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Autism Spectrum Disorder and International Travel

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Abstract

The literature on international travellers with psychiatric disorders is limited. This perspective article highlights various travel-related aspects of autism spectrum disorder (ASD), including its aetiological association with maternal migration, the difficulties faced by longterm travelers with autistic children, and the facilitation of international travel for autistic individuals by the travel industry. Depending on the severity of their condition, autistic individuals may find specific aspects of the travel experience particularly distressing. Travel medicine practitioners should be aware of the unique needs of autistic travelers when providing pre-travel health counseling. There is also an onus on the travel industry to facilitate safe and enjoyable travel and remove barriers faced by autistic travellers.
Introduction
People living with mental illness are among the most
vulnerable groups of international travellers.1,2 The literature
on international travellers with psychiatric disorders is
limited.3 Autism spectrum disorders (ASDs) comprise a
group of neurodevelopmental disorders. Affected patients
exhibit difficulties with communication and social interaction
and demonstrate restricted, repetitive patterns of behavior,
interest, and activities.4 A prevalence for ASD of 0.6%-1.13%
has been reported, and there is a marked male predominance
in this condition.5 Deka et al described the domestic travel
patterns, needs, and barriers of adults with ASD in the United
States and identified unique transportation challenges such as
negotiating fixed-route transit and crossing roads safely.6 It can
reasonably be assumed that overseas travel would pose even
greater challenges for the autistic individual. This perspective
article will reflect on various international travel-related
aspects of ASD, including its putative link with maternal
migration, the difficulties faced by long-term travelers with
autistic children, and the facilitation of international travel for
autistic individuals.
Migration as a Risk Factor for Autism
Apart from the recognized underlying genetic causes such as
fragile X syndrome, Rett syndrome and tuberous sclerosis,
risk factors for ASD include advanced maternal age,7 preterm
delivery, and intra-uterine growth restriction. Maternal
migration has recently been postulated as an independent
risk factor for the development of low-functioning ASD. A
retrospective analysis of children presenting to the National
Child Developmental Service in Ireland revealed an increased
rate of low-cognitive functioning ASD in children born
to mothers who migrated from sub-Saharan Africa.8 The
authors hypothesize a role for maternal vitamin D deficiency
as a basis for this phenomenon. The prevalence of ASD
was three to four times higher in children born to Somali
migrants than in a matched cohort.9 The majority of autistic
children were male, and all affected children had evidence of
intellectual disability. Most of the Somali mothers had resided
in Sweden for the entire gestation period. A further Swedish
study of almost 5000 children with ASD observed a lower
risk of high-functioning autism and a higher risk of low-
functioning autism in children of parents who had migrated
from regions with a low human development index.10 A
case-control study of second-generation migrants in Finland
found a positive association between ASD and the migration
of both parents, immigrant mothers, but not immigrant
fathers.11 Paradoxically, a lower prevalence of autism has been
documented in the children of Hispanic migrants living in
the United States, presumably owing to epigenetic changes
resulting from larger social networks and improved obstetric
outcomes.12
http://ijtmgh.com
Int J Travel Med Glob Health. 2019 Mar;7(1):1-3 doi 10.15171/ijtmgh.2019.01
TMGH
I
International Journal of Travel Medicine and Global Health
J
Perspective Open Access
Autism Spectrum Disorder and International Travel
Wee Xuan Neo1, Gerard Thomas Flaherty1,2*
1School of Medicine, National University of Ireland Galway, Galway, Ireland
2School of Medicine, International Medical University, Kuala Lumpur, Malaysia
Corresponding Author: Gerard Thomas Flaherty, MD, Professor, School of Medicine, National University of Ireland
Galway, Galway, Ireland. Tel: +353-91495469, Fax: +353-91494540, Email: gerard.flaherty@nuigalway.ie
Copyright © 2019 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://
creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Citation: Neo WX, Flaherty GT. Autism spectrum disorder and international travel. Int J Travel Med Glob Health. 2019;7(1):1-3. doi:10.15171/
ijtmgh.2019.01.
Abstract
The literature on international travellers with psychiatric disorders is limited. This perspective article highlights various travel-related
aspects of autism spectrum disorder (ASD), including its aetiological association with maternal migration, the difficulties faced by long-
term travelers with autistic children, and the facilitation of international travel for autistic individuals by the travel industry. Depending
on the severity of their condition, autistic individuals may find specific aspects of the travel experience particularly distressing. Travel
medicine practitioners should be aware of the unique needs of autistic travelers when providing pre-travel health counseling. There is also
an onus on the travel industry to facilitate safe and enjoyable travel and remove barriers faced by autistic travellers.
Keywords: Migrants, Travel, Autistic Disorder, Mental Health
Received June 28, 2018; Accepted October 1, 2018; Online Published November 24, 2018
Neo and Flaherty
International Journal of Travel Medicine and Global Health. 2019;7(1):x–x
2
Autism in Long-Term Travellers
Modern approaches to the management of ASD in childhood
emphasize the importance of timely diagnosis and intervention,
with access to multidisciplinary paediatric developmental
services which can manage issues related to speech and
language delay, motor problems, and behavioral challenges.
Long-term travelers and expatriates whose children have been
diagnosed with ASD may encounter difficulties in identifying
and accessing reliable therapeutic services overseas. This
may be compounded by discontinuities in care which may
be detrimental to their special needs children. An example
stems from the relocation abroad of families where one or
more parents serve in the military. Frequent redeployment
may hinder efforts to develop a therapeutic relationship with
the autism care provider. Coupled with the lack of social
support, this may lead to greater behavioral disturbances in
affected children when parental redeployment compromises
the continuity of family-centered care.13
Challenges of Travel for Autistic Individuals
Depending on the severity of their condition, autistic
individuals may find specific aspects of the travel experience
particularly distressing. The desire for predictability and
maintenance of a fixed routine may be diffic ult to satisfy during
international travel, especially where the travel itinerary
itself is uncertain.14 Auditory overload may be prominent
in airports and in crowded destinations with a high urban
population density and traffic volume. Queuing in airports
may be difficult for some travelers with ASD, and manual
body searches at security stations may be poorly tolerated. A
lack of familiarity with a foreign environment can provoke
significant anxiety, depression, and social isolation in autistic
travelers. A recent qualitative study of mothers of autistic
children provided insight into the triggers of underlying
emotional and behavioral disturbances, including the need
to avoid spontaneous, unplanned, and highly stimulating
activities during travel.15 The difficulties autistic children
encounter during routine transportation were highlighted in
a retrospective study of 82 children who had escaped from
their child safety restraint during road travel.16 It is reasonable
to suggest that these issues may be amplified during
international travel, including on commercial airplanes and
in taxis, with obvious safety implications for those involved.
Role of the Travel Industry
Travel medicine practitioners should be aware of the unique
needs of autistic travelers when providing pre-travel health
advice. There is also a responsibility on the travel industry
to facilitate enjoyable travel and remove barriers faced by
autistic travelers. A study from Northern Ireland evaluated
a video modeling technique based on applied behavior
analysis research to prepare autistic children for travel by
airplane.17 Shannon Airport in the Republic of Ireland was the
first airport in Europe to create a sensory room for autistic
travelers which is located air-side, adjacent to the departure
lounge. This quiet, dimly lit room is designed to provide
relief from the hectic airport environment and includes
features such as an undulating wavy wall, an aquatic bubble
tube, color-changing, light-emitting diodes, and a wheel
projector. There have been efforts to design tourism websites
to make them more acceptable for travelers with ASD based
on a greater use of icons, symbols, and simple text with less
structural variation between webpages.18 Hamed underscored
the need for quieter accommodations and a greater focus on
nature tourism and exposure to cultural and historic sites of
interest to the autistic traveler.19
Conclusion
Travel is a recognized risk factor for the development of autism
in children whose mothers migrated during pregnancy.
International travel poses significant challenges for autistic
individuals, many of which can be addressed by promoting
greater awareness throughout the travel industry about
the special needs associated with this common psychiatric
disorder. There is a need for greater qualitative research
that would serve to illuminate aspects of the autistic travel
experience which have not heretofore been discussed in the
literature.
Authors’ Contributions
Both authors contributed equally to the conception, planning,
writing, and editing of the article. The final version was read
and approved by both authors.
Conflict of Interest Disclosures
None declared.
Ethical Approval
Not applicable.
Funding/Support
None received.
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... Apart from these factors, families with disabilities tend to have similar travel motivations as non-disabled people, such as the need to change environment and to see and live new experiences (Dominguez, Darcy & González, 2015). Neo and Flaherty (2018) examined the difficulties that travelers with autism face during long-term travels in their study. The study stated that the excessive noise, traffic, and population density to which autistic individuals were exposed during travel and manual controls for security purposes were disturbing for those people. ...
... In foreign literature, some studies address autism spectrum disorder with different aspects of tourism such as travel, accommodation, gastronomy, and recreation (Freund et al. 2019;Neo & Flaherty, 2018;McKercher & Darcy, 2018;Sedgley et al. 2017;Stuhl & Porter, 2015;Amet, 2013;Hamed, 2013). When these studies are examined, it is seen that their findings support the results of this study. ...
... It was also observed that families having children with autism avoid public transportation for similar reasons, especially for long distances in the study. Neo and Flaherty (2018) also found that families with ASD child, face several difficulties during travel such as overcrowd, loud noise, waiting in long queues, heavy traffic, and increased waiting time due to delays in vehicles. Studies in the literature have shown that internal limitations and the severity of the disease affect travel to accessible accommodation and tourism facilities. ...
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... The changes in routine, unpredictability, crowds, and new noises and sights can all make the experience difficult for children with ASD and their families. The literature on international travellers with psychiatric disorders is limited [1,2]. Public health officials should be aware of the unique needs of travellers with ASD when providing pre-travel health advice [2]. ...
... The literature on international travellers with psychiatric disorders is limited [1,2]. Public health officials should be aware of the unique needs of travellers with ASD when providing pre-travel health advice [2]. People living with mental illness are among the most vulnerable groups of international travellers [3,4]. ...
... In 2014, the World Health Organization [9] called for the access needs of people with ASD to be properly addressed. The travel industry and public health sector, therefore, should endeavour to eliminate the major constraints encountered by passengers with autism [2][3][4][5][6][7][8][9][10], yet research on international travellers with developmental or cognitive disabilities is limited [2]. Compared with the general population, children diagnosed with autism spectrum disorder (ASD) tend to have deficits in adaptive skills, which makes novel environments such as an airport very difficult to manage [11,12], and the airport experience for a child with ASD and their family can therefore be overwhelming [10]. ...
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... Evidently, vacation experiences that involve out-of-routine activities at unusual environments can be distressing to the children with ASD. Auditory overload, crowds, queuing, and high-security check at the airport can provoke a significant level of anxiety, potentially overwhelming and leading to a meltdown (Neo & Flaherty 2018).Persons with autism pose a great variation, yet there are a few common challenges usually exhibit in the daily life of almost all autistic persons (see Table 1). Extremely interested in detailed information on 'how-it-works' and this stereotyped or repetitive behaviour challenge may increase during trip due to change in custom and surroundings. ...
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