Autism in India - The Challenges of Misdiagnoses

Numerous studies have placed the occurrence of autism at a rate of approximately 1 in 500 people. At India’s current population, this means there are an estimated 1.7 million autistic persons in the country, assuming that there are no significant variations in this rate worldwide, which is a question that has not yet been addressed by epidemiologists outside the West. While the disorder is not rare, the majority of autistic people in India have not been diagnosed and do not receive the services they need. The main reason for this is a lack of awareness and misunderstanding about autism among medical professionals, who may either misdiagnose or under diagnose the condition.

One of the major difficulties faced by parents of children with autism in India is obtaining an accurate diagnosis. A parent may take their child to a paediatrician only to be reassured that their child is just "slow." Unsatisfied, they may visit a psychologist, to be told their child is "mentally subnormal." Convinced that their child does not fit the typical picture of mental retardation, they may visit a psychiatrist, to be told that their child has attention deficit disorder, and must be put on medication to control hyperactivity. After months of sedation and unsatisfactory progress, they may again begin a cycle of searching for the correct name for their child’s problem.

It is therefore very likely that a dentist may find himself/herself treating an Austistic child when the parents are unaware of the condition. It is therefore necessary for the dentist to be able to recognize the symptoms of autism and be aware of the steps he/she may take to render optimal care to autistic individuals. It is similarly important for parents to know the symptoms their child may face, and be mentally prepared for a visit to the dentist.

Large parts of this post have been based on information made available free by the NGO action for autism. Readers can read more at http://www.autism-india.org/afa_autisminindia.html

DCSN does not endorse or take responsibilty for information provided by external sources; we have however verified the information in this post and find it to be accurate to the best of our knowledge.

Preparing to treat an autistic patient

Forewarned is fore-armed. The challenge of managing an autistic patient in the dental office may be greatly reduced by taking the knowledge of the signs exhibited by an autistic child and adapting your treatment plan suitably.

Autistic children like routine

Autistic children are most comfortable in repeating activities they are comfortable with. The dentist can use this knowledge to his/her advantage by:

• Offering parents and children the opportunity to tour your dental office, so that they may ask questions, touch equipment, and get used to the place.
  
• Allow autistic children to bring comfort items, such as a blanket or a favorite toy.
  
• Children with autism need sameness and continuity in their environment. A gradual and slow exposure to the dental office and staff is therefore recommended.
  

No one knows the child like the parent.

Treating the autistic child may be a challenge to you; but the parent knows the habits and tendencies of the child. Spend some time talking to the parent before the procedure - it is time well spent.

The First Visit - Getting started...

• Make the first appointment short and positive.
• Approach the autistic child in a quiet, non-threatening manner. Don’t crowd the child.
• Use a “tell-show-do” approach to providing care. Explain the procedure before it occurs. Show the instruments that you will use. Provide frequent praise for acceptable behavior.
• Invite the child to sit alone in the dental chair to become familiar with the treatment setting.

Use a rational approach

The nature of the disease makes it essential for the dentist to explain each step of the procedure. An autistic individual likes order and can , even in the absence of mental retardation, find abstract expalnations hard to follow.

• Autistics will want to know what’s going to happen next. Explain what you’re doing so it makes sense to them. Explain every treatment before it happens.
• Always tell the autistic child where and why you need to touch them, especially when using dental or medical equipment.
• Talk in direct, short phrases. Talk calmly. Autistics take everything literally – so watch what you say. Avoid words or phrases with double meanings.

Moderate pressure can calm an autistic child

A child may be calmed by moderate firm pressure. The use of a body wrap or a bedsheet to cover the child tightly can greatly enhance the cooperation of the child.Light pressure, such as air from a syringe, however can greatly agitate the child.

Sensory responses of an autistic child may be exaggerated

Autistic children may have an irritability to bright light or some form of hyperaccusis.

• Keep the light out of the child's eyes.
  
• Make sure the child can tolerate the high pitched sound of the airotor; you may be better off using a micromotor handpiece
  

Do we need General Anesthesia or Sedation

Tempting as it may be to directly post an autistic child under general anesthesia DCSN strongly reccomends that the child be given every opportunit y to cooperate on the dental chair. It is also imperitive that the pediatric dentist spots early signs of oral disease and acts swiftly to minimize the operative treatment required by the child. 

• Some children will need sedation or general anesthesia so that dental treatment can be accomplished. Sedation of autistic children who are 8 years and older simply does not work.
  

The following article provides excellent background reading on autism, though its primarily written for the physician, some of you may find it worth reading

Prater CD, Zylstra RG. Autism: A medical primer. American Family Physician 2002; 66: 1667-1674.