Autism, Middle Ear Disease and the "Dustbin Syndrome"

Autism, like a number of other challenging conditions, is impressive by the multiple theories of aetiological explanation in the face of a concrete universally accepted Up till the 1970's it was being wrongly labelled as childhood schizophrenia. Since then, much ground has been covered both by researchers and the condition itself, which according to the National Disease Control centres, effects 1 in 42 boys and 1 in 89 girls. In 2013, the American Psychiatric Association merged four previously distinct diagnoses into one umbrella diagnosis of autism spectrum disorder (ASD). These included autistic disorder, childhood disintegrative disorder, pervasive developmental disorder-not otherwise specified (PDD- NOS) and Asperger syndrome. Some disregard the Spectrum altogether. These are but a tiny fraction of evidence exhibition the flux of uncertainty in the very perception of the condition.

In this communication, we touch lightly on the known association of Autism and the child's deficiency of hearing. Whereas the brain stem type of auditory deficit may be part of the brain wiring altered function, the middle ear causation raises other questions, which we ask here. We ask a simple question with a doubtlessly extremely complex answer. Is it possible that say a 2 year old child with severe hearing deficit from middle ear disease, exhibits features essentially indistinguishable from what is labelled autism? If by bypassing speech and all its "normal" concomitant and automatic facial-visual mimicry? If so, why does this happen in some children and not in others? Is there a particular type of personality yes, why does it happen with some children and not with others which determines the child's reaction to such hearing loss?

At the moment, it is not unjustified to think of Autism as a dustbin diagnosis where a particular reactive pattern caused by multifactorial causes involving both heredity and environmental factors. Is it time to take the well known association between middle ear disease causing partial or full deafness and Autism to a possible "causality" level? Re -phrasing: is it not possible that a child trapped into his little world by being deprived of hearing construes his own reality and the reaction to it is being labelled Autism? Take the situation of a child with middle ear disease and resultant serious lack of hearing in a set up where the hearing problem is missed for the first two years of life. This is far commoner than one would think. Such a child may not learn to make eye contact because his perception is not what a normally hearing child would know it is. He learns to withdraw in his own world, play on his own, not seek the company of other children whose language is beyond him, whose facial signs, automatic for them, is incomprehensible to him.

Consider these "red flags by Autism Speaks applicable to little children. (These are not diagnostic but only "red flags").

A. By 6 months, no social smiles or other warm, joyful expressions directed at people

B. By 6 months, limited or no eye contact

C. By 9 months, no sharing of vocal sounds, smiles or other nonverbal communication

D. By 12 months, no babbling

E. By 12 months, no use of gestures to communicate (e.g. pointing, reaching, waving etc.)

F. By 12 months, no response to name when called

G. By 16 months, no words

H. By 24 months, no meaningful, two-word phrases

I. Any loss of any previously acquired speech, babbling or social skills

In the presence of a child with undiagnosed serious hearing loss, these "red flags" have a ready explanation. If hearing is intact, that is another story.

The following signs are considered worrying in a child of any age:

I. Avoids eye contact and prefers to be alone

II. Struggles with understanding other people’s feelings

III. Remains nonverbal or has delayed language development

IV. Repeats words or phrases over and over (echolalia)

V. Gets upset by minor changes in routine or surroundings

VI. Has highly restricted interests

VII. Performs repetitive behaviors such as flapping, rocking or spinning

VIII. Has unusual and often intense reactions to sounds, smells, tastes, textures, lights and/or colors

In suggested scenario of missed hearing loss in a 2-3 yr old, points 3, 5, 6 and 8 are also easily acceptable. It explains sought isolation, loss of eye contact because he may hardly know if he is being spoken to, never mind what is being said to him. His interests are restricted to the world he has been forced to create. The minute attention say to the wheels on a toy truck, so avidly pounced upon as another red flag may be play magnification of what is available to him. He might even ask mental questions his peers are too busy and distracted, to bother about. Point VI is difficult, though not impossible to ascribe to the alien world of the "outsider" child who can't hear and participate. Such children would obviously be drawn to tv, i pads and play stations all of which add beautiful new elements to their lonely world.

The scope of this communication is far from challenging the existence of Autism. It seeks to turn the lens on those situations where the condition is present in for example a 2-3 year old child with severe auditory impairment, especially if missed for a substantial period of time. Autism in the young child with middle ear auditory impairment is too well established a relationship to be co-incidental. The chances of double co-existent primary pathology in this relationship must be remote indeed. Yet it is crucial to distinguish between auditory deficiency induced autism-like behaviour (ADIALB) and Autism as commonly understood.

Firstly, in an age where medical paternalism has been decried by the Courts, the right of disclosure of information is paramount. The doctor may know best but legal medicine exhorts us to make sure that the doctor explains all to the patient. Secondly shredding away misinformation from Autism helps uncover the real truth about the condition. Thirdly, the morale of the parents of the child and of the family may sink or high rise by the use of a single world. Truth needs must out. But, we must make sure it is the truth and it is science which, ust divulge such truth. In the scenario discussed here, it may well be that the child suffering from ADIALB) besides treatment of his hearing difficulty may also need to be restored to normality using the support mechanisms designed for Autism, at least unless more specific treatment comes to light e.g. possibly the greater use of music therapy....Moving out of the diagnosis of Autism may make life more difficult e, g, the potential loss of Autism related help at school. Yet, these can be remedied as the system absorbs new scientific facts and adjusted accordingly.