A MOTHER, visibly upset, sought my advice regarding her son’s teachers recommending his enrolment in a Special Education School. The school did not provide a formal assessment report, yet they cited his difficulties with math, limited eye contact, social communication challenges, and sporadic behavioural issues, such as tantrums, as reasons.

I suggested she request an official evaluation from the school, which, unfortunately, was not provided. In my experience as a psychiatrist in Pakistan, the absence of detailed school assessments is a recurring problem. In the last three years alone, I have diagnosed 329 cases of autism, and not one was accompanied by a detailed referral or report from their educational institution.

Autism Spectrum Disorder (ASD), initially identified by Leo Kanner in 1943, features social communication challenges and repetitive behaviours. Common symptoms include delayed speech, limited interest in peers, avoidance of eye contact, selective responsiveness, and repetitive activities like hand-flapping. These traits typically surface by age three, with a higher prevalence in males. Diagnosis relies on clinical observations, and results from a combination of genetic, environmental, and prenatal factors. In countries like Pakistan, where ASD is underreported, a lack of awareness and resources hinders care.

In Pakistan, tackling mental health issues presents significant challenges. Despite some progress in healthcare, these areas are largely overlooked, with child mental health not receiving dedicated budgetary support. The country allocates only about three per cent of its national budget to health, limiting psychiatric services to departments in teaching hospitals and private clinics. Of the approximately 550 psychiatrists in Pakistan, only a small number specialise in child psychiatry.

Lack of awareness of mental health issues hinders care.

In Pakistan, the Autism Society’s estimate exceeds 350,000 children living with ASD, and this number keeps growing. Diagnosis relies on behaviour-based clinical assessments. There is a notable lack of understanding among healthcare professionals, leading to ineffective management. Despite a prevalence of approximately 0.9 per 1,000 in the developing world, with many cases in rural areas, Pakistan struggles with a significant awareness gap among both the public and medical experts. This gap results in delayed diagnoses, hindering the well-being of children with ASD.

Effective impulse management is key for those with ASD. Innovators with ASD, like Hassan bin Rizwan of Pakistan with his educational tech company Muse, and India’s artist Sourav Sarkar, use their unique perspectives to excel. Advocate Nidhi Goyal, also from India, champions disability rights with a focus on autism. Icons including Temple Grandin, Albert Einstein, Sir Isaac Newton, and Elon Musk — all associated with ASD — highlight the importance of early intervention in unlocking extraordinary potential.

People with ASD may show increased impulsivity, often due to challenges in sensory processing and executive functioning. This can significantly affect daily life and safety. For those with ASD, impulsive behaviours and emotions can be harder to control. Impulse control issues are caused by impaired executive functions, vital for planning, organisation, problem-solving, and behaviour inhibition.

A 17-year study tracking 1,570 adults with ASD found that 23pc faced legal issues, often associated with coexisting conditions like substance abuse, primarily among 30-year-old men. The resear­­ch identified three distinct ASD subgroups, underscoring the necessity for tailored interventions. The study also noted that men with high-functioning ASD exhibited a higher propensity for hypersexual behaviour compared to women with ASD, who displayed better social adaptation. Observations of psychopathic traits in serial killers prompt investigations into connections with high-functioning autism, calling for in-depth forensic psychiatric assessments. Traits of psychopathy — empathy deficits, callousness, paraphilia — and those of autism — social retreat, behavioural issues, obsessionality — highlight developmental trajectory risks.

Effective early management of autism can steer a child towards creativity, while mismanagement may lead to psychopathy, crime, and substance issues. This emphasises the urgent need to establish forensic psychiatry in Pakistan as directed by the Supreme Court in the Safia Bano Case (PLD 2021) and to bolster child psychiatry to address these critical concerns.

The writers serve on the psychiatry faculty at a tertiary care teaching hospital in Rahim Yar Khan.

Published in Dawn, January 15th, 2024