Why autism is different for girls
Jeremy Laurance

With hindsight, Nicky Clark says early signs of autism were present in both her children. The elder one, though very bright, had a love of routine and was not interested in fantasy games like other children. The younger one liked to line things up in rows and would watch the same video clip over and over again for hours. When she got the diagnosis it came as a huge shock, as it would be for any parent. But there was an additional reason why it was unexpected – both her children are girls.

Autism is an overwhelmingly male diagnosis – it has been described as the “extreme male brain”. Boys with the diagnosis outnumber girls by between 10 and 15 to one. The typical high functioning male, if he is lucky, finds a secure post in a university where he can use his exceptional powers for academic study, shunning most social contact as the “eccentric professor”, and relaxing at home with his train set in the attic.

But in the developing story of autism – interest in which has increased hugely in the last decade – girls have been neglected.

According to Janet Treasure, professor of psychiatry at the Institute of Psychiatry, King’s College, London, around a fifth of girls diagnosed with anorexia have autistic spectrum features and 20 to 30 per cent may have exhibited rigidity and perfectionism in childhood. Anorexia has been called the female Asperger’s (the mild version of autism).

Professor Treasure says: “When I was training at the Maudsley 30 years ago, anorexic girls were treated as little more than malfunctioning machines. The view was that it was an illness that mainly affected middle-class intelligent white girls and was little more than an awkward phase of adolescence. Today there has been a huge change in the understanding of the disease. People with eating disorders find it difficult to change self-set rules and learnt behaviour once fixed in the brain. They also see the world in close up as if looking through a zoom lens, and get lost in the detail. There is a strong similarity to autistic spectrums.”

She says that there are two aspects to the link. First, people with autistic spectrum disorder are more at risk of getting anorexia. “If girls are obsessed with systems and rules then the rules governing eating become very attractive. They grab them very much.”

Second, being undernourished and underweight as a result of an eating disorder exaggerates any autistic traits. The effect of starvation on brain function impairs set-shifting – the ability to think flexibly and to multi-task instead of focusing on one thing – and the ability to read other people’s minds. “They become more socially isolated, withdraw more and more into their own world and become cut off and lonely,” she adds.

The task for therapy is to bring them out of their obsession with eating, or avoiding it. But they have to make “big choices that require a lot of courage”. The autistic features are reversible in the majority of sufferers once they regain full weight but it requires “a leap so they stop listening to their eating disorder voices”.

Girls whose autistic traits predated their anorexia face a harder task, even supposing they conquer the eating disorder. “For those with high functioning Asperger’s they can work out what they have to do – to remember to smile, to ask, ‘How are you?’ They need to work at it because autistic traits make them uncharming and can cause heartache throughout life. If they remember the social rules it makes them a bit more charming,” Professor Treasure says.

Ignorance about the condition in the female sex extends to professionals, adding to the distress it causes. Research suggests that even when girls are screened autistic traits are not picked up. In one study of 60 patients at a psychiatric hospital in England, none were diagnosed as autistic but 11 were later shown to have autistic traits. They were diagnosed with other conditions such as personality disorder and schizophrenia.

It is to combat the ignorance and neglect of the condition among girls and women that a recent conference was held. Mark Lever, chief executive of the National Autistic Society, says: “So many women tell us that trying to get a diagnosis feels like an insurmountable hurdle and they have to fight tremendous battles to get the help support and services they desperately need. Autism is a lifelong condition. Without the right support it can have a profound effect on individuals and families.”

— The Independent

Rehabilitation after heart surgery 
Dr Ravinder Chadha

People undergoing open-heart surgery /angioplasty are always in a fix regarding the rehabilitation programme to be followed. Open-heart surgery has become one of the most commonly performed surgical procedures over the last few years. After undergoing surgery probably due to lack of counselling, generally people cut down on their physical and social activities thereby risking depression. They do not realise that after undergoing angioplasty or bypass surgery their blood circulation to the heart is back to normal and is even better than an individual suffering from high blood pressure, diabetes, a high cholesterol level, etc. Here comes into play the vital role of cardiac rehabilitation --- post- operative programme of physical activity which is crucial in the following manner:

* Decreasing bad cholesterol and keeping the arteries free of blockage, thereby decreasing the risk of a recurrence.

* Motivating the patient to lead a normal life and undertake daily activities.

* Starting an exercise programme to regain strength.

* Decreasing both systolic and diastolic blood pressure.

After surgery a mandatory two or three weeks of rest is required before starting normal activities. The usual complaints are poor appetite, constipation, generalised weakness, sweating, depression, etc. Daily walking and exercise regimens not only help in overcoming these problems but also prevent the heart blood vessels to be blocked again.

Exercises should be performed under expert supervision. Low-level activity should be initiated with appropriate lifestyle changes. It is a well-known fact that lack of physical activity is one of the major factors leading to heart disease. Undergoing heart surgery does not mean that one is free from heart disease forever. Physical activity after surgery is very important.

The following precautions should be taken before starting the exercises.

* Start doing exercises for 10 minutes and increase it gradually to 30 minutes, six days a week.

* For the first three months after surgery one can start doing light house work but should avoid pushing and lifting heavy objects which includes carrying children, pets, suitcases, etc.

* Do not exercise outdoor when it is too cold, hot or humid.

* Climbing stairs or uphill should be restricted initially and can gradually be increased.

* Stop exercises immediately in case you experience chest pain or tightness, palpitation, breathlessness, dizziness and sweating more than usual, etc.

Walking is the most important exercise after heart surgery. It improves blood circulation, muscle tone and strength.

* Walking time can be increased from one to two minutes per day. Once one can safely walk for a mile, then gradually speed can be increased. However, running or jogging initially should be avoided.

* Do not increase the distance and speed simultaneously. It is important to walk at a speed where one can simultaneously talk.

* During winter, walk in the afternoon and in summer during the cool part of the day. In very humid and cold weather, it is advised to walk indoors.

EXERCISES

Patients undergoing coronary surgery require a minimum level of muscular strength to perform activities of daily life but they often lack the confidence or strength. The resistance exercises are similar to the exercises for healthy adults except the fact that the intensity and progression of training volume are reduced. Resistance Stretch Bands should be used and repetitions can be increased with the passage of time.

Exercises for upper limb

* Sit on a chair with the band under the foot. Hold the band in a fist with the palm facing upward. Move the wrist upwards and then slowly return to the starting position. Repeat 10 times.

* While sitting, put one end of the stretch band under the foot. hold the other end and bend elbow thereby feeling tension at the biceps muscle. Repeat 10 times.

* Rowing strengthens the muscles of upper back and shoulders. While sitting, loop the band around one foot. With arms straight out in front, grasp the band and slowly pull it toward the chest. Release slowly. Repeat 10 times.

Exercises for lower limb

* Resisted knee extension: Loop the stretch band around the bottom of the foot, hold onto the ends while in a sitting position, and bend one knee about 30 degrees. Straighten the knee against the resistance of the tubing and return back. Repeat 10 reps.

* Lying on back, loop the band around ankles. Raise one leg feeling the stretch on the front of the thigh. Return back. Repeat 10 times.

* Calf strengthening — while sitting, loop the band around the ball of the foot and hold each end in both hands respectively. Pull the foot towards the body and return back. Repeat 10 times.

The main objective of physical activity after surgery is to reduce the stiffness due to prolonged bed rest, to enhance muscle strength and improve overall well-being. Proper rehabilitation after heart surgery can make life comfortable.

The writer runs his pain management clinic in Chandigarh. E-mail—chadha_r2003@yahoo.co.in 

Now scarless surgery
Dr Pankaj Garg

A synonym of science is ‘skill’, which forms the basis of surgery. A progressive improvement in surgical skills has been as important for advancement in surgery as has been the development of newer sophisticated surgical gadgets.

After the invention of asepsis (meticulous cleaning of surgical site and instruments), development of keyhole (laparoscopic) surgery about 20 years back was one of the most significant advancements in surgical fields in the last century. In laparoscopic surgery, instead of a big cut (as made in conventional open surgery), 4-5 small cuts are made. An endoscopic camera is introduced through one of these cuts and long narrow instruments are inserted through the other cuts to perform surgery.

The advantages of the laparoscopic technique over open surgery were tremendous. As it was cosmetic (the scars were much smaller) and less painful, it replaced open surgery in almost every possible surgical field.

Now the introduction of scarless surgery [single puncture or single incision laparoscopic surgery (SILS)] has led to a major improvement over laparoscopic surgery. In this, only a single small cut is made through which complete surgery is done. By a special technique, this lone puncture of 1.5 to 2 cm is given inside the umbilicus (navel). It is given in such a way that the small scar is practically invisible after the operation, and hence the expression ‘scarless’ surgery.

This operation requires expertise and special instruments. The latter are straight but can bend once inside the tummy. So, the advantages of scarless surgery are lesser pain, as the number of cuts is less, early recovery, early return to work, less chances of infection and, most important, better cosmetic results.

It is very good for youngsters, especially women. The disadvantage is that the single puncture surgery requires greater expertise and, therefore, only the surgeons who are proficient in laparoscopic surgery can do it.

A gall bladder stone operation is most common surgery now, done with the scarless technique. Apart from the gall bladder operation, uterus removal, appendix, hernia, kidney and intestine operations are also being done with this method. It is believed the scarless surgery may revolutionise the surgical practice as laparoscopic surgery did about 20 years back.

The writer is Senior Consultant Surgeon, Fortis Hospital, Mohali. E mail – drgargpankaj@yahoo.com)