Caregiver experiences of feeding children with developmental disabilities: a qualitative study using interpretative phenomenological analysis from India.

OBJECTIVE: We aimed to explore caregiver experiences of feeding children with developmental disabilities, in the context of it being influenced by biological, personal and social factors. DESIGN: This study applied a qualitative study design through focus group discussions (FGDs), using interpretative phenomenological analysis. Data were analysed using thematic content analysis. SETTING: This study was conducted at the Child Psychiatry Unit of a tertiary care centre in South India, between March and November 2020. PARTICIPANTS: Seventeen mothers of children with developmental disabilities, who provided written informed consent, participated in four FGDs. RESULTS: Three over-arching themes were identified. Feeding experience: (a) a tedious, confusing task; (b) disproportionate onus on mothers; (c) influenced by sociocultural norms. CONCLUSION: Feeding can be a stressful activity for both caregiver and child, influenced by family structure and sociocultural belief systems. Considering caregivers' emotional status, facilitatory and hindering environmental factors, and actively exploring strategies to promote the generalisation of strategies learnt into real-life outcomes are essential in tailoring deficit-specific feeding interventions.

Psychometrics and utility of Psycho-Educational Profile-Revised as a developmental quotient measure among children with the dual disability of intellectual disability and autism.

There is no agreement about the measure to quantify the intellectual/developmental level in children with the dual disability of intellectual disability and autism. Therefore, we studied the psychometric properties and utility of Psycho-Educational Profile-Revised (PEP-R) as a developmental test in this population. We identified 116 children with dual disability from the day care and inpatient database of a specialised Autism Clinic. Scale and domain level scores of PEP-R were collected and analyzed. We examined the internal consistency, domain-total correlation of PEP-R and concurrent validity of PEP-R against Gesell's Developmental Schedule, inter-rater and test-retest reliability and utility of PEP-R among children with dual disability in different ages, functional level and severity of autism. Besides the adequate face and content validity, PEP-R demonstrates a good internal consistency (Cronbach's α ranging from 0.91 to 0.93) and domain-total correlation (ranging from 0.75 to 0.90). The inter-rater reliability (intraclass correlation coefficient, ICC = 0.96) and test-retest reliability (ICC = 0.87) for PEP-R is good. There is moderate-to-high concurrent validity with GDS (r ranging from 0.61 to 0.82; all Ps = 0.001). The utility of PEP-R as a developmental measure was good with infants, toddlers, pre-school and primary school children. The ability of PEP-R to measure the developmental age was good, irrespective of the severity of autism but was better with high-functioning children. The PEP-R as an intellectual/developmental test has strong psychometric properties in children with dual disability. It could be used in children with different age groups and severity of autism. PEP-R should be used with caution as a developmental test in children with dual disability who are low functioning.

Pediatric Anesthesia Emergence Delirium Scale: A diagnostic meta-analysis.

BACKGROUND: Emergence delirium (EmD) is a troublesome motoric, emotional, and cognitive disturbance associated with morbidity. It is often misdiagnosed despite being present in a substantial proportion of children and adolescents during emergence from anesthesia. AIM: To evaluate the summary diagnostic accuracy of Pediatric Anesthesia Emergence Delirium Scale (PAEDS) for EmD among children and adolescents. METHODS: Two researchers electronically and hand searched the published literature from May 2004 to February 2021 that evaluated the diagnostic accuracy of PAEDS for EmD among children and adolescents, using appropriate terms. Two independent researchers extracted the diagnostic parameters and appraised the study quality with QUADAS-2. Overall, the diagnostic accuracy of the measures was calculated with the summary receiver operating characteristic curve (SROC), the summary sensitivity and specificity, and diagnostic odds ratio (DOR) for EmD. Various diagnostic cut-off points were evaluated for their diagnostic accuracy. Heterogeneity was analyzed by meta-regression. RESULTS: Nine diagnostic accuracy studies of EmD that conformed to our selection criteria and PRISMA guidelines were included in the final analysis. There was no publication bias. The area under the SROC was 0.97 (95% confidence interval [CI]: 95%-98%). Summary sensitivity and specificity were 0.91 (95%CI: 0.81-0.96; I 2 = 92.93%) and 0.94 (95%CI: 0.89-0.97; I 2 = 87.44%), respectively. The summary DOR was 148.33 (95%CI: 48.32-455.32). The effect size for the subgroup analysis of PAEDS cut-off scores of < 10, ≥ 10, and ≥ 12 was 3.73, 2.19, and 2.93, respectively; they were not statistically significantly different. The setting of the study and reference standard were statistically significantly related to the sensitivity of PAEDS but not specificity. CONCLUSION: The PAEDS is an accurate diagnostic measure for the diagnosis of EmD among children and adolescents. Further studies should document its clinical utility.

Prevalence of intellectual disability in India: A meta-analysis.

BACKGROUND: Burden due to intellectual disability (ID) is only third to the depressive disorders and anxiety disorders in India. This national burden significantly contributes to the global burden of ID and hence one has to think globally and act locally to reduce this burden. At its best the collective prevalence of ID is in the form of narrative reviews. There is an urgent need to document the summary prevalence of ID to enhance further policymaking, national programs and resource allocation. AIM: To establish the summary prevalence of ID during the past 60 years in India. METHODS: Two researchers independently and electronically searched PubMed, Scopus, and the Cochrane library from January 1961 to December 2020 using appropriate search terms. Two other investigators extracted the study design, setting, participant characteristics, and measures used to identify ID. Two other researchers appraised the quality of the studies using the Joanna Briggs Institute critical appraisal format for Prevalence Studies. Funnel plot and Egger's regression test were used to ascertain the publication and small study effect on the prevalence. To evaluate the summary prevalence of ID, we used the random effects model with arcsine square-root transformation. Heterogeneity of I 2 ≥ 50% was considered substantial and we determined the heterogeneity with meta-regression. The analyses were performed using STATA (version 16). RESULTS: Nineteen studies were included in the meta-analysis. There was publication bias; the trim-and-fill method was used to further ascertain bias. Concerns with control of confounders and the reliable measure of outcome were noted in the critical appraisal. The summary prevalence of ID was 2% [(95%CI: 2%, 3%); I 2 = 98%] and the adjusted summary prevalence was 1.4%. Meta-regression demonstrated that age of the participants was statistically significantly related to the prevalence; other factors did not influence the prevalence or heterogeneity. CONCLUSION: The summary prevalence of ID in India was established to be 2% taking into consideration the individual prevalence studies over the last six decades. This knowledge should improve the existing disability and mental health policies, national programs and service delivery to reduce the national and global burden associated with ID.

Psychological treatments in intellectual disability: the challenges of building a good evidence base.

Psychological treatments are widely used for the management of mental health and behavioural problems in people with intellectual disabilities. The evidence base, including the cost-effectiveness of such interventions, is limited. This editorial explores the current evidence base and analyses its strengths and limitations. The editorial also highlights current problems in conducting randomised controlled trials in this area and suggests a way forward.

Diagnostic accuracy and clinical utility of non-English versions of Edinburgh Post-Natal Depression Scale for screening post-natal depression in India: A meta-analysis.

BACKGROUND: The prevalence of post-natal depression (PND) is high in India, as it is in many other low to middle income countries. There is an urgent need to identify PND and treat the mother as early as possible. Among the many paper and pencil tests available to identify PND, the Edinburgh Postnatal Depression Scale (EPDS) is a widely used and validated measure in India. However, the summary diagnostic accuracy and clinical utility data are not available for this measure. AIM: To establish summary data for the global diagnostic accuracy parameter as well as the clinical utility of the non-English versions of the EPDS in India. METHODS: Two researchers independently searched the PubMed, EMBASE, MEDKNOW and IndMED databases for published papers, governmental publications, conference proceedings and grey literature from 2000-2018. Seven studies that evaluated the diagnostic accuracy of EPDS in five Indian languages against DSM/ICD were included in the final analysis. Two other investigators extracted the Participants' details, Index measures, Comparative reference measures, and Outcomes of diagnostic accuracy data, and appraised the study quality using QUADS-2. Deek's plots were used to evaluate publication bias. We used the area under the curve of the hierarchical summary area under the receiver operating characteristic curve, with the random effect model, to summarize the global diagnostic accuracy of EPDS. Using the 2 × 2 table, we calculated positive and negative likelihood ratios. From the likelihood ratios, the Fagan's nomogram was built for evaluating clinical utility using the Bayesian approach. We calculated the 95% confidence interval (95%CI) whenever indicated. STATA (version 15) with MIDAS and METANDI modules were used. RESULTS: There was no publication bias. The area under the curve for EPDS was 0.97 (95%CI: 0.95-0.98). The pre-test probability for the nomogram was 22%. For a positive likelihood ratio of 9, the positive post-test probability was 72% (95%CI: 68%, 76%) and for a negative LR of 0.08, the negative post-test probability was 2% (95%CI: 1%, 3%). CONCLUSION: In this meta-analysis, we established the summary global diagnostic parameter and clinical utility of the non-English versions of the EPDS in India. This work demonstrates that these non-English versions are accurate in their diagnosis of PND and can help clinicians in their diagnostic reasoning.

Nutritional status, cognitive achievement, and educational attainment of children aged 8-11 in rural South India.

BACKGROUND: Malnutrition among children is one of the most pressing health concerns middle- and low-income countries face today, particularly those in Sub-Saharan Africa and South Asia. Early-life malnutrition has been shown to affect long-term health and income. One hypothesized channel linking early-life malnutrition and long-term outcomes is cognitive development. However, there is limited empirical evidence on the relationship between nutritional status and cognitive achievement in middle childhood. STUDY DESIGN: As part of the South India Community Health Study (SICHS), we collected educational attainment and anthropometric data from 1,194 children in rural Vellore district of Tamil Nadu, India, and assessed their math and reading skills. We analyzed the relationship between continuous and binary anthropometric measures of nutritional status and three measures of cognitive achievement (reading, math, and grade level), adjusting for potential confounders, using a regression framework. RESULTS: Lower height-for-age and weight-for-age and their corresponding binary measures (stunting, underweight) were associated with lower reading scores, lower math scores, and lower grade level, with the exception of the association between weight-for-age and reading, which was marginally significant. A stunted child had one-third of a grade disadvantage compared to a non-stunted counterpart, whereas an underweight child had one-fourth of a grade disadvantage compared to a non-underweight counterpart. Lower BMI-for-age was associated with grade level and marginally associated with lower math scores, and its binary measure (thinness) was marginally associated with lower math scores. CONCLUSIONS: Acute and chronic malnutrition in middle childhood were negatively associated with math scores, reading scores, and educational attainment. Our study provides new evidence that cognitive achievement during middle childhood could be an important mechanism underlying the association between early-life malnutrition and long-term wellbeing.

Can only intelligent children do mind reading: The relationship between intelligence and theory of mind in 8 to 11 years old.

BACKGROUND: The mind reading ability of children has evoked wide interest, but its relationship with general cognitive abilities remains obscure. METHODS: We studied the relationship between the mind reading ability and general intelligence. Children (N = 105) between 8 to 11 years from educational institutions were assessed for the mind reading ability using Picture Sequencing Task and Unexpected Contents Theory of Mind task. We used Strengths and Difficulties Questionnaire to rule out psychiatric morbidity. An independent investigator quantified intelligence and adaptive behavior with Binet- Kamat Test of intelligence and Vineland Adaptive Behavior Scale respectively. We employed bivariate and multivariate statistical tests. RESULTS: We demonstrated that mind reading ability was not significantly related to general intelligence or its domains except for the social intelligence after controlling the confounders methodologically and statistically. CONCLUSION: These findings argue that mind reading skill exists as an independent cognitive domain and has clinical, research as well as educational implications.

Validation of a measure to assess Post-Traumatic Stress Disorder: a Sinhalese version of Impact of Event Scale.

BACKGROUND: There is paucity of measures to conduct epidemiological studies related to disasters in Sri Lanka. This study validates a Sinhalese translation of the Impact of Event Scale- 8 items version (IES-8) for use in Sri Lanka. METHODS: This cross-sectional validation study was conducted in the densely populated rural area of Tangalle in the Southern province of Sri Lanka. The English version of the IES-8 after translation procedures in to Sinhalese was administered by trained raters to a community sample of 30 survivors of tsunami aged 13 years and above. Diagnostic accuracy, reproducibility and validity of the translated IES was assessed in terms of sensitivity, specificity, predictive values, likelihood ratios, diagnostic odds ratio, inter-rater reliability, internal consistency, criterion validity and construct validity. RESULTS: The cut-off score of 15 gave a fair sensitivity (77%) for screening along with other components of diagnostic accuracy. The inter-rater reliability was high (0.89). The internal consistency for the whole scale was high (0.78) with a high face and content validity. The criterion validity was high (0.83) and the construct validity demonstrated the two factor structure documented in the literature. CONCLUSION: This study demonstrates that this Sinhalese version of the Impact of Event Scale has sound diagnostic accuracy as well as psychometric properties and makes it an ideal measure for epidemiological studies related to natural and man made disasters in Sri Lanka.

Prevalence of depression and past suicide attempt in primary care.

BACKGROUND: It is known that persons who die by suicide commonly visit a primary care physician (PCP) shortly before the fatal act.There is little information on history of suicide attempt in depressed patients who consult PCPs for non-mental health indications.This information is important because past history of suicide attempt is a known predictor of future suicide risk. OBJECTIVE: To estimate the prevalence of depression among outpatients in primary care and to determine the prevalence and determinants of past suicide attempt among them. METHOD: This cross-sectional study was conducted in six primary care settings, both public and private, in Kerala, India. A psychiatrist evaluated adult outpatients (n=827), diagnosed depression using ICD-10 Diagnostic Criteria for Research, and elicited history of suicide attempt. RESULTS: Overall depression prevalence was 27.2% and was higher in women. Past suicide attempt was identified in 6.9% (95% CI, 5.17-8.63%) of all outpatients; higher in women (9.2%) than men (3.6%). Among the depressed, 21.3% had previously attempted suicide; while this figure was 1.5% in the non-depressed. The prevalence of current depression was 81% (severe depression, 61%) in patients reporting past suicide attempts. In univariate analyses, female gender, perceived financial stress, and being depressed were significantly associated with past suicide attempts. In multivariate analysis, current depression was the largest predictor of past suicide attempt (adjusted odds ratio, 14.3; 95% CI, 6.60-31.07). CONCLUSION: Depression and suicide attempt are both common in primary care. Depression is the single most important predictor of suicide attempt.

Primary care Screening Questionnaire for Depression: reliability and validity of a new four-item tool.

BACKGROUND: Unidentified depression in primary care is a public health concern, globally. There is a need for brief, valid and easily administered tools in primary care. AIMS: To estimate reliability and validity of the newly developed Primary care Screening Questionnaire for Depression (PSQ4D), a four-item tool, with 'yes' or 'no' options. METHOD: PSQ4D was administered verbally (time required, <1 min) by primary care physicians to adult outpatients (n=827) in six primary care settings in Kerala, India. A psychiatrist evaluated each patient on the same day, using ICD-10 Diagnostic Criteria for Research, based on unstructured clinical interview. RESULTS: The Cronbach's alpha for internal consistency reliability was 0.80; kappa coefficient for test-retest reliability was 0.9 and that for interrater reliability was 0.72. At a score ≥2, sensitivity was 0.96, specificity was 0.87, positive predictive value was 0.74, negative predictive value was 0.98, positive likelihood ratio was 7.4 and negative likelihood ratio was 0.05. CONCLUSIONS: When physician administered, PSQ4D has good reliability. At a cut-off score of ≥2, it has high sensitivity and specificity to identify depressive disorder in primary care. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Self-injurious behavior to the lower extremities among children with atypical development: a diagnostic and treatment algorithm.

Self-injurious behavior is a devastating and persistent condition that results in severe tissue damage, permanent impairment, or, occasionally, death. This aberrant behavior seen in specific childhood syndromes is compounded when the lower limbs are injured. Secondary complications are more frequent, depending on the site of the injury, resulting in significant morbidity and depletion of hospital resources. A substantial body of empirical evidence indicates that this deviant behavior is partly learned and partly of biologic origin. Therefore, this article presents a case study and reviews the components of a biopsychosocial paradigm of treatment for self-inflicted wounds to the lower extremity and formulates a prototypical algorithm for its diagnosis and management.

Comparison of the Diagnostic Accuracy and Validity of a Short Version of Teen Screen Questionnaire-Mental Health (TSQ -M-Short) for Use in Community.

BACKGROUND: A few self-administered questionnaires are available for assessing mental health among adolescents in primary-care settings. Brief measures are desirable for use in big-data, epidemiological studies. OBJECTIVES: To evaluate a 7-item version, of the Teen Screen Questionnaire-Mental Health (TSQ-M), the TSQ-M-Short. MATERIALS AND METHODS: In this prospective cross-sectional study of 140 adolescents, recruited from 6 rural or urban schools, the newly developed TSQ-M-Short as the measure for validation and General Health Questionnaire-12 item (GHQ-12) as the gold standard measure were administered by independent trained raters. Tests for diagnostic accuracy and validity were conducted. RESULTS: A total TSQ-M-Short score of ≥ 6 had a sensitivity of 76%, specificity of 74%, positive likelihood ratio of 2.99, negative likelihood ratio of 0.33, positive predictive value of 6% and a negative predictive value of 82.1%. The area under curve (AUC) in the Receiver Operating Characteristic (ROC) for the TSQ-M-Short version was 0.84 (95% cumulative incidence (CI) = 0.76-0.89). The AUC for the TSQ-M-Short version was higher than the AUC for the original version, and the difference between the areas was 0.10 (95% CI = 0.02-0.19), which was statistically significant (z = 2.49; P = 0.01). The internal consistency of TSQ-M-Short, as measured by chronbach's α, was 0.34 (95% CI = 0.15-0.48). The construct validity demonstrated a 3-factor structure, which explained 55% of the variance. CONCLUSION: The TSQ-M-Short has an overall diagnostic accuracy which is better than the original TSQ-M. Although the original version includes symptoms for more mental health disorders, providing a wider screen. This short version will prove useful in big-data studies.

Complementary psychosocial interventions in child and adolescent psychiatry: pet assisted therapy.

Pet assisted therapy (PAT) is a form of complementary psychosocial intervention used in the field of mental health and disability. The form of therapy has the potential to augment the other forms of psychotherapies and pharmacotherapy. This article is an overview of history and clinical origins of PAT, classification and therapy models, scientific basis, the current use in specific disorders, preventive and diagnostic role as well as the potential risks among children and adolescents with mental health needs with a special focus on the Indian needs. A systematic electronic search strategy was undertaken to identify the intervention effectiveness of PAT in MedLine (PubMed), cochrane database of systematic reviews, high-wire press and Google Scholar. We augmented our electronic search with a search of additional articles in reference lists of retrieved articles, as well as a hand search available journals that were not indexed in any electronic database in consultation with colleagues and experts. To qualify for inclusion, studies were required to meet predetermined criteria regarding study design, study population, interventions evaluated and outcome measured to reduce the publication bias.

CDC Kerala 10: Diagnostic accuracy of the severity scores for childhood autism rating scale in India.

OBJECTIVE: To document the diagnostic accuracy of the Childhood Autism Scale (CARS) thresholds to identify mild, moderate and severe autism in India. METHODS: The CARS scores of 623 children, with and without autism were compared against the Diagnostic and Statistical Manual for Mental Disorders 4th edition (DSM-IV-TR) for ASD diagnosis and clinical consensus between two developmental paediatricians as the reference standard for autism severity using the Receiver operating characteristics (ROC) curve analyses and contingency tables. RESULTS: The CARS total score for mild, moderate and severe autism ranged from 30.5 to 35, 35.5-40 and ≥40.5 respectively in this study. The overall diagnostic accuracy of CARS total score in the mild range was moderate [AUC = 0.68 (95%CI = 0.62-0.88), z = 1.34; P = 0.18], moderate range was high [AUC = 0.90 (95%CI = 0.77-0.97), z = 8.62; P = 0.0001] and severe range was also high [AUC = 0.85 (95%CI = 0.77-0.90), z = 7.09; P = 0.0001]. CONCLUSIONS: There are validated severity scores for Childhood Autism Rating Scale for clinical and research use in India.

A meta-analysis of the diagnostic accuracy of Autism Diagnostic Observation Schedule Module-1 for autism spectrum disorders.

OBJECTIVE: Autism Diagnostic Observation Schedule (ADOS) is considered gold standard for the diagnosis of Autism Spectrum Disorders (ASD). The authors evaluated the cumulative diagnostic accuracy of ADOS-Module 1 (ADOS(M1)) using the original diagnostic algorithm with meta-analysis and meta-regression. METHODS: The authors, electronically and manually searched for studies from 1999 to 2013 that evaluated the accuracy of ADOS(M1) using the original diagnostic algorithm in detecting ASD. Primary results of Sensitivity (Sn), Specificity (Sp) and Diagnostic Odds Ratio (DOR) for ADOS(M1) were summarized using random-effects model. Summary Receiver Operating characteristic Curves and its Area Under the Curve (SROC-AUC) were used to summarize overall diagnostic accuracy of ADOS(M1). The modifying effects of quality of study and sample size, on the diagnostic odds ratio, were investigated using meta-regression. RESULTS: A total of 7 cross-sectional studies provided data on 4057 children. The pooled Sn, Sp, DOR and SROC-AUC for the overall diagnostic accuracy of ADOS (M1) were: 0.91 (95 %CI=0.89 to 0.93), 0.73 (95 % CI=0.69 to 0.76), 44.20 (95 %CI=15.89 to 122.95) and 0.90 respectively [corrected]. Meta-regression analysis showed a non-significant relationship between ADOS(M1) and study quality as well as sample size. There were subgroup differences in the DOR. CONCLUSIONS: It is concluded that ADOS (M1) with the original diagnostic algorithm has the overall diagnostic accuracy and pooled specificity suggesting moderate accuracy. The pooled sensitivity is high to be used as a screening test for Autism Spectrum Disorders. ADOS( M1)with the revised diagnostic algorithm should be used for diagnostic purpose [corrected] ADOS(M1) with the revised diagnostic algorithm should be used instead for the diagnosis of this group of disorders.

CDC Kerala 12: Socio-demographic factors among children (2-6 y) with autism--a case control study.

OBJECTIVES: To compare the socio-demographic factors among children between 2 and 6 y of age with autism and a control group of normal children. METHODS: One hundred forty three confirmed cases of 2-6 y-old children with autism, attending autism clinic of Child Development Centre, who had a CARS score of more than 30 were included in the study. Two hundred normal children in the same age group were recruited from the well-baby/immunization clinic of SAT Hospital, Thiruvananthapuram. Data was collected using a structured pre-piloted questionnaire consisting of 11 socio-demographic possible risk factors. RESULTS: The multivariate analysis on socio-demographic characteristics as possible risk factors for autism has shown that (i) upper and upper middle socioeconomic status (OR: 7.13; CI: 3.26-15.57) and (ii) male gender (OR: 3.95; CI: 2.22-7.04) were significant risk factors for autism, whereas place of residence, rural (OR: 0.41; CI: 0.24-0.68) is a protective factor. CONCLUSIONS: This case control study involving 143 children between 2 and 6 y with autism as per CARS criteria and a control group of 200 normal children has shown that upper and upper middle socioeconomic status and (ii) male gender are significant risk factors for autism, whereas place of residence, rule is a protective factor.

CDC Kerala 8: Effectiveness of a clinic based, low intensity, early intervention for children with autism spectrum disorder in India: a naturalistic observational study.

OBJECTIVE: To document the effectiveness of low intensity, clinic based intervention models for Autism Spectrum Disorders (ASD) in countries with low disability resources. METHODS: Thirty-nine participants with a mean (SD) of 36.03(11.15) mo were assessed before and after intervention with Childhood Autism rating scale (CARS), and at baseline with the Denver Developmental Screening Test for quantifying the effectiveness of the clinic-based intervention in ameliorating autism symptoms and studying the effect of developmental disability respectively. Developmental therapists in the clinic gave low-intensity group intervention for 45-60 min to the child through mother and encouraged to continue the training, for 3-4 h, at home to address the specific goals in the three ASD symptom clusters. Most of the children were also placed in play-schools. Follow-up support was given either on a weekly, fortnightly or monthly basis. Data was analyzed using appropriate bivariate and multivariate techniques. RESULTS: There was amelioration in the severity of autism after intervention, which was statistically and clinically significant. Intervention was useful to help children with mild to severe autism. CONCLUSIONS: Low-intensity, clinic-based intervention can be effectively used in situation where there is paucity of disability resources.

CDC Kerala 14: Early child care practices at home among children (2-6 y) with autism--a case control study.

OBJECTIVES: To compare early child care practices at home as possible risk factors among children between 2 and 6 y of age with autism and a control group of normal children without any symptom of autism, presenting at the well-baby/immunization clinic. METHODS: This case control study was undertaken at the autism clinic of CDC Kerala, comparing possible risk factors for autism among 143 children between 2 and 6 y with autism as per CARS criteria and a control group of 200 normal children of the same age from well-baby/immunization clinic of SAT hospital. The data was collected using a structured pre-piloted questionnaire, which included 11 questions administered by the same senior social scientist, on early child care practices at home that have been universally considered as important for child development. RESULTS: On multivariate analysis on early child care practices at home as possible risk factors for autism, it was observed that statistically significant high odds ratios were present for (i) no outings (OR = 3.36; 95% CI: 1.39-8.16; p 0.007); (ii) child does not play with children of same age (OR = 19.57; 95% CI: 9.50-40.32); (iii) do not tell stories/sing songs to the child (OR = 3.21; 9 % CI: 1.61-6.41); and (iv) breastfeeding duration nil/ < 6 mo (OR = 3.40; 95% CI: 1.28-8.99). CONCLUSIONS: This case control study involving 143 children between 2 and 6 y with autism as per CARS criteria and a control group of 200 normal children has shown that early child care practices at home, specifically breastfeeding duration nil/ < 6 mo, child does not play with children of same age, do not tell stories/sing songs to the child and no outings for the child are possible risk factors for autism.