Early Intervention in Autism - it works

Autism, in its broadest interpretation, has a prevalence of about 1:110 population. There is a severe shortage of early intervention facilities for persons with autism in India. World Disability Day is commemorated on 3rd December. Autism is not specifically included as a disability in the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995. This may be contributing to the lack of funding for early intervention facilities.

Protodeclarative pointing - joint attention

 Disability in autism manifests during infancy in three domains

1. Social - Infants with autism show delays in smiling, gazing at their mothers and responding to their names and gesturing (e.g., pointing, waving bye-bye). This pattern continues, with the most impaired children growing to be avoidant or aloof from all social interaction.
2. Communication - Infants and toddlers with autism have delays in babbling, using single words, and forming sentences. Effective language acquisition and use remains a problem throughout life. 50% of people with autism never learn to speak.
3. Behavioural - Children with autism have difficulty tolerating any changes in routine leading to frequent tantrums. They display repetitive movements of the hands in front of the face, later giving rise to other peculiar and stereotyped movements and behaviours that stigmatise them as individuals.

These disabilities affect the ability of the person with autism to live independently and to carry out normal day-to-day activities of life

Various treatments clamour for the attention of parents of children with autism. These include HBOT (Hyperbaric oxygen therapy), chelation, animal therapies (dolphins, horses), various diets, and secret therapies. Despite celebrity and other endorsements there is no unbiased evidence that any of these therapies is effective, they are never curative. At best they are harmless and provide some diversion for the child and caregivers, at worst they can be life threatening.

Early intervention is effective in autism (Dawson et al 2010). The earlier the intervention the better. Effective early intervention programs can reduce disability to the extent that after two years nearly 30% of affected children no longer meet the diagnostic criteria for autism. There are numerous programs based on different philosophies and strategies, but most have some common components. Educational and behavioural techniques form the mainstay of these programs. Family involvement is essential. There is currently no evidence that any one program is better than the other.

Educational interventions

• Most programs involve 15 to 25 hours of intervention a week. They capitalize on natural tendency of children with autism to respond to visual structure, routines, schedules, and predictability.
• Good programs incorporate the child’s current interests and actively engage the child in a predictable environment with few distractions.
• They incorporate effective and systematic instructional approaches and use standard behavioural principles. The aim is generalization and maintenance of skills learned in therapy to life situations.

Behavioural interventions

• Challenging behaviours are managed with functional behavioural assessment and positive behavioural supports

Before starting on an Early Intervention program parents should check that the program

1. Is conducted by qualified professionals
2. Addresses deficit areas

• Inability to attend to relevant aspects of the environment, shift attention, and imitate the language and actions of others
• Difficulty in social interactions, including appropriate play with toys and others, and symbolic and imaginative play
• Difficulty with language comprehension and use, and functional communication.

3. Focuses on long-term outcomes

4. Considers individual developmental level and formulates goals.

I understand the anxiety of a parent confronted with a diagnosis of autism in their child. Unfortunately there are no quick-fix treatments or miraculous cures. Early intervention is time consuming and labour intensive, but in the long run it pays off.

Geraldine Dawson, Sally Rogers, Jeffrey Munson, Milani Smith, Jamie Winter, Jessica Greenson, Amy Donaldson, and Jennifer Varley. Randomized, Controlled Trial of an Intervention for Toddlers with Autism: The Early Start Denver Model. Pediatrics 2010; 125: e17-e23

Corex Cough Syrup - Opioid Addiction Over-the-Counter

Codeine is methyl-morphine

Corex Cough Syrup contains codeine – an addiction causing opioid. One 100ml bottle of codeine containing Corex cough syrup has the same effect as a 30mg tablet of morphine. The drug belongs to the same class of substances as heroin. Medicines are routinely purchased over-the-counter at most pharmacies in Pune and cough syrups very frequently so. Always read the fine print.

Codeine suppresses the cough reflex through a direct effect on the cough centre in the brain stem. However, there is little evidence in the medical literature to support its use as a cough suppressant. Several studies show that codeine does not reduce cough frequency, intensity, or duration (Herbert & Brewster, 2000).

Patients who are prescribed Corex cough syrup or those who buy it over-the-counter are not warned of its addiction potential. They subsequently continue using it as they 'feel restless and anxious' without it. These feelings are part of the spectrum of withdrawal symptoms associated with all opioids, and are another sign of addiction. A 36 year old woman who came to me for treatment of lethargy and lack of interest was consuming a bottle of Corex cough syrup every day for more than two years. Patients and parents should be educated about the lack of benefit and the addiction risk of codeine cough syrups (American Academy of Pediatrics, 1997).

Pharmacists dispensing Corex cough syrup know its potential for addiction. They have their 'regulars' who buy litres of Corex cough syrup over the month. The bottles are handed over in a paper bag without the exchange of a word, leave alone a prescription.

Corex is the top selling medication in India earning Pfizer, the drug manufacturer, Rs 1,820,000,000 during the year 2009. U.S.-based Pfizer and Abbott Laboratories are leading players in India's $103-million market for codeine-based cough syrups. The ministry of finance is now pressuring the companies to enable tracking of each batch produced. The sheer malevolence of this entire chain is brought home by the patient who relapses repeatedly during treatment. Every time he tries to fill his prescription for deaddiction the pharmacist takes advantage of his craving cues to resupply him with codeine containing Corex cough syrup.

So it was with a certain joy that I read

Store employee nabbed for selling drugs without prescription

That was the Indian FDA (Food and Drug Administration) in action in Pune. Their sting on a reputed chain of pharmacies gives us new hope for control of over-the-counter codeine opioid addiction. 

Codeine prescription restrictions - Update

Ministry of Health (2016)
Bans codeine containing cough syrups. Ban upheld by Drugs Technical Advisory Board in July 2018

EMA-CMDh (2015)
(European Medicines Agency – Coordination Group for Mutual Recognition and Decentralised Procedures - Human)
Use of codeine for cough and cold

• contraindicated in children below 12 years. This means it must not be used in this patient group.
• not recommended in children and adolescents between 12 and 18 years who have breathing problems

Govt of India Notification 2014

• Codeine cough syrup is not available over-the-counter (OTC) without a prescription
• Record keeping by the dispensing pharmacist is now mandated

References

1. Committee on Drugs, American Academy of Pediatrics. Use of codeine-and dextromethorphan-containing cough remedies in children. Pediatrics 1997;99:918-20
2. EMA-CMDh. Codeine Article-31 referral - Codeine not to be used in children below 12 years for cough and cold. EMA/249413/2015. 24 April 2015
3. Herbert ME, Brewster GS. Myth: codeine is an effective cough suppressant for upper respiratory tract infections. West J Med 2000;173:283.

Is discipline harming my child?

Last Sunday, 14th November was Children's Day. The papers and supplements were full of articles about children and how to parent them. The need to let the child do whatever he or she wanted to do was stressed. Some articles went so far as to highlight families where the child's every whim was indulged. Until a worried parent of a five-year-old asked our counsellor

Is discipline harming my child?

The message from these articles being
If you love them set them free - from your control

Does it actually matter as to how you parent your child?
Well, there are some associations between parenting styles and outcomes for the child.

4 Parenting Styles based on Responsiveness and Demands

The concept of parenting style has evolved through three major influences

1. The differentiation of parenting style into four types based on "parental responsiveness" and "parental demandingness" by Maccoby and Martin (1983). The neglectful style where the parents display no warmth and exert no control or demands over their child; permissive style where warmth is displayed but no demands or behaviour control is displayed; authoritarian where there are only demands without parental support or warmth; and the authoritative type where there is parental warmth and also high expectations and demands on the child.
   
2. How much should parents control their child?  Diana Baumrind (1967, 1980, 1989, and 1991) showed that children brought up in a neglectful style tend to do poorly on behavioural, emotional, social and academic measures. Children and adolescents from permissive homes are more likely to be involved in problem behaviour, and perform less well in school, but have higher self-esteem, and better social skills. An authoritarian style produces children and adolescents with no problem behaviour and good academic functioning, but they have poor social skills, and emotional problems. With an authoritative parenting style children do well on all behavioural, emotional, social and academic measures.
3. The role of psychological control of the child is the third major influence on the concept of parental styles (Barber, 1996). Authoritarian and authoritative parents both exert behavioural control over their children. They differ in the degree of psychological control they exert on the child's mind. Authoritative parents acknowledge that their children and adolescents could have opinions and values that are different from their own, while authoritarian parents do not allow this. Availability of the parent for communication and discussion is probably the crucial difference that enables children and adolescents of authoritative parents to be consistently more competent in behavioural, social, emotional and academic spheres.

The story would be incomplete if I did not mention that each child is born with a temperament of his or her own. Parental style is partly a response to the child's temperament. Not every troubled child or adolescent is the product of poor parenting.

So, should I discipline my child?

Well, you must discipline the behaviour, but remain open for dialogue on their opinions. Indulge their dreams, ensure they work towards that dream in the real world. Control the behaviour not the mind.

References

1. Barber, B. K. (1996). Parental psychological control: Revisiting a neglected construct. Child Development, 67(6), 3296-3319.
2. Baumrind, D. (1967). Child care practices anteceding three patterns of preschool behavior. Genetic Psychology Monographs, 75(1), 43-88.
3. Baumrind, D. (1980). New directions in socialization research. Psychological Bulletin, 35, 639-652.
4. Baumrind, D. (1989). Rearing competent children. In W. Damon (Ed.), Child development today and tomorrow (pp. 349-378). San Francisco: Jossey-Bass.
5. Baumrind, D. (1991). The influence of parenting style on adolescent competence and substance use. Journal of Early Adolescence, 11(1), 56-95.
6. Maccoby, E. E., & Martin, J. A. (1983). Socialization in the context of the family: Parent–child interaction. In P. H. Mussen (Ed.) & E. M. Hetherington (Vol. Ed.), Handbook of child psychology: Vol. 4. Socialization, personality, and social development (4th ed., pp. 1-101). New York: Wiley.

Attempted suicide prosecuted in Pune

Woman booked for attempting suicide

A 21-yr woman attempted suicide by jumping from the fourth floor of the gynaecology ward she was admitted in. She could not stand the pain of complications after a Caesarean Section. Section 309 of the Indian Penal Code was slapped against her by the police. 612 people committed suicide in Pune in 2008. This gives a documented suicide rate in Pune of 16.3 persons per 100,000 population. The national suicide rate is 10.8/100,000. This data is based on police records. A verbal autopsy study (1994-99) estimated an actual suicide rate of 95.2/100 000 population —nine times the national average.

This tragic incident and its background needs further analysis

How common is attempted suicide in a 21 year old woman during and after pregnancy?
The suicide rate for 15–24 year females is 109/100000. This exceeds the male rate of 78/100 000. Suicide is responsible for 49% of all deaths in women at these ages. During pregnancy attempted suicide is about 40 per 100,000 pregnancies. Women that attempted suicide during pregnancy had increases in caesarean delivery. One percent of people who attempt suicide complete it within a year

Why are official suicide rates gross underestimates?
Attempted suicide is a symptom associated with the stigma of mental illness and also the stigma of crime. To avoid this double stigma patients and we doctors collude to label the suicide attempt as accidental. Another verbal autopsy study (1997-98) of all deaths in a rural area showed that half the deaths ascribed to injuries were actually suicides. The real suicide rates are distorted depending on the degree of under-reporting.

So what if official suicide rates are gross underestimates?
80-95% of suicide is associated with treatable physical problems (including unremitting pain) and psychiatric problems (including post partum depression). When under-reported - resources meant for treatment of psychiatric disorders, including those for knowledge dissemination and manpower, are diverted to other problems.  A California study found that a psychiatric disorder increased the risk of postpartum suicide attempts 27.4-fold. The discrimination against females with mental illness is raised to a national level. People are left unaware that the conditions resulting in suicide attempts are disorders that are treatable; doctors and paramedical staff are not trained to recognise conditions that could lead to suicide; primary care doctors are unaware of simple, effective and available psychiatric treatment options. 

Why is the suicide rate in Pune one-and-a-half times the national average?
Among the many social factors associated with suicide, addressing suicide attempts humanely would contribute more to bringing down the actual suicide rate – definitely more so than prosecution. This high suicide rate in Pune may also have a flip side – we may have a better reporting system.

How to get somebody to consult a psychiatrist

Some excerpts (reproduced with permission) from responses to my last post.

"My Dad was a closet alcoholic"

"...asking for help on alcohol consumption for my friend's son who will soon turn 19 years...parents now try to monitor his timings, where he is but he is slippery and generally seems to be ahead of them."

People may know that a loved one requires help with an alcohol habit or other behavioural or emotional problem. The reluctance to seek help is mainly due to the stigma attached and the individuals lack of insight (blindness to the presence of the illness). How does the family or society (a neighbour) get the person to a psychiatrist or other mental health professional?

Individual choice and potential for harm are in the balance

I've listed out some methods  - by no means exhaustive - used successfully by other caregivers. They are in descending order of individual choice and autonomy. Use your discretion.

How to get a person to consult a psychiatrist

• Talk to the person then hold them to their word. If the person asks for 'another chance', get an undertaking for consultation if the problem recurs.
• If the problem is with a child talk it over with the person who can veto the consultation (your spouse, your mother-in-law). The child will exploit any lack of consensus.
• Put across the consultation as a confidential discussion with a neutral person.
• Focus on the physical complaints - sleeplessness, loss of appetite, fatigue. Fix a consultation for these "stress related problems".
• Seek help from a person they trust. This may be an uncle, a grandparent or daughter-in-law who may not be aware of the problem but would be willing to intervene for the benefit of their loved one.
• Get the family physician to refer. Physicians may prefer not to go in for a discussion on the need for psychiatric referral. Letting the physician know in advance will facilitate referral.
• Use coercion. If the person is still refusing to consider an evaluation threaten withdrawal of some support for which they are dependent on you (you should be prepared to follow through on this). Play on their insecurities (eg. to divulge information to a colleague or boss).
• If there is any kind of self-harm be firm and seek an urgent consultation
• In case of escalations with violence and agitation seek admission to a mental health centre. There are provisions for this under the Mental Health Act.

Remember, untreated psychiatric illness will increase stigma