A New Frontier in Autism Care and Forensic Psychiatry in Pakistan: Challenges and Innovations

Abstract

Rahim Yar Khan is on the verge of a major achievement with the soon-to-be-inaugurated Autism Center, a beacon of innovation in the region. This venture is the culmination of a dynamic collaboration involving the district's Deputy Commissioner, and the diligent efforts of the  Principal Prof. Dr. Muhammad Saleem through the Psychiatry and Pediatrics Departments of Sheikh Zayed Medical College, Sheikh Zayed Public School, and the Special Education Department. Enjoying robust support from the Punjab Government, this initiative is further strengthened by the contributions of esteemed professionals such as Prof. Muhammad Ayub from the University College London, UK, Prof Nazish Imran, the Chairperson of Child and Adolescent Psychiatry at King Edward Medical University in Lahore, and Mrs. Shumaila Khan from Lahore. United by a shared vision, these experts are committed to improving the life quality and developmental trajectories of children with autism. This initiative is a testament to their collective dedication to providing comprehensive support and fostering developmental opportunities for autistic children, embodying a deep commitment to healthcare excellence and community service.

Pakistan, a vibrant and populous nation located in Southeast Asia, boasts a population exceeding 240 million, making it the sixth most populous country globally.¹ Astonishingly, over 38% of this population comprises individuals under the age of 15, highlighting the significant youth demographic. While commendable strides have been made in the domain of pediatric healthcare services in recent decades, the unfortunate reality remains that child mental health and learning disabilities continue to be largely overlooked. To gain comprehensive insight into healthcare professionals' understanding and perspectives regarding autism spectrum disorders (ASD), it becomes imperative to first examine the healthcare delivery system in Pakistan.

The rise in autism prevalence in the developed world is notable, with current estimates from the CDC (2009) indicating that 1 in 110 children are affected by the disorder. However, awareness and understanding of autism in Pakistan have only started to gain traction in recent years.² This is particularly significant given the higher rates of learning disabilities identified in numerous Pakistani studies, suggesting that autism prevalence may also be notably higher due to its close association with these disorders.²

For instance, a study sampling 6,365 children reported mild mental retardation in 6.5% of cases and serious cognitive disability in 1.9%.³ Furthermore, an estimated 19.0 per 1,000 children in Karachi are suffering from mental retardation or learning disabilities, according to Durkin (1998)⁴. Another study found that nearly 16 per 1,000 children aged between 3 and 9 suffer from severe mental retardation.⁵ Additionally,⁶ observed that Pakistani children exhibited a slightly increased prevalence of autism (2.57 per 1,000), cerebral palsy, severe learning difficulties, and higher rates of hearing and vision problems.

In Pakistan, the situation for children with autism spectrum disorder (ASD) is pressing, with the Autism Society reporting that over 350,000 children are living with the condition, a number that is steadily increasing.⁷ The challenge of diagnosing ASD is compounded by the reliance on behavioral clinical assessments, which are not always easily accessible or understood. This gap in understanding among healthcare professionals leads to suboptimal management of ASD, underscoring the critical need for improved awareness and training within the medical community. For individuals with ASD, effective management of impulses is crucial. Despite the challenges, there are inspiring examples of individuals with ASD who harness their unique perspectives to achieve success. Hassan bin Rizwan from Pakistan has made significant strides with his educational technology company, Muse, while India's Sourav Sarkar has carved a niche for himself as an artist. Advocacy is also a vital component in the fight for disability rights, as seen with Nidhi Goyal from India, who tirelessly works to promote autism awareness. The legacies of notable figures like Temple Grandin, and the speculated traits of historical icons such as Albert Einstein, Sir Isaac Newton, and contemporary innovator Elon Musk, who are all associated with ASD, underscore the transformative impact that early intervention and support can have in realizing the extraordinary potential within those with ASD.

A longitudinal study spanning 17 years and involving 1,570 adults with autism spectrum disorder (ASD) has uncovered that 23% encountered legal challenges, with a notable correlation to coexisting conditions such as substance abuse, predominantly among men around the age of 30.⁸ This comprehensive research delineated three distinct subgroups within the ASD population, highlighting the critical need for customized intervention strategies. The study further revealed that, compared to their female counterparts who generally exhibited superior social adaptation skills, men with high-functioning ASD were more prone to exhibit hypersexual behavior.⁸

In Pakistan, the awareness and diagnostic framework for autism spectrum disorder (ASD) is critically deficient. There is an urgent call to action for the establishment of Forensic Psychiatry to address the interplay between criminal behavior and potential psychiatric conditions, including ASD. Moreover, there is a compelling need to reinforce Child Psychiatry services to improve early diagnosis and intervention for ASD. These measures are not only imperative for the betterment of individual health outcomes but are also crucial for societal well-being.