Language Problem in Bangladeshi Children with Autism spectrum disorder : Observation through a Neurolinguistics Approach

Methodology : A descriptive observational study conducted during the period of April 2014 to December 2014 in the department of Linguistics, University of Dhaka, Bangladesh among the Bangladeshi children aged between 3–12 years. A total of 10 children with normal hearing ability who were diagnosed as ASD according to the diagnostic criteria (DSM5 or ICD 10) were enrolled in the study purposively from two tertiary care hospitals of Dhaka city.

Original Article difficulty in communicating nonverbally, such as through gestures, eye contact, and facial expressions etc. [1][2][3] Most children with ASD have little or no problem pronouncing words. The majority, however, have difficulty ensuing language effectively, especially when they talk to other people. [2][3] Many have problems with the meaning and rhythm of words and sentences. They also may be unable to understand body language and the nuances of vocal tones. 3

Introduction
Autism spectrum disorder (ASD) covers a set of developmental disabilities that can cause significant social, communication, and behavioral challenges. [1][2][3] People with ASD process information in their brain differently than other people. They share some symptoms, such as difficulties with social interaction, but there are differences when the symptoms start, how severe they are, how many symptoms there are, and whether other problems are present.
The signs of ASD begin before the age of 3 years, although some children may show hints of future problems within the first year of life. [1][2][3] Children with ASD often are self-absorbed and seem to exist in a private world where they are unable to successfully communicate and interact with others. They may have difficulty in developing language skills and understanding what others say to them. They also may have January 2018 n Volume 9 n Number 2 296 have shown increased prevalence estimates for all ASDs of between 30 and 90 cases per 10000. [5][6][7][8][9] In addition to a true increase in prevalence, alternative explanations have been proposed, including changing diagnostic criteria, different methods of ascertainment, varying urban, rural, and country location, and population of study, younger age, and inclusion of individuals with average intelligence quotient (IQ) and those with other neuropsychiatric and medical disorders. 3,7 Individual with ASD may have problems impeding their development of speech and language that are well outside the scope of traditional speech and language therapy (such as social deficits) or, at the very least, in the very frontiers of clinical knowledge as to appropriate treatment (developmental articulation disorders). 1,2 Parents and teachers are confronted by a bewildering range of options and apparent philosophies of treatment of these individuals. Thus, identifying and treating specific speech and language problems at the earliest possible age is of the utmost importance in children with autism.
Neurolinguistics is the study of how language is represented in the brain: that is, how and where our brains store our knowledge of the language (or languages) that we speak, understand, read, and write, what happens in our brains as we acquire that knowledge and what happens as we use it in our everyday lives. Neurolinguistics try to answer questions like these: What about our brains makes human language possible. 10 To date, research on speech and language development in children with ASD has been limited, and dearth of literature in the developing countries like Bangladesh. The language problem in ASD children is still under attended though we have huge population with a significant portion of growing children in Bangladesh.
Therefore, we aimed to find out the language problem in children with ASD in Bangladesh following the basis of neurolinguistics approach.

Methodology
This was a neurolinguistics study conducted during the period of April 2014 to December 2014 at the department of Linguistics, University of Dhaka among the Bangladeshi children aged between 3-12 years. A total of 10 consecutive children with ASD were enrolled in the study on the basis of the inclusion criteria.
inclusion criteria · Children who have hearing abilities within normal limits as documented by audio logical evaluation by Audiologist. · Children who diagnosed as ASD according to the diagnostic criteria (DSM-5 or ICD 10) for the first time at the tertiary center and had no previous interventions. Exclusion criteria · Children who have got previous interventions were excluded from the study.
Sampling was done purposively from two tertiary care hospitals of Dhaka city (National Institute of Mental Health, Sir Salimullah Medical College). Informed consent was taken from all the parents or attendant before enrollment in the study.
Data were collected using predeveloped questionnaire. The questionnaire was composed of 18 questions, which was developed for find out the linguistics output in children with ASD.
In this study a questionnaire of 18 questions were used to find out the linguistics output of children with ASD. All these questions covered the Receptive language development, Expressive language development and Social communication of child with ASD. In the questionnaire 3 questions were covered the receptive language development, 8 questions covered the expressive language development and further 7 questions covered the social communication.
Data were collected on clinical observation and history taking from mother/care giver, following linguistics approach Data analysis was done by using SPSS, Version-16

Results
In this study regarding the distribution of demographic variables of the children with ASD it was observed that majority (60%) of the patients were found in 3-6 years age group and rest 4 (40%) as found in > 6-9 years group. It was observed that male was found 9 (90%) and female was 1 (10.0%). The respondents' relation to patients was mother 8 (80%), father was 2 (20%). History of consanguinity was found in 1 (10%) respondents and 9 (90%) of the children had non consanguineous parents. 8 (80%) had term pregnancy, 1 (10%) had preterm pregnancy and 1 (10%) had post term pregnancy. Three (30%) had normal vaginal deliver (NVD) and 7 (70%) had lower uterine section (CS) delivery (Table 1).   On clinical observation and history taking from mother/care giver, regarding Receptive language development following linguistics approach we found that all (100%) parents thought that their children were not deaf. Hearing was normal in all cases even though most of the children 7(70%) dose not respond to his/her name. Also most of the study patients 8 (80%) could not identify 4/5 body parts (Table II).

Expressive language development
Regarding assessment of Expressive language development, we used 8 questions and the linguistics output of the study showed that all children (100%) had speech delay and 6 (60%) children used his/her index finger to point, to indicate interest in sometimes. We found that 9 (90%) children did not ever use his/her index finger to point, when we asked something and could not able to use noun and pronoun and repeatedly utter any words but they did not have any fluency disorder. In our study majority children 8 (80%) could not say name of known object and 7(70%) children used idiosyncratic/neologism words (Table III).
January 2018 n Volume 9 n Number 2 298 Most of the children did not ever playing with symbol 9(90%) 4. Does your child take part in conversation with others? you take rice? In answering this question whether the child answer Yes or No Within 3 years to 3.5 years a normal child can take part in conversation.
Most of the children did not take part in conversation. Majority children did not smile in response to any activity which he/she likes 9(90%) Regarding assessment of Social communication, we had used 7 questions and the linguistics output of the study showed that all children (100%) were unable to participate in rhymes/song with other children and could not point or look at things with others jointly. Majority of them (60%) did not try to attract your/others attention to his/her activity and 70% could not make eye contact and did not understand others facial expression. We found that 9 (90%) children did not ever play with symbol and did not take part in conversation and did not smile in response to any activity which he/she likes (Table IV).

Discussion
Bangladesh is a developing country having population of 167 million. According the World health Organization supported survey 2009 there are 0.84% children are suffering from Autism Spectrum disorders. 11 Studies recommended that among the developmental disorders, developmental language disorder was the second most common and in ASD it is an important part. 12 With this huge magnitude of disease burden of ASD children, their language problem is still under attended.
Therefore, we aimed to find out the language problem in children with ASD following the basis of neurolinguistics approach and so far our knowledge this might be the first study carried out in Bangladesh in this regards.
In this study total 10 children were included according to inclusion criteria and their age range were found 3 to 6.5 years. Male was predominant, which was 90%. Male to female ratio was 9:1. Bertrand et al. found the male-to-female ratio for children with autistic disorder was 2.2 males for each female. 6 Another review revealed that the most widely reported malefemale ratio for autism prevalence is 4-5:1, lower in individuals with intellectual disability and higher at the high-functioning end. 13 In our study 70% parents mentioned that their children could not respond to his/her name and 90% children ever use his/her finger to point, to indicate something of his interest. Seventy percent parents mentioned that their children ever use his/her index finger to point, to ask for something. Sixty percent parents also mentioned that their children did not try to attract others attention to his/her own activity. Only 10% children could play with symbol, could take part in conversation and have any fluency disorder in speech.
Recent reviews recommended that pragmatic impairments are universal in autism and comprise a significant element of the disorder. 14,15 Clinically important diagnostic characteristics of ASD include lack of spontaneous seeking to share enjoyment, emotions, affect, interests, or achievements with other people, and a lack of emotional reciprocity. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] The present study aimed at the language aspects and revealed similar outcomes found in the previous literatures. 15,16 In this study we found that 20% children were able to say name of the known objects and 80% children could identify 4/5 body parts. Seventy percent children could not make eye contact and understand others facial expression. Ninety percent children could not use "noun" and "pronoun". 90% parents mentioned that their children smiled in response to their activity which he/she likes. Ninety percent children repeatedly utter any words and 70% parents mentioned that their children use idiosyncratic/neologism words.
ASD is characterized by persistent impairments in social communication and interaction, restricted and repetitive behavior, and an onset of the disorder in earlychildhood. 16 Outcome of all these studies showed the same observations in the language development which was found in the Bengadeshi children. This study would act as a baseline observation in respect of the language problem in children with autism in Bangladesh.

Conclusion
Autism spectrum disorder affects the language and communication significantly as the patients with autism have deficiency in language development. This study also tries to find out the extend of these problem in Bangladeshi children with ASD. But with the results of a minimum sample size, city based short duration study a straight cut conclusion would be difficult. Therefore, further large scale multi centered study would be needed to better visualize the problem more efficiently.