Frequency of visual impairment in autistic children of autism school of Lahore,Pakistan

Key messages

Introduction

Autism is a condition in which abnormal development of the brain occurs as a key factor. This condition remains latent in the first 3 years of life and manifests after 3 years of life. The behavior and interests of autistic patients changed as compared to the other normal subjects. One of the behaviors that are changed in autism is communication with other person (Absoud et al., 2011).

Eye contact in communication is very difficult for the autism child; this is because of the fear which is in their minds. The head, hands, and body of the autistic patient show repeated movements due to a lack of confidence. According to the centers for disease control, autism causes a significant effect on communication with others, behavior, and social interaction problems (Absoud et al., 2011).

The reported prevalence of Autism varies depending upon the geographic location, diagnostic tools, and awareness regarding autism among the population. This is mentioned in the background that the researchers started working on autism statics/data in 1960. The first prevalence data were published for 20 years of duration from 1960 to 1980. At this time, the prevalence was 2 persons among the 10,000 population. These data about the prevalence of autism disorder were increasing every year (Keel & Cieza, 2021).

The behaviors of autistic children are quite different from other normal children. May have limited, repetitive patterns of behavior, interests, or activities, including any of these signs, that is, performing repetitive movements, such as rocking, spinning, or hand flapping (Achermann et al., 2020).

One of the main issues of autistic children is a lack of interest, which is very important to learn skills and knowledge (Bathelt et al., 2017).

The milder form of autism is known as Asperger Syndrome. The children having this type of autism do not have the problems that those with autistic disorder have, for example, language and communication but they frequently have problems with social clues (Gillberg et al., 2019).

The symptoms include minimal social interactions, understanding nonverbal communication, difficulty managing emotions, and hypersensitivity to lights, sounds, and textures. Become upset about any small modification in daily routines (Little, 2018).

An accurate and early diagnosis of autism spectrum disorder (ASD) can lead to a better understanding of the problems facing a person with ASD and it may enable the individual to access appropriate support(Nebhinani & Jain, 2019). Now a day a range of therapies and rehabilitations can help the person to adapt their behavior for a better social outcome, and deal with anxiety. This can reduce the risk of social isolation and make the person execute a task in their daily life (Fehr et al., 2011).

A rare genetic neurological disorder that occurs only in females aged 6–18 months and leads to severe impairments, affecting nearly every aspect of the child’s life: their ability to speak, walk, eat, and even breathe easily known as Rhett’s syndrome. it is an atypical form of autism (Black et al., 2013).

Atypical autism occurs due to pervasive impairment called pervasive development disorder (PDD). PDDs are now called ASD (Cohen & Volkmar, 1997). This name changed in 2013 when the American Psychiatric Association reclassified autistic disorder, Asperger’s syndrome, childhood disintegrative disorder, and PDD not otherwise specified as ASDs (Butchart et al., 2017).

The major sign and symptoms of PDD include inappropriate social behavior, uneven skill development, poorly developed speech, and language comprehension skills, difficulty with transitions, and deficits in nonverbal and/or verbal communication (Thankappan et al., 2017).

Objectives

Methodology

A descriptive, cross-sectional study was conducted in autism centers of Lahore named Autism care center, Oasis schools of Autism, and Autism school of Lahore. This study was approved by the institutional review board and all procedures were conducted in accordance with the tenets of Declarations of Helsinki 1975 as amended in 2000. All the parents and teachers of the potential study participants were informed verbally and written informed consent was taken prior to enrollment. A convenient and purposive sample of 400 students (aged 3–20 years), enrolled in the above-mentioned schools were included in this study. Children having other diseases like cerebral palsy, general health disorders, other developmental disorders and/or serious cognitive disability were excluded from the study. During data collection, visual acuity assessment was performed using Snellen’s alphabets chart (verbal participants) and Tumbling E/ symbols chart (non-verbal participants) at the distance of 6 m. Refractive error assessment was conducted by retinoscopy and autorefractometry, while in some non-cooperative children Bruckner’s test also was applied to determine myopia or hypermetria. Cycloplegic refraction was performed in children <12 years of age. Ocular motility examination was also performed with the cover uncover test and Hirschberg’s test. After that, anterior and posterior ocular segment examination was conducted using a direct ophthalmoscope. Data analysis was done on SPSS version 2020. During statistical analysis, the association between refractive error and squint with ASD was explored by using Pearson’s chi-square analysis.

Results

A total of 127 participants were included in this study, of which 77 (60.6%) were male and 50 (39.4%) were female (Figure 1). As shown in Table 1, participants having age group 0–5 years were 44 (34.6%), 6–10 years old was 52 (40.9%), 11–15 years old 21 (16.5%), and 16–20 years old were 10 (7.9%). Figure 2 shows that around half of the study population (51%) had no visual problems and the other half i.e. 49% were diagnosed with visual impairment, Out of 127, 43 were diagnosed with refractive errors, and 20 were diagnosed with squint which is the main cause of visual impairment. In 43 participants who were diagnosed with refractive errors, 19 (15%) were myopes, 15 (11.8%) were hypermetropic, and 9 (7.1%) were Astigmatic (Figure 3). Twenty participants were diagnosed with a squint, out of them 12 (9.4%) were with inward deviation, 6 (4.7%) were with outward, and 2 (1.6%) were having oblique squint (Figure 4). As reported in Figure 5, out of 49% of the study population with visual problems, 33.8% had refractive errors and 15.7% had squint associated with visual impairment.

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Figure 1.

Pie chart showed gender distribution among participants.

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Table 1.

Age distribution of study participants.

Age	Frequency	Percent	Valid percent	Cumulative percent
0–5 year	44	34.6	34.6	34.6
6–10 year	52	40.9	40.9	75.6
11–15 year	21	16.5	16.5	92.1
16–20 year	10	7.9	7.9	100.0
Total	127	100.0	100.0

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Figure 2.

Pie chart showed the frequency of visual impairment among participants.

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Figure 3.

Pie chart showed the frequency of refractive errors among autistic children.

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Figure 4.

Pie chart showed the frequency of squint among autistic children.

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Figure 5.

Pie chart showed the frequency of visual impairment due to refractive error and squint.

Discussion

This research was carried out for the first time in Pakistan, and very little global research on autistic children and vision impairment has been done. This study found that autistic children need visual rehabilitation in addition to treatment and that an optometrist or ophthalmologist should handle their problems because autism is one of the etiologies that contribute to visual impairment.

In 2017, a systematic study was conducted in the United Kingdom about autistic children to determine the frequency of visual impairments. Data from seven different studies looked into how often people with ASD have visual problems. Most of them were basic screening studies employing a variety of techniques, making up a relatively new field of study. Results of this study concluded that the major cause of visual impairment was refractive error and misalignment of the eyeball, total visual impairment was 41.0% out of which refractive errors were 32.7% and squint was 8.3% These results correlate with the findings of current study, concluding the major causes of visual impairment as refractive errors 33.8% and squint 15.8% in autistic children. Both these studies have similar results and concluded that refractive error was a major cause of visual impairment. Our study showed that the frequency of refractive errors and squint is higher than in Maggie’s study. The reason would be that both the studies were concluded in different countries.

Another study was conducted in Thiruvananthapuram India on autistic children in 2017. They determined that the total visual impairment was 57.7% out of which the frequency of visual impairment in that study is higher than those of current study; this difference may be explained by the higher percentage of autistic people living there, a lack of health care facilities, or a lower literacy rate than in the area where this study was done, that is, in Pakistan, Lahore.

Conclusion

For the first time ever, a study of children with autism was done in Pakistan. This research has led to the conclusion that ASD is associated with visual impairment, which can be treated with rehabilitation in addition to other treatments. It is concluded that by performing basic visual screening for autism in schools, ophthalmologists and optometrists can support children with their educational and everyday life tasks by giving them a visual rehabilitation.

Recommendation

There was a high frequency of visual impairment in autistic schools, and the main causes of visual impairment were refractive errors. Identifying refractive errors in these children early and providing appropriate corrective lenses may help optimize their visual functioning and impact their activities of daily life positively.