Abstract
Background:
The COVID-19 pandemic impacted children with neurodevelopmental disorders (NDDs), such as Autism Spectrum Disorder (ASD) significantly. It is not known if such altered circumstances impact the identification of developmental delays as well as help-seeking.
Methods:
We conducted a retrospective review of the comprehensive intake assessments completed by a senior clinician (VR) at our hospital. The objective was to investigate potential differences in the age at which individuals sought help, comparing two six-month periods: one prior to the onset of the COVID-19 pandemic and one following its onset.
Results:
The findings indicated that ASD formed a significantly larger proportion (45% vs. 21.1% Chi-square test ϰ² = 36.185, P < .001) of all children seen in our services during the pandemic than in the previous year. These children were brought at a lower age (87 months vs. 104 months, t = 3.341, P < .001) than in the previous year. This difference was not noted in non-ASD children during the same two time periods (89 months vs. 79 months, t = 1.83, P < .068).
Conclusions:
Our findings suggest that school-age children were less likely to be brought in for clinical assessment during periods of prolonged school closures. Several factors may have contributed to this trend, including reduced access to community pediatricians and other primary points of referral during the pandemic. At the same time, extended periods of home confinement may have heightened caregiver observation, potentially facilitating the earlier identification of developmental concerns and prompting help-seeking behavior, particularly for younger children. These findings highlight the importance of examining time trends in clinical data on NDDs to better understand how external events, such as the COVID-19 pandemic, influence help-seeking patterns. They also underscore the value of public health strategies that support early engagement of parents and carers with toddlers, especially in families considered at high risk for ASD. Strengthening such initiatives could improve early identification and access to intervention services.
Introduction
The COVID-19 pandemic has been a significant source of stress for children across all age groups. 1 Children with Autism Spectrum Disorder (ASD), who characteristically present with deficits in social interaction and communication, along with restricted and repetitive behaviors, are particularly vulnerable to the effects of such disruption. 2 Due to their heightened sensitivity to changes in routine and environment, these children may experience greater distress during periods of upheaval, such as those brought about by lockdowns, school closures, and social distancing.
The pandemic has also resulted in parents and caregivers spending considerably more time at home with their children. This prolonged cohabitation may have created opportunities for more attentive observation of developmental patterns and potential delays. In addition, the remote work environment may have provided families with the time and flexibility to pursue medical consultations, an option that may have been more difficult when bound by traditional in-person work schedules.
Materials and Methods
The author reviewed new cases presenting to the child psychiatry outpatient department at a tertiary care hospital in South India. The child psychiatry division offers comprehensive inpatient and outpatient services addressing a wide range of mental health concerns in children and adolescents. Additionally, the hospital houses a dedicated center for children with ASD, where specialized assessments and interventions are provided.
Pervasive Developmental Disorder (as classified in ICD-10 as ASD) is diagnosed in our clinic based on a detailed evaluation using the International Classification of Diseases, 10th Edition (ICD-10, World Health Organization, 1993). 3 We reviewed records of in-person new cases (screened using a detailed screening proforma that includes demographic data, presenting complaints, family history, birth history, developmental milestones, schooling history, medical history and leads to a multiaxial diagnosis. This article is based on cases seen only by the author) that presented to the outpatient department in a tertiary care hospital during a specified period. Data was obtained for the six-months data was obtained for the six months following hte completion of the nationwide lockdown, from October 2020 to March 2021. For comparison, we analyzed data from the previous year, covering the six-month period between October 2019 and March 2020. Institutional ethics committee approval was obtained.
Results
As seen in Table 1, not surprisingly, we found that the total number of new children screened in the clinic declined from 2019–2020 to 2020–2021 (346 new cases vs. 226 new cases). More importantly, 21.4% of the 346 children (n = 74) received a diagnosis of ASD in 2019–2020, while 45% of the 226 children (n = 102) in 2020–2021 received the same diagnosis.
Children Evaluated in the Clinic During the Two Time Periods of Interest.
It can be noted from Table 1 that the age range of children with ASD in the period October 2019-March 2020 was 21 months to nine years, while the age range of children with ASD in the period October 2020-March 2021 was 14 months to seven years. It is worth reporting here that the youngest child with ASD features during the pandemic was 14 months old, and there were six children in the 102 children with ASD who were below 18 months of age. This suggests a trend toward early identification.
Discussion
Our retrospective review of intake assessments conducted across two six-month periods—before and after the onset of the COVID-19 pandemic—revealed a relative increase in the identification of ASD cases by parents during the pandemic period. This shift in help-seeking behavior may be attributed to several contextual factors unique to the pandemic.
With many working parents staying at home due to lockdowns and remote work arrangements, there was increased opportunity for direct observation of their children’s behavior. This prolonged and close contact may have enabled caregivers to recognize subtle or previously overlooked developmental concerns. Behaviors that might have been dismissed, or for which help-seeking was postponed in pre-pandemic times became more prominent and, in some cases, disruptive to daily routines, prompting families to seek professional evaluation. 4 For example, in two of the newly diagnosed ASD cases, parents reported noticing signs, such as poor response to name, reduced eye contact, stereotyped behaviors (e.g., hand flapping, toe walking), and impaired joint attention – observations that emerged during two weeks of quarantine in a single room.
While the reduction in typical school-age referrals due to school closures may have shifted the clinical profile seen during this time, the age distribution among non-ASD referrals remained relatively consistent across both time periods. It is also important to note that we lack referral pattern data and cannot determine the extent to which reduced access to community pediatricians influenced help-seeking. Nonetheless, our data suggest two central phenomena: First, parents are more likely to identify developmental concerns when they have increased time with their children; and second, when given the opportunity and availability, families tend to prioritize help-seeking.
One limitation of the study is the possibility that the observed findings are incidental, given the overall increase in ASD diagnosis globally. This broader trend may have influenced the results, making it difficult to attribute changes solely to the variables under investigation. Additionally, the absence of data from the post-COVID-19 period limits the strength of the argument, as such data could have provided valuable insight into the role of increased parent–child interaction—particularly during lockdowns—in the earlier identification of social and communication difficulties. However, it is important to note that the primary focus of the study was to explore whether increased parent–child interaction was associated with earlier recognition of developmental concerns.
Conclusions
These findings have important implications for public health strategies focused on the early identification of neuro-developmental disorders (NDDs). Our observations support the development of targeted educational programs that promote active engagement between parents and young children, particularly during infancy and toddlerhood.
By fostering greater awareness of early developmental milestones and red flags, such initiatives can promote timely identification, enable early intervention, and ultimately contribute to better long-term developmental outcomes for these children.
It is also essential to emphasize the need for sensitization and increased awareness among primary care pediatricians, who often serve as the first point of contact for children with ASD.
Footnotes
Acknowledgements
The author would like to thank Dr. Ashok Mysore V for his inputs in designing the study and Dr. Shanti Thomas, Fellow in Child Psychiatry, for her help with the statistical analysis.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.
Statement of Informed Consent and Ethical Approval
The study was accorded Ethical Committee Approval vide Ethics Committee (Institutional Ethics Committee, St. John’s Medical College, Bangalore) No. (166/2022). Written/Verbal Informed Consent was not taken from the participants as this was a retrospective chart review. The study was carried out in accordance with the principles as enunciated in the Declaration of Helsinki.