Short CommunicationToddlers at risk for Autism Spectrum Disorders from Kerala, India – A community based screening
Introduction
India has made rapid strides in health care in the last two decades with decline in childhood mortality (Rajaratnam et al., 2010). The focus has now shifted to issues of childhood morbidity including ways to reliably identify and provide early intervention for neurodevelopmental disorders (Maulik and Darmstadt, 2007; Dawson, 2008). Screening for neurodevelopmental disorders will help in early identification and intervention which will reduce disability and improve outcomes (Dawson, 2008; Mukherjee et al., 2014).
Autism Spectrum Disorder (ASD) is one such neurodevelopmental disorder with estimated worldwide prevalence of 6.2/1000 (Elsabbagh et al., 2012) associated with significant morbidity that needs better awareness, screening and surveillance. This is especially so in low and middle-income countries which has scarce mental health resources. There are very few prevalence studies on ASD in India, especially among toddlers. The reasons include absence of appropriate and culturally validated screening instruments in toddlers; lack of awareness; lack of trained human resources; and, stigma associated with the diagnosis (Mukherjee et al., 2015; Daley, 2004). These reasons may also explain the low prevalence rate of ASD of 0.9/1000 reported in a community study done in northern India in children between the ages of 1–10 years (Raina et al., 2015). In high income countries, there are a number of tools that are routinely used for screening children for ASD (Council on Children with Disabilities et al., 2006) and the Modified Checklist for Autism in Toddlers Revised (M-CHAT-R) is one such screening tool which good specificity and sensitivity (Robins et al., 2009). An indigenous tool called the Indian Scale for Assessment of Autism (ISAA) (Ministry of Social Justice and Empowerment, 2009) is available but has limited accuracy in younger age groups especially toddlers and therefore was not used in this study (Deshpande et al., 2015; Mukherjee et al., 2015).
To date, there are no community surveys from India which have assessed the prevalence of the risk for ASD using age-appropriately validated tools among toddlers. It is in this background that the study was executed using community health nurses to identify children at risk for ASD using the M-CHAT-R. The findings reported in this study are part findings of a larger survey which assessed health and wellness of mothers and children in the State of Kerala, India.
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Material and methods
This study reports findings of a single stage cross sectional community survey conducted in 2016, of toddlers aged between 13 and 24 months in the State of Kerala, South India. Children who were born in the period from 1st April 2014 to 31st March 2015 registered in Mother & Child Tracking System (MCTS) formed the population of the survey. The MCTS had 4,76,975 (96.1%) registered births. A sample size of 8600 was calculated based on the expected coverage of 90%, confidence interval of 1% and
Results
A total of 6237 toddlers were surveyed of whom 3139 (50.3%) were males. The mean age of the sample was 20.13 (±2.72) months. Of the 341 toddlers (5.5%) who had a total score of 3 or above on the M-CHAT-R, 259 toddlers (4.2%) scored between 3 and 7 and were considered to have a medium risk and 82 toddlers (1.3%) scored between 8 and 20 and were considered to be at high risk for ASD. Toddlers at risk as per “Best Seven” were 162 (2.7%). See Table 1 for item endorsement. At the time of the survey,
Discussion
The state of Kerala in South India has made significant advances in health care especially with respect to infant and maternal mortality and thus in many ways this was an ideal place in India to screen for causes of childhood morbidity such as neurodevelopmental disorders (Census of India, 2011).
In this study, toddlers identified to be at risk for ASD was 5.5% using the M-CHAT-R total and 2.7% using the “Best-Seven” of M-CHAT-R. Previous studies using the M-CHAT-R as a screener both in low risk
Ethical approval
This work received ethical approval from Government Medical College, Ernakulam. The questionnaire has been administered only to consenting mothers.
Conflicts of interest
All authors have no conflict of interest or financial disclosures to make.
Acknowledgements
The authors would like to thank the School Junior Public Health Nurses of the RBSK program who were involved in administering the questionnaire and Shri Ajayakumar & team who helped in the data entry.
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