This week Dr. Miyuru Chandradasa, MD Psych, University of Kelaniya - Sri Lanka (Overseas Leave), Monash University - Australia (Honorary) speaks about Autism, a disease that affects many in the world and in Sri Lanka.
Q – What is autism?
A - Autism is a lifelong developmental condition that affects the way an individual reacts and interacts with other people and the environment. The condition is termed as autism spectrum disorder by medical specialists. The word spectrum is used as there is a range of deficits or difficulties between persons having this condition. Some people with autism would live near-normal lives; however, others may have long-term problems related to independent living and may require extensive support due to their social communication deficits and learning issues.
Q – What are the clinical features of autism?
A - Boys are affected more than the girls. The early symptoms are evident in the first few years of life. An individual who is affected would have both social communication difficulties and repetitive restricted behaviour. The social communication deficits would include lack of emotional reciprocity, poor non-verbal communication skills and deficiencies in understanding social relationships. In regards to restricted and repetitive behaviour, the affected child would demonstrate stereotyped acts or utterances, insistence on sameness, fixated interests and an abnormal reaction to sensory stimuli.
Q – How can autism be diagnosed?
A - The diagnosis of autism requires extensive clinical and structured assessments. This should be done by a medical specialist trained specifically in neurodevelopmental disorders. A child psychiatrist would gather information from clinical observations, information from parents and teachers and structured tools before coming to a diagnosis. The diagnosis would be done according to standard internationally known criteria which are used worldwide. Most widely used criteria are the Diagnostic and Statistical Manual of Mental Disorders constructed and published by the American Psychiatric Association and International Classification of Diseases by the World Health Organization. In addition to this, a culturally relevant pictorial screening tool has been developed for Sri Lanka.
Q – Explain the Aetiology of Autism?
A - The exact cause of autism is not known. There has been much scientific research over the decades on possible causes for the disorder. What is certain is that it is a brain disorder related to the development of neuronal pathways. However, the reason why these abnormalities occur is exactly not known. The genetics have a significant role to play in the causality of the disease and autism is one of the conditions that are heavily influenced by genetic variations. There has been a substantial increase in the prevalence of autism all over the world. The reason for this increase is not clearly identified at present. A study by a group of researchers led by Professor Hemamali Perera in 2009 showed that the prevalence of autism in Sri Lanka is 1 in 93 in the 18-24 month age group. It is possible that over the last decade this ratio has increased.
Q – What are the treatment available for autism?
A - At present, the main mode of treatment for autism is intensive behavioural interventions that are more effective when employed in early life. The behavioural interventions aim to improve sustained eye contact, joint attention, pragmatics, which is the social use of language and other behaviour deficits. Apart from this, specific cognitive therapies are used in adolescents and adults. In addition, there is a limited role for medications in autism for behavioural improvements, which should be carefully prescribed and monitored by a medical specialist. These treatment methods have been studied extensively in many countries and proven to be reasonably effective and safe. Many international organisations such as the National Institute of Health and Care Excellence (NICE) of the United Kingdom only recommend these well researched behavioural and limited pharmacological treatments. A study by a group of researchers including child psychiatrists Professor Hemamali Perera and Dr Sudarshi Seneviratne, published in 2016 has found that home-based early behavioural interventions are effective to improve symptoms of children with autism in Sri Lanka.
Stem cell therapy
A stem cell is an undifferentiated cell obtained from an organism. These cells can differentiate into other types of cells. They can produce the same type of cells as well. Stem cell therapy uses stem cells to prevent or treat disorders. The commonly used stem cells are from the bone marrow of the treated individual and at times from the umbilical cord blood.
Risks of stem cell therapy
Many of the specific stem cell therapy methods for disorders are still being experimented. On most disorders, there is only a limited number of studies at present. Therefore the potential risks of these forms of therapies are yet to be identified. The past experience has been that in some forms of biological therapies, the adverse effects are only identified many months or even years after the therapy. Therefore, the possible long-term complications are not certain at present. Because these therapies are not well established, it requires a great deal of monitoring and control by an independent external authority. At present, there is no such committee to oversee the execution of stem cell therapy by various individuals in Sri Lanka. Since the public health services are not heavily involved in many specific forms of stem cell therapy, there is no uniform structure or monitoring of the procedures and outcomes. There is no approved method to report any adverse reactions or complications. Stem cell therapy is costly and this could potentially become a pathway for people to provide services that are driven by commercial goals rather than health outcomes.
Stem cell therapy in autism
There have been a small number of published studies on using stem cell therapy in children with autism spectrum disorder. These studies have been done mainly in the United States of America, other Western countries and India. Most of the studies have been done on a very small number of highly selected patients. The results are not practically relevant when a study is not done in a naturalistic setting and recruits only selected patients in small numbers. Many of the studies are not controlled studies. That means this method of treatment has not been compared with other types of management for autism and the results are not that valid. In addition, the limited studies published have been done over a short period and the long-lasting effects are uncertain.
There have been few studies published recently. In a controlled trial done in California in the United States and published in April 2018, the researchers did not find any significant benefit of stem cell therapy using umbilical cord blood cells for children with autism spectrum disorder. Another study done by a group of scientists in Italy and United States and published in 2014 using foetal stem cells stated that at present this form of therapy for autism is controversial.
Q – Is the therapy recommended?
A - At present, there is inadequate scientific evidence on stem cell therapy in autism. The minor benefits shown by certain limited studies are doubtful and require to be further explored by large-scale controlled studies. In conclusion, stem cell therapy is not recommended for any aspect of autism spectrum disorder in the current context.
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