Neurodevelopmental Disorders

Neurodevelopmental disorders are a group of conditions that begin early in life and follow
a persistent course. They are believed to arise from disruptions in normal brain
development (Andrews et al., 2009; Insel, 2014). These disorders affect cognition,
behavior, and social functioning and often require long-term support.
Intellectual Disability (Intellectual Developmental Disorder)

• Intellectual disability (also called intellectual developmental disorder) involves

deficits in general mental abilities, including: Reasoning, Problem solving, Planning,
Abstract thinking, Judgment, Academic learning & Learning from experience
• For a diagnosis, these difficulties must begin before age 18 (APA, 2013). The disorder
is based on impairments in both:
1. Intelligence, and
2. Level of performance.

• Any similar impairment that starts after age 17 is called dementia, not intellectual
disability. This distinction matters because the experiences and challenges of
someone who loses intellectual abilities after maturity are very different from
someone who had low intellectual functioning throughout development.
• Intellectual disability is found among children around the world (Fryers, 2000). In
severe cases, it places significant emotional, social, and economic burdens on
families and communities.
Legal Classification
Most U.S. states classify individuals as “mentally retarded” (older terminology) if:
• Their IQ is below 70, and
• They show social incompetence or persistent problematic behavior.
Some individuals in these categories may be placed in institutions if considered
unmanageable.
Age of Diagnosis
Initial diagnoses most commonly occur:
• Ages 5–6: when formal schooling begins
• Peak at age 15
• Sharp decline after adolescence
These trends reflect increases in life demands during school years.
Course and Functioning
Mild Intellectual Disability
Most individuals with intellectual disability fall into the mild range. During early childhood:
• They often appear normal.
• Difficulties become noticeable when schoolwork begins and problems emerge,
leading to evaluation.
Education and Adaptation
With appropriate facilities and support:
• Children can learn basic academic skills.
• They usually attain a satisfactory level of social adaptability.
Adult Adjustment
After the school years:
• Many individuals adjust reasonably well in the community.
• As a result, they may no longer be identified as having an intellectual disability.
Levels of Intellectual Disability
The different levels of intellectual disability are explained
below.
1. Mild Intellectual Disability
IQ Range
• IQ between 50–55 and 70 (more than two
standard deviations below the mean).
• This is the largest group among all diagnosed
cases.
Intellectual and Educational Characteristics
• Considered educable in school settings.
• Adult intellectual functioning is similar to that of
an average 8- to 11-year-old.
• However, mental age comparisons should not be
taken too literally:
o Adults may differ from children in information-processing speed and ability.
o Their wider life experience can influence test performance.
Social Adjustment
• Social functioning often resembles that of adolescents, but with: Less imagination ,
Less inventiveness, Poorer judgment
Physical and Behavioral Profile
• Usually no signs of brain damage or physical abnormalities.
• May need some supervision due to limited ability to foresee consequences.
Outcome
With early diagnosis, parental support, and special education:
• Most individuals can learn basic academic and work skills.
• They can adjust socially and become partially or fully self-supporting (Maclean,
1997).
2. Moderate Intellectual Disability
IQ Range
• IQ between 35–40 and 50–55.
Intellectual Characteristics
• Adult intellectual level is similar to that of average 4- to 7-year-old children.
• Learning is slow, and conceptual thinking is very limited.
Academic and Communication Abilities
• Some may learn basic reading and writing.
• Can acquire simple spoken language, though with difficulty.
Physical Features
• Often appear clumsy, with:
o Bodily deformities
o Poor motor coordination
Outcome
With proper diagnosis, parental support, and training:
• Many can achieve partial independence in:
o Daily self-care
o Acceptable behavior
o Living in a family or sheltered environment
• Can learn routine skills like cooking or low-level maintenance work with special
instruction.
3. Severe Intellectual Disability
IQ Range
• IQ between 20–25 and 35–40.
Functional Characteristics
• Common difficulties include:
o Impaired speech development
o Sensory defects
o Motor handicaps
Self-Help Abilities
• Can develop limited personal hygiene and self-help skills.
• Always require significant dependence on others.
Outcome
• Can benefit from training.
• May be able to perform simple tasks under close supervision.
4. Profound Intellectual Disability
IQ Range
• IQ below 20–25.
Adaptive and Intellectual Functioning
• Severe impairment in adaptive behavior.
• Can learn only the simplest tasks.
• Speech, if it develops at all, is minimal.
Physical Conditions
• Frequently show:
o Physical deformities
o Central nervous system (CNS) abnormalities
o Very delayed growth
• Common issues include: Seizures, Mutism, Deafness, Other physical anomalies
Life Expectancy and Care
• Require lifelong custodial care.
• Often have poor health and low resistance to disease, leading to shorter life
expectancy.
Diagnosis
• Severe and profound cases are typically diagnosed in infancy due to:
o Noticeable physical abnormalities
o Extremely delayed development (e.g., difficulty taking solid food)
o Clear symptoms of severe impairment
DSM-5 Criteria
Intellectual developmental disorder (intellectual disability) is a disorder with onset during
the developmental period that includes both intellectual and adaptive functioning deficits in
conceptual, social, and practical domains. The following three criteria must be met:
A. Deficits in intellectual functions, such as reasoning, problem solving, planning,
abstract thinking, judgment, academic learning, and learning from experience,
confirmed by both clinical assessment and individualized, standardized intelligence
testing.
B. Deficits in adaptive functioning that result in failure to meet developmental and
sociocultural standards for personal independence and social responsibility. Without
ongoing support, the adaptive deficits limit functioning in one or more activities of
daily life, such as communication, social participation, and independent living, across
multiple environments, such as home, school, work, and community.
C. Onset of intellectual and adaptive deficits during the developmental period.

Epidemiology
Prevalence
Global data:
• According to a 2019 systematic analysis, about 107.6 million individuals globally had
ID — representing ≈ 1.39% of the global population.
• Broader meta-analyses of population-based studies suggest a global prevalence
ranging between 1% and 3% depending on criteria and study design
Indian data:
• A 2022 meta-analysis of 19 studies over six decades estimated a “summary
prevalence” of ID in India at 2% (95% CI: 2–3%); after adjustment, the figure was ≈
1.4%.
• Earlier data from a large-scale Indian rural/urban sample (2002 NSSO) reported an ID
prevalence of 10.5 per 1,000 (~ 1.05%) overall — with urban slightly higher than rural
(11/1,000 vs. 10.08/1,000).
Age of Onset
Global data:
• By definition (as per clinical guidelines), ID has its onset during development, i.e.,
generally before adulthood. Systematic burden studies assume developmental onset
for ID
• For example, in analyses of preterm-associated developmental intellectual disability
in children/adolescents (0–19 years), onset is naturally early
Indian data:
• Indian epidemiological studies and reviews rely on the same conceptualization: ID
refers to deficits with onset during the developmental period (childhood or
adolescence), not adult-onset impairments.
• Prevalence estimates often cover wide age ranges (children and adults), but
underlying assumption remains developmental onset.
Gender Differences
Global data:
• The 2019 global analysis found a slight male predominance: about 54.9 million males
(≈ 1.42%) versus 52.7 million females (≈ 1.37%) with ID.
• The modest male: female difference is consistent with earlier international reviews of
ID prevalence.
Indian data:
• A 2023 household-level study estimated prevalence per 100,000: 179 (95% CI: 173–
185) for males and 120 (95% CI: 115–125) for females, indicating a significant gender
gap.
• The same study noted that the gender difference narrows with higher education
levels and is more pronounced at younger ages and lower-income households —
suggesting under-reporting or under-identification among females
Comorbidity
Global data:
• Global burden data and reviews note that a substantial proportion of individuals with
ID also accompany other developmental or neurological conditions (e.g., from birth-
related risks, congenital disorders) — especially in low- and middle-income regions.
• For instance, a 2021 study of preterm-associated developmental intellectual
disability (PDID) found high prevalence of ID among children/adolescents born
preterm, with YLDs indicating ongoing disability burden.
Indian data:
 • The 2022 meta-analysis highlighted that ID constitutes a significant portion of the
burden of mental and developmental disorders in India; among mental disorders, ID
ranks third in terms of disability-adjusted life years (DALYs), after depressive and
anxiety disorders.
• Indian field studies and national surveys also suggest frequent co-occurrence of ID
with other neurodevelopmental, neurological, or psychiatric conditions — though
comprehensive national-level comorbidity data remain limited.
Organic Intellectual Disabilities
Organic intellectual disabilities are forms of intellectual disability caused by biological or
physiological factors, such as genetic abnormalities, metabolic disorders, or brain
malformations/injury.
They include several well-known clinical types:
1. Down Syndrome
• Cause: Usually trisomy 21 (an extra chromosome 21).
• Prevalence: About 5.9 per 10,000 in the general population.
• Key Features:
o Almond-shaped eyes, flat and broad face, thick eyelids, short/broad neck &
hands.
o Tongue appears large; speckled iris.
• Course:
o Irreversible intellectual impairment, especially in language skills.
o Higher risk of respiratory infections and early-onset dementia/Alzheimer’s.
o Life expectancy has improved due to medical care.
2. Phenylketonuria (PKU)
• Cause: Genetic metabolic disorder—absence of a liver enzyme needed to break
down phenylalanine.
• Prevalence: ~ 1 in 12,000 births.
• Key Points:
o Baby appears normal at birth; symptoms show by 6–12 months.
o If phenylalanine builds up → brain damage → intellectual disability.
o Symptoms: light skin/hair, seizures, motor issues, eczema.
• Treatment:
 o Early screening + strict low-phenylalanine diet → prevents disability.
o Must be started before 6 months for best outcome.
3. Cranial Anomalies
Conditions where head size/brain growth is abnormal, leading to intellectual disability.
a. Macrocephaly
• Large head/brain due to abnormal glial cell growth.
• Symptoms: vision problems, convulsions, neurological deficits.
b. Microcephaly
• Small head size (more than 3 SD below normal) due to reduced brain growth.
• Causes: genetic factors, brain damage in utero, maternal infections, birth
complications.
• Leads to severe–profound ID, very limited language, developmental delays.
c. Hydrocephaly
• Excess cerebrospinal fluid in the skull → pressure on brain.
• Causes: congenital issues or blockage after birth (e.g., tumor, infection).
• Features: enlarged head, visual/hearing impairment, seizures, intellectual disability.
• Treatment: shunt surgery to drain fluid; early treatment prevents severe damage.

Attention-Deficit/Hyperactivity Disorder (ADHD)

• ADHD is a neurodevelopmental disorder marked by persistent problems with

sustaining attention, impulsiveness, and excessive or exaggerated motor activity.
• While occasional inattention or bursts of energy are normal in children, ADHD is
diagnosed only when these symptoms are frequent, long-lasting, and cause
impairment at home, school, or work (See DSM-5 criteria).

Cognitive and Academic Difficulties

Intellectual and Neuropsychological Issues

• Children with ADHD often perform 7–15 points lower on IQ tests (Barkley, 1997).
They also show neuropsychological deficits linked to poor academic performance
(Biederman et al., 2004).

Learning and School-Related Problems

 • Many children with ADHD have specific learning disabilities, such as difficulties with
reading or other basic academic skills. They are also at higher risk for school-related
issues like suspension or repeating grades, mostly because of disruptive behaviors
(Kessler et al., 2014).

Social Impairment

• Symptoms frequently cause social difficulties. Hyperactive children may struggle to

follow rules, leading to conflicts with parents, and their behavior can cause peers to
view them negatively (Hoza et al., 2005).

DSM-5 Criteria

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with

functioning or development, as characterized by (1) and/or (2):

1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months
to a degree that is inconsistent with developmental level and that negatively impacts
directly on social and academic/occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, defiance,
hostility, or failure to understand tasks or instructions. For older adolescents and adults (age
17 and older), at least five symptoms are required.

a. Often fails to give close attention to details or makes careless mistakes in

schoolwork, at work, or during other activities (e.g., overlooks or misses details,
work is inaccurate).

b. Often has difficulty sustaining attention in tasks or play activities (e.g., has
difficulty remaining focused during lectures, conversations, or lengthy reading).

c. Often does not seem to listen when spoken to directly (e.g., mind seems
elsewhere, even in the absence of any obvious distraction).

d. Often does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the work place (e.g., starts tasks but quickly loses focus and is
easily sidetracked).

e. Often has difficulty organizing tasks and activities (e.g., difficulty managing
sequential tasks; difficulty keeping materials and belongings in order; messy,
disorganized work; has poor time management; fails to meet deadlines).

f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained

mental effort (e.g., schoolwork or homework; for older adolescents and adults,
preparing reports, completing forms, review ing lengthy papers).

g. Often loses things necessary for tasks or activities (e.g., school materials, pencils,
books tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
 h. Is often easily distracted by extraneous stimuli (for older adolescents and adults,
may include unrelated thoughts).

i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older
adolescents and adults, returning calls, paying bills, keeping appointments).

2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for
at least 6 months to a degree that is inconsistent with developmental level and that
negatively impacts directly on social and academic/ occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, defiance,
hostility, or a failure to understand tasks or instructions. For older adolescents and adults
(age 17 and older), at least five symptoms are required.

a. Often fidgets with or taps hands or feet or squirms in seat.

b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his
or her place in the class room, in the office or other workplace, or in other situ ations
that require remaining in place).

c. Often runs about or climbs in situations where it is inappropriate. (Note: In

adolescents or adults, may be limited to feeling restless.)

d. Often unable to play or engage in leisure activities quietly.

e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or

uncomfortable being still for extended time, as in restaurants, meetings; may be
experienced by others as being restless or difficult to keep up with).

f. Often talks excessively.

g. Often blurts out an answer before a question has been completed (e.g., completes
people’s sentences; cannot wait for turn in conversation).

h. Often has difficulty waiting his or her turn (e.g., while waiting in line).

i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or

activities; may start using other people’s things without asking or receiving per
mission; for adolescents and adults, may intrude into or take over what others are
doing).

B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12

years.

C. Several inattentive or hyperactive-impulsive symptoms are present in two or more

settings (e.g., at home, school, or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social,
academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of schizophrenia or another
psychotic disorder and are not better explained by another mental disorder (e.g., mood
disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication
or withdrawal).

Epidemiology
Prevalence

• ADHD occurs in about 9% of children and adolescents (Merikangas et al., 2010).

Although not the most common disorder in youth (specific phobia is 19%), ADHD is
most often diagnosed by professionals (Ryan-Krause et al., 2010), likely because
disruptive symptoms prompt parents to seek help more often.
• Indian studies estimate ADHD prevalence to range from 1.6% to 12% in community
samples and 5–15% in school-based samples. Large studies such as INCLEN (2015)
report a prevalence of around 7–9% among Indian children.

Gender Differences

• ADHD is more common in boys (13%) than girls (4%) (Merikangas et al., 2010).
• Consistent with global trends, ADHD in India is more common in boys, with male-to-
female ratios ranging from 2:1 to 4:1. Boys are more often diagnosed because
disruptive symptoms are more likely to be noticed by parents and teachers.

Age of Onset

• ADHD in India typically has its onset between 3–7 years of age, similar to global
patterns. Most cases are first identified when children begin formal schooling, where
academic and behavioral demands increase.

Comorbidity

Common Comorbidities

• ADHD is frequently comorbid with other externalizing disorders such as Oppositional

Defiant Disorder (ODD) and Conduct Disorder (CD) (Beauchaine et al., 2010; Frick &
Nigg, 2012).
• Indian research shows high comorbidity of ADHD with learning disabilities,
oppositional defiant disorder, conduct problems, anxiety, and emotional disorders.
Studies report that 40–60% of Indian children with ADHD have at least one
additional psychiatric condition.

Cross-Cultural Occurrence
 • ADHD occurs across cultures worldwide. For example, a large study of 1,573 children
in 10 European countries found that ADHD symptoms are similarly recognized across
nations and associated with impairments in many areas of functioning (Bauermeister
et al., 2010).

ADHD Beyond Adolescence

Continuation Into Adulthood

• Research from the United States and other countries shows that about half of
children diagnosed with ADHD continue to meet criteria in adulthood (Kessler,
Green, et al., 2010; Lara et al., 2008). This indicates that ADHD is not only a
childhood disorder but can persist across the lifespan.

Symptom Patterns in Adults

• In adulthood, ADHD symptoms shift in pattern. Inattention remains highly common

(95%), while hyperactivity is much less frequent (35%) (Kessler, Green, et al., 2010).
This means adults often struggle more with focus, planning, and organization than
with physical restlessness.

Prevalence in Adults

• Approximately 4% of adults in the United States meet criteria for ADHD, and the
condition is more frequently seen in men, individuals who are divorced, and those
who are unemployed (Kessler, Adler, et al., 2006). These demographic differences
highlight the broader social impact of adult ADHD.

Impact on Occupation

• ADHD in adulthood can significantly affect occupational functioning. People with

ADHD tend to miss more workdays—around 22 extra days per year—compared to
those without ADHD (de Graaf et al., 2008). This may result from difficulty finding
suitable work, poor work performance, or absenteeism, demonstrating the long-
term functional impairment associated with the disorder.

Specific learning Disorder

Learning disorders refer to delays in cognitive development involving language, speech,

mathematical abilities, or motor skills. These difficulties cannot be explained by physical or
neurological defects.

Types of Learning Disorders

1. Dyslexia (Most Common)

• Involves reading/writing difficulties.

 • Problems include word recognition, reading
comprehension, poor spelling, and weak memory.
• Errors such as omissions, additions, distortions of
words are common.
• Reading is often very slow and effortful.

Diagnostic Features

When Is a Learning Disorder Diagnosed?

• Only when there is clear impairment in school

performance or daily functioning.
• The impairment cannot be due to:
o Intellectual disability
o Autism spectrum disorder
o ADHD (skill deficits due to ADHD are diagnosed separately)

Attention Issues

• Some experts believe attention deficits contribute to learning disorders, but

evidence is inconclusive.

Prevalence and Gender Differences

• Learning disorders affect approximately 1 in 59 individuals (about 4.6 million in the

U.S.).
• More boys than girls are diagnosed, although the degree of difference varies across
studies.

Identification in School Settings

Children are typically identified because of a mismatch between expected and actual
academic performance in subjects such as Reading , Writing, Spelling, Mathematics

Characteristics of Affected Children

• Have average or above-average IQ.

• Normal family and cultural backgrounds.
• Usually motivated, cooperative, and eager to learn in early schooling.
• Despite this, they consistently fail in academic tasks, often in puzzling and persistent
ways.

Psychological and Social Impact

Negative Outcomes
 • Rigid school systems can create severe emotional stress.
• Failure experiences often damage self-esteem and psychological well-being.
• These negative effects can persist into adulthood, affecting careers and adjustment.

Positive Outcomes

• Many individuals with learning disorders show high talent, creativity, and strong
motivation to succeed.
• Famous examples include:
o Winston Churchill
o Woodrow Wilson
o Nelson Rockefeller

These cases show that a learning disorder does not prevent exceptional achievement.

DSM-5 Criteria

A. Difficulty learning and using academic skills, as indicated by the presence of at least one
of the following symptoms that have persisted for at least 6 months, despite the provision
of interventions that target those difficulties:

1. Inaccurate or slow and effortful word reading (e.g., reads single words aloud incorrectly
or slowly and hesitantly, frequently guesses words, has difficulty sounding out words).

2. Difficulty understanding the meaning of what is read (e.g., may read text accurately but
not understand the sequence, relationships, inferences, or deeper meanings of what is
read).

3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants).

4. Difficulties with written expression (e.g., makes multiple grammatical or punctuation

errors within sentences; employs poor paragraph organiza tion, written expression of ideas
lacks clarity).

5. Difficulties mastering number sense, number facts, or calculation (e.g., has poor
understanding of numbers, their magnitude, and relationships; counts on fingers to add
single-digit numbers instead of recalling the math fact as peers do; gets lost in the midst of
arithmetic computation and may switch procedures.

6. Difficulties with mathematical reasoning (e.g., has severe difficulty applying mathematical
concepts, facts, or procedures to solve quantitative problems).

B. The affected academic skills are substantially and quantifiably below those expected for
the individual’s chronological age and cause significant interference with academic or
occupational performance, or with activities of daily living, as confirmed by individually
administered standardized achievement measures and comprehensive clinical assessment.
For individuals aged 17 years and older, a documented history of impairing learning
difficulties may be substituted for the standardized assessment.
C. The learning difficulties begin during school-age years but may not become fully manifest
until the demands for those affected academic skills exceed the individual’s limited
capacities (e.g., as in timed tests, reading or writing lengthy, complex reports for a tight
deadline, excessively heavy academic loads).

D. The learning difficulties are not better accounted for by intellectual disabilities,
uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial
adversity, lack of proficiency in the language of academic instruction, or inadequate
educational instruction.

Note: The four diagnostic criteria are to be met based on clinical synthesis of the individual’s
history (developmental, medical, family, educational), school reports, and
psychoeducational assessment. Specify if:

Epidemeology

Prevalence of SLD

Global Data

• Many reviews estimate that about 5–15% of school-aged children worldwide meet
criteria for SLD (reading, writing, or mathematics difficulties
• A meta-analysis of primary-school children globally estimated the prevalence of
developmental dyslexia (a type of SLD) at about 7.1% (95% CI: 6.27–7.97%).

🇮🇳 Indian Data

• A recent large meta-analysis found a pooled prevalence of SLD in Indian children and
adolescents of ~ 8% (95% CI: 4–11%). Other Indian studies report wide variation in
prevalence — from 2.16% to 30.77% depending on region, diagnostic methods, and
criteria.

Age of Onset / Typical Age Range of Detection

Global Data

• SLD is usually identified when children start formal education and fail to meet
expected academic performance, commonly by early school years (around ages 6–9).
This is when reading, writing, and arithmetic become structured academic demands.

🇮🇳 Indian Data

• In the 2023 meta-analysis of Indian studies, the median age of children diagnosed
with SLD was reported to be 6–12 years.
• This suggests that most cases are identified during primary to early middle school
years, when academic difficulties become evident.

Gender Differences
Global Data

• Many studies report a male predominance among children with SLD. For example, in
dyslexia, boys tend to be diagnosed more often than girls, with gender ratios often
around 2:1 in favor of males.
• Some more recent research has explored whether gender affects specific cognitive
profiles (e.g., working memory, processing speed) among children with SLD, with
modest gender differences observed in certain cognitive indices.

🇮🇳 Indian Data

• The 2022 meta-analysis reported pooled prevalence of SLD as 13.6% in boys vs 8.4%
in girls.
• This suggests that boys are more likely to be diagnosed with SLD in India, though as
with global data, this likely reflects a combination of true differences, diagnostic
practices, and possibly referral or detection biases.

Comorbidity / Associated Issues

Global Data

• SLD often co-occurs with other neurodevelopmental or psychiatric issues, especially

attention-deficit/hyperactivity disorder (ADHD), given overlap in attentional and
processing challenges.
• Children with SLD may also be at increased risk for emotional/behavioral difficulties,
low self-esteem, anxiety, and depression — especially when academic failure
persists without support.

🇮🇳 Indian Data

• In India, studies report frequent comorbidity of SLD with ADHD (particularly

inattentive type) and other neurodevelopmental or emotional/behavioral problems.
• Some research also notes fine-motor issues, delayed developmental milestones, and
higher rates of academic backwardness and psychosomatic complaints among
children with SLD

Cultural and Social Perspectives

1. Cultural Understanding of SLD

• Awareness of SLD varies across cultures; many still misunderstand learning

difficulties.
• Children are often wrongly labeled as lazy, careless, or unmotivated.
• Fear of judgment and lack of awareness prevent parents from seeking help.
• Inclusive school and community environments are essential for early support.

2. Cultural Attitudes in India

 • Academic success is strongly linked to intelligence, career, and family prestige.
• Children struggling academically are often blamed for poor motivation, disobedience,
or low ability instead of being assessed for SLD.
• Parents compare children with peers, leading to negative judgments.

Findings from Sahu et al. (2018)

• Parents had limited knowledge of SLD and negative attitudes towards the diagnosis.
• They misunderstood academic and emotional difficulties as attitude or
concentration problems.
• Children face low self-esteem, anxiety, and depression due to unmet expectations.
• After accepting the diagnosis, parents become more supportive.

3. Prevalence & Identification Differences Across Cultures

• Indian prevalence rates vary widely:

o 8% (Scaria et al., 2023)
o 12% (Srinath et al., 2005)
o 2.16%–30.77% (Joseph & Devu, 2022)
• Identification rates remain much lower, especially in rural/government schools.
• Causes: lack of screening, few trained professionals, and limited culturally suitable
tools.
• NIMHANS SLD Index is commonly used but cannot assess native language
proficiency.

4. Stigma and Its Impact

• Despite urban awareness, the “disability” label still carries strong stigma.
• Children may face peer rejection and social exclusion.
• Parents often avoid psychological services due to shame and fear of labeling.
• Stigma harms the mental well-being of both children and parents.
• Poor resources, untrained school staff, and low socioeconomic status worsen delays
in identification and intervention.

Autism Spectrum Disorder (ASD)

Autism spectrum disorder is a neurodevelopmental condition involving a wide range of

difficulties, including problems in language, perceptual and motor development, reality
testing, and social communication.

Autism was first described by Kanner (1943). It affects children across all socioeconomic
backgrounds.

Prevalence
Estimates suggest 30–60 cases per 10,000 children (Fombonne, 2005). A CDC report found
the rate to be 1 in 68 children (Baio, 2014).
The apparent rise in prevalence is believed to stem from changes in diagnostic practices,
increased awareness, and improved detection, not an actual increase in cases (Williams et
al., 2006).

Age of Onset and Early Identification

Typical Onset

Autism is usually identified before 30 months of age. Estimates show high diagnostic
stability—children diagnosed at age 2 are highly likely to maintain the diagnosis by age 9
(Lord et al., 2006).

Early Social Communication Signs

Research shows that early signs can appear within the first 6 months of life (Jones & Klin,
2014).

• Typically developing infants increasingly focus on faces and eyes from 2–6 months,
aiding social interaction.
• Infants later diagnosed with autism show a decline in eye contact beginning at 2
months, falling to half the typical level by 24 months.
• At the same time, they show increased attention to inanimate objects, reaching
double that of typical infants by 24 months.

Clinical Features of Autism Spectrum Disorder

Children with autism vary in their difficulties and abilities, but several characteristic
symptoms are commonly observed.

1. Social Deficits

A major sign is that the child appears aloof and disconnected, even in early infancy (Hillman
et al., 2007).
Parents often report that such infants:

• Do not enjoy cuddling

• Do not reach out when picked up
• Do not smile or make eye contact
• Do not respond to people coming and going

Emotional Expression

Contrary to early beliefs, children with autism do express emotions, but their difficulty lies in
social understanding and responding to cues (Jones et al., 2001).

Brain Differences
Neuroimaging shows:

• Reduced activity in the medial prefrontal cortex (mental-state understanding)

• Increased activity in ventral occipitotemporal areas (object perception) (Sigman et
al., 2006)

Attention and Sensory Issues

Children with autism often have difficulty orienting to sounds and may show unusual
responses to auditory stimuli—sometimes distressed by soft sounds yet unaware of loud
noises (Hillman et al., 2007).

2. Absence or Impairment of Speech

Children with autism do not learn well through imitation (Smith & Bryson, 1994),
contributing to:

• Absent or limited speech

• Speech that is not used for true communication
• Echolalia (repeating words like an echo), found in about 75% of affected children
(Prizant, 1983)

3. Self-Stimulation

Repetitive movements such as head banging, rocking, or spinning are common and may
continue for long periods.

4. Insistence on Sameness

Children with autism often form strong attachments to unusual objects (e.g., rocks, keys).
Even slight changes in environment or routine can trigger:

• Severe tantrums
• Crying spells
These behaviors reflect their strong desire to maintain sameness.

DSM-5 Criteria

A. Persistent deficits in social communication and social interaction across multiple

contexts, as manifested by the following, currently or by history (examples are illustrative,
not exhaus tive; see text):

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social

approach and failure of normal back-and-forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction,

ranging, for example, from poorly integrated verbal and nonverbal communication;
 to abnormalities in eye contact and body language or deficits in understanding and
use of gestures; to a total lack of facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for

example, from difficulties adjusting behavior to suit various social contexts; to diffi
culties in sharing imaginative play or in making friends; to absence of interest in
peers.

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at

least two of the following, currently or by history (examples are illustrative, not exhaustive;
see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple

motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal

or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transi tions,
rigid thinking patterns, greeting rituals, need to take same route or eat same food every
day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong
attachment to or preoc cupation with unusual objects, excessively circumscribed or
perseverative interests).

4. Hyper- or hyporeactivity to sensory input or unusual inter est in sensory aspects of the
environment (e.g., apparent indifference to pain/temperature, adverse response to specific
sounds or textures, excessive smelling or touch ing of objects, visual fascination with lights
or movement).

C. Symptoms must be present in the early developmental period (but may not become fully
manifest until social demands exceed limited capacities, or may be masked by learned strat
egies in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or other

important areas of current functioning.

E. These disturbances are not better explained by intellectual dis ability (intellectual
developmental disorder) or global develop mental delay. Intellectual disability and autism
spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum
disorder and intellectual disability, social communication should be below that expected for
general developmental level.

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s

disorder, or pervasive developmental disorder not otherwise specified should be given the
diagnosis of autism spectrum disorder. Individuals who have marked deficits in social
communication, but whose symptoms do not otherwise meet criteria for autism spectrum
disorder, should be evaluated for social (pragmatic) communication disorder
Epidemeology

Prevalence

Global:

Recent estimates vary by method, but well-controlled analyses place ASD prevalence
between ~0.7% and 3.2% of children (examples: ~1 in 36–1 in 31 in U.S. surveillance; global
meta-analyses report ~0.7%–1%). (Maenner et al., 2023; Santomauro et al., 2025).

India:

Indian studies and reviews report wide heterogeneity (method/sample dependent) —

pooled estimates often fall between ~0.1% and 1.5%, with some recent reviews estimating
1.0%–1.8 million affected children nationally. (Uke et al., 2024; Cureus review, 2024).

Age of Onset

Global:

ASD is usually identified by 24–36 months; research shows early social-attention signs can
appear within the first 6 months, and diagnostic stability from age 2 to later childhood is
high. (Jones & Klin, 2014; Lord et al., 2006).

India:

Indian clinical and screening studies report identification typically before 2–3 years, with
many children first recognized when social/communication delays become evident during
infancy or early toddlerhood. (Srivastava, 2023; Uke et al., 2024).

Gender Differences

Global:

ASD is consistently more common in males; surveillance shows roughly 3–4 times higher
prevalence in boys than girls, though recent increases in female diagnoses are narrowing
the gap in some settings. (Maenner et al., 2023; Grosvenor et al., 2024).

India:

Indian data also show a male predominance (commonly reported male:female ratios in the
range of 2–4:1), with under-identification of females likely contributing to variability across
studies. (Srivastava, 2023; Uke et al., 2024).
Comorbidity

Global:

High rates of co-occurring conditions — especially intellectual disability, ADHD, epilepsy,

anxiety, and language/learning disorders — are typical; many children have one or more
additional neurodevelopmental or psychiatric diagnoses. (Talantseva et al., 2023;
Santomauro et al., 2025).

India:

Indian studies likewise report frequent comorbidity (ID, seizure disorders, learning
problems, and behavioral/emotional disorders); however, comprehensive national
comorbidity data are limited and vary by study setting. (Cureus review, 2024; Srivastava,
2023).