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expert reaction to observational study of autistic traits and early ear and respiratory symptoms

An observational study published in BMJ Open looks at associations between autistic traits and early ear and upper respiratory signs.


Dr Amanda Roestorf, Head of Research, Autistica, said:

“Over the past 30 years, there has been converging evidence to show that autistic children are likely to have more medical conditions than non-autistic children. Of relevance to this paper, autistic children are more likely to experience problems and physical health conditions related to ear infections, auditory sensitivities and hearing problems including conductive hearing loss, ear/nose/throat (ENT) problems such as snoring or sleep apnoea and are more likely to be on antibiotics.1,2,3

“However, because ear conditions, such as otitis media (middle ear infection) and otitis media with effusion (‘glue ear’), can be overshadowed by communication difficulties or delays, research has also highlighted the challenges that exist for autistic children in being diagnosed and receiving effective treatment for these health problems. Children who are pre-verbal or who speak few to no words are less likely to receive appropriate diagnosis or treatment at the right time.4,5

“The present study identified 177 autistic children (1.26%; identified with “probable autism” based on autistic traits scores, diagnostic records, and parent reports) among a cohort of 13,988 children enrolled in a longitudinal study of health outcomes. The study provides new insights into the potential association between early childhood ENT symptoms and autism. The longitudinal data suggest that autistic children are 3.29 times more likely to have symptoms akin to ‘glue ear’ or similar ear infections, and 2.18 times more likely to have hearing loss or difficulties related to cold infection. This was particularly of relevance to very young children. Given the issues raised in previous literature, the study findings provide a basis for considering treatment pathways for ENT problems in autistic children in general practice and secondary care.

“There are, however, some potential methodological challenges and considerations for generalising the study findings. Some of these challenges include:

  • The authors identify 10 confounding environmental factors that were not controlled for at the start of the study and which may influence the outcomes for this cohort. These were adjusted for post-hoc in the analysis and the authors report no significant impact on the study outcomes greater than chance. However, given the relatively small sample size for the autistic group it would be worth considering if or how the adjustments might have affected the study power.
  • Given the environmental factors already mentioned, and that the study is reporting on a cohort of children enrolled more than 30 years ago, it would have been interesting to compare incidence of these ENT issues in a current day cohort of same age children. Future replication of these findings would be useful for future research considerations.
  • The study relied on self-reported data from mothers, which may not accurately reflect the child’s symptoms or developmental outcomes as independently validated.
  • Similarly, the study relied on questionnaires that were completed by mothers at a single time point, which may not capture the full range of symptoms or developmental outcomes over time.
  • The study only included children from one cohort in the Bristol area, which has a large migrant population and environmental considerations specific to that region, which may limit the generalizability of the findings to other populations.
  • The study did not account for other potential co-occurring conditions or medications that may have influenced the relationship between ENT symptoms and autism.

“Overall, the study provides interesting insights into the potential association between ENT symptoms and autism. However, whilst the study does not establish a causal relationship between autism and ENT symptoms, it does acknowledge that there may be other confounding factors that contribute to the issues outlined in this paper. Further research is needed to replicate these findings and better understand the underlying mechanisms of ENT symptoms in autistic children and young people. Nevertheless, the study provides important research-informed justifications for evaluating ENT care and treatment supports for autistic children across developmental stages.”

  1. Niehus, R., & Lord, C. (2006). Early medical history of children with autism spectrum disorders. Journal of Developmental & Behavioral Pediatrics27(2), S120-S127.
  2. Bishop‐Fitzpatrick, L., Movaghar, A., Greenberg, J. S., Page, D., DaWalt, L. S., Brilliant, M. H., & Mailick, M. R. (2018). Using machine learning to identify patterns of lifetime health problems in decedents with autism spectrum disorder. Autism Research11(8), 1120-1128.
  3. Rafal, Z. (2013). Conductive hearing loss in children with autism. European Journal of Pediatrics172(8), 1007-1010.
  4. Bishop, D. V. (2008). Specific language impairment, dyslexia, and autism: Using genetics to unravel their relationship. Understanding developmental language disorders: From theory to practice, 67-78.
  5. Adams, D. J., Susi, A., Erdie-Lalena, C. R., Gorman, G., Hisle-Gorman, E., Rajnik, M., … & Nylund, C. M. (2016). Otitis media and related complications among children with autism spectrum disorders. Journal of Autism and Developmental disorders46, 1636-1642.



‘Associations between autistic traits and early ear and upper respiratory signs: a prospective observational study of the Avon Longitudinal Study of Parents and Children (ALSPAC) geographically defined childhood population ‘ by Amanda Hall et al. wa published in BMJ Open at 23:30 UK time on Monday 24th April, which is also when the embargo will lift.

DOI: 10.1136/bmjopen-2022-067682



Declared interests

Dr Amanda Roestorf: “No relevant declarations of interest.”

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