychiatrist Eugene Bleuler, coined the term Autism to describe pepole who had a difficulty in communication, he however was referring to adult schizophrenia. The term as we know it today is attributed to Leo Kanner, an American Psychiatrist, who in 1943 coined the term while studying children at Johns Hopkins University. He based his discovery on findings from 11 children he observed between 1938 and 1943. What he studied were children who had withdrawal from human contact as early as age one.Until the 1960’s Autism was thought to be a form of schizophrenia, a misdiagnosis that led many parents to blame themselves for the problem.  It has only been in the last few decades that the medical fraternity has truly  begun to understand Autism; so it is not surprising that a great deal of confusion exists, even among the medical fraternity about the diagnosis, treatment and dental management of children with autism.

In this series of Posts DCSN looks at Autism, it's causes, probable management strategies and useful tips for the parent who is anxious about taking the child to the dentist for the first time; and also the dentist who is probably equally anxious about treating a child with autism.

 Posts for parents

 Posts for Dentists

Diagnosing Autism  

What causes Autism?  

Is a child with Autism always mentally retarded?  

Preparing your Child for a vist to the Dentist 

Preparing yourself to treat an autistic child 

Autism in India - the challenges of misdiagnosis  

Autism in India - Support Centers in India

Diagnosing Autism

Autism Symptoms vary widely in severity, include impairment in social interaction, fixation on inanimate objects, inability to communicate normally, and resistance to changes in daily routine. Characteristic traits include lack of eye contact, repetition of words or phrases, unmotivated tantrums, inability to express needs verbally, and insensitivity to pain.

Behaviors may change over time. Autistic children often have other disorders of brain function; about two thirds are mentally retarded; over one quarter develop seizures. Symptoms of autism can begin immediately after birth, but often parents begin to notice them when the child is between 12 and 18 months old. This is the age at which most infants begin to use language and show interest in social activities. A diagnosis of autism is usually made when the child is between 2 and 3 years, but new research is looking at ways to diagnose children as young as 12 to 14 months. Children with Asperger syndrome (one of five developmental disorders that represent the autism spectrum) may be diagnosed later because they do not have the same language or communication problems children with autism exhibit early on.

Some Common Signs Exhibited by Autistic Children

Spinning	Repetitive behavior (perseverance)
No speech	Balancing, e.g. standing on a fence
Flapping hands	Behavior that is aggressive to others
Walking on tiptoes	Lack of interaction with other children
Lack of eye contact	Extreme dislike of touching certain textures
Self-injurious behavior	Desire to keep objects in a certain physical pattern
Lack of interest in toys	Desire to follow set patterns of behavior/Interaction
Dislike of being touched	Treating other people as if they were inanimate objects
Non-speech vocalizations	Delayed echolalia: repeating something heard at an earlier time
Preoccupation with hands	Confusion between the pronouns "I" and "You"
Lack of response to people	Echolalia: speech consisting of literally repeating something heard
Extreme dislike of certain foods	Either extremely passive behavior or extremely nervous, activebehavior
Delayed development of speech	When picked up, offering no "help" ("feels like lifting a sack of potatoes")
Extreme dislike of certain sounds	"Islets of competence", areas where the child has normal or even advanced competence. Typical examples include drawing skill, musical skill, arithmetic, calendar arithmetic, memory skills, perfect pitch

Etiology of Autism

There is no theory of the cause of autism which everyone has found convincing. There may be multiple causes. Thus we will review some of the proposed causes. Most researchers are absolutely convinced that the cause is biological rather than psychological. Bernard Rimland in his book Infantile Autism (1965) cited the following evidence for a biological genesis and against the idea that parents cause their children to be autistic:

1. MERCURY poisoning in a genetically predisposed child 
2. Some clearly autistic children are born to parents who do not fit the autistic parent personality pattern.
3. Parents who do fit the description of the supposedly pathogenic parent almost invariably have normal, non-autistic children.
4. With very few exceptions, the siblings of autistic children are normal.
5. Autistic children are behaviorally unusual "from the moment of birth."
6. There is a consistent ratio of three or four boys to one girl.
7. Virtually all cases of twins reported in the literature have been identical, with both twins afflicted.
8. Autism can occur or be closely simulated in children with known organic brain damage.
9. The symptomatology is highly unique and specific.
10. There is an absence of gradations of infantile autism which would create "blends" from normal to severely afflicted.

Autism and the Brain

Even though the precise cause of autism remains unknown the following areas of the brain have been implicated in autism

What Does Not cause Autism

 

Of the many supposed causes for Autism, the one that created the greatest stir when published was the supposed association with the MMR (measles, mumps, rubella) vaccine . When published in Lancet in 1998 the study created a flurry of lawsuits, with parents in the United States rushing to sue the drug companies that manufactured the vaccine. However later investigation showed that the lead author of the article had a conflict of interest. In 2004 the New York Times reported that 10 of the original 13 authors had retracted their claims. Ealier this year a case control study proved without doubt the absence of any link between autism and the MMR vaccine

Hornig M, Briese T, Buie T, Bauman ML, Lauwers G, et al. 2008 Lack of Association between Measles Virus Vaccine and Autism with Enteropathy: A Case-Control Study. PLoS ONE 3(9): e3140 doi:10.1371/journal.pone.0003140